Vaginal conservative myomectomy. Myomectomy: varieties and indications

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4. The desire of a woman

In some cases of fibroid treatment, a woman wants to save not only the organ, but also the menstrual function, even if there is no need for childbearing. If there is a technical possibility and there are no contraindications, then the doctor can meet this wish.

Complications after conservative myomectomy

The main disadvantage of partial tumor removal is the high risk of fibroid recurrence after treatment. Even if the operating doctor is confident in the complete removal of the node, there is no guarantee that after a certain period of time in the same place or nearby, the nodular formation will not grow again. In addition, the following complicating points are possible:

• inflammatory process in the pelvic area, the risk of which after myomectomy is more pronounced;
• the formation of adhesions between the uterus and appendages, which can cause adhesive disease and tubal-peritoneal variant of infertility;
• the occurrence of a scar, which to one degree or another can affect the course of a future pregnancy.

Of great importance in conservative treatment is the availability of modern endoscopic equipment in the hospital and sufficient experience of the doctor in performing myomectomy.

Preparing for a Myomectomy

In addition to the standard examination before the treatment of fibroids, which is typical for any gynecological operation (smears for the degree of purity, general clinical blood and urine tests, biochemical analysis of venous blood and coagulogram, determination of the blood group and pathogens of syphilis, hepatitis viruses and HIV), the following diagnostic studies will be required:

• Ultrasound of the pelvic organs with an accurate description of the location and size of myomatous nodes;
• hysteroscopy and aspiration from the uterine cavity to exclude precancerous changes or the presence of oncological pathology;
• colposcopy (examination of the cervix under a microscope) with a mandatory smear for oncocytology.

It is mandatory to perform an ECG followed by a consultation with a therapist, which is necessary for the selection of effective pain relief.

Operation types

There are many ways to remove fibroids. The following operation options are possible:

1. Myomectomy by abdominal surgery (abdominal myomectomy)

The most technically simple and frequently used method in the treatment of fibroids, when, after a suprapubic incision in the abdomen, the doctor can easily and quickly remove any myomatous formations emanating from the uterine wall.

Nodes located deep in the wall of the organ are removed by gradual husking. The best option for a woman is if the doctor managed to remove the node without opening the uterine cavity, because in this case the risk of complications is much lower.

2. Laparoscopic myomectomy

The use of optical instruments makes it possible to detect and remove a node growing from the wall of the uterus through three small openings in the abdomen.

The technique requires the availability of equipment, experience and qualifications of the doctor, so it is not used everywhere.

3. Myomectomy through the vagina (hysteroscopic myomectomy)

This version of the operation is used in the case when the myomatous node grows from the uterine cavity. With the help of a special optical instrument (hysteroresectoscope), the doctor will detect and remove the nodular formation. In this case, the risk of complications is minimal.

In some cases, to remove a node growing from the posterior or lateral wall of the uterus, the doctor will use the vaginal myomectomy technique, when laparoscopic access to the small pelvis is through the posterior wall of the vagina.

Contraindications

Node-only deletion with preservation of the organ cannot be performed in the following cases:

• the serious condition of a woman, due to a large blood loss and a pronounced degree of anemia, in which the abandonment of the organ can cause deadly uterine bleeding;
• recurrence of the occurrence of a myomatous node after a previous conservative operation;
• violation of blood flow in the nodular formation with the development of partial necrosis of fibroid tissue;
• the presence of an acute or chronic inflammatory process in the small pelvis, which can lead to serious complications in the postoperative period;
• suspicion of a malignant tumor in the pelvic organs.

In each case, the doctor individually can decide to preserve the uterus, even if there are contraindications for the treatment of fibroids. Or the doctor decides to refuse a conservative myomectomy and perform a hysterectomy if a situation arises that threatens the health and life of a woman.

What does the patient feel during the operation?

The basic rule for all types of operations with penetration into the abdominal cavity is the need for good anesthesia. As a rule, different methods of general anesthesia are used. Therefore, with the conventional and laparoscopic methods of treating fibroids, the patient will be under anesthesia and will not feel anything.

When removing a node in the uterine cavity using a doctor may use local or regional anesthesia. In this case, a woman may have discomfort in the lower abdomen, but there will be no pain during treatment.

Rice. Removal of a nodule

After any surgical intervention, a recovery period is required, but, as a rule, after myomectomy this time period is minimal. The need for subsequent treatment of fibroids depends on the initial condition (presence of anemia, condition after prolonged bleeding, inflammatory complications). If there are no problems, then after the usual operation, when a suprapubic incision is made in the abdomen, you need to stay in the hospital for about 5 days. After laparoscopic myomectomy, the doctor will let you go home after 3-4 days, and after hysteroscopic surgery - after 1 day.

Benefits of Myomectomy

Unlike a hysterectomy, any type of myomectomy has the following advantages:

• preservation of the organ and menstrual function;
• a woman has the opportunity to bear and give birth to a child.

Given the rather high risk of new nodes formation, the doctor in most cases advises to try to become pregnant in the near future after myomectomy in order to perform the childbearing function. This is especially important for women with infertility.

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Zhumanova Ekaterina Nikolaevna

Head of the Center for Gynecology, Reproductive and Aesthetic Medicine, Candidate of Medical Sciences, Doctor of the Highest Category, Associate Professor of the Department of Restorative Medicine and Biomedical Technologies, A.I. Evdokimova, Member of the Board of the ASEG Association of Specialists in Aesthetic Gynecology.

