Below is a video showing a large broad ligament fibroid (in an awkward position) being removed by keyhole surgery. The important thing is careful surgical technique, and the use of substances to reduce blood loss and to help prevent the development of scar tissue.

Having fibroids removed is a major undertaking both for the surgeon and the patient. The method of operation will depend on the number and size of the fibroids and how the fibroids are related to the womb.

Traditionally all fibroids were removed by open surgery but increasingly it is now possible to operate on fibroids laparoscopically (using “keyhole surgery), though size, number and site of the fibroids is taken into consideration it is possible to operate and large, “awkwardly” located  and numerous fibroids by means of keyhole surgery.

Irrespective of the type of surgery there are complications that should be considered, this is what I tell all patients who are having a myomectomy:

Just because the fibroids are there does not mean you have to remove them the only reason for removal is to improve symptoms.

Removing fibroids is not a sport

There are reports of more than 200 fibroids being removed from one individual. On occasion this may be necessary but I will remove fibroids that are causing symptoms with the aim to improve fertility. I will not continue just because I can if I feel that the womb will be too scarred it may on occasion be necessary to leave some behind

Things you need to consider before you go ahead

1.     Adhesions (scar tissue formation after surgery)

Most women who have fibroids removed will develop adhesions (scar tissue that is a consequence of tissue healing). The quoted figure is about 90% however this can be halved with laparoscopic surgery. Measures to prevent the development of adhesions should be used during fibroid surgery.

Adhesions can lead to:

a.     Problems with fertility
b.     Problems with chronic pelvic pain
c.      Problems with intestinal obstruction

It is important to ask your doctor what type of adhesion prevention will be used during your surgery

2.     Blood Transfusion:

Fibroid operations are potentially bloody operations; most women who have these operations will bleed. The risk of a blood transfusion ranges from 1 in 20 to 1 in 50 depending on the size of the fibroid, the number of fibroids and their location.

There are surgical techniques that are used to decrease bleeding including temporary tourniquets.

There are also medications that are used to decrease the risk of bleeding these include:

a.     Vasopressin
b.     Misoprostol
c.      GnrH analogues like Zoladex. I prefer not to use this particular drug unless my patients are anaemic as women in whom it is used preoperatively are at greater risk of fibroid regrowth after myomectomy.

For women who want to avoid blood transfusions “cell-savers” where own blood is filtered and used for transfusion can be used.

Ask your doctor about these issues before you proceed with surgery.

Kurt Semm one of the leading innovators of his time is credited as performing the first laparoscopic myomectomy in the 1970s

Since then laparoscopic myomectomy has become a mainstay treatment for selected women with uterine fibroids, with its proven advantages as a minimal access surgical technique.

Women require less pain relief. In most cases it takes longer to perform than open surgery but women t return to normal activities quicker. It is associated with less blood loss, and less adhesion formation (formation of scar tissue).

Factors limiting the availability of this therapy to most women is surgeon training and skill but having said that it is not the operation of choice for all. But where feasible it should be offered.

Traditionally laparoscopic myomectomy used to be limited to women with fibroids of 5cm or less, ideally the fibroids would have been subserous or intramural and not more than 3 in number.

With increasing technological advancement it is now possible to manage deep intramural or submucous fibroids laparoscopically. In fact in medical literature there are reports of fibroids of up to 15cm being removed laparoscopically.

The advantages of laparoscopic surgery to open surgery for women with fibroids includes:

Less Adhesion formation:

Adhesions are defined as scar tissue that results from the body healing itself. Tissues that are in proximity to each other during the healing process tend to stick together.

More than 90% of women who have myomectomy will develop adhesions. In 30% of these women they may be significant and lead to intestinal obstruction, chronic pain. If the adhesions involve the fallopian tubes or distort the pelvic anatomy they can lead to infertility

Laparoscopic surgery for the treatment of fibroids decreases adhesion formation by half and the adhesions tend to be less dense and less significant.

