LAPAROSCOPY
Removal of Fibroids
Laparoscopic Surgery
Laparoscopic surgery is usually performed as out-patient surgery under general anesthesia and has absolutely revolutionized gynecologic surgery because of the short hospital stay and quick recovery. The technique continues to evolve as new instruments are developed. Because of the small size of the incisions and the level of skill needed to correctly perform the surgery, this procedure is actually harder for a physician to perform and takes more skill and training than abdominal surgery.
The laparoscope is a slender telescope that is inserted through the navel to view the pelvic and abdominal organs. Two or three small, half-inch incisions are made below the pubic hairline and instruments are passed through these small incisions to perform the surgery.
For laparoscopic myomectomy, a small scissors is used to open the thin covering of the uterus. The fibroid is found underneath this covering, grasped, and freed from its attachments to the normal uterine muscle.
Laparoscopic Myomectomy
After the fibroid is removed from the uterus, it must be brought out of abdominal cavity. The fibroid is cut into small pieces with a special instrument called a morcellator, and the pieces are removed through one of the small incisions. New morcellators allow the easy removal of even large fibroids. The openings in the uterus are then sutured closed using specially designed laparoscopic suture holders and grasping instruments. Laparoscopic suturing with small instruments, in particular, requires special training and expertise. The entire procedure can take one to three hours, depending on the number, size, and position of the fibroids.
- Myomectomy should be performed only if appropriate indications exist. And since it is a technically difficult surgery, your physician should have the extra training and experience that it requires.
Many gynecologists have not been trained to suture with laparoscopic instruments, and some may even say that laparoscopic surgery is not possible. It is often a good idea to get a second opinion from a gynecologist who performs laparoscopic myomectomies on a regular basis to see if this procedure is feasible for you (see below).
Following laparoscopic myomectomy, most women are able to leave the hospital the same day as surgery. For more extensive surgery, a one-day stay may be a good idea. Because the incisions are small, recuperation is usually associated with minimal discomfort. Since the abdominal cavity is not opened to air, bacteria are less likely to reach the area of surgery, and the risk of infection is very low. The intestines are not exposed to the drying effect of air, or the irritating effects of the sterile gauze sponges used to hold the bowel out of the way during abdominal surgery. As a result, the intestines usually begin to work normally again immediately after laparoscopic surgery. This avoids the one- or two-day delay before a person is able to eat following regular abdominal surgery. After laparoscopic myomectomy, women usually can walk the day of surgery, drive in about 1 week and return to normal activity, work, and exercise within two weeks.
Can Laparoscopic Myomectomy be Performed if You Want to Have Children?
The use of laparoscopic myomectomy for women who desire to have children is controversial. The concern is how well the uterus will be able to withstand the stress of labor after having been cut and repaired with laparoscopic techniques. Fewer women have gone through labor and delivery after having a laparoscopic myomectomy than the numbers of women going on to have children after an abdominal myomectomy. The uterine scar, however, appears to heal as securely with a laparoscopic myomectomy as with myomectomy done by laparotomy. While many women have gotten pregnant and delivered safely, some physicians may recommend Caesarean section for delivery to avoid the stress of labor on the uterus. There are now a number of studies showing the safety and success of laparoscopic myomectomy for women who wish to get pregnant. However, a study comparing laparoscopic myomectomy and standard myomectomy with regard to fertility, labor, and delivery has not yet been performed by the research community. Further study will be needed to clarify this issue.
Can Myomectomy Lead to Scar Tissue?
Any surgery can cause scar tissue to form. Your body makes new tissue as part of the healing process to help connect things back together. This new tissue is called scar tissue or adhesions. Unfortunately, this natural defense can work against us when it occurs internally after surgery, because scar tissue may stick to and pull the normal tissue around it, sometimes causing pain. Scar tissue near the fallopian tubes or ovaries may decrease fertility by making it difficult for the egg to travel to the fallopian tube.
One of the major benefits of laparoscopic surgery is the principle that it causes fewer adhesions than abdominal surgery. A group of Italian doctors recently performed laparoscopy on a group of women a few months after they had fibroids removed by either laparoscopy or traditional abdominal surgery. The number of women studied was small (thirty-two), but the doctors found fewer and thinner adhesions in the women who had laparoscopic surgery. Further studies need to be performed, but this information is encouraging for women wishing laparoscopic surgery.
Can Adhesion Barriers Prevent Scar Tissue?
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| This adhesion barrier looks and feels like a silky piece of gauze. | When placed over the uterus and sprinkled with sterile water, the adhesion barrier sticks to the uterus and prevents other organs from sticking to the sutured area. |
Another new advance in surgery has been the use of special substances, called adhesion barriers, which help prevent the formation of scar tissue after surgery. Small sheets of cloth-like material can be wrapped around the raw areas from surgery and the material prevents nearby tissue such as the intestines from sticking to the surgery sites. After a few weeks, the material dissolves, leaving the newly healed surgery sites fairly free of adhesions. While the barriers are not perfect, they have been shown to help reduce the formation of adhesions
Summary
In conclusion, the main issues to remember are that all operations have complications. The main issues for laparoscopic myomectomies is the risk of heavy bleeding that may lead to a hysterectomy at the time of the operation or result in a conversion to an open procedure requiring longer hospital stay and recovery time.. The longer term risk of uterine rupture in subsequent pregnancies although a small risk is a significant risk and needs to be discussed & understood.