• Graduated from the Moscow Medical Academy named after I.M. Sechenov, has a diploma with honors, passed clinical residency at the Clinic of Obstetrics and Gynecology named after. V.F. Snegirev MMA them. THEM. Sechenov.
• Until 2009, she worked at the Clinic of Obstetrics and Gynecology as an assistant at the Department of Obstetrics and Gynecology No. 1 of the Moscow Medical Academy. THEM. Sechenov.
• From 2009 to 2017 she worked at the Medical and Rehabilitation Center of the Ministry of Health of the Russian Federation
• Since 2017, she has been working at the Center for Gynecology, Reproductive and Aesthetic Medicine, JSC Medsi Group of Companies
• She defended her dissertation for the degree of candidate of medical sciences on the topic: "Opportunistic bacterial infections and pregnancy"

Myshenkova Svetlana Alexandrovna

Obstetrician-gynecologist, candidate of medical sciences, doctor of the highest category

• In 2001 she graduated from the Moscow State University of Medicine and Dentistry (MGMSU)
• In 2003 she completed a course in obstetrics and gynecology at the Scientific Center for Obstetrics, Gynecology and Perinatology of the Russian Academy of Medical Sciences
• He has a certificate in endoscopic surgery, a certificate in ultrasound diagnostics of pathology of pregnancy, fetus, newborn, in ultrasound diagnostics in gynecology, a certificate in laser medicine. He successfully applies all the knowledge gained during theoretical classes in his daily practice.
• She has published more than 40 works on the treatment of uterine fibroids, including in the journals Medical Bulletin, Problems of Reproduction. He is a co-author of guidelines for students and doctors.

Kolgaeva Dagmara Isaevna

Head of Pelvic Floor Surgery. Member of the Scientific Committee of the Association for Aesthetic Gynecology.

• Graduated from the First Moscow State Medical University. THEM. Sechenov, has a diploma with honors
• Passed clinical residency in the specialty "obstetrics and gynecology" on the basis of the Department of Obstetrics and Gynecology No. 1 of the First Moscow State Medical University. THEM. Sechenov
• She has certificates: an obstetrician-gynecologist, a specialist in laser medicine, a specialist in intimate contouring
• The dissertation work is devoted to the surgical treatment of genital prolapse complicated by enterocele.
• The sphere of practical interests of Kolgaeva Dagmara Isaevna includes:
  conservative and surgical methods for the treatment of prolapse of the walls of the vagina, uterus, urinary incontinence, including the use of high-tech modern laser equipment

Maksimov Artem Igorevich

Obstetrician-gynecologist of the highest category

• Graduated from the Ryazan State Medical University named after Academician I.P. Pavlova with a degree in General Medicine
• Passed clinical residency in the specialty "obstetrics and gynecology" at the Department of Clinic of Obstetrics and Gynecology. V.F. Snegirev MMA them. THEM. Sechenov
• He owns a full range of surgical interventions for gynecological diseases, including laparoscopic, open and vaginal access
• The sphere of practical interests includes: laparoscopic minimally invasive surgical interventions, including single-puncture access; laparoscopic surgery for uterine myoma (myomectomy, hysterectomy), adenomyosis, widespread infiltrative endometriosis

Pritula Irina Alexandrovna

Obstetrician-gynecologist

• Graduated from the First Moscow State Medical University. THEM. Sechenov.
• Passed clinical residency in the specialty "obstetrics and gynecology" on the basis of the Department of Obstetrics and Gynecology No. 1 of the First Moscow State Medical University. THEM. Sechenov.
• She is a certified obstetrician-gynecologist.
• Possesses the skills of surgical treatment of gynecological diseases on an outpatient basis.
• He is a regular participant in scientific and practical conferences on obstetrics and gynecology.
• The scope of practical skills includes minimally invasive surgery (hysteroscopy, laser polypectomy, hysteroresectoscopy) - Diagnosis and treatment of intrauterine pathology, pathology of the cervix

Muravlev Alexey Ivanovich

Obstetrician-gynecologist, oncogynecologist

• In 2013 he graduated from the First Moscow State Medical University. THEM. Sechenov.
• From 2013 to 2015, he underwent clinical residency in the specialty "Obstetrics and Gynecology" on the basis of the Department of Obstetrics and Gynecology No. 1 of the First Moscow State Medical University. THEM. Sechenov.
• In 2016, he underwent professional retraining on the basis of GBUZ MO MONIKI them. M.F. Vladimirsky, majoring in Oncology.
• From 2015 to 2017, he worked at the Medical and Rehabilitation Center of the Ministry of Health of the Russian Federation.
• Since 2017, she has been working at the Center for Gynecology, Reproductive and Aesthetic Medicine, JSC Medsi Group of Companies

Mishukova Elena Igorevna

Obstetrician-gynecologist

• Dr. Mishukova Elena Igorevna graduated with honors from the Chita State Medical Academy with a degree in general medicine. Passed clinical internship and residency in obstetrics and gynecology at the Department of Obstetrics and Gynecology No. 1 of the First Moscow State Medical University. THEM. Sechenov.
• Mishukova Elena Igorevna owns a full range of surgical interventions for gynecological diseases, including laparoscopic, open and vaginal access. He is a specialist in providing emergency gynecological care for such diseases as ectopic pregnancy, ovarian apoplexy, necrosis of myomatous nodes, acute salpingo-oophoritis, etc.
• Mishukova Elena Igorevna is an annual participant of Russian and international congresses and scientific and practical conferences on obstetrics and gynecology.

Rumyantseva Yana Sergeevna

Obstetrician-gynecologist of the first qualification category.

• Graduated from the Moscow Medical Academy. THEM. Sechenov with a degree in General Medicine. Passed clinical residency in the specialty "obstetrics and gynecology" on the basis of the Department of Obstetrics and Gynecology No. 1 of the First Moscow State Medical University. THEM. Sechenov.
• The dissertation work is devoted to the topic of organ-preserving treatment of adenomyosis by FUS-ablation. He has a certificate of an obstetrician-gynecologist, a certificate in ultrasound diagnostics. He owns a full range of surgical interventions in gynecology: laparoscopic, open and vaginal approaches. He is a specialist in providing emergency gynecological care for such diseases as ectopic pregnancy, ovarian apoplexy, necrosis of myomatous nodes, acute salpingo-oophoritis, etc.
• Author of a number of publications, co-author of a methodological guide for physicians on organ-preserving treatment of adenomyosis by FUS-ablation. Participant of scientific and practical conferences on obstetrics and gynecology.

Gushchina Marina Yurievna

Gynecologist-endocrinologist, head of outpatient care. Obstetrician-gynecologist, reproductive specialist. Ultrasound doctor.