Less Blood loss:

Myomectomy is potentially a very bloody operation. This of course depends on the number and the location of fibroids. The greater the number of fibroids and the deeper the fibroids the greater the bleeding.

In my personal series there is about a 1:50 risk of needing a blood transfusion. With open surgery the risk can be as high as 1:20

Hospital stay:
After laparoscopic myomectomy the majority of women stay in hospital for 1-2 days
Return to normal activity
Recovery after any sort of surgery depends on the individual level of fitness and health before surgery.

Depending on the number of fibroids removed and the difficulty of the procedure the majority of women are able to return to 50-75% of their normal activity within 1-2 weeks. Women who work from home should be able to do this within 2 weeks.

By the 4th week women should be able to return to most of the activities they used to enjoy before surgery and by 6 weeks they should be able to return to the Gym.

After open surgery the above figures are usually doubled.

Educational video depicting actual surgery for a fibroid located on the posterior aspect of the uterus (video contains actual surgery)

Laparoscopy (Lap-a-ros-cop-ee) is a type of surgery where doctors can fix things easily through tiny cuts in the tummy. These heal faster, cause lesser pain and look better than a big scar. 

it allows surgeons to perform relatively big operations through small incisions

with this sort of surgery it may take the surgeon longer to perform but takes patients shorter time to recover

It uses a pencil thin tube called a laparoscope, which is connected to a light and a camera so that the doctors can see what’s happening inside of you. 

Gas is used to swell the tummy so that the doctor can see your inside more clearly. 

Then the laparoscope is put into the tummy through a small cut (about 1 cm) near the belly button. The shining of the light allows to doctor to view any problems that can be fixed. 

Usually to do this one or two more cuts are made in the pubic hairline so that other instruments can be used to obtain tissue samples (a biopsy) or fix what is making you unwell such as taking out a diseased part. 

An instrument may also be passed from the vagina into the womb so as to move it around and look for any problem. 

After the operation the instrument is removed, gas released, and the cuts are closed, usually with the stitches that dissolve. 

A laparoscopy is performed under general anaesthesia, so you will be completely asleep throughout and unable to feel any pain. 

The operation lasts for about one hour and can usually be done as a day case. This means you come into the hospital on the day of the operation and go home on the same day. However this depends on the extent of the surgery and how well you recover from the operation. 

Why do I need one? 

If you are having pains or swellings in the tummy that point out towards the womb, ovaries, fallopian tubes a look inside is sometimes needed to see what is going on. 

Laparoscopy can be used in the diagnosis and the treatment of: 

• Pelvic pain due to

• endometriosis,
• infections,
• twisting (torsion) of an ovary, ovarian cyst, scar tissue (adhesions) in the pelvis.
• Pelvic swellings such as fallopian tube or ovary or the uterus (fibroids)
• infertility

Laparoscopy can also be used for relatively complicated operations such as 

• Hysterectomy
• Myomectomy removal of fibroids
• Treatment of severe endometriosis
• Division of scar tissue Adhesions
• Repair of prolapse
• Correction of abnormalities of the womb

Are there any risks or possible complications?

Complications in young healthy women undergoing laparoscopy are rare and occur in only about 1-3 women in about 1000 cases. These include:

• Rare chance of an unexpected reaction to the anaesthetic.
  

•  infection 
  

• Risk of damage to an internal organ such as 
  

     Bowel,

                                                                        Bladder, and

                                                                       Blood vessels.

Certain condition affecting the tummy increases the possibility of these complications like adhesions (internal scars) from previous operations a large growth, and obesity.

If this happens then you might need a bigger cut (laparotomy) where the tummy is opened. This may require a stay in the hospital for a few days and the recovery is longer.

