Laparoscopic myomectomy: essence and features of the intervention. Myomectomy: postoperative period Pain syndrome after conservative myomectomy and laparoscopy

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

Uterine fibroids (leiomyoma, fibromyoma) are 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: preserving the patient’s ability to become pregnant and bear children.

Disadvantages of conservative myomectomy:

• There is no certainty that all nodes and areas of fibroid growth in the uterus will be removed;
• 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, taking into account the above-mentioned disadvantages of the method, such operations are carried out strictly according to indications.

Indications for conservative myomectomy:

• The presence of individual, no more than 3-4 myomatous nodes.
• The size of the uterus is no more than 12 weeks of pregnancy.
• The patient's age is up to 37-40 years.
• The feasibility of preserving the patient’s reproductive function.

Exactly how to perform a myomectomy depends on the type of fibroid node.

Types of uterine fibroid nodes

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

Laparotomy conservative myomectomy

- this is an operation to remove fibroid nodes using traditional abdominal wall access - transection.

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

Laparoscopic conservative myomectomy

is an endoscopic operation to remove fibroid nodes using special equipment.

The laparoscopic complex is inserted into the abdominal cavity through several “punctures” of the anterior abdominal wall - see the detailed Video:

Indications for laparoscopic myomectomy:

• Subserous nodes of fibroids on a stalk.
• Small subserous nodes types 0 and 1.

Advantages of laparoscopy:
/compared to transection/

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

Disadvantages of laparoscopy:

• The edges of the wound do not always connect adequately.
• There is a high risk of the formation of a defect in the uterine wall due to a large area of ​​coagulation necrosis (laser or electrical burn of tissue) after removal (husking, enucleation) of a large myomatous node.

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

Contraindications to laparoscopic myomectomy

• Many intramural fibroid nodes, low nodes, nodes in the cervix.
• The size of the fibroid node after hormonal preparation is ≥8-10 cm.
• Repeated surgery (scars on the anterior abdominal wall), hernia.
• The need for revision of the abdominal cavity (suspicion of a malignant process).
• Obesity or wasting.
• Adhesive disease, peritonitis.
• Severe somatic pathology, blood clotting 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 canal of the uterus. During hysteroscopy, no incisions are made on the patient's body.

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

Hysteroresectoscopy is a surgical hysteroscopy. Hysteroresectoscopic myomectomy is a hysteroscopy during which the myomatous node is removed.

Indications for hysteroresectoscopic myomectomy:

• Submucosal nodes of fibroids types 0 and 1, size

Contraindications to hysteroresectoscopy:

• Inflammation or infection of the genital organs.
• Uterine bleeding.
• Cervical stenosis.
• Cervical cancer.

Hormonal preparation for conservative myomectomy

If large (>4-5 cm) fibroid nodes are located on a broad 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 enucleation of the fibroid node.

Analogs of gonadotropin-releasing hormones (GnRH agonists) are considered the most effective means of preoperative hormonal preparation. The regimen and duration of taking GnRH agonists is individual. It is prescribed by a doctor.

Article outline

When a diagnosis of uterine fibroids is made to a woman of reproductive age, especially if she has not yet realized her maternal function, in the vast majority of cases, specialists give preference to organ-preserving operations, which leave women a chance to bear offspring.

Most often, if surgical intervention is necessary to treat uterine fibroids, conservative myomectomy is prescribed.

What is myomectomy

The main purpose of this operation is to remove myomatous nodes while preserving the uterus. In gynecology, myomectomy is given the greatest preference, since after it is performed, a woman remains able to become pregnant and give birth to healthy offspring. This intervention is carried out using modern laser, mechanical and electrosurgical technologies.

What happens

There are 3 types of conservative removal of uterine fibroids:

• laparotomy myomectomy;
• laparoscopic myomectomy;
• transcervical myomectomy.

What type of surgical intervention will be applied to the patient depends on the type of myomatous node.

If a submucosal node of type 0 and 1, located entirely in the uterine cavity, is diagnosed, then hysteroscopic myomectomy is prescribed. Hysteroresectoscopy is also prescribed for partial location of the submucosal node in the uterus and in a smaller part intramural. When the node is located mostly in the intermuscular space, various intervention options can be used, this could be hysteroresectoscopic myomectomy or abdominal laparotomy, it all depends on individual parameters.

Subserous nodes of type 0, 1, located in the abdominal cavity, are operated only by laparoscopic methods. But for subserous-intramural type 2 and intramural nodes located in the thickness of the myometrium, only laparotomy is prescribed.

Which method will be called the final hysteroresectoscopy, laparotomy or myomectomy using the laparoscopic method depends not only on the type of node, but also on its size, structure, general condition of the patient, the professionalism of the surgeon and the technical equipment of the medical institution. The safest and least traumatic is bloodless laparoscopic myomectomy.

