Conventional Surgery

Open Myomectomy
This is the accepted method employed by most gynaecologists for treating fibroids where a woman wishes to retain her fertility.  It should be possible for all consultant gynaecologists to offer this procedure, but some perform it more regularly than others, and as one might expect these surgeons tend to have better results than those who perform myomectomy infrequently.  It is also true to say that some surgeons, especially those who are involved in fertility treatment recognise more particularly the importance of avoiding excessive tissue handling and employing microsurgical techniques to reduce adhesion formation after surgery.   
A conventional myomectomy is performed through a low, horizontal or transverse skin incision along the bikini line (some fibroids are too large for this approach and may need a longitudinal or vertical incision).  The muscle of the uterus is incised and the fibroid shelled out.  The muscle must then be repaired taking care to handle the tissue as little as possible to avoid the risk of adhesion formation.  Apart from adhesions there is a risk of haemorrhage and infection in the short term, and rupture of the uterus in the longer term during pregnancy and labour.
Many obstetricians will recommend a caesarean section after myomectomy because of the risk of uterine rupture.  Some fibroids can be very vascular, and particularly in larger cases, and where the fibroid is close to the main artery supplying the uterus, women should be aware that there is a risk of such heavy bleeding that their surgeon may be required to perform a hysterectomy. This is only done as a last resort, as a life saving procedure in cases of catastrophic haemorrhage.
In such cases the fibroids are usually so large and the uterus so distorted that pregnancy would have been impossible anyway, however myomectomy is not a procedure to be undertaken lightly and should only be performed by experienced surgeons. The photograph below shows a large fibroid uterus at open myomectomy.

Some women, whose family is complete, or who are happy to remain childless, may elect to have a hysterectomy rather than try to save their uterus.  A hysterectomy is often recommended for particularly large fibroids where the uterus is causing severe compression symptoms or causing notable distension of the lower abdomen.  For some women, the time taken to recover from their surgery is much more important than whether or not they can conserve their uterus.  Women with a very large fibroid mass will recover from a hysterectomy very much more quickly than a myomectomy.  Other women are so fed up with the problems they have had managing their periods, often for many years that the added guarantee of no periods following a hysterectomy is more than welcome.  Hysterectomy also has an advantage over embolisation because tissue is sent to the laboratory for histological examination.
There are risks of complications with hysterectomy, notably from bleeding or infection and also of damage to the bowel, bladder or ureters and possibly prolapse at a later date. The risk of damage is greater with a larger uterus because the anatomy is often distorted by the sheer size of the fibroids, particularly cervical fibroids. The risks are also greater in women who have had previous surgery, Caesarean sections and pelvic infection in the past.  Provided your surgeon is alert to these possibilities and appropriately trained and experienced the risk of serious complication can be minimised.
The risks of a hysterectomy can be reduced by performing a subtotal hysterectomy so that the pelvic floor supports are left intact and the bowel or bladder are not disturbed.  In some cases, provided the uterus is not too large this can be achieved by laparoscopic surgery.  Most women will be well enough to go home from hospital the day after a laparoscopic hysterectomy.

What about the ovaries?
A total abdominal hysterectomy means removal of the whole uterus, including the cervix and does not relate to the question of whether or not the ovaries are removed.  The ovaries can almost always be conserved at hysterectomy, unless there is an unusually large fibroid close to the ovary, compromising its blood supply, or severe post-operative adhesions.  In women of childbearing age who have elected for hysterectomy, or in the incredibly rare situation where we have been obliged to perform a hysterectomy due to bleeding in the course of a myomectomy, we will always try to conserve the ovaries.  
In women who are menopausal, it is thought that the ovaries contribute very little to the hormone status, and removal will remove any risk of development of ovarian cancer.  Therefore in the rare cases in which we perform hysterectomy for women their late 40’s or early 50’s we will usually discuss whether or not we should remove the ovaries.  This is a very personal decision.  Some women are very risk averse and have a dread of developing cancer, others have a strong family history of breast and ovarian cancer and are at risk through inheritance of the BRCA-1 gene.  It would obviously be sensible to remove the ovaries in such cases.  Other women prefer to remain intact and we respect their wish to retain their ovaries.


© Adrian Lower 2014