Reviewed By : Dr. Aarti Joshi
Listed below is the step by step procedure of hysteroscopic myomectomy:
- What is Hysteroscopic Myomectomy?
- Why is Hysteroscopic Myomectomy Required?
- Pre-operative Preparation
- Day Before Surgery
- Procedure Day
- Methods/Techniques of Hysteroscopic Myomectomy
- Post Procedure
- Risks and Complications
What is Hysteroscopic Myomectomy?
Fibroids, also known as uterine myomas, fibromas or leiomyomas are the most common tumors of the female reproductive system. About 20-40% of all women above 35 years of age are affected with this condition. About half of these go undiagnosed.
When non-invasive methods such as hormonal therapy and pain-killers don't seem to work, surgery is considered the final option. This is where hysteroscopic myomectomy comes to the rescue. It is particularly helpful when the fibroids are bulging into the uterine cavity.
An instrument called the resectoscope (similar to a telescope) is inserted into the uterus. A small camera attached to the hysteroscope allows the surgeon to see what's inside and remove the fibroids easily with the help of special surgical instruments.
Why is Hysteroscopic Myomectomy Required?
Following are the reasons why a hysteroscopic myomectomy is a preferred approach:
- It is done on an outpatient (OPD) basis. You can return home on the same day after surgery.
- There are lesser chances of scarring after surgery.
- You require lesser time to recover in comparison to other techniques.
- Low chances of risks and complications.
Fibroids and its associated symptoms are the only reason why you may need to undergo a hysteroscopic myomectomy. The fibroids should be well projecting inside the uterine cavity to be considered for this procedure.
Symptoms of fibroids include -
- Unsuccessful pregnancies
- Excessive bleeding from the uterus
Other uncommon causes to be considered before hysteroscopic myomectomy include:
- Leukorrhea: Abnormal whitish/yellowish discharge from the vagina
- Dysmenorrhea: Painful menstrual cycles with cramps
- Necrotic leiomyoma: following uterine fibroid embolization
- When the tissue structure seems uncertain in pelvic imaging.
However, hysteroscopic myomectomy is contraindicated in the following situations:
- In the presence of an acute pelvic infection
- During pregnancy
- Uterine or cervical cancer
- If you are suffering from any other medical condition – heart disease, bleeding disorders, etc.
- Your gynaecologist will discuss the surgical plan with you in this stage. If you have any doubts, feel free to clarify with him/her. An open communication will help reduce your worries and anxieties about the surgery.
- You will be asked to take certain medications about 6-8 weeks before the surgery (Zoladex, Synarel). These drugs have the ability to thin the lining of the womb (uterus), helping to obtain a better view of the womb during the surgery with lesser chances of bleeding.
- Eat a healthy diet rich in fruits, green leafy vegetables and proteins. You can start exercising to increase your body strength.
- Once you start taking the above mentioned drugs, you will notice that your periods have stopped. You will start experiencing hot flushes, vaginal dryness and night sweats. Don't worry, as their effects will wean off about 4 weeks after the surgery.
- Sometimes GnRH agonists are also given to thin the endometrial (inner lining of the womb) and to shrink the size of the fibroid and of the uterine blood vessels. These too decrease the extent of bleeding during the surgery.
- In some cases the gyanaecologist may consider dilating the cervix (especially in menopausal women who have a narrow cervix) before the surgery. Though not used all the time, but a discussion with your doctor may help you understand the need behind it.
- Let your doctor know about the details of any past medical history you might have had. This includes surgeries and diseases like hypertension, heart problems, diabetes, liver disease, renal (kidney) disorders, any respiratory problems, bleeding disorders etc.
- Inform the medical team if you are currently taking any prescription medicines, especially blood thinners (warfarin, clopidogrel), pain-relief medications like Aspirin and other NSAIDs (Non-Steroidal Anti Inflammatory Drugs and Analgesics). These medications can increase the risk of both intra-operative and post-operative bleeding.
- You will be asked to stop these medications a week or two before surgery.
- If you smoke or consume alcohol, you should stop it in the days before surgery. Smoking and alcohol interfere with the healing process.
- Antibiotic prophylaxis is not usually given but is allowed in cases where there is a history of valvular hear disease or tubal obstruction in pelvic inflammatory disease (PID).
Your gynaecologist will evaluate the condition of the uterus and then go ahead with the surgery after confirming her suspicions:
- Blood Test: A common finding in women suffering with fibroids is heavy bleeding. Your doctor would check your hemoglobin levels (Hb) to look for anemia because of this.
- Transvaginal Ultrasound (Sonography): A transducer like instrument is placed on your vagina and sound waves are used to see the images on a monitor.
- Hysteroscopy: The cervical region region is examined with the help of a hysteroscope. The camera on its head helps study the cervix visually.
- Hysterosalpingography: A dye is introduced inside the uterus and fallopian tubes and an X-ray is taken. Any tubal obstruction is ruled out with the help of this test.
- Magnetic Resonance Imaging (MRI): A 2-D view of soft tissues is produced with the help of magnetic and radiation waves.