When they do

For a woman in a normal state, it does not really matter on what day of the cycle a myomectomy is performed; usually the operation is scheduled from the 6th to the 18th day of the cycle. But for pregnant women, the optimal period for manipulation is 14-19 weeks of fetal development. At this time, the placenta is already fully functioning, and the level of progesterone in the woman’s peripheral circulatory system is doubled. This hormone closes the internal os of the uterus and reduces the risk of increased uterine tone due to surgery.

Indications for surgery

The uterus may have the following indications:

• the woman is of reproductive age, especially if she does not have children yet;
• if the tumor grows rapidly and within a year grows to the size of 4-5 weeks of pregnancy;
• the tumor should be the size of the uterus at 12 weeks of pregnancy;
• heavy blood loss and a drop in hemoglobin levels;
• severe pain and pulling sensations;
• additional gynecological diseases, for example, endometriosis;
• the presence of atypical cells in the results of histological examination (suspicion of malignancy of the formation);
• if the tumor has a long stalk, prone to torsion, as well as with multiple fibroids;
• localization of the formation on the cervix or between the sheets of the broad ligament;
• infertility and spontaneous abortions;
• if the normal activity of neighboring organs is disrupted (frequent urge to urinate, problems with stool).

Contraindications

It is not always possible to preserve childbearing function for a woman with uterine fibroids; in some cases, it is necessary to completely remove the entire affected organ in order to save the patient’s life. There are the following contraindications to myomectomy:

• if the patient is in serious condition due to severe blood loss and severe anemia;
• if the tumor has recurred after a previous organ-conserving operation;
• if there is chronic inflammation in the pelvic organs.

Preparing for surgery

Before myomectomy, it is necessary to undergo standard examinations for all gynecological operations - smears for microflora and cytology, general urine and blood tests, testing for HIV, syphilis and hepatitis, coagulogram, etc. Additionally, it is necessary to undergo the following types of diagnostics:

• Ultrasound examination of the reproductive system to accurately determine the location, size and number of myomatous nodes;
• video colposcopy of the cervix with simultaneous smear taking for cytology;
• biopsy of the formation and tissue of the uterus to exclude oncology;
• ECG to select anesthesia to be used during surgery.

Features of myomectomy

When performing myomectomy of uterine fibroids, the technique of the operation is very important, because the quality of the scar on the uterus and the absence of adhesions after surgery depend on it. The surgeon must correctly select the site of the incision on the organ, accurately open the capsule of the myomatous node, remove it correctly and carefully stop the bleeding without using diathermocoagulation.

If the uterine cavity is opened during myomectomy, then 3 rows of sutures with vicryl threads are placed on the incision. This suture material takes a long time to dissolve and is well accepted by the body. If there has been no opening of the uterine cavity, then the bed is closed with two rows of sutures with a certain distance from each other to normalize blood circulation in the tissues.

During a conservative myomectomy, the surgeon tries to cut the capsule of the node at the top of the fibroid to prevent damage to large blood vessels and, if there are many nodes, remove them all. The nodes are peeled to the full plane of the bed. In some cases, the round uterine ligament is cut to prevent bleeding.

After the operation is completed, the pelvic cavity is thoroughly drained and anti-adhesive substances are pumped into it.

Performance during pregnancy and childbirth

During pregnancy, the principle of surgical intervention remains the same, but it has its own characteristics, since there is a fetus inside the uterus, its size is very large, and the blood vessels are dilated and there is a high risk of severe blood loss. In order for pregnancy and childbirth to be successful in the future, during myomectomy, which is performed during such an important period for a woman, it is necessary to minimize blood loss, avoid trauma to the fetus and prevent purulent-septic complications.

During the operation, a middle incision is made in the lower part of the abdominal wall, the pregnant uterus is pulled out into the wound, an assistant holds it, and at this time the surgeon removes not all, but only the largest fibroid nodes, which can harm the development of the fetus and the woman’s health.

For women who underwent surgery to remove fibroids while carrying a child, natural childbirth is contraindicated, and a cesarean section will be performed using the same incision that was made for the myomectomy.

Restrictions after intervention

For the first time after surgery, the following restrictions apply:

• You cannot take a bath, only a shower, and wounds should be treated with iodine or potassium permanganate;
• intimacy must be excluded;
• Do not lift weights or play sports;
• You cannot become pregnant immediately after surgery, so you should use contraception.

Rehabilitation period

Rehabilitation of the patient begins immediately after the cessation of anesthesia. The main tasks that the postoperative period includes:

• prevention of inflammatory processes in the pelvic organs;
• reducing the likelihood of hormonal dysfunction, somatic diseases and autonomic disorders;
• reducing the risk of tumor recurrence;
• restoration of all body functions.

To achieve these goals, the patient must begin early activity, use anti-anemia drugs, anticoagulants and medications to normalize blood microcirculation in tissues. Compression garments for the lower extremities, breathing exercises that are available for bedridden patients, etc. are methods that accelerate the restoration of uterine tissue, promote the formation of a full-fledged scar and reduce the risk of complications. Antibiotics may be prescribed to prevent inflammation.