• Gushchina Marina Yuryevna graduated from the Saratov State Medical University. V. I. Razumovsky, has a diploma with honors. She was awarded a diploma from the Saratov Regional Duma for excellent academic and scientific achievements, and was recognized as the best graduate of the SSMU. V. I. Razumovsky.
• She completed a clinical internship in the specialty "obstetrics and gynecology" at the Department of Obstetrics and Gynecology No. 1 of the First Moscow State Medical University. THEM. Sechenov.
• He has a certificate of an obstetrician-gynecologist; doctor of ultrasound diagnostics, specialist in the field of laser medicine, colposcopy, endocrinological gynecology. She repeatedly took advanced training courses in "Reproductive Medicine and Surgery", "Ultrasound Diagnostics in Obstetrics and Gynecology".
• The dissertation work is devoted to new approaches to differential diagnosis and tactics of managing patients with chronic cervicitis and early stages of HPV-associated diseases.
• He owns a full range of minor surgical interventions in gynecology, performed both on an outpatient basis (radiocoagulation and laser coagulation of erosions, hysterosalpingography), and in a hospital setting (hysteroscopy, cervical biopsy, conization of the cervix, etc.)
• Gushchina Marina Yurievna has more than 20 scientific publications, is a regular participant in scientific and practical conferences, congresses and congresses on obstetrics and gynecology.

Malysheva Yana Romanovna

Obstetrician-gynecologist, pediatric and adolescent gynecologist

• Graduated from the Russian National Research Medical University. N.I. Pirogov, has a diploma with honors. Passed clinical residency in obstetrics and gynecology at the Department of Obstetrics and Gynecology No. 1 of the Medical Faculty of the First Moscow State Medical University. THEM. Sechenov.
Graduated from the Moscow Medical Academy. THEM. Sechenov with a degree in General Medicine
• Passed clinical internship in the specialty "Ultrasound diagnostics" on the basis of the Research Institute for Emergency Medicine named after A.I. N.V. Sklifosovsky
• Has a Certificate of the FMF Fetal Medicine Foundation confirming compliance with international requirements for screening of the 1st trimester, 2018. (FMF)

Owns methods of performing ultrasound examination:

• Abdominal organs
• Kidney, retroperitoneal space
• Bladder
• Thyroid gland
• mammary glands
• Soft tissues and lymph nodes
• Pelvic organs in women
• Pelvic organs in men
• Vessels of upper and lower extremities
• Vessels of the brachiocephalic trunk
• In the 1st, 2nd, 3rd trimester of pregnancy with dopplerometry, including 3D and 4D ultrasound

Kruglova Victoria Petrovna

Obstetrician-gynecologist, pediatric and adolescent gynecologist.

• Kruglova Victoria Petrovna graduated from the Federal State Autonomous Educational Institution of Higher Education "Peoples' Friendship University of Russia" (PFUR).
• Passed clinical residency in the specialty "Obstetrics and Gynecology" on the basis of the Department of the Federal State Budgetary Educational Institution of Additional Professional Education "Institute for Advanced Studies of the Federal Medical and Biological Agency".
• He has certificates: an obstetrician-gynecologist, a specialist in the field of colposcopy, non-operative and operative gynecology of children and adolescents.

Baranovskaya Yulia Petrovna

Doctor of ultrasound diagnostics, obstetrician-gynecologist, candidate of medical sciences

• Graduated from the Ivanovo State Medical Academy with a degree in general medicine.
• Passed an internship at the Ivanovo State Medical Academy, clinical residency at the Ivanovo Research Institute. V.N. Gorodkov.
• In 2013 she defended her Ph.D. thesis on the topic “Clinical and immunological factors in the formation of placental insufficiency”, and was awarded the degree of “Candidate of Medical Sciences”.
• Author of 8 articles
• He has certificates: doctor of ultrasound diagnostics, doctor of obstetrician-gynecologist.

Nosaeva Inna Vladimirovna

Obstetrician-gynecologist

• Graduated from Saratov State Medical University named after V.I. Razumovsky
• She completed an internship at the Tambov Regional Clinical Hospital with a degree in obstetrics and gynecology
• He has a certificate of an obstetrician-gynecologist; doctor of ultrasound diagnostics; a specialist in the field of colposcopy and treatment of cervical pathology, endocrinological gynecology.
• Repeatedly took advanced training courses in the specialty "Obstetrics and Gynecology", "Ultrasound Diagnostics in Obstetrics and Gynecology", "Fundamentals of Endoscopy in Gynecology"
• He owns the full range of surgical interventions on the pelvic organs, performed by laparotomy, laparoscopic and vaginal accesses.

Uterine fibroids are often mistakenly perceived by women as a diagnosis that deprives them of the opportunity to ever have a child. A benign tumor that occurs in the muscular layer of the uterus can be single or multiple, can be of menacing size or be quite small. It is these tumors that can be treated with drugs.

However, when a fibroid impairs a woman's quality of life, or she is planning a pregnancy, a myomectomy, or surgical removal of the mass, is required.

What is a myomectomy and why is it performed?

There are several methods of surgical treatment of fibroids. In complex and advanced cases, when the tumor is large, several myomatous nodes are diagnosed, the uterus is completely removed while preserving its cervix.

But in most cases in women of reproductive age, the doctor tries to save the uterus, using conservative methods to remove the nodes.

Indications for removal of fibroids:

• Tumor size equal to 12 weeks' gestation;
• Frequent uterine bleeding, development of anemia due to blood loss;
• Frequent pain;
• Myoma on a leg, prone to twisting;
• Localization of the myomatous node between the sheets of the broad ligament, on the cervix;
• Infertility in the absence of other causes;
• The impact of a large node on nearby organs (constipation, urination disorders);
• Necrosis or infection of the tumor;
• Rapid growth of the myomatous node.

Before performing the operation, laboratory and instrumental diagnostic procedures are carried out - ultrasound of the pelvic organs, chest x-ray, ECG, blood tests for biochemistry and hormones. After the examination, the doctor chooses the tactics of surgical intervention.

What is the difference between conservative and laparoscopic myomectomy?

