The incidence of fibroids ranges from 30% to 70% in women of reproductive age, with the peak incidence occurring between 35 and 49 years of age. Risk factors for fibroids include nulliparity, obesity, black ethnicity, family history, polycystic ovarian syndrome, diabetes, and hypertension. Fibroids are present in 5–10% of the patients presenting with infertility. Laparoscopic myomectomy is preferred over abdominal myomectomy because several small incisions are used rather than one larger incision. Related to the small incisions, recuperation is usually associated with minimal discomfort. Women with infertility and fibroids become pregnant after myomectomy in approximately 50% of cases. The pregnancy rate in patients undergoing hysteroscopic and laparoscopic/abdominal myomectomy is 45–49%. Laparoscopic myomectomy is a technically challenging procedure with surgeon-specific limitations. Preoperative treatments with gonadotropin-releasing hormone have been shown to reduce blood loss and shorten operative time. The consensus states that the maximal size must be 8–10 cm and the total number of fibroids should not exceed four. It is important not to perform laparoscopic myomectomies with more than 5–7 large fibroids because in these cases, the procedure is excessively time-consuming and gives the surgeon opportunities to miss the smaller fibroids after the uterus has been incised and repaired in too many places. The role of vasoconstrictors such as vasopressin, epinephrine, and ornipressin help with the control of bleeding from the incised sites. Temporary clipping of the uterine artery is an effective procedure in reducing hemoglobin loss during laparoscopic myomectomy.
Do you need surgery?
Uterine fibroids are growths in your uterus. Because they’re typically not cancerous, you can decide whether or not you want to have them removed.
You may not need surgery if your fibroids don’t bother you. However, you might consider surgery if your fibroids cause:
• heavy menstrual bleeding
• bleeding between periods
• pain or pressure in your lower belly
• frequent urination
• trouble emptying your bladder
Surgery might also be an option if you want to get pregnant in the future. Sometimes fibroids can increase your risk of having a miscarriage or complications during your pregnancy.
If you decide to have fibroid surgery, you have two options:
Surgery can relieve your fibroid symptoms, but it does come with risks. Your doctor will talk you through your options. Together, you can decide whether to have a procedure and, if so, which one to have.
Types of fibroid surgery
There are two types of fibroid procedures. Which one you have depends on:
• the size of your fibroids
• the number of fibroids you have
• where in your uterus they’re located
• whether you want to have children
Myomectomy removes your fibroids and can relieve bleeding and other symptoms. This surgery is an option if you’d like to have children in the future, or if you want to keep your uterus for another reason.
About 80 to 90 percent of women who have a myomectomy get relief from their symptoms or see their symptoms reduced. The fibroids won’t grow back after surgery, but you may develop new fibroids. Up to 33 percent of women who have this surgery will need a repeat procedure within 5 years because they grow new fibroids.
This surgery can be done in one of three ways, depending on the number, size, and location of your fibroids. You’ll be under general anesthesia for all of these procedures.
This procedure is more effective for women with smaller and fewer fibroids. Hysteroscopy can also remove fibroids that have grown into the inside of your uterus.
During the procedure, the doctor inserts a long, thin, lighted telescope through your vagina and cervix into your uterus. Fluid is injected into your uterus to expand it and help your doctor see your fibroids.
Then, the surgeon uses a device to cut or destroy your fibroids. The fibroid pieces wash out with the fluid that was used to fill your uterus.
With hysteroscopy you may go home the same day as your surgery.
This procedure, also known as a laparotomy, is better for large fibroids, but it leaves a bigger scar than the other two types of myomectomy. For this procedure, your surgeon makes a cut in your lower belly and removes your fibroids.
After abdominal myomectomy, you’ll stay in the hospital for one to three days. Complete recovery takes 2 to 6 weeks.
Laparoscopy is used for women who have smaller and fewer fibroids. During laparoscopy, your surgeon makes two small cuts in your belly. A telescope is inserted into one of the openings to help your doctor see inside your pelvis and around your uterus. A tool is inserted into the other opening to remove your fibroids.