Hormonal therapy after myomeectomy

You will need to take hormones for some time after your myomectomy. These medications are taken for several months. Most often, hormonal drugs are steroidal oral contraceptives, for example, Buserelin or Mifepristone. Other drugs are also prescribed as part of hormone replacement therapy (HRT).

Complications

The most serious consequence of complications after myomectomy is relapse of the disease. There are others:

• inflammatory processes in the pelvis;
• adhesive disease due to fusion of the uterus with the uterine appendages, as a result, infertility;
• a postoperative scar can complicate subsequent pregnancies and childbirths;
• recurrence of the disease in another part of the uterus.

If the temperature rises, severe bleeding and pain appear after surgery, you should urgently seek help from a doctor.

Discharge after surgery

If we talk about discharge after myomectomy, then in the first two days it can be quite intense and even resemble bleeding, but over time the spotting will become scanty, and within 1 month the bleeding will disappear completely.

For a long time it was believed that the only way to get rid of fibroids was a hysterectomy, that is, removal of the uterus. Of course, you can’t argue with this – the method is effective. However, it is completely unacceptable for young patients who have not yet fulfilled their main female mission and want to have offspring. Fortunately, for those women who, for one reason or another, need to preserve the reproductive organ, there is an alternative treatment option - laparoscopy of uterine fibroids.

Today, according to leading Russian gynecologists, there is no fibroid for which hysterectomy would be a mandatory operation. Removal of uterine fibroids using the laparoscopic method while preserving the reproductive organ is the gold standard of surgical treatment, and reviews from patients who have undergone this type of surgery are overwhelmingly positive.

What is laparoscopy?

Nowadays, medicine has reached a high technological level, making it possible to perform it without the use of a scalpel and without an incision in the anterior abdominal wall. Now, modern endoscopic equipment is used for this - a device in the form of a flexible tube equipped with a lens system and a video camera, called a laparoscope.

Laparoscopy is performed using endoscopic equipment (monitor, light) and accompanying surgical instruments.

For reference

Translated from Greek, “lapara” means belly, “scopeo” means look, see. Thus, the main difference between this method and classical surgery is indicated by its very name - “laparoscopy”. During such a procedure, the surgeon, without exposing the internal organs or touching them with his hands, can see them using a camera and even perform an operation.

Laparoscopy is divided into diagnostic and therapeutic. Diagnostic laparoscopy allows, without making large incisions on the patient’s body, to examine the internal organs, obtain information about their condition and make the correct diagnosis. Therapeutic laparoscopy involves surgical removal of the detected pathology.

Today, gynecologists can remove uterine fibroids without looking directly into the surgical wound. Using laparoscopic access, it is possible to remove even, looking only at the screen, while preserving the uterus and giving the patient a chance for happy motherhood.

With laparoscopy, the doctor can remove the tumor while looking only at the monitor screen.

Myomectomy is the surgical removal of single or preserving the uterus. This operation is performed on women who wish to have children in the future after it is performed. The intervention is most effective for interstitial fibroids, as well as for nodes that grow outside the uterus (subserous, pedunculated). In this case, no significant damage to the uterine muscle occurs. This type of operation is called conservative, and it can be performed in two ways: laparoscopic and by laparotomy.

is a surgical intervention with minimal trauma, in which three small punctures 5-10 mm long are made on the anterior abdominal wall, through which the tumor is removed with special instruments, while the uterus is preserved. Subsequently, a woman can plan a pregnancy, bear and give birth to a child.

The goal of laparoscopic surgery is to gently remove the myomatous tumor, while preserving the menstrual cycle and the woman’s ability to bear children.

Carrying out such a manipulation requires the highest professionalism and skill from the surgeon: without touching the organ with his hands, the doctor must reliably suture the muscle after removing the node, so that during subsequent pregnancy and childbirth the uterus does not rupture in this place. can be found in a separate article.

Laparoscopy can only be performed by highly qualified specialists.

Laparoscopic surgery to remove fibroids is performed in large medical centers, and the cost of such an intervention is sometimes considerable. As a rule, prices depend on the category and status of the medical institution, on the qualifications of the operating surgeon, as well as on the quality of the endoscopic equipment used. The price range for this service in the Russian Federation is from 35 thousand rubles in large regional centers to 100 thousand rubles in elite clinics in Moscow.

Free removal of fibroids by laparoscopy is also possible. This operation is performed in public clinics that have endoscopic equipment and highly qualified specialists, subject to quotas for the provision of high-tech care from the federal budget.

Advantages of laparoscopic surgery

Before the introduction of laparoscopic equipment into gynecological practice, doctors could also save the uterus by removing only fibroid nodes. But at the same time, it was performed, that is, an incision of about 15 cm in length was made with a scalpel in the anterior abdominal wall, through which the tumor was removed. After such an operation, a scar remained on the skin of the abdomen, which caused a lot of grief to representatives of the fair half of humanity.