The husking of myomatous nodes is carried out by the following methods of surgical technique:

• Conservative myomectomy by laparotomy and hysteroscopy;
• Laparoscopic myomectomy.

This method is practiced with excessive deformation of the uterus and a large number of nodes. The rehabilitation period for laparotomy is quite long, a scar remains on the abdomen.

The technique has a positive moment - the doctor controls its progress throughout the operation. For a long time after laparotomy, you need to avoid stress, keep the suture clean.

Removal of fibroids by hysteroscopic method.

It is carried out under the control of a hysteroscope - an optical device inserted into the uterus through the vagina. The main indication for the choice of such an operative technique is a fibroid no more than 5 cm.

For some reasons, conservative myomectomy is inferior to laparoscopic surgery. For its implementation, several punctures are performed on the abdomen, through which a miniature video camera and manipulators are inserted into the abdominal cavity to remove nodes.

Indications for such an intervention - the myomatous node should not be more than 9 weeks in size, be in an easily accessible place. Among the shortcomings, one can note the complexity of manipulation when bleeding occurs. The rehabilitation period is very short, after 3 days a woman can leave the surgical hospital.

How is the operation carried out?

Laparoscopy is performed under general anesthesia. Carbon dioxide is supplied into the punctures in the abdominal wall to visualize the surgical field, a camera and manipulators are introduced. After that, the uterus is dissected and the myomatous node is husked. If it is small, the knot can be reached through an incision.

Large-sized fibroids are dissected into parts that are removed one by one. To remove large nodes, removal through the posterior fornix of the vagina is possible. At the end of the operation, sutures are placed on the walls of the uterus and on all layers of the peritoneum. The duration of laparoscopy is 1-3 hours.

Possible complications:

• recurrence of fibroids;
• Inflammatory process in the pelvis;
• The appearance of adhesions;
• Traumatization of the myometrium and endometrium;
• Damage to blood vessels during surgery.

Unlike laparoscopy, conservative myomectomy by abdominal surgery is much less common, although this surgical technique allows you to control possible bleeding and improve the quality of the sutures. Laparotomy allows you to remove large nodes located in an inconvenient place.

How is the post-op recovery going?

After laparoscopic removal of fibroids, bed rest should be observed on the first day, although it is allowed to turn and sit down. The next day, a woman can get up, walk, she is allowed to eat. After 2-5 days, in the absence of complications, she is discharged from the hospital.

After conservative surgery, you need to eat right to avoid constipation. Straining during bowel movements can lead to increased intra-abdominal pressure.

For a long time, a woman is limited to physical activity in order to avoid rupture of the seams. You can not carry or lift a load heavier than 4-7 kg. To prevent stagnation, walking at a moderate pace is allowed.

In the first 14-18 days it is not allowed to take a bath, only a shower. Traces of intervention are treated with iodine or manganese solution. After 2-3 weeks, the woman returns to her previous working capacity.

After the operation, to prevent infection, a course of antibiotics, drugs to treat anemia is prescribed. In order to prevent relapses, hormone treatment is used, since fibroids always occur against the background of hormonal imbalance.

Can I get pregnant after myomectomy?

It is better to postpone pregnancy planning for a year or two after the operation. It is not worth delaying conception longer, because with a predisposition to the appearance of fibroids, relapses are not ruled out, and then pregnancy will be impossible.

When carrying a fetus, a bandage should be worn to reduce the load on the suture on the wall of the uterus. The method of resolving pregnancy depends on which surgical technique was used to remove the fibroids. With a large scar, it is planned to do a caesarean section, with a small defect in the uterine wall, natural delivery is allowed.

When can I have sex after myomectomy?

Allowed after 1.5-2 months. In this period, there will be confidence that the scar on the uterus has healed, and the infection will not be introduced into the woman's body.

What happens to my periods after myomectomy?

Menstruation begins no later than 35-45 days after surgery, the normal cycle of menstruation is immediately established. The discharge has a normal volume and consistency, although a slight increase in the density of menstrual blood is not considered a deviation from the norm.

If your period started too early after surgery, it's most likely uterine bleeding. Negative signs are the absence of menstruation, scant or liquid discharge, cycle instability.

Removal of myomatous nodes, carried out in the best way, taking into account all contraindications, will help a woman conceive and bear a child without complications.

Myomectomy is the most comfortable method of removing a tumor while preserving the reproductive function of a woman. A sparing operation allows you to radically get rid of fibroids, so young women willingly agree to it, planning children in the future. The use of modern endoscopic technologies completely takes myomectomy to a different level, making the procedure practically bloodless and relatively safe. Minimally invasive operations allow a woman to quickly recover and return to her usual life without significant restrictions.

In modern gynecology, conservative myomectomy is a good alternative to radical removal of the uterus, but does not replace other methods of treatment. With the introduction of UAE (uterine artery embolization) into practice, tumor enucleation fades into the background, giving way to more comfortable and safer methods. At the same time, myomectomy does not lose its positions in the treatment of single intermuscular formations, submucosal and subserous nodes on the pedicle, and also in the situation when other methods of treatment are not available to the patient.

Pros and cons of conservative myomectomy

Benefits of conservative myomectomy:

• The possibility of simultaneous removal of the tumor;
• Preservation of the uterus and reproductive function;
• The possibility of carrying out the operation is not only open, but also;
• Availability: the majority of practicing gynecologists own the technique of myomectomy.

The disadvantages of the methods include:

• Probability of recurrence: according to statistics, within 5 years, 70% of patients again have fibroids;
• A certain risk of complications, as with any operation;
• When performed, a scar remains on the uterus - an indication for a planned caesarean section;
• Technical complexity of implementation in multiple interstitial fibroids.

The final choice of treatment tactics is determined after a complete examination of the patient and an assessment of all risk factors.

Laparoscopic conservative myomectomy.

Indications for the operation

Tumor enucleation is possible in such situations:

• Submucosal (submucosal node) on the leg, completely protruding into the uterine cavity (type 0 according to FIGO classification) up to 10 cm in size;
• Submucosal tumor partially protruding into the uterine cavity (FIGO type 1 and 2);
• (including on the leg);
• Interstitial fibroids with few nodes;
• The size of the uterus up to 12-14 weeks;
• Infertility or miscarriage against the background of a diagnosed fibroid (in the presence of at least one node with a size of 3 cm or more).

