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Types of Myomectomy - Hysteroscopic, Laparoscopic, Abdominal

Fibroid Specialist Dr. Michael Lalezarian explains hysteroscopic, laparoscopic, abdominal, and other types of myomectomy surgeries. Compare invasiveness, recovery time, complications, and post-surgery scars in this overview of the types of myomectomy.



In this Article

  • Different types of myomectomy surgeries used to treat fibroids

  • Explanation of hysteroscopic, laparoscopic, abdominal, vaginal and Da Vinci (robotic-assisted) myomectomy techniques

  • Recovery time, complications, and scars of each myomectomy technique

  • Non-surgical fibroid options



More often than not, women seeking treatment for their fibroids will face the option of whether or not to undergo some type of surgery to have them removed. Despite other options that women now have access to, hysterectomy (removal of the uterus) is still one of the most common approaches to treating fibroids. On the other hand, women that want to keep their uterus may be offered an alternative to hysterectomy called myomectomy.


Myomectomy, like hysterectomy, is a surgical procedure used to treat fibroids. But unlike hysterectomy, myomectomy removes the fibroids while keeping the uterus intact. There are multiple types of myomectomy surgery, and some are more invasive than others. To help you navigate your options, we step through 5 types of myomectomy surgery and explain the associated surgical risks, recovery time, and myomectomy scars that follow with each of them.



Hysteroscopic Myomectomy


A hysteroscopic myomectomy is a good option for women who have fibroids on the inner surface of their uterus (submucosal fibroids). It is performed by navigating a hysteroscope, a long and flexible camera with tools on the end, through the vaginal canal and into the uterus. Once the camera is inside the uterus, the surgeon is able to visualize the fibroid tissue and remove it through a variety of methods. The entire operation can be done as an outpatient procedure and with as much, or as little, sedation as is preferred. Occasionally, due to the size and position of the fibroids, a hysteroscopic myomectomy may need to be performed in two stages.¹


Hysteroscopic Myomectomy Recovery Time


A hysteroscopic myomectomy is often performed as an outpatient procedure, which means that you would not need to stay in the hospital overnight. It usually takes around 1-2 days after hysteroscopic myomectomy to recover.


Hysteroscopic Myomectomy Complications


A hysteroscopic myomectomy is typically a very safe procedure with minimal complications. The most worrisome complications include uterine perforation, venous air embolism, and fluid overload, however appropriate awareness of these complications by surgeons ensures that they happen well under 1% of the time.²


Hysteroscopic Myomectomy Scars


Because the entire procedure is performed trans-vaginally, there are no external scars from a hysteroscopic myomectomy.



Laparoscopic Myomectomy


A laparoscopic myomectomy is the most performed surgical procedure for the removal of symptomatic fibroids. Several small incisions are made on the abdominal wall. Once access to your abdomen and uterus has been obtained, the surgeon will remove the fibroid tissue with the use of a camera and long tools, then suture closed any incisions they made. Like open surgeries, a laparoscopic myomectomy is performed under general anesthesia.³


Laparoscopic Myomectomy Recovery Time


Laparoscopic myomectomy is a minimally invasive procedure, which means that the recovery time following operation tends to be shorter than more invasive methods. However, there is no recommended length of hospital stay or consensus on recovery time. Many surgeons report patients needing to stay in the hospital for 1-2 days, although in some cases, patients have been able to go home the same day as the surgery is performed.⁴ Once home, there are no restrictions on activity, but the abdominal incisions may take several days or weeks to fully heal. Total recovery time to return back to feeling normal is estimated to be at 2-4 weeks.


Laparoscopic Myomectomy Complications


The complications following laparoscopic myomectomy are similar to any surgery that enters the abdomen. This includes bowel injury, ureteral injury, bleeding, and embolism, but these are all very rare. In women who go on to be pregnant, one major long term risk is uterine rupture during pregnancy or labor. This is fortunately very rare, and surgeons have developed techniques to minimize this risk as much as possible.⁵


Laparoscopic Myomectomy Scars


Most laparoscopic myomectomies involve creating three small incisions (1-2 inches) in the abdominal wall. A new technique called laparoendoscopic single-site surgery (LESS) has recently been developed, however further study needs to be done to determine how safe and effective it is.



Abdominal Myomectomy (Laparotomy)


An abdominal myomectomy is performed in much the same way as a total hysterectomy but with targeted removal of the fibroid. Abdominal myomectomy is performed under general anesthesia, so the patient does not remember or feel anything during the surgery. A large incision is made in the lower abdominal wall, so the surgeon can adequately see your uterus. From there, they will surgically remove the fibroid tissue before closing any incisions they made.³


Abdominal Myomectomy Recovery Time


Abdominal myomectomy is a major surgical operation, so recovery time is much longer as compared to other less invasive methods. After the surgery, patients typically stay between 2-7 days, then the total recovery time to return to normal is between 4-6 weeks.⁴


Abdominal Myomectomy Complications


Compared to laparoscopic or robotic-assisted myomectomies, abdominal myomectomies are associated with a higher risk of blood loss, post-operative pain, increased hospital length of stay, and intra-abdominal adhesions.⁶


Abdominal Myomectomy Scars


Abdominal myomectomies leave much larger scars than other surgical techniques. The most common scarring pattern is from the Pfannenstiel incision, although the incision may vary depending on your unique fibroid location.