The chances of the complications depend on the exact type of operation you are having and other factors such as your general health. 

other Minor complications include
Bruising
shoulder tip pain

it is also important to put the risk of complications  in context a recent RCOG publication looking at risk defined a risk of 1:10 as being very common and likely to happen to a known family member
a risk of 1:100 as common and something that may happen to someone on the street
a risk of 1:1000 as uncommon and likely to happen to one person in small village
a risk of 1,10,000 is rare and likely to happen to someone in a small town
a risk of 1:100,000 as very rare and something likely to happen to someone in a large town.

If a laparoscopic surgeon were to carry out 200 procedures a year it may take 10 years for one complication to occur.
As with all things it is important to ask your own doctor about their individual track record.

How you recover after a laparoscopy will depend on how fit you are, what the laparoscopy was for and how long the operation takes. women tend to recover quicker after a diagnostic procedure than after an operative laparoscopy

After Surgery 

You will be monitored closely for a few hours until after the anaesthetic wears off. Once you are able to walk and get out of bed without help and have emptied your bladder you will be allowed to go home. If you are unable to empty the bladder of have lot of pain or sickness be prepared to stay.

What to Expect?

Going Home

Even though you may feel awake the effects of anaesthetic may take some time to wear

• It can make you drowsy slow clumsy, unsteady on your feet and forgetful so:
• Plan to have a friend or relative to take you home and stay overnight.
• Avoid driving, alcohol, using power tools, or even boiling a kettle of water till 24 hours after.
• Wear low-heeled shoes.

For the drive home recline your seat halfway. Hug a pillow gently against your tummy to soften any road bumps. Have a paper bag and tissues nearby in case you vomit.

Pain

You may have a period like crampy pain for a day or two. The amount you have depends on how much surgery you have had.

Sneezing, laughing, crying and coughing may be uncomfortable. The pain should improve by the next day and can be eased by taking the usual painkillers and wearing loose fitting clothes to prevent any pressure on your tummy especially the belly button. Lie in whichever position is most comfortable.

If it helps, keep your legs bent upwards, propping your legs up with pillows. Hugging a pillow can also help protect your cuts especially if you are lying on your side or with your partner. The gas used to swell up your tummy can cause rib, neck or shoulder pain and tummy bloating. It may also make you burp or break wind a lot. It will take a few days for the symptoms to ease. Try moving around and lying flat to help the gas disappear. Heat (e.g. hot water bottle, warm shower) massage and drinking water either hot or cold /tea with fresh lemon can also help as can peppermints. your partner. The gas used to swell up your tummy can cause rib, next or shoulder pain and tummy bloating. It may also make you burp or fart a lot. It will take a few days for the symptoms to ease. Try moving around and lying flat to help the gas disappear. Heat (e.g. hot water bottle, warm shower) massage and drinking water either hot or cold /tea with fresh lemon can also help as can peppermints.

Activity

Expect to feel sore and “washed out for the first few days .Most women need at least 2 days to recover from the anaesthetic alone. In this time spend as much time as possible lying down or sleeping. After this if you feel up to it, walk around the house a little bit but don’t overdo it or you may end up feeling light headed and exhausted. It is usually safe to resume your normal activities but avoid strenuous exercises /activity until you are feeling fit, usually after your first post operative visit. Arrange to take a week off work but ask your doctor as it largely depends on your condition and the type of surgery performed.

Sore Throat

You may experience sore throat caused by the irritation of the tube passed down your throat during anaesthesia. Throat lozenges may help.

Eating

Nausea as a result of anaesthetic may be made worse by greasy or oily food. Try eating light easily digestible food for a few days such as a cup of tea, soup, dry toast, jelly or crackers. Start with liquids and slowly work up to a normal diet as your stomach will accept it. Room temperature foods are better than hot or cold foods at first. Chewing gums or sucking on hard sweets can help control nausea as can waving an alcohol wipe under your nose (ask nurses for a few).To prevent dehydration and constipation (side effects of both general anaesthesia and pain killers )be sure to drink lots of fluids and include high fibre fruits and vegetables like prunes and spinach.