Prior to the introduction of UAE, patients with multiple interstitial fibroids were often offered a radical solution - removal of the uterus. Today embolization allows you to get rid of myomatous nodes with the preservation of the reproductive function of a woman. In particular, EMA is the method of choice.

If embolization is not available for one reason or another (the clinic does not have equipment or a doctor who knows the technique), the doctor can perform a conservative myomectomy for intermuscular fibroids, but the outcome of such an operation will not always be favorable. Often, the surgeon has to excise a fairly large area of ​​healthy tissue, and in the future, the injured uterus will not be able to perform its main function - bearing the fetus.

On a note

If UAE is not possible, and conservative myomectomy is associated with high risks, the doctor can offer only one option for a patient with children - removal of the uterus. A technically simpler operation and, moreover, it is guaranteed to solve the problem.

UAE for multiple uterine myoma.

Contraindications for organ-preserving surgery

Conservative myomectomy is inappropriate to perform in such situations:

• The size of the uterus is more than 14-16 weeks in the presence of multiple nodes;
• The unwillingness of a woman to have children in the future;
• Premenopause and menopause;
• Confirmed or suspected uterine sarcoma;
• when it is technically difficult to perform a myomectomy without serious consequences for the patient;
• Recurrence of fibroids after the operation;
• when other methods have proven ineffective;
• The node size is more than 10 cm even after preoperative preparation with hormonal preparations;
• The development of complications that threaten the life of a woman.

Myomectomy according to Morrow is a rather traumatic operation, and often when the node is husked, severe bleeding opens. In this situation, the only way to save the patient may be to remove the uterus.

The operation is not performed in acute infectious diseases, as well as exacerbation of chronic pathology. In this case, the procedure is performed after complete recovery or remission.

Preparation: what to do before surgery

List of mandatory tests required for myomectomy:

• Blood tests: general and biochemical, coagulogram, determination of blood group and Rh factor;
• Blood for syphilis, viral hepatitis, HIV;
• General urine analysis;
• smear for flora and oncocytology;
• ECG and consultation of a therapist;
• Gynecological examination;
• Ultrasound of the pelvic organs with dopplerometry (assessment of tumor blood flow).

Evaluation of the blood flow of fibroids on ultrasound.

If comorbidity is identified, additional examinations are carried out.

3-6 months before the operation, the doctor may prescribe the goal of treatment is to reduce the diameter of the formation and reduce the likelihood of blood loss when the node is removed. This tactic is indicated for multiple fibroids and tumor sizes greater than 5 cm. As an alternative to hormones, UAE can be used.

Technique for conservative myomectomy

There are several options for performing the operation:

• Laparotomy myomectomy - classical access through an incision on the anterior abdominal wall and uterus;
• Laparoscopic surgery - through small punctures without opening the uterine cavity;

The choice of method will depend on the location, number and size of nodes, as well as on the technical capabilities of the clinic. According to the CHI policy, myomyectomy is carried out free of charge in a public clinic. The cost of the operation in private clinics in Moscow ranges from 100 to 150 thousand rubles, depending on the access, volume and complexity of the procedure.

On a note

Removal of fibroids is carried out in the first week of the menstrual cycle - usually on the 5-10th day.

Laparotomy with myomectomy

It is used in such situations:

• As an alternative in clinics where it is not technically possible to perform laparoscopy or hysteroresectoscopy;
• The size of the uterus is more than 12 weeks;
• The total number of myomatous nodes is more than 4 (especially with interstitial location);
• Low location of the tumor: the cervix or isthmus.

Operation progress:

1. Chevosection - an incision in the skin, subcutaneous tissue and muscles, opening the abdominal cavity;
2. Incision of the uterine wall and opening of the tumor capsule;
3. Enucleation of the tumor from the capsule;
4. Stop bleeding and suturing / cauterization of the tumor bed;
5. Layered suturing of the uterus and overlying tissues.

Removal of the myomatous node by open access.

On a note

Reviews of women about this method of treatment are quite contradictory, due to the large number of complications. Laparotomy is a fairly traumatic operation that requires prolonged anesthesia. After recovery from anesthesia, many patients report nausea, headaches, and other unpleasant symptoms. Recovery after laparotomy is quite long - up to 4-6 weeks. In addition, postoperative suture care is required. Whenever possible, doctors try to do without an incision, but in some cases it is simply impossible to perform a myomectomy using endoscopic access.

Laparoscopic myomectomy

The fundamental difference from the classical operation is that here the surgeon does not open the abdominal cavity and does not make an incision on the uterus. An endoscopic instrument is inserted into the pelvic cavity through neat holes (near the navel and on the sides of the pelvis), and with its help the doctor performs all the necessary manipulations: excision of the formation, cauterization of the bed, removal of the tumor through a puncture. The doctor controls his actions with the help of a video camera that displays all the information on the screen at the operating table.

Laparoscopic myomectomy has certain advantages over conventional surgery:

• Fast recovery after the procedure;
• Relatively low risk of complications;
• There is no incision on the uterus, which means that a woman is more likely to be able to give birth to a child through the natural birth canal.

Stages of laparoscopic myomectomy: 1. Capture of fibroids with instruments. 2. Dissection of the capsule of the node and its husking. 3. Treatment of the fibroid bed. 4.Remote node.

On a note

According to the numerous reviews of women who underwent laparoscopic surgery, it is clear that the removal of the tumor is rarely accompanied by complications. The postoperative period takes about 2 weeks. In the absence of complaints and complications, the patient can be discharged home already on the second or third day after endoscopic surgery. There is no scar left on the skin - only almost imperceptible traces of punctures for the instrument.

Indications for laparoscopic myomectomy:

• Subserous and up to 8-10 cm in size;
• The total number of tumors is up to 4.