Needless to say, such incisions caused women not only cosmetic troubles, but also took a very long time to heal after surgery, and also caused long-term rehabilitation for patients.

The laparotomy operation, in which an incision is made in the anterior abdominal wall, is quite painful during the rehabilitation period and is often associated with various complications, including bleeding and inflammatory processes.

So, the main advantages of the laparoscopic technique, compared with laparotomy, are:

• Cosmetics – post-operative scars are almost invisible;
• Less surgical trauma;
• Bloodless procedure or minimal blood loss;
• No need for a long hospital stay;
• Quick recovery and return to an active lifestyle;
• Reducing postoperative pain;
• Improving the quality of life of patients;
• Reducing the volume of drug therapy in the postoperative period;
• Less risk of adhesions.

Indications for laparoscopy

Conservative myomectomy is performed laparoscopically in the following cases:

• Uterine fibroids up to 12-15 weeks in size in women of childbearing age;
• When uterine fibroids are the only cause of infertility and (or) miscarriage;
• Severe anemia in a woman due to uterine bleeding, the cause of which is uterine fibroids;
• Severe pain arising from malnutrition of the node;
• Rapid tumor growth;
• Disruption of the normal functioning of organs adjacent to the uterus (ureters, bladder and intestines).

The laparoscopic method of removing fibroids is used, among other things, in cases of rapid growth of the tumor.

Contraindications

Laparoscopic surgery is contraindicated under the following circumstances:

• The patient has diseases in which surgical intervention can create a real threat to her life (pathology of the heart and blood vessels, decompensated respiratory failure, liver failure, bleeding disorders, diabetes mellitus);
• Oncological pathology of the genital area cannot be excluded;
• The size of myomatous nodes after hormonal treatment at the stage of preoperative preparation remains more than 10 cm and there is no tendency to reduce them. we discussed in another article;
• It is known that removal of multiple nodes will not restore the reproductive function of the uterus and the desired pregnancy will not occur;
• Acute inflammatory processes in the abdominal cavity, acute respiratory viral infections or exacerbation of chronic diseases;
• Period of menstruation;
• Uterine pregnancy (if there are no strict indications for surgical treatment);
• The patient is severely malnourished;
• There are hernias in the abdominal area.

Obesity and severe adhesions in the abdominal cavity can also serve as a limitation to surgery.

With progressive adhesive disease, there is a limitation on laparoscopic myomectomy. The picture shows the degrees of the adhesive process: I - limited to the area of ​​the postoperative scar; II - localized in combination with single spikes in other places; III - adhesions occupy 1/3 of the abdominal cavity; IV - occupy most of the abdominal cavity.

It is believed that laparoscopic myomectomy is most effective when there are no more than 4 myomatous nodes on the uterus and when the size of the organ is up to 12 weeks. In all other cases, preference should be given to laparotomy access. At the same time, it should be noted that with the advent of high-tech morcellators in practice, it became possible to perform laparoscopic operations for fibroids up to 15-16 weeks in size. can be found in our article.

In addition, with multiple nodes, there is a high probability of disease recurrence (more than 30%), while with single formations, relapse occurs only in 10-20% of cases.

How to prepare for surgery

As with any other planned operation, it is necessary to undergo an examination, which includes:

• Blood tests - clinical, biochemical, identification of coagulation system indicators, examination for hepatitis B and C, HIV infection and syphilis, as well as determination of blood group and Rh factor;
• General urine analysis;
• Gynecological ultrasound;
• Smear to determine vaginal microflora and cytological examination;
• Fluorography;
• Dentist's conclusion about the absence of caries;
• The therapist’s conclusion about the absence of chronic diseases, the course of which may worsen during the operation;
• Consultation with a doctor who will administer anesthesia.

Among the examinations that must be completed in preparation for laparoscopic myomectomy are a smear for flora and cytology.

Preparation for laparoscopic tumor removal includes the following points:

• A few days before surgery, exclude foods that cause increased gas formation;
• On the eve of the procedure, a light dinner is allowed no later than 18:00;
• In the evening and morning, intestinal cleansing is carried out;
• On the day of surgery, food and liquid intake is prohibited.

To prevent thromboembolic complications before surgery, elastic bandaging of the lower extremities or the use of compression stockings (anti-varicose stockings) is necessary.

How the operation is performed

Removal of uterine fibroids using the laparoscopic method is always carried out in a gynecological clinic or hospital in a sterile operating room.

Elective surgery is usually performed in the morning or early afternoon and lasts from 30 minutes to two hours, depending on the scope of the operation and the size of the tumor.

Any day of the cycle is suitable for laparoscopic manipulation, except for the period of menstruation. During menstruation, increased bleeding is observed, so the risk of bleeding during surgical procedures increases.

