Myomectomy Flashcards
Indications for myomectomy
Uterine fibroid causing:
- AUB
- Urinary sx
- Pelvic pressure, pain
Asymptomatic with infertility or RPL:
- After all investigations for other causes normal
- Cavity-distorting fibroid
- Previous adverse pregnancy outcome
Pre-op investigations for myomectomy
- Pelvic USS
- Pelvic MRI
- Endometrial biopsy to exclude malignancy/hyperplasia if AUB.
- FBC, iron studies.
- TFTs
Pre-op optimisation for myomectomy
Optimise Hb:
- Iron supplementation
- Reduce bleeding: GnRH agonist
Reduce size of fibroid: GnRH agonist
Immediately pre-op investigations for myomectomy
Pregnancy test
Group and screen
Indications for open myomectomy
High number of myomas (>3)
Larger than 10-12 cm
Describe performing an open myomectomy
Positioning: lithotomy.
Consider cell saver.
Incision: Pfannenstiel or midline.
Exteriorise uterus if large.
Foley catheter torniquet: dissect bladder peritoneum sharply off anterior lower segment to visualise parametrium. Make opening in posterior leaf of broad ligament and pass tourniquet through this; tie anterior ro posterior and clamp to prevent knot slippage.
Dilute vasopressin: inject into pseudocapsule and myometrium surrounding myoma. Communicate with anaesthetist and monitor for changes in haemodynamic stability.
Preventing breaching endometrial cavity: inject diluted methylene blue via cervix.
Myomectomy: incision, dissection of myometrium until pseudocapsule is exposed. Enucleation of myoma by traction-counter traction (use towel clip to grasp myoma).
coagulation as goes.
Use 0-Vicryl to close myometrial incision with at least 2 layers. Use 2/0-Vicryl to close serosa.
Separate closure of endometrium if cavity entered; leave intrauterine paediatric catheter in situ for 1 week.
Removal of equipment.
Close incision.
Post-op plan for myomectomy
Immediate:
- Admission
- Mobilise then TROC
- Analgesia, laxatives
- Ensure passing flatus
Longer term:
- Surgeon to chase histology
- Follow-up 6 weeks post-op