Cuts

Keep your cuts clean by bathing and showering as normal and dry your skin thoroughly. Avoid possible irritants like talc or bubble bath. If you have stitches they usually dissolve over a few weeks or can be removed by your GP, You may also have a watery pink tinged discharge from your cuts for a day or two. Steri strips which look like tape may be used to cover your cuts and prevent your clothing from rubbing on them. They can be removed 2 to 3 days following surgery or if they become too wet. The cuts tend to heal quickly and tech to itch more than they hurt. The area around your belly button will be tender and swollen for a week so avoid clothing that may rub.

Bleeding

You may have light vaginal discharge or bleeding like at the end of the period. It will last for up to 2 weeks. If your laparoscopy was to investigate infertility, there may also be some bluish discharge (from a blue dye used during surgery).

To reduce the risk of infection whilst bleeding:

• Use sanitary towels instead of tampons.
• Avoid sexual intercourse until the bleeding has stopped
• Avoid swimming
• Shower rather than bathe 

What is the ideal pathway for women with symptomatic fibroids?

Comparing Myomectomy with hysterectomy for the management of fibroids

Management of symptomatic fibroids will always depend on the number, size and location of the fibroids.

Importantly however is the woman’s age and need for present or future reproductive capacity. In the ideal world once a woman’s family is complete and she remains symptomatic of her fibroids she should have definitive treatment, which would either be Uterine artery embolization or surgery

When surgery is considered comparing myomectomy and hysterectomy there are trade-offs in terms of benefits and drawbacks. When a myomectomy is performed;

Benefits: retaining the womb and potential reproductive capacity

Drawbacks:

The complications of a myomectomy include;

Adhesions, which can give, rise to

Pain and

Bowel obstruction,

Delayed recovery being a potentially bloody operation recovery can sometimes be delayed. There is also the risk of

New growth of fibroids.

If there is a reason to retain the womb for fertility purposes then these risks may be worth taking otherwise when family is complete and fertility no longer desired a hysterectomy might be a superior operation to myomectomy.

For women who do not want a hysterectomy

Understandably for a number of reasons women may not want to have their wombs removed. For this group of women the choices would either be a uterine artery embolization or a formal myomectomy either open myomectomy or laparoscopic, having weighed up the risks and benefits.

Young women who have not completed their family and fertility desire is not immediate

The hardest group of women to advise are those who have relatively asymptomatic fibroids are young and have no children because of the inherent risk of hysterectomy with whatever modality they choose to treat the symptoms of their fibroids. Though the risk is low (about 1:100-250) it is a real risk.

Traditionally the advice was to keep the fibroids try for pregnancy and if pregnancy does not happen then come and have the fibroids removed. However no one knows what the natural progression of growth of fibroids are. There are studies that have looked at growth difference between women over time and growth of different fibroids in the same woman and the conclusion is that no two fibroids grow at the same rate either in different women or in the same individual.

With increasing advancements in laparoscopic surgery for the management of fibroids and because it is not as traumatic as open surgery, with less risk of adhesion formation, it may be appropriate to advise these women to have a laparoscopic myomectomy while the fibroids are still of a manageable size. The cut off point would be 5cm or more.

The modern trend after a hysterectomy is to be discharged as soon as possible.

The advice varies according to the type of hysterectomy.

The shortest length of stay in hospital is after a laparoscopic hysterectomy. The modern approach to this operation is as a day case procedure meaning you stay in hospital for less than 24 hours. Most women will be discharged in 1-2 days.  You may feel tired for the first few days after surgery and find yourself napping a lot. This is because your body is concentrating on healing itself.

The advice after hysterectomy is to rest, this does not mean complete bed rest. Women can expect to potter about the house but still need to take things easy and in most cases should have someone around for the first few days. Most women at this stage will still need to take some painkillers. Depending on the strength of this medication they will be advised not to operate machinery and if the medication contains “opiates” strong painkillers they may be advised not to use a hot kettle. Recovery after a laparoscopic hysterectomy will take about 1-2 weeks for the majority of women and return to work can take as little as 2-4 weeks. Of course this depends on the type of job you do.