Anesthesia - endotracheal with the use of mechanical ventilation. The patient sleeps, hears nothing, sees nothing and does not experience pain.

Before the operation begins, combined anesthesia is used - endotracheal anesthesia, which helps to endure the entire surgical process without pain and stress.

Before the operation, the woman signs an informed consent, thereby confirming that the doctor explained to her how the fibroids will be removed and the possible change in the scope of the operation if complications arise. In the event of an unforeseen development of events, the surgical intervention may end, which the doctor also warns about before the operation.

What happens in the operating room

• The patient is placed on the operating table. After treating the abdominal skin, the surgical field is covered with sterile sheets;
• After the anesthesia has taken effect, punctures are made at the navel and on the sides of the abdomen in the iliac regions, through which endoscopic instruments are inserted;
• For a better view of the uterus, carbon dioxide is injected into the abdominal cavity, which is completely harmless to the body. The intestinal loops move from the pelvis to the upper abdomen and do not create an obstacle to the operation;
• The surgeon examines the uterus, appendages, and fibroid nodes. An image of what is happening in the patient’s abdominal cavity is transmitted to the monitor screen. During the operation, the doctor does not touch the pelvic organs with his hands.

Operation stages

• Cutting off a fibroid node (if it has a stalk) or enucleating a tumor located in the muscular wall of the uterus. To do this, an incision is made on the surface of the capsule, the knot is fixed with two clamps and removed by successive pulling. Myomatous nodes are characterized by the presence of a clearly defined capsule, due to which they are easily removed without additional trauma to the uterine wall. The tumor bed (the place where it was located) is washed with saline, and then the bleeding areas are carefully coagulated;

The process of myomectomy begins with cutting off or enucleating the tumor.

• Suturing a defect in the muscular wall of the uterus. The myometrial defect formed after tumor removal must be sutured. The surgeon also performs this manipulation without touching the organ with his hands, but only by looking at the screen and using instruments inserted into the woman’s abdominal cavity. Applying an endoscopic suture is the most time-consuming and labor-intensive stage of the operation. The suture must be reliable so that there is no threat of uterine rupture in this place in subsequent births. This requires some experience on the part of the surgeon;
• Removal of fibroids from the abdominal cavity. Small myomatous nodes can be easily removed through existing incisions in the abdominal wall. To extract large nodes, you will need to use a special tool - an electric morcellator, which, using a system of rotating knives, first crushes and then “sucks” parts of the tumor into itself, like a vacuum cleaner. In this way, large fibroid nodes are removed;
• Inspection and sanitation of the abdominal cavity is the final stage. At the end of the operation, the surgeon once again examines the abdominal cavity, removes accumulated blood clots, checks the integrity of the sutures on the uterus, performs hemostasis of small bleeding vessels and removes instruments. The total volume of blood loss during surgery is no more than 50 ml;
• To prevent the formation of adhesions, a special anti-adhesion mesh is used, which dissolves after 14 days and does not allow the intestines or omentum to be soldered to the postoperative scar;
• Intradermal cosmetic sutures are applied to the puncture site, which dissolve on their own within 2-3 months and subsequently become pale and invisible;

After laparoscopy, the punctures are sutured subcutaneously, and cosmetic stitches are applied to the skin.

The progress of the laparoscopic operation is recorded on video, and each patient has a video protocol.

Postoperative period

Compared with abdominal surgery, myomectomy performed by laparoscopic access has a more favorable postoperative course:

• Patients are activated early, which is the prevention of thromboembolic complications;
• Due to the low invasiveness of laparoscopy, the pain syndrome is mild, which means that narcotic painkillers are not required;
• Antibacterial and anti-inflammatory therapy is indicated only for those women who have a high risk of infectious complications;
• If thrombosis is likely to develop, anticoagulants (drugs that prevent blood clots) are prescribed, and elastic leg bandaging or wearing compression stockings for at least two weeks is recommended.

On a note

After laparoscopic removal of uterine fibroids, patients can get up, walk, serve themselves, drink and eat light liquid food on the day of myomectomy after 3-6 hours. Strict bed rest is not required on the first day after surgery.

After laparoscopic myomectomy, a woman, in agreement with the attending physician, can take care of herself even on the first day after the operation.

Possible complications

Complications after laparoscopy are quite rare. But, as with any other surgical operation, they are possible. These may include:

• Unsuccessful introduction of gas into the abdominal cavity, which causes subcutaneous emphysema (on palpation, a characteristic crunch is detected in the subcutaneous fat layer);
• Puncture of the intestine with a needle while filling the abdominal cavity with gas. To avoid this, it is very important to have a good bowel movement before surgery;
• Injury to organs (ureter, bladder) and large vessels;
• Bleeding from the bed of myomatous nodes;
• Formation of hematomas in the wall of the uterus;
• Infectious complications in the early postoperative period.