Laparoscopy is usually not performed with a pronounced adhesive process in the pelvis, obesity of II degree and above, as well as with multiple interstitial fibroids. An experienced gynecologist can take up the operation under such conditions, however, the outcome of the manipulations is not always favorable. With the introduction of electromechanical morcellators into practice, it became possible to perform laparoscopic myomectomy even with large formations (up to 15 cm), however, not every clinic has such equipment, and not every surgeon is fully familiar with this technique.

Hysteroresectoscopic myomectomy

Indications for operation:

• Submucosal nodes on the leg up to 10 cm in diameter;
• Submucosal formations, partially located in the myometrium (subject to preliminary preparation - a decrease in the size of the tumor by the UAE method or with the help of hormonal therapy).

Hysteroresectoscopy is the method of choice when removing submucosal nodes, especially for women planning a pregnancy. During the operation, no incision is made in the uterus, no scars remain, and in the future there are no obstacles to bearing a child and natural childbirth.

There are two options for hysteroresectoscopy:

• Mechanically - excision of fibroids with a scalpel, unscrewing the legs of the tumor with forceps. It is used for knot sizes of 5-10 cm;
• Electrosurgical myomectomy with a wire loop. Indicated for tumor diameter up to 5 cm.

Myomectomy by hysteroresectoscopy is performed on an outpatient basis under anesthesia or local anesthesia. The doctor expands the cervix and inserts a hysteroscope through it, after which he performs all the necessary manipulations to remove the tumor.

Removal of the myomatous node hysteroscopically.

On a note

According to reviews, hysteroresectoscopy is well tolerated by women. The operation takes only 15-20 minutes, does not always require general anesthesia, and is rarely accompanied by complications. 2 hours after the removal of the fibroids, the patient can be allowed to go home.

Possible undesirable consequences of surgical treatment

After myomectomy, the following complications may develop:

Bleeding

One of the most dangerous complications that occur in the early postoperative period. For this reason, not all gynecologists undertake myomectomy with multiple interstitial nodes, fearing profuse blood loss. To reduce the risk of such complications, one of the following schemes is used:

• Preoperative course of hormones;
• Temporary occlusion of the iliac arteries during surgery.

Menstrual irregularity

It happens that after the operation, the periods do not come on time or go too long - more than 7 days. It is also possible the appearance of intermenstrual bleeding ("daub"). The operation is a powerful stress for the body, and it is not surprising that hormonal failure may occur against this background. The cycle should recover within three months. If the problem persists, you should see a doctor.

infection

After removing the fibroids, there should be no pain. Some discomfort persists up to 7 days after the operation, but in the future this discomfort disappears. If after myomectomy the stomach hurts and the body temperature rises, the development of an infection in the uterine cavity is not excluded. The appearance of purulent discharge from the genital tract also speaks in favor of the inflammatory process. A gynecological examination and ultrasound will help determine the diagnosis.

Divergence of seams

A rare complication that occurs when the suture area is not properly cared for or when the technique of its application is violated. The stitches can also become infected, which is accompanied by pain and the appearance of purulent discharge. In this situation, the appointment of antibiotics, washing the wound with antiseptics is indicated. A second operation may be required.

It is very important to properly care for the postoperative wound in order to prevent the development of complications.

adhesive process

This complication often occurs after abdominal surgery. The appearance of adhesions is accompanied by pulling pain in the lower abdomen and in its lateral sections. Synechia of the fallopian tubes can lead to the development of an ectopic pregnancy or cause infertility. With complete obstruction of the fallopian tubes, IVF is indicated.

Growth of new nodes

Statistics indicate that myomectomy is not a panacea. After 5-10 years, most patients have a relapse of the disease. It may be a tumor that has arisen from the remnants of the node after myomectomy, but the formation occurs in a different place in the uterus. That is why gynecologists do not advise delaying the birth of a child and recommend planning a pregnancy 6-12 months after the operation.

It is important to know

The menstrual cycle after the operation is restored quite quickly, and theoretically, the conception of a child can occur as early as the first month after the removal of the fibroids. For this reason, gynecologists strongly advise to protect yourself in the first months after surgery. Early pregnancy with an inconsistent scar threatens with serious complications up to uterine rupture with massive bleeding.

You can assess the condition of the scar on the uterus after conservative myomectomy using ultrasound. The follow-up examination is carried out 1, 6 and 12 months after the operation. Until the moment the doctor declares a fully formed scar, it is not worth getting pregnant.

Ultrasound after surgery allows you to assess the condition of the scar and the presence of recurrence of fibroids.

Childbirth after myomectomy can go through the birth canal only in two situations:

• No scar on the uterus (after hysteroscopic surgery);
• In the presence of a wealthy scar (according to the results of ultrasound).

In other situations, a caesarean section is shown in a planned manner. It is worth noting that doctors often play it safe and recommend surgical delivery to all women who have undergone myomectomy with opening of the uterine cavity. This tactic is justified, because even with a full-fledged scar, there is a risk of complications:

• Low attachment of the placenta or its presentation with possible bleeding;
• Rupture of the uterus along the scar during pregnancy or childbirth.

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Operations for benign tumors of the uterus occupy a significant place in the practice of a gynecologist. Many interventions on the uterus can be performed laparoscopically with undeniable advantages over open surgery.

uterine fibroids- one of the most common benign diseases of the uterus, recorded in 20-25% of women of reproductive age.

The terminology for benign uterine tumors varies. The tumor may be dominated by smooth muscle fibers (myoma), connective tissue (fibroma), possibly the content of both components (fibroma). Before histological examination, the term “myoma” is more often used, which we will use in the future.

Uterine fibroids can be accompanied by heavy menstruation (menorrhagia), acyclic blood discharge (metrorrhagia), severe pain associated with a violation of the blood supply to the node, and with a significant increase in the diameter of the tumor - a violation of the function of neighboring organs.
Myomatous nodes that deform the uterine cavity may be due to infertility or miscarriage. However, an asymptomatic course or poor symptoms are possible even with large fibroids.

The growth of uterine fibroids appears to be related to the effect of estrogens on tissues. Uterine fibroids have been shown to decrease with the use of antiestrogen drugs or gonadotropin-releasing hormone (GnRH) agonists, so they are often prescribed before surgery.

