Open myomectomy principles procedure complications

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Open Myomectomy: Principles, Procedure, and Complications

Overview

Myomectomy is the surgical removal of uterine fibroids (leiomyomas) while preserving the uterus in situ. Open (abdominal) myomectomy - also called abdominal myomectomy - is indicated for intramural and subserosal fibroids (FIGO types 3-8) that cannot be addressed hysteroscopically or vaginally, and is preferred when fibroids are large, numerous, or their location makes laparoscopic access technically demanding.

As Victor Bonney, an early advocate, stated in 1931: "The restoration and maintenance of physiologic function is, or should be, the ultimate goal of surgical treatment."

Berek & Novak's Gynecology, p. 521

Indications

Symptomatic fibroids (heavy bleeding, bulk symptoms, pelvic pain) in women who wish to retain uterine function
Infertility or recurrent pregnancy loss attributed to fibroids
Intramural/subserosal fibroids (types 3-8) not amenable to hysteroscopic approach
Large or numerous fibroids where laparoscopic removal is not feasible
Fibroids discovered at the time of cesarean section (in selected patients, in experienced hands)

Preoperative Planning

Imaging: MRI is the preferred modality. It provides superior detail on:

Number, size, and location of fibroids
Vascularity
Path of the endometrial cavity - essential for planning incisions to avoid inadvertent entry
CT is less useful; ultrasound is often used first but MRI is gold standard for surgical planning

Preoperative optimization:

GnRH agonist therapy (e.g., leuprolide) reduces fibroid volume and corrects anemia preoperatively, though it may obscure small fibroids and make the fibroid capsule more adherent
Iron supplementation for anemia correction
Type and screen / crossmatch (blood transfusion risk is significant)
Berek & Novak's Gynecology; Sabiston Textbook of Surgery

Surgical Technique - Step by Step

1. Access and Orientation

The abdomen is opened via a Pfannenstiel or midline vertical incision (the latter preferred for large uteri)
The orientation of the uterus relative to adnexal structures is noted
The uterine arteries run along the lateral sides of the uterus - incisions are therefore made medially to avoid vascular injury
Location of adnexal structures guides assessment of uterine artery position when normal anatomy is distorted

2. Hemostatic Measures (Before Incision)

Blood loss control is the central challenge of myomectomy. Multiple strategies are available:

Method	Approximate Blood Loss Reduction
Intramyometrial vasopressin	~246 mL
IV tranexamic acid	~243 mL
Cervical tourniquet (Foley)	~240 mL
Vaginal misoprostol	~98 mL
Polyglactin suture around cervix + IP ligaments	~1,870 mL

Vasopressin (dilute: typically 20 units in 100 mL normal saline) is injected into the serosal and myometrial layer overlying the fibroid until blanching is noted. Maximum total dose suggested is <5 units to avoid cardiovascular collapse. The half-life of intramuscular vasopressin is 10-20 minutes with duration of action 2-8 hours. Cardiovascular collapse, peripheral arterial vasospasm, and loss of peripheral pulses have all been reported - the anesthesiologist must be alerted before injection.

Intraoperative tourniquet: A Penrose drain, pediatric feeding tube, or suture is placed around the lower uterine segment (after opening the broad ligament bilaterally) to impede uterine blood flow. Can be augmented with temporary bulldog clamps on the uterine arteries and ovarian vessels. Tourniquets should not be left on more than 60 minutes.

Misoprostol (400-800 mcg rectally before incision) induces uterine contraction, creating a tamponade effect on smaller vessels.

Tranexamic acid (1,000 mg IV bolus at time of incision) - antifibrinolytic; well tolerated.

Cell saver: Recommended for large cases (uterine size >16 weeks). Avoids transfusion reaction risk; salvaged red cells have equal or superior oxygen transport capacity to stored allogeneic cells. In one series of 92 women with uterus >16 cm, mean reinfused volume was 355 mL.

3. Uterine Incision and Fibroid Enucleation

An incision is made sharply, with monopolar current, or with a harmonic scalpel in the serosa overlying the fibroid and carried through the myometrium until the fibroid capsule is identified
The fibroid is grasped with a tenaculum or penetrating towel clamp
Blunt dissection, monopolar current, sharp dissection, or harmonic scalpel is used to dissect the fibroid from adjacent myometrium - direct incision into the myometrial layer is avoided
Hemostasis is maintained with judicious cautery or suture ligation

4. Closure of the Myometrial Defect

The myometrial incision is closed in layers with delayed absorbable suture
Number of layers is determined by depth of defect
Barbed suture is commonly used (facilitates efficient layered closure)
A final serosal suture layer approximates the hysterotomy edges
Meticulous closure is important - inadequate closure increases risk of uterine rupture in subsequent pregnancy

5. Adhesion Barrier Placement

An adhesion barrier (e.g., Interceed, Seprafilm) can be placed before abdominal closure
A randomized study of 127 women showed Seprafilm significantly reduced adhesion incidence and severity scores vs no treatment
Posterior uterine incisions carry higher adhesion risk than anterior incisions
Berek & Novak's Gynecology, p. 531

Open vs. Laparoscopic Myomectomy

A systematic review of 6 RCTs (576 patients) found:

Outcome	Open Myomectomy	Laparoscopic Myomectomy
Operating time	Shorter	Longer
Intraoperative blood loss	Greater	Less
Postoperative hemoglobin drop	Greater	Less
Postoperative pain	More	Less
Recovery at day 15	Fewer fully recovered	More fully recovered
Overall complications	More	Fewer
Major complications	Comparable	Comparable
Pregnancy rates	Comparable	Comparable
Fibroid recurrence	Comparable	Comparable

Open myomectomy remains preferred for very large, numerous, or technically complex fibroids. Conversion from laparoscopic to open is required in ~1-2% of laparoscopic cases even in expert hands.