Your surgeon may cut your fibroids into small pieces before removing them. In robotic laparoscopy, your surgeon uses robotic arms to perform the procedure.
Laparoscopic procedures may require an overnight hospital stay but have a faster recovery than abdominal myomectomy.
Hysterectomy removes part or all of your uterus. This procedure may be an option if you have a lot of fibroids, they’re large, and you’re not planning to have children.
The surgeon can remove your uterus in a few different ways:
• Laparotomy or abdominal hysterectomy. Your surgeon makes a cut in the lower abdomen and removes your uterus.
• Vaginal hysterectomy. The surgeon removes your uterus through your vagina. This approach may not work for very large fibroids.
• Laparoscopic hysterectomy. The surgeon inserts the instruments and removes the uterus through small incisions. This procedure can be done robotically.
The surgeon may leave your ovaries and cervix in place. Then you will continue to produce female hormones.
Complete recovery from an abdominal hysterectomy takes 6 to 8 weeks. Recovery from laparoscopic and vaginal hysterectomy is quicker.
Hysterectomy is the only surgery that cures uterine fibroids and fully relieves their symptoms. However, you will no longer be able to have children.
Recommendations of Laparoscopic surgery in COVID era
Even if it is still unknown whether SARS-CoV-2 shares the properties of other viruses that can be found in laparoscopic surgical smoke, many scientific societies have published online their recommendations on laparoscopy during this pandemic. The Society of American Gastrointestinal and Endoscopic Surgeons (SAGE) recommends stopping elective surgeries. In urgent or necessary surgeries, since laparoscopy could potentially release viruses, SAGE states that the use of devices to filter released CO2 for aerosolized particles, the reduction of medical staff to the minimum inside the operating room, and the use of personal protective equipment (PPE) should be strongly considered .
The European Society for Gynecological Endoscopy (ESGE) has also suggested postponing elective surgery for benign conditions until the pandemic ends. The screening of patients for coronavirus infection before planned surgical treatment or the postponement of surgery on suspected or documented SARS-CoV-2-positive patients until their full recovery, if there is no immediate life-threatening situation, is strongly recommended. If this is not possible, surgery must be performed with full PPE for the entire theater staff. Surgery for gynecological cancer should continue unless alternative interim options are possible after the end of the outbreak. The ESGE also provides suggestions to reduce CO2 release: (a) closing the port taps before insertion, (b) attaching a CO2 filter to one of the ports for smoke evacuation if needed, (c) not opening the tap of any ports unless they are attached to a CO2 filter or being used to deliver the gas, (d) reducing the introduction and removal of instruments through the ports, (e) deflating the abdomen with a suction device before removing the specimen bag from the abdomen, (f) deflating the abdomen with a suction device and via the port with a CO2 filter at the end of the procedure, and (g) minimizing the use of cauterization .
The Royal College of Obstetrics and Gynecology (RCOG) together with the British Society for Gynecological Endoscopy (BSGE) provides similar advice on CO2 evacuation and prevention of aerosol transmission and in addition suggests performing laparotomies or deferring operations that have a risk of bowel involvement due to an increased theoretical risk in such cases .The American Association of Gynecologic Laparoscopists (AAGL), along with many other surgical and women’s health professional societies, supports suspension of non-essential surgical care during the immediate phases of the coronavirus disease 2019 (COVID-19) pandemic .In addition to suggestions to reduce aerosol diffusion during and immediately after laparoscopy, the AAGL provides similar advice on screening patients before surgery and suggests additional imaging evaluation (chest computed tomography) prior to any surgical procedure, based on published data on its high predictive ability for early disease.
Dr. Ruchi Tandon is a reputed Gynecologist practicing in leading hospitals in South Delhi namely Max and Apollo hospitals, doing Laparoscopy for fibroids , by latest techniques and recommendations.