Rehabilitation period

After laparoscopy of uterine fibroids, the woman recovers very quickly and returns to her normal lifestyle. If the course of the postoperative period is favorable, the woman is discharged from the hospital home on the 2-3rd day after surgery. In case of complications, which are rare, there is a need for a hospital stay of up to 7 days.

Sick leave is usually issued for 7-14 days. If a woman’s work does not involve heavy physical labor, she can begin her duties, if desired, on the 4th day after the operation. The temporary disability certificate can be extended if necessary (for example, if complications arise or if general health is unsatisfactory).

Full restoration of working capacity occurs in 15-30 days.

Menstruation after surgery usually begins within 28-30 days, but their delay is not a reason to panic. This may be due to previous surgery. Surgery is stressful for the body and can cause menstrual dysfunction. Intermenstrual discharge is also acceptable.

After surgery, possible intermenstrual bleeding is considered normal.

Physiotherapy during the rehabilitation period is not a mandatory procedure and is prescribed at the discretion of the doctor to prevent adhesions or inflammation.

For six months after the operation, the woman is under dynamic observation by a gynecologist. She should return for examination and ultrasound 1, 3 and 6 months after fibroid laparoscopy.

Until the scars on the uterus completely heal (and this will take 3-6 months), hormonal contraception is prescribed. The choice of the appropriate drug is made by the doctor depending on the condition of the woman’s reproductive system.

6 months after the follow-up examination and ultrasound, when the doctor is confident that the uterine scar is intact, the patient is allowed to plan a pregnancy.

It is important to know

After laparoscopic myomectomy, delivery is possible either through the birth canal or by cesarean section. The method of delivery is determined by the doctor based on obstetric indications.

During the rehabilitation period for 1 month it is recommended:

• Wear a bandage to reduce the load on the anterior abdominal wall;
• Limit heavy lifting and physical activity;
• Abstain from sexual intercourse;
• Follow a diet and organize proper nutrition - exclude from the diet fatty foods, foods that cause bloating and increased gas formation (legumes, fresh vegetables and fruits), as they can cause abdominal pain and cause diarrhea;
• Postpone sports activities for up to 4-6 months to ensure complete healing of the uterine scar.

To reduce the load on the abdominal wall during the rehabilitation period, it is advisable to wear a postoperative bandage.

Myoma is one of the most common diseases of the reproductive system in women aged 35-50 years. This is a benign tumor formed from the muscle tissue of the uterus. It can only be determined by examination or ultrasound. The disease is often asymptomatic, but there are a number of signs (irregular menstrual cycle, pain, bleeding, unsuccessful attempts to get pregnant) that should force a woman to see a doctor.

In gynecology, hormonal therapy, conservative myomectomy and radical hysterectomy are used today for fibroids.

Each case is individual. Once the patient has been diagnosed, specialists must determine the most effective treatment method. If the nodes were detected at an early stage, they are small in size, and doctors do not see a growth trend, therapy with hormonal drugs is used - Duphaston, Norkolut, Decapetil, etc.

They help stop the progression of the disease and even stimulate tumor regression. When uterine fibroids deprive a woman of a normal life, surgical intervention is indispensable.

Not every woman, when gynecological problems arise, knows how best to act, what treatment methods are more effective to use in her situation. The doctor’s task is to explain to the patient what myomectomy is, what advantages it has, and what side effects may occur after the operation.

In medicine, when surgery to remove fibroids cannot be avoided, two options are used: hysterectomy and myomectomy.

The first method is removal of the uterine body with or without appendages. Accordingly, after the operation the woman will not be able to have children. In addition, patients experience a disorder of the nervous and autonomic systems. A more loyal solution would be a myomectomy, during which all organs remain in place, reproductive function is preserved, and only the nodes are removed. But it is not always possible to use this option; indications for surgery are:

• reproductive age;
• the patient does not have children;
• small tumor size;
• structure of nodes (they are easier to remove if they have a base).

Conservative myomectomy has contraindications.

It cannot be carried out if the patient’s life and health are in danger. The woman’s serious condition, large blood loss and falling hemoglobin are grounds for a radical hysterectomy.

Also, removal of the uterus along with fibroids is indicated for inflammatory processes in the pelvis, recurrence of the tumor after myomectomy, impaired blood circulation of the tumor and tissue necrosis, and suspected cancer.

Doctors independently choose the best option, based on the clinical picture of the disease, the individual circumstances of the case, and the presence of indications and contraindications for the patient.

Features of myomectomy

The operation to remove nodes is carried out using high-quality modern equipment. The surgeon must have sufficient knowledge and experience so that complications do not arise after the operation. With the correct removal technique, a high-quality scar will be formed, and the possibility of developing adhesions will be reduced to zero.

Before performing surgery, it is important to prepare the patient according to all the rules.

It is necessary to undergo all standard types of examination:

• take a blood and urine test;
• check biochemical parameters and coagulability;
• determine blood type;
• undergo an ECG, pelvic ultrasound and radiography;
• examine hormone levels.