If you work from home it is possible to undertake some work within the first week.

By the end of the week it should be possible to negotiate stairs and even visit the “corner shop” to by the newspaper. It may be best to be accompanied on the first venture out doors.

Lifting: it is important not to lift heavy objects immediately after major surgery. This includes lifting children as is often tempting. Hovering also works the muscles of the abdomen and pelvic floor it is important not to under take this activity for the first 4 weeks

Driving may take up to 2 weeks after a laparoscopic hysterectomy; you need to be free from the effects of painkillers. The advice is that if you are able to sit in a car that does an emergency stop without any discomfort. Other things you should be able to do before you drive are:

 Be able to sit in the car comfortably and work the controls

Be able to wear the seatbelt comfortably

Be able to make an emergency stop

Be able to comfortably look over your shoulder to manoeuvre.

For the vaginal hysterectomy hospital stay is usually 2-3 days and return to normal activity 2-4 weeks.

For the traditional abdominal open hysterectomy recovery can somewhat be delayed as because as well as internal healing the outside scar also needs time to heal. Hospital stay is longer and can take up to 4-5 days and recovery takes about 6 weeks

The video below shows a large fibroid uterus weighing 850g being removed laparoscopically the normal uterine size is between 60-90g. This video shows that even for large uteruses laparoscopic subtotal hysterectomy "LASH" is possible

The laparoscopic subtotal hysterectomy also known as the Laparoscopic supracervical hysterectomy or LASH for short is the ideal hysterectomy and here is why:The laparoscopic subtotal hysterectomy is least traumatic hysterectomy to recover from.

There should be no reason why a woman with a normal cervix, who has had normal smears should have her cervix removed, especially if she is having a hysterectomy for fibroids or for heavy periods.

The arguments for and against having a laparoscopic subtotal hysterectomy are:

1. Shorter recovery time: recovery from the procedure takes about 1-2 weeks with a full return to function for most women within 2-4 weeks
2. Better sex: the jury is still out on this, but what is known is that

• Women who have subtotal hysterectomy resume sex earlier than women who have had a total hysterectomy.
• Some believe that from some women orgasm originates from the cervix. If this is the case then if the cervix is left behind then the source of orgasm is not removed.
• The vagina is not entered when a subtotal hysterectomy is performed therefore the vagina is not shortened therefore theoretically sex life should not change

  3. Prolapse: theoretically the use of subtotal hysterectomy should prevent prolapse. 
     This is because the ”pericervical ring” tissue around the cervix that helps support the vagina is not interrupted   
      during the procedure. Scientific studies however have not been done to support or refute this.
 4. Bladder of bowel function: there is no difference in bowel or bladder function
 5. Decrease in complication rates:  
     the major injury that is reduced is injury to the ureters. Because the operation is above the ureters they are
    protected.
 6. Easier operation for the surgeon

Those that argue against leaving the cervix behind argue that it may be the source of future cancer. The risk of developing cervical cancer on the cervical stump after 3 negative smears is less than 0.4%.  This risk is much less than developing cancer of the vagina after total hysterectomy but no one removes the vagina because of future risk of that cancer.

As with all things the risks need to be balanced against the benefits.

In summary LASH is the ideal hysterectomy for heavy menstrual bleeding it is ideal because:

1. Hospital stay can be only 24 hours in fact it can be done as a day case procedure
2. It produces minimal scaring - Minimally invasive
3. It is the most cosmetic - no large abdominal incision
4. Causes the least stress to your body
5. There is no scar in vagina 
6. There is no shortening of the vagina
7. Fewer complications
8. It provides more satisfactory sex life after surgery

Before having your hysterectomy get into discussion with your surgeon. Ask whether there is any reason why your cervix should not be left behind.

Hysteroscopic fibroid resection (part II)

Continuing our discussion about resection of submucous fibroids.