Once your surgeon confirms the need for surgery, the anesthesiologist will order a general pre-operative workup to evaluate your fitness before the surgery:
- Blood Test: This includes blood sugar, blood urea, blood pressure (BP), hemoglobin (Hb), bleeding time, clotting time (BT,CT) and blood grouping.
- Urinalysis: Color and specific gravity of urine is checked. Along with this, presence of blood, proteins, pus cells etc are looked for to rule out any pre-existing pathology.
- Electrocardiogram: To study the electrical activity of heart, plotted on a graph paper.
- Renal Functional Test: Blood Urea Nitrogen (BUN) and creatinine levels are seen.
- Liver Function Tests: AST (aspartate transaminase) and ALT (alanine transaminase) levels are calculated.
- Skin Test: To rule out allergies.
- Imaging Tests: Ultrasound, CT and MRI scans are repeated to get the latest condition of the uterus.
- Clinical examination:is repeated.
- Airway: The airway (beginning of your respiratory tract) is checked for suitability of intubation.
Day Before Surgery
- Ask your doctor if there is a need to be admitted in the surgical facility a day before. Hysteroscopic myomectomy being an outpatient procedure, you need to be present at the surgical facility on the day of surgery itself.
- Pack all the necessary things you will need during the recovery time – books, magazines, your I-pod, anything to distract you.
- Bring loose fitting clothes and slippers to be worn later.
- Keep your valuables such as jewellery, ornaments, extra cash at home.
- Do remember to make travel arrangements to drop you and pick up from the surgical center.
- You should not eat or drink at least 6-8 hours before the surgery.
- Medications if any should be taken according to the doctor's recommendation.
- Report to the surgical centre on time.
- Come accompanied with a dear one who will be with you throughout the surgery and recovery.
- The nursing staff will check your vitals and do repeat a few lab tests.
- Your gynaecologist will discuss the entire procedure with you one more time. You can ask any doubts you want to clarify.
- The nursing staff will shave the pubic area. Don't shave it yourself.
- You will be asked to read and sign the consent form. The surgical procedure, risks and complications will be mentioned in it. Only when you feel ready for the surgery should you sign it.
If you are undergoing a myomectomy and not a hysterectomy (unless a situation where saving your life is more important), remember to mention it in the consent form.
- Wear the clean surgical gown provided by the nursing staff.
- A sedative will be given to you and some medication before the operation begins. The sedative will make you sleepy and then you will be taken to the operation theatre.
Two modes of administering anesthesia are possible:
- General Anesthesia
The anesthesia will be given to you either with the help of an I/V line or by inhalation of gases, but I/V is the preferred method. You will be asleep throughout the surgery and not even realise what happened during the procedure. The anesthesiologist will be monitoring your vitals (BP, pulse rate, temperature, breathing rate) throughout the surgery. Propofol and remifentanil are the preferred drugs for this process, but other drugs work just as fine.
- Local/Regional Anesthesia
In the case of this surgery, paracervical anesthesia is given to numb your cervical region and the dilate the cervix to some degree. Since only a specific location of your body is being numbed, you would remain awake. That is why you are given a sedative drug along with it to put you in a deep sleep.
Lidocaine is the most popular choice of anesthetic combined with remifentanil (a sedative). Research has proven the use of paracervical local anesthesia along with the use of a sedative drug as an efficient way to obtain anesthesia for hysteroscopic myomectomy.
Methods/Techniques of Hysteroscopic Myomectomy
Hysterectoscopic myomectomy is beneficial for removal of maximum 3 fibroids, where the largest permissible size of the fibroid is 5cm.
- After being taken to the operation theatre, anesthesia is administered to you.
- You are made to lie on the operating table in a position known as 'dorsal lithotomy.' You will be on your back with your thighs raised and feet supported with the help of leg stirrups. This gives the surgeon adequate access and visibility.
- The perineum (area between anus and vulva) is positioned slightly beyond the edge of table with the lower back (scarum and coccyx) well supported on the table.
- An injection containing vasopressin may or may not be given to dilate your cervix.
- The surgeon will use a hysteroscope to visualise the uterine cavity.
- Now the surgeon will insert the resectoscope through the cervix and distend the uterine cavity with fluid.
- The resectoscope is powered at 60 to 120 Watts depending on the size and consistency of the fibroids. Firm fibroids need a higher power.
- The fibroid is cut near at its base with the loop of the resectoscope. This cutting motion is done by first moving the loop ahead and then bringing it towards the surgeon. This motion is continued until the entire fibroid is cut.
- The resected tissue is now taken to the lab fo histopathological examination.
- The uterus is again reinspected using the hysteroscope. It is checked for any remnants of fibroid tissue.
- The area from where fibroid was resected will heal itself by covering with more endometrial tissue.
- Typically, this procedure takes about 1-2 hours to perform.
Hysteroscopic myomectomy is a routine outpatient procedure and may require from a few days to 2 weeks to recover. Your doctor will keep you in the surgical center for at least 4-5 hours until the effect of anesthesia wears off (if you are given locally) or be discharged after a day (if given general anesthesia).