If during the operation the doctor opened the uterine cavity, three rows of sutures with vicryl threads will be required. This material is easily absorbed and does not cause a tissue reaction. The incision of the fibroid capsule is made in the upper pole of the node. This will avoid massive bleeding, damage to the walls of blood vessels and makes it possible to remove other nodes if there are several tumors.

At the final stage of the operation, the pelvic cavity is subject to drainage, after which special solutions are injected into it to prevent the development of adhesions.

After surgery, a woman may experience spotting during the first two weeks. Sometimes they last for the first month with maximum abundance in the first day.

Menstruation after myomectomy is restored as before. The first day after menstruation will be considered the date of the operation.

Methods of conservative myomectomy

Modern technologies are actively used in medicine, which makes surgery safer and the body’s recovery faster and easier. Thanks to innovation, node removal can be done in different ways. The most popular and effective options are:

• Laparotomy myomectomy. This is an abdominal operation in which the uterus is accessed through an incision in the abdominal wall. Laparotomy is used infrequently, mainly in cases of severe deformation of the uterus due to a large number of nodes. After the operation, the patient must carefully monitor the cleanliness of the suture. Physical activity over a long period is contraindicated for her. A noticeable scar remains on the abdomen.
• Laparoscopic method. It can be called as painless and bloodless as possible. Access to the affected organ is through small holes in the abdominal wall. The postoperative period during laparoscopy is easy and without complications. However, this method can only be used if the size of the uterus with fibroids does not exceed 9 weeks. Also, laparoscopy is contraindicated if the tumors are located in a hard-to-reach place.
• Hysteroscopic myomectomy. The presented method can be used on an outpatient basis. Removal of nodes by hysteroscopy occurs through the vagina. An important condition in this case will be the small size of the tumors.

Each method has its own advantages and disadvantages. Your doctor should determine which option is best in your particular case. One more method can be added to the presented methods – embolization of the uterine arteries.

EMA– a minimally invasive intervention with which you can stop blood circulation in the fibroid. The tumor loses the ability to feed itself with blood, which is why its cells die within two weeks, the growth of the tumor stops, or the fibroid completely resolves. Embolization is performed by puncturing the femoral artery. From here, doctors with modern equipment will be able to clog the fibroid vessels.

Doctors' opinions on myomectomy

Gynecologists are the main experts in the methods and techniques of myomectomy. To understand more about the procedure, you need to study the reviews of specialists.

“Myomectomy is the most gentle way to remove tumors while preserving a woman’s reproductive function. Patients are reluctant to agree to abdominal surgery, but hysteroscopic myomectomy or removal of nodes using laparoscopy is gaining popularity every day. And this is not surprising, because the presented methods reduce the risks of bleeding and injury to internal organs, rehabilitation after the procedure is quick and painless.”

“The main thing that doctors focus on when determining the method of removing fibroids is the effectiveness of the surgical intervention. It is important that women have no complications after surgery. Conservative methods of tumor removal allow patients to become pregnant after recovery and bear a healthy baby. Scars after the procedure are practically invisible, and hysteroscopic myomectomy leaves no scars or adhesions at all.”

Consequences of myomectomy and rehabilitation period

When a doctor prescribes a myomectomy, he must take into account all the details and features of the disease. Even if a specialist completely removes the nodes, this does not guarantee that the tumor will not return over time. In addition to fibroid recurrence, other complications occur:

• inflammatory processes in the pelvis;
• the occurrence of adhesions accompanied by pain;
• infertility.

Such consequences can be prevented in the postoperative period if you follow the doctor’s instructions and organize the correct regimen. The minimally invasive intervention allows the patient to move on the second day after the procedure. Recovery may take 1-3 months.

For the first time after surgery, you should avoid physical activity and wear a bandage. It will be necessary to improve nutrition, because a woman should not be constipated.

They can cause seams to rip apart. Also, disturbances in the functioning of the gastrointestinal tract will cause inflammatory processes in neighboring organs.

A woman's diet after a myomectomy should include foods that help cleanse the body of waste and toxins.

If the surgery went without complications, the chances of getting pregnant are 90%. Doctors recommend planning to conceive a baby six months after the procedure. It is during this period of time that the endometrium of the uterus will have time to recover, and the female body will have time to prepare for pregnancy and bearing a child. Learn more about myomectomy in the videos above.

The only remedy for FIBROID and its prevention, recommended by Natalya Shukshina!

Myomectomy is a surgical technique for removing myomatous nodes, which occupies a significant place in modern gynecology. Today, laparoscopic myomectomy is considered the most common and effective. The main advantage of removing myomatous nodes using the laparoscopic method is that during the operation it is possible to remove tumors without damaging the uterus itself. Due to the fact that the most important reproductive organ retains its functionality, after laparoscopy a woman can become pregnant and carry a child.