The issue of indications for surgery, its volume (amputation, hysterectomy or myomectomy) and surgical access is decided individually. It depends on the age of the woman, her desire to maintain fertility and menstrual function, the size and location of myoma nodes, clinical manifestations and complications (menometrorrhagia, infertility, etc.). The use of GnRH analogues to reduce the size of nodes and the possibility of their removal by endoscopic methods (laparoscopically and hysteroscopically) have significantly changed approaches to solving this issue in recent years.

Classification

In relation to the muscular layer of the uterus, the following types of fibroids are distinguished:
1. Myoma on the leg.
2. Subserous-interstitial myoma.
3. Interstitial fibroids.
4. Submucous myoma.
5. Intraligamentally located fibroids.

Along with the above, there are mixed options for the localization of myomatous nodes.

Conservative myomectomy

Choice of surgical approach. Currently, conservative myomectomy can be performed by two operational approaches: laparoscopic and laparotomy. The results of myomectomy depend on the correct selection of patients and preoperative treatment with GnRH agonists.

A surgeon who prefers laparoscopic access should clearly understand the problems that may arise during the operation:
1. Bleeding.
2. Injury to neighboring organs.
3. Difficulties in extracting macropreparations of significant size.
4. The need for layer-by-layer restoration of uterine defects after husking of myomatous nodes, etc.

Laparoscopic myomectomy for multiple myomas, significant size of nodes, their interstitial or intraligamentary localization is classified as a highly complex operation, often accompanied by complications.

Indications

Absolute contraindications

In the literature, the issue of the size of the myomatous node is discussed, which allows conservative myomectomy by laparoscopic access. According to many domestic and foreign authors, the size of the myomatous node should not exceed 8-10 cm, since with a larger size of the myomatous nodes after husking, it becomes difficult to remove them from the abdominal cavity. With the introduction of electromechanical morcellators into practice, it became possible to remove myoma nodes up to 15–17 cm in size.

4. Multiple interstitial nodes, the removal of which will not allow to preserve the childbearing function.
According to some surgeons, laparoscopic myomectomy can be performed in patients with no more than 4 nodes. In cases of more nodes, laparotomy is necessary.
5. With multiple uterine myoma, it is necessary to generally evaluate the possibility of conservative surgery due to the high recurrence rate (50% or more), while single fibroid nodes recur only in 10-20% of cases.
6. It should also be taken into account that the relativity of contraindications often depends on the qualifications of the surgeon.

Relative contraindications, according to some surgeons, include obesity of the II-III degree and a pronounced adhesive process after previous abdominal surgeries.

Preoperative hormonal preparation with GnRH agonists

Based on our own experience with the use of preoperative hormonal preparation, we noted a decrease in the size of myomatous nodes after the second injection of the drug by 35-40% compared with the initial ones (according to the results of ultrasound). These data allow us to recommend the use of 2 injections of GnRH agonists for hormonal preparation before conservative myomectomy.

Clinical Effects of GnRH Analogs

However, the disadvantages of GnRH agonists are also well known: hot flashes, sweating, irritability, changes in the localization of the nodes and the high cost of treatment.

Carrying out hormonal preoperative preparation is indicated when the size of the fibroid node is more than 4-5 cm. With subserous localization of the myomatous node on the leg, preoperative preparation is not carried out.
The technique of laparoscopic myomectomy largely depends on the size, location, presence of single or multiple nodes.

Conservative myomectomy is performed in four stages:
1. Clipping and husking of myomatous nodes.
2. Restoration of defects in the myometrium.
3. Extraction of myoma nodes.
4. Hemostasis and sanitation of the abdominal cavity.

Clipping and husking of the myomatous node

Myomectomy:
1 - subserous myoma node; 2 — capture of a node by a gear clip and cutting off by a Redik's hook; 3 - coagulation of the node bed with a spherical electrode; 4 - removal of the drug
With subserous-interstitial localization of the myomatous node, a circular incision is made. The distance from the edge of the incision to the unchanged myometrium is determined individually, it depends on the size of the node and the uterine defect that occurs after the myomatous node is husked.

Exfoliation of the subserous-interstitial myomatous node. For fixation, use a toothed clamp or a corkscrew.

With an intraligamentary location of the myomatous node, the incision of the serous cover of the uterus is carried out in the place of its greatest protrusion. With such localization of fibroids, special attention should be paid to identifying the ureters and atypically located vascular bundles of the uterus before making an incision. The direction of incisions in intraligamentary fibroids is usually transverse or oblique.

Both when removing deep intramural nodes, and when removing intraligamentary myomas, the principle of "onion skin" is used. The essence of the method lies in the fact that the pseudocapsule of fibroids is represented by myometrium rather than fibrous tissue. For husking, successive 1-2 mm incisions are made on the node near the site of splitting of the serous-muscular layers and the pseudocapsule, imagining the layers of the pseudocapsule in the form of onion layers.

This technique eliminates the possibility of opening the uterine cavity with intramural nodes. With the intraligamentary location of the node, this technique avoids damage to the vessels of the uterus and other adjacent structures. The technique is extremely useful for cervical myoma, when there is a lateral displacement of the uterine vessels and ureter.

Uterine incisions can be made with a monopolar coagulator or scissors after prior bipolar coagulation. The incision is made to the surface of the capsule of the myomatous node, easily recognizable by its white-pearl color. The knots are exfoliated by successive tractions in different directions with the help of two clamps with simultaneous coagulation of all bleeding areas.

With conservative myomectomy by laparoscopic access, it is necessary to use rigid toothed clamps that allow you to securely fix the node during its exfoliation. The bed of the myomatous node is washed with saline and hemostasis is performed on all significantly bleeding areas of the myometrium. For these purposes, bipolar coagulation is preferred.

Repair of myometrial defects

Stages of suturing uterine defect after removal of fibroids

Extraction of macropreparation from the abdominal cavity

in. Extraction through an incision in the posterior fornix of the vagina. In the absence of a morcellator, posterior colpotomy can be used to extract myomatous nodes from the abdominal cavity. Posterior colpotomy can be performed using special vaginal extractors. In this case, the ball of the vaginal extractor is placed in the posterior fornix of the vagina, protruding it into the abdominal cavity.