Berek & Novak's Gynecology, p. 523

Compared with Hysterectomy

A retrospective review of 197 myomectomies vs 197 hysterectomies (similar uterine size ~14-15 weeks) showed:

Operating time was longer for myomectomy (200 vs 175 min)
Estimated blood loss was greater for hysterectomy (484 vs 227 mL)
Risks of hemorrhage, febrile morbidity, unintended surgical procedure, life-threatening events, and rehospitalization were comparable

Myomectomy is a safe alternative to hysterectomy for appropriately selected patients.

Berek & Novak's Gynecology, p. 521

Complications

Intraoperative

Complication	Notes
Hemorrhage	Most significant risk; average EBL can be substantial in large cases; may require blood transfusion or conversion to hysterectomy
Vasopressin toxicity	Cardiovascular collapse, bradycardia, loss of peripheral pulses, peripheral vasospasm - even with dilute injections
Inadvertent entry into endometrial cavity	Occurs when fibroid is close to cavity; must be recognized and closed in layers; risk of Asherman syndrome
Injury to adjacent structures	Ureter, bladder, bowel - more likely when anatomy is distorted
Conversion to hysterectomy	Uncontrolled hemorrhage is the main indication; patient must be counseled preoperatively

Postoperative

Complication	Notes
Adhesion formation	Major concern; posterior incisions carry higher risk; use of barriers (Interceed, Seprafilm) reduces but does not eliminate
Febrile morbidity / wound infection	Standard surgical infection risk
Fibroid recurrence	New fibroids appear in 15-30% at 5 years; symptomatic recurrence requiring re-intervention in ~10-27%
Urinary complications	Retention, UTI

Pregnancy-Related (after fertility-preserving myomectomy)

Uterine rupture in subsequent pregnancy - rare but serious; risk is highest when the endometrial cavity was entered or when a large, deep posterior intramural fibroid required multi-layer closure. Mode of delivery (cesarean vs trial of labor) depends on depth and extent of myometrial disruption
Placenta previa/accreta - increased risk if uterine scar is near or over the endometrium
Pregnancy outcomes (fertility, live birth rates) are generally improved after myomectomy for fibroids that distort the uterine cavity

Concurrent Cesarean Myomectomy

In carefully selected women, myomectomy can be safely performed at the time of cesarean section by experienced surgeons. One series of 111 women showed no increase in mean operative time, febrile morbidity, or hospital stay compared to cesarean alone; only one patient required transfusion and none required hysterectomy or embolization.

Berek & Novak's Gynecology, p. 521

Key Principles Summary

Patient selection - open approach for large, multiple, or anatomically complex fibroids
Preoperative MRI - essential for surgical planning
Blood loss control - use multiple complementary strategies (vasopressin + tourniquet + tranexamic acid)
Medial incisions - avoid lateral placement near uterine arteries
Meticulous layered closure - critical for uterine integrity in future pregnancies
Adhesion prevention - use barriers, minimize uterine trauma
Counsel on conversion - all patients must consent to possible hysterectomy

Recent evidence (2024-2025): A meta-analysis (PMID 39520831) confirms laparoscopic myomectomy offers advantages over open surgery in operative blood loss, pain, and recovery time, while major complication rates are comparable. A 2025 systematic review (PMID 40938091) highlights intrauterine adhesion formation following fibroid surgery as a significant concern, with strategies including adhesion barriers and meticulous technique.

Sources: Berek & Novak's Gynecology; Sabiston Textbook of Surgery (28th ed.)

Principles of myomectomy

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Principles of Myomectomy

Myomectomy is the surgical removal of uterine leiomyomas (fibroids) while preserving the uterus. The guiding philosophy was articulated by Victor Bonney in 1931: "The restoration and maintenance of physiologic function is, or should be, the ultimate goal of surgical treatment."

1. Preserve Uterine Function

The fundamental principle distinguishing myomectomy from hysterectomy is uterine conservation - whether for:

Fertility preservation (women who desire future pregnancy)
Preservation of menstrual function (women not desiring hysterectomy)
Avoidance of surgical menopause sequelae

Myomectomy is the preferred surgical approach in women desiring fertility who require treatment for fibroids. Uterine artery embolization is relatively contraindicated in this group.

Berek & Novak's Gynecology, p. 2065

2. Match the Approach to Fibroid Characteristics

The route of removal depends on fibroid size, location (FIGO type), number, and surgeon experience:

Fibroid Type (FIGO)	Preferred Route
Type 0, 1 (intracavitary/submucous)	Hysteroscopic
Type 2 (partially submucous)	Hysteroscopic (if feasible)
Types 3-8 (intramural, subserosal)	Laparoscopic or open (abdominal)
Cervical / prolapsing through cervix	Vaginal

Hysteroscopic removal is generally preferred for small submucous fibroids
Open (laparotomy) is used when fibroids are large, numerous, anatomically inaccessible laparoscopically, or when surgeon laparoscopic skill is limiting
The use of any approach ultimately depends on patient preference, operator skill, and presence of other pelvic pathology

3. Preoperative Planning is Non