One of the determinants of success of this procedure depends and size of the amount of fibroid in the cavity of in relation to the muscle of the womb.

A simple classification used is:

Type 0= where all the fibroid is in the cavity of the womb

Type I = where most of the cavity is within the cavity of the womb and some within the muscle

Type II = where most of the fibroid is within the muscle of the womb and a little projecting into the cavity.

(Type 0 fibroids are generally easier to remove than type II)



Other factors that determine success are:

1.     The size of the fibroids and uterus and

2.     The number of fibroids.

In a recent scientific study women with a normal sized womb and no more than 2 fibroids were projected to need additional surgery less than 10% of the time within 5years compared to women who had an enlarged womb and 3 or more fibroids where the risk increased to 35%.

If your gynaecologist feels that your fibroids are too large you may be advised have some medication to shrink the fibroids. The commonest medication used in a GnrH analogue. This may help make the procedure easier and help reduce some complications, reducing the fibroid size by up to 30% after 2-3 injections, reducing the operating time and reducing the amount of fluid absorbed into the body.

The commonest complication of this procedure is tearing of the cervix at the time of entry into the womb. For this reason your surgeon may advise that your cervix be prepared before the operation. Commonly the night before or a few hours before the procedure you may be advised to insert a tablet or two of Misoprostol, which is a tablet that makes the neck of the womb softer and easier to dilate for the procedure.

Another complication that surgeons encounter is fluid overload. This happens when the fluid used to distend the uterus for the operation is absorbed into the body. Special fluid monitoring systems are available to help avoid this complication to ensure that the amount of fluid that goes in is what comes out. Surgeons generally stop the procedure if they notice that the fluid “lost” is more than 1000mls.

Bleeding can also be a complication of this type of surgery and in most cases is put right either by the use of medication or the use of compression during the procedure. Only in extreme cases would a hysterectomy be necessary in cases of intractable bleeding as a life saving measure. The risk of this is generally put at 1:10,000.

If bleeding is encountered or the fibroid found to be too big for some women a

2-stage procedure may be necessary. This is where the procedure is stopped and completion surgery scheduled for another time.

If you have been advised to have a Hysteroscopic resection of your fibroid discuss these issues with your doctor. You should ask whether

1. Cervical preparation is necessary and whether is will be used in your case?
2.  What measures will be taken to avoid fluid overload?
1. Will a special pump be used to monitor fluid?
3. What their success and complication rates are. 

The most important part of a gynaecological exam and consultation is the atmosphere in which the discussion is carried out.  With both partners in the discussion equipped with knowledge.

The woman (the patient) the knowledge of her symptoms and how these symptoms and signs affect her quality of life and sometimes the quality of life of those dearest and nearest to her.

Her Gynaecologist should possess not only the knowledge of female anatomy and physiology but also have the ability to piece together the pieces of an evolving jigsaw to eventually come to a conclusion and institute management and hopefully cure.

The understanding of the human body is ever evolving and treatments that would have been acceptable for years quickly become obsolete. Current treatments may also have serious complications.Thus the gynaecologist needs to be up to date both with the literature and the interpretation thereof and how this applies to the individual patient.

With the growth of the internet and social media and special interest groups, information is widely available and most women have abundance of information to present during the consultation, most of which is relevant but may not apply to her particular circumstance.

The modern gynaecologist therefore should the ability to search this media at short notice and point out the relevance of the information and be able to guide the woman down the right path, allowing the woman to make an informed and educated decision about the course she wishes her management to take.

The gynaecologist also needs to possess the most up to date skills and in this day and age for the most part Minimal access surgery should be the norm where applicable. Minimal access surgery is associated with less pain, less blood loss, quicker recovery, and quicker return to normal activities.

The skill of Minimal access surgery should not however be looked at as a panacea for all, and procedures should not be carried out just because the surgeon “can” but should be carried out for the right reasons and because it what is required under the particular circumstance. “ Just because one has a hammer not all objects are nails”