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Myomectomy for fibroids (part 1) MYOMECTOMY FOR FIBROIDS (part 1)
Myomectomy is the surgical removal of one or more fibroids from the uterus with the aim of providing relief from prolonged or heavy bleeding. It is an option worth considering for women who have not finished their families and who therefore want their uterus intact to preserve their fertility. Pregnancy rates of 40-59% following myomectomy have been reported. It is, however, a difficult operation which is more likely than hysterectomy to cause blood loss requiring transfusion and postoperative ill-health. For these reasons, women with fibroids are five times more likely to have a hysterectomy than a myomectomy.
In most women, myomectomy initially relieves bleeding symptoms. But, ten years after the operation, 20-30% have returned to their doctors with a recurrence of their earlier problems. The reasons for this recurrence rate are as uncertain as the reasons for the development of fibroids in the first place. There is some evidence to suggest that recurrence rates are higher when multiple fibroids are present or the initial fibroid removal is incomplete. The latter suggestion is, however, body disputed; and there is also support for the view that it is only necessary to remove that part of the fibroid protruding from the wall of the uterus to obtain long-lasting relief from heavy bleeding. It has also been suggested that some women have an inherited tendency to develop fibroids and that this has a big influence on the recurrence rate.
Abdominal or open myomectomy, where the operation is performed through a large (approximately 13 cm) incision, has been the procedure used for many years. Recently, several new approaches have been devised which make use of a hysteroscope inserted through the vagina (hysteroscopic myomectomy), or a laparoscope inserted in the abdomen (laparoscopic myomectomy). These procedures avoid the need for large abdominal incisions. (Similar techniques may be used to remove adenomyosis, a condition that is closely related to fibroids.) A vaginal ultrasound showing the position and size of fibroids is helpful in deciding which of the above approaches is advisable.
Open myomectomy is performed more often in Australia than hysteroscopic or laparoscopic myomectomy. Likely explanations for this include the suitability of open myomectomy for the removal of large fibroids and for the removal of fibroids from sites where they are often found, such as the outer wall of the uterus. Open myomectomy is also a more entrenched procedure than
either hysteroscopic or laparoscopic fibroid removal. Fibroids up to 8 cm in size can also be made smaller or destroyed using laser techniques or electrocoagulation.
Some doctors are becoming skilled in these techniques, making them increasingly suitable alternatives to myomectomy, particularly for women with heavy periods.
Whichever method is employed, the procedure should be conducted in a well-equipped clinic or hospital under general anaesthesia. During the removal of fibroids it is important that the surgeon minimises blood loss and the inadvertent formation of adhesions, and that he or she skilfully reconstructs the uterus. Some blood loss is inevitable as the uterus is particularly well supplied with arteries and veins. It is usual for surgeons to clamp blood vessels or to inject chemicals that decrease the flow of blood to certain areas of the uterus. Particular types and locations of incisions also help minimise blood loss during myomectomy as does the use of laser surgery or diathermy in experienced hands. In some cases, doctors may remove the endometrium at the same time as performing a myomectomy.
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