Vaginal Myomectomy


A vaginal myomectomy differs from an abdominal or laparoscopic myomectomy in how the surgeon accesses the uterus. In a vaginal myomectomy, the surgeon goes through the vaginal canal (as in a hysteroscopic approach), however instead of continuing into the uterus, they will then make incisions into the cervix (called a colpotomy) and surrounding tissue to enter the pelvis and lower abdominal cavity. Again similarly to the hysteroscopic approach, a vaginal myomectomy can be performed with pain control ranging anywhere from a regional block to general anesthesia.⁷


Vaginal Myomectomy Recovery Time


There is currently an absence of good published data about the recovery time from vaginal myomectomy, but it is expected to be similar to or better than the laparoscopic approach. However, due to how the uterus is accessed, you should expect to wait longer to return to sexual activity after a vaginal myomectomy.


Vaginal Myomectomy Complications


It is hard to know the current rates of complications after vaginal myomectomies due to the lack of data, but there appears to be a increased risk for a few notable complications. First, the difficulty of the approach leads to a higher likelihood for converting to a laparoscopic or abdominal myomectomy. Infections may also be higher in vaginal myomectomies.


Vaginal Myomectomy Scars


There will be no external scars from a vaginal myomectomy, but if the surgery is converted, then you will have scars as noted above for the laparoscopic or abdominal approaches.



Da Vinci Myomectomy (Robotic-Assisted Myomectomy)


Da Vinci surgery is very similar to laparoscopic surgery, and in fact, the surgical tools are nearly identical. The differences between the two techniques largely come down to safety and cost, with robotic-assisted surgery costing more money but having fewer complications.⁸


Da Vinci Myomectomy Recovery Time


Recovery time from a da Vinci myomectomy is identical to that of the laparoscopic approach noted above.


Da Vinci Myomectomy Complications


The complications in da Vinci myomectomy are again similar to the laparoscopic approach, although da Vinci surgery is associated with significantly less blood loss, post-operative bleeding, and risk for surgical conversion as compared to laparoscopic myomectomy. However the two approaches show no difference when it comes to the long term outcomes of fertility and need for reoperation.⁴


Da Vinci Myomectomy Scars


Da Vinci myomectomies will have a very similar scarring pattern to the laparoscopic approach. Occasionally your surgeon may perform one additional small incision for a total of four 1-2 inch scars.



Is Myomectomy Right for Me?


Myomectomy is a good alternative to hysterectomy for women that want to get pregnant in the future, and for those that just want to keep their uterus. But with any medical procedure, it’s ideal to minimize invasiveness so you can heal and get back to your life as quickly as possible. In many cases, the least invasive myomectomy technique does not work for the locations of your fibroids, and a more invasive myomectomy technique is required. In general, myomectomy becomes a less favorable option as more fibroids need to be removed, because more cutting is necessary to rid your uterus of multiple fibroids.


For women that want to avoid surgery, uterine fibroid embolization (UFE) is an equally effective alternative to myomectomy that doesn't require you to go under the knife. Like myomectomy, the UFE procedure is fertility sparing and keeps your uterus intact, but without all of the cutting. You can learn more non-surgical fibroid treatment at fibroidspecialists.org. And if you're still weighing your options, we've put together a guide on how to decide which fibroid treatment makes the most sense for you.



About the Author


Dr. Michael Lalezarian is a practicing interventional radiologist with the Fibroid Specialists of University Vascular in Los Angeles, CA. In addition to patient care, Dr. Lalezarian teaches and supervises medical students, residents, and fellows as a full time teaching Professor in the Department of Radiology at UCLA. He is regarded as an expert in uterine fibroid embolization. You can view Dr. Lalezarian's full bio here.


This blog post was written with research and editorial assistance from OnChart™.



References


[1] Piecak K, Milart P. Hysteroscopic myomectomy. Prz Menopauzalny. 2017;16(4):126-128.

[2] Ciebiera M, Łoziński T, Wojtyła C, Rawski W, Jakiel G. Complications in modern hysteroscopic myomectomy. Ginekol Pol. 2018;89(7):398-404.

[3] Grifo, J, Nassari, A, et al, Glob. libr. women's med., (ISSN: 1756-2228) 2008; DOI 10.3843/GLOWM.10040. https://www.glowm.com/section_view/heading/Myomectomy/item/40#8431.

[4] Stoica RA, Bistriceanu I, Sima R, Iordache N. Laparoscopic myomectomy. J Med Life. 2014;7(4):522-4.

[5] Wang T, Tang H, Xie Z, Deng S. Robotic-assisted vs. laparoscopic and abdominal myomectomy for treatment of uterine fibroids: a meta-analysis. Minim Invasive Ther Allied Technol. 2018;27(5):249-264.

[6] Faivre E, Surroca MM, Deffieux X, Pages F, Gervaise A, Fernandez H. Vaginal myomectomy: literature review. J Minim Invasive Gynecol. 2010;17(2):154-60.

[7] Senapati S, Advincula AP. Surgical techniques: robot-assisted laparoscopic myomectomy with the da Vinci(®) surgical system. J Robot Surg. 2007;1(1):69-74.

[8] Wang T, Tang H, Xie Z, Deng S. Robotic-assisted vs. laparoscopic and abdominal myomectomy for treatment of uterine fibroids: a meta-analysis. Minim Invasive Ther Allied Technol. 2018;27(5):249-264.



Medical Disclaimer


The Materials available on the FibroidSpecialists.org blog are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients.

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