- After the surgery you will be taken to a recovery room to relax. You will feel dizzy because of the effects of anesthesia. A drip will be attached to a vein in your arm. It contains saline and provides ou with electrolytes. It will be removed before you leave for home.
- The nursing staff will give you pain-relief medications, antibiotics (if needed) to eat after the surgery.
- If you had been under general anesthesia, your throat will feel slightly sore due to the intubation.
- Some vaginal discharge may be present for a few days.
- A urine catheter may be placed in your body for some time till you recover.
- You should rest as much as possible for the first 1 or 2 weeks. Avoid lifting any heavy things.
- Start with some walking a few days after surgery. Then slowly increase it according to your level of comfort.
- Initially, you may need some help while going to the bathroom. It's better if a dear one is with you all the time. After 2-3 days you would be easily able to do simple activities.
- You will feel tired a bit too soon than usual. It is normal and shall subside in a few days.
- Start with few breathing and relaxing exercises to ease out the discomfort due to surgery.
- Try refraining from any sexual activity at least for the first weak after surgery.
- You are encouraged to shower after the surgery. But avoid any tub baths.
- There might be heavy bleeding post surgery and continue for days.
- Don't use tampons as they can again cause a vaginal infection. You can use sanitary napkins instead.
- While bathing, use a very mild soap. Avoid using perfumed bath products and douches (mixture of water and vinegar) to clean your vagina.
- Remember to take the medicines exactly as prescribed by your doctor.
- Some women may complain of cramping after the procedure. Ketorolac tromethamine is effective in reducing discomfort after the surgery.
- Opiod analgesics (pain-killers) may be given if the pain is too much.
Emotional Well Being
- Surgery is a major step for many people as it is considered stressful. Our bodies produce hormones to cope up with such stresses. Because of their after-effects, you might feel slightly different than what you felt initially.
- Many women are worried about the impact of hysterectoscopic myomectomy on their sex lives. There is nothing to worry, as you would be able to resume your activities soon after recovery.
- You might feel quite sensitive or emotional after the surgery. This is normal and both you and your family should be ready for this sudden change. Your doctor can counsel all of you together to help you recover.
Risks and Complications
The complications of hysteroscopic myomectomy can be categorised into:
- General complications
- Complications specific to hysteroscopic myomectomy
- Anesthetic: Some people's bodies react adversely to the anesthesia administered in the form of nausea, vomiting, respiratory depression, arrhythmias, headache, coma, etc.
- Bleeding: This is especially seen in women who have heavy menstrual bleeding and anemia.
- Blood Clots: It is a rare complication but there is a possibility that they can form and travel towards the lower limbs. If not taken care of, the chances of developing deep vein thrombosis increases significantly.
Complications Specific To Hysteroscopic Myomectomy
- Adhesion/Scar formation: In an attempt to heal the tissues after surgery, scar (adhesions) formation can take place. As a result adhesions can block the fallopian tubes or trap the intestines.
- Damage to internal organs: It happens about in 1% of the cases. Sharp surgical instruments may accidentally damage the neighboring abdominal organs. Another surgery would be required to fix the damage.
- Reappearance of fibroids: There are chances of recurrence of fibroids even after their thorough removal.
- Hyponatremia: This happens because of excessive absorption of distension fluid after resecting the fibroids. The electrolyte levels decrease.
- Hysterectomy: Sometimes the bleeding is difficult to control or the surgeon may find additional abnormalities apart from fibroids in the uterus. This calls for a complete hysterectomy (removal of uterus). It is a rare occurrence.
- Complications in future pregnancies: Normal deliveries are risky once you have had a myomectomy. The next time you are pregnant, your gynaecologist most likely would go for a cesarean delivery (C-section) to avoid any problems to the uterus (rupture, for example).
- Spreading a cancerous tumor: A cancerous growth in your uterus could be mistaken for a fibroid. If this fibroid gets broken into tiny pieces during its removal, it can lead to spreading of the cancer. Menopausal women are more at risk of such a complication.
- Can I get pregnant after hysteroscopic myomectomy?
A. Yes. Unless your uterus has been removed under any circumstances during the surgery, you can perfectly conceive a child. You should discuss with your gynaecologist as to how and when you can plan a baby.
- When can I start driving after the procedure?
A. Being an outpatient procedure with no stitches at all, you can resume activity quite soon. But it is best recommended that you wait for 5-7 days before resuming driving.
- Can't I have a normal delivery after undergoing a myomectomy?
A. No. The next time you get pregnant after any myomectomy procedure, your doctor will prefer not to cause any more trouble to the uterus. A C-section will protect the uterus and keep it healthy.
Hysteroscopic myomectomy is a minimally-invasive procedure with few complications. There is nothing to worry about, as you will be leading a very normal life in all respects. Regular check ups with the gynaecologist can help in early detection and nip the problem of fibroids in the bud.
This article is not exhaustive but can guide you about the process.