Laparoscopic access using a monopolar electrode produces a transverse incision of the posterior fornix between the sacro-uterine ligaments. Then, a toothed 10-mm clamp is inserted into the abdominal cavity through the trocar, the myomatous node is captured by it, and it is removed from the abdominal cavity.
The vaginal extractor, due to the spherical expansion at the end, allows you to save the PP in the abdominal cavity after opening the posterior fornix of the vagina. If the node is larger than 6-7 cm, before removing it, it is first cut into two halves.

Removal of myomatous nodes from the abdominal cavity using posterior colpotomy does not lead to an increase in the duration of the operation, provides less trauma, prevention of postoperative hernias and a better cosmetic effect.

Hemostasis and sanitation of the abdominal cavity

Postoperative period

Contraception after surgery

Complications

Common complications of laparoscopy include damage to the main vessels and abdominal organs during the introduction of trocars, complications of anesthesia, respiratory disorders, TE, etc.

Also, with laparoscopic myomectomy, intra- and postoperative bleeding from the uterus or the bed of the myomatous node, hematomas in the uterine wall with inadequate layer-by-layer suturing of defects, and infectious complications are possible. Injuries to the ureters, bladder, and intestines are more likely to occur with a low or interstitial location of myomatous nodes. Perhaps the occurrence of hernias of the anterior abdominal wall after the extraction of macropreparations through it.

G.M. Savelyeva

Conservative myomectomy is a gentle surgical operation to remove the uterine fibroid node. After this operation, the patient retains her uterus, menstrual and childbearing functions.

Uterine fibroids (leiomyoma, fibromyoma) is a benign tumor of the muscular layer of the uterus.

Conservative myomectomy is an organ-preserving palliative method of surgical treatment of fibroids. In other words: during this operation, only a node or several nodes of the tumor are removed, and the uterus is preserved.

Conservative myomectomy is performed using modern mechanical, electrosurgical and laser techniques.

The advantage of conservative myomectomy over other types of surgical treatment of uterine fibroids: the preservation of the patient's ability to pregnancy and childbearing.

Disadvantages of conservative myomectomy:

• There is no certainty in the removal of all nodes and growth zones of fibroids in the uterus;
• High percentage of tumor recurrence;
• A single fibroid node recurs in 12-20% of cases;
• Multiple nodes - up to 50% of cases.

Most fibroids can be removed conservatively. But, given the above disadvantages of the method, such operations are carried out strictly according to indications.

Indications for conservative myomectomy:

• The presence of separate, no more than 3-4 myoma nodes.
• The size of the uterus is no more than 12 weeks of pregnancy.
• The age of the patient is up to 37-40 years.
• The expediency of preserving the reproductive function of the patient.

How exactly to do a myomectomy depends on the type of fibroid node.

Types of uterine fibroids

The final choice of conservative myomectomy method is individual.
It depends on the size and consistency of the myomatous node, on the general health of the patient, the qualifications of the surgeon, and the technical equipment of the clinic.

Laparotomic conservative myomectomy

is an operation to remove fibroid nodes with a traditional abdominal-wall access - abdominal dissection.

Unconditional indications to laparotomy myomectomy:
- intramural nodes of fibroids;
- nodes in the cervical-isthmus region of the uterus.

Laparoscopic conservative myomectomy

is an endoscopic operation to remove fibroids using special equipment.

The laparoscopic complex is inserted into the abdominal cavity by several "punctures" of the anterior abdominal wall - see the detailed Video:

Indications for laparoscopic myomectomy:

• Subserous nodules of pedunculated fibroids.
• Small subserous nodes of types 0 and 1.

Benefits of laparoscopy:
/compared to abdominal dissection/

• Less trauma.
• Easier course and reduction of the postoperative period.
• Reducing the risk of postoperative complications.

Disadvantages of laparoscopy:

• Not always the edges of the wound are connected adequately.
• There is a high risk of defect formation in the uterine wall due to a large area of ​​coagulation necrosis (laser or electric tissue burns) after removal (husking, enucleation) of a large myomatous node.

Overestimation of the technical possibilities of laparoscopic myomectomy creates the risk of formation of an inconsistent postoperative scar on the body of the uterus. Later, during pregnancy or childbirth, such a scar may rupture.

Contraindications for laparoscopic myomectomy

• Numerous intramural nodules of fibroids, low location of nodules, nodules in the cervix.
• The size of the fibroid node after hormonal preparation is ≥8-10 cm.
• Reoperation (scars on the anterior abdominal wall), hernia.
• The need for revision of the abdominal cavity (suspicion of a malignant process).
• Obesity or malnutrition.
• Adhesive disease, peritonitis.
• Severe somatic pathology, bleeding disorder.

Transcervical conservative myomectomy or hysteroresectoscopy

is an endoscopic operation to remove a fibroid node using a hysteroscope - a special device that is inserted into the uterine cavity through the vagina and cervical (cervical) canal of the uterus. During hysteroscopy, no incisions are made on the patient's body.

What is hysteroscopy, how is it done, what tests should be taken - watch the video:

Hysteroresectoscopy is a surgical hysteroscopy. Hysteroresectoscopic myomectomy is a hysteroscopy during which the fibroids are removed.

Indications for hysteroresectoscopic myomectomy:

• Submucosal nodes of fibroids types 0 and 1, size

Contraindications for hysteroresectoscopy:

• Inflammation or infection of the genitals.
• Uterine bleeding.
• Stenosis of the cervix.
• Cervical cancer.

Hormonal preparation for conservative myomectomy

If large (>4-5 cm) fibroids are located on a wide base, then the patient is prescribed hormonal treatment before surgery.

The purpose of preoperative hormonal therapy:

• reduction in the volume of the fibroid node;
• compaction of the tissues of the node;
• in the future: reduction of the wound on the uterus, which is formed during the husking of the fibroid node.

Gonadotropin-releasing hormone analogues (GnRH agonists) are considered the most effective means of preoperative hormonal preparation. The scheme and duration of taking aGnRH is individual. She is prescribed by a doctor.