What are uterine fibroids?

The main indication for laparoscopic myomectomy is uterine fibroids. This disease is considered one of the most common gynecological pathologies. According to statistics, uterine fibroids occur in approximately 50% of women of reproductive age. Many representatives of the fair sex do not even suspect that they are developing this pathology, since fibroids most often do not have pronounced symptoms and do not bring any concern to the woman. In most cases, the disease is detected accidentally during an ultrasound examination of the pelvic organs.

Fibroids, also called fibroids, are benign growths that develop in the muscle tissue of the uterus. The tumor is benign in nature and in rare cases can degenerate into malignant. Myoma can take the form of a single node, as well as multiple nodules covering the surface of the reproductive organ and deforming it. Myomatous node can have a variety of sizes - from several grams to a kilogram. Treatment of gynecological diseases is only surgical.

Main advantages and technique of uterine myomectomy

One of the most important advantages of laparoscopic myomectomy is that during surgical treatment the tumor itself is directly removed, while the reproductive organ remains intact. It is the removal of the myomatous node by laparoscopic method that is the most preferable option for nulliparous girls. But, in turn, preserving the uterus also has an obvious disadvantage - in this case, the risk of developing a relapse of the disease cannot be excluded.

The following positive aspects of laparoscopic removal of myomatous nodes can be highlighted:

• Minimum level of injury. Since surgical intervention during laparoscopy is carried out without direct penetration into the abdominal cavity, the risk of accidental damage to other internal organs is minimal.
• With this surgical treatment, in most cases there is no bleeding.
• There is no adhesive process after laparoscopic treatment.
• This type of surgical treatment does not leave visible stitches or rough scars on the surface of the abdominal cavity.
• In the process of removing a myomatous node, surgeons do not resort to amputation of the reproductive organ. Thanks to this, already some time after the operation, a woman can plan a pregnancy and give birth to a child on her own, without resorting to a caesarean section. Myomectomy is characterized by the fact that a small scar remains on the surface of the uterus, which has absolutely no effect on the birth process.
• One of the main advantages of laparoscopic myomectomy is the short recovery period. In frequent cases, already 4-5 days after the operation, the woman is discharged from the hospital, and sometimes even earlier.

Laparoscopic myomectomy is recommended only if the myomatous nodes are single or small in size. In the case of multiple or large tumors, laparoscopy is not performed due to its high complexity and the possible development of severe complications.

The technique of laparoscopy for uterine fibroids is no different from this procedure performed for other diseases.

• Using a trocar, the anterior abdominal wall is pierced in several places - most often in 4. The surgery is performed using general anesthesia, so the woman does not feel any pain.
• A mini-video camera is inserted into one of the holes, which shows the abdominal cavity from the inside on the screen of a special monitor, while the other holes are used for inserting surgical instruments.
• Before proceeding with direct surgical procedures, carbon dioxide is supplied to one of the holes made in the anterior abdominal cavity. This is necessary in order to make the surgeon’s work as accurate and convenient as possible. Carbon dioxide provides better visualization of the surgical field and the fibroid node, as a result of which there is no risk of careless damage to internal organs with laparoscopic instruments.
• Next, surgical instruments are used to dissect the uterine cavity and directly remove the myomatous node. If the tumors are small, they are removed through holes made in the wall of the abdominal cavity. If the myomatous node is large, an incision is made in the lower abdomen or in the vaginal area to remove it. The neoplasm is dissected into several small parts, which are removed one by one.
• Laparoscopic myomectomy lasts from 1 to 3 hours, depending on the number of nodules and their size. After the fibroids are removed, sutures are placed on the holes.

Contraindications to myomectomy

Laparoscopy for uterine fibroids is usually well tolerated by the female body and does not cause serious complications. But, like any other surgical intervention, the procedure has several limitations. Myomectomy is not recommended in the following cases:

1. If there is a suspicion of a malignant neoplasm in any of the internal organs, laparoscopic myomectomy is not performed.
2. A contraindication to surgical treatment of uterine fibroids is severe renal failure.
3. Laparoscopic removal of myomatous nodes is contraindicated if a woman has various diseases of the cardiovascular system or respiratory system.
4. When diagnosing diabetes mellitus, laparoscopy of fibroids is not prescribed.
5. If the size of the node in the uterine tissue is more than 10 cm, laparoscopic myomectomy is performed only after a preliminary course of hormonal drugs.
6. Obesity is considered a relative contraindication. This means that surgery and removal of the fibroid node is permitted only after the woman’s weight has returned to normal.

On the first day after surgical removal of a myomatous node, a woman may be prescribed narcotic analgesics. This is done in order to reduce pain, which can be quite severe. In some cases, anti-inflammatory or antibacterial drugs may be prescribed to prevent the development of inflammatory or infectious complications. In most cases, within 4-6 days after laparoscopic myomectomy and removal of the node, the patient is discharged from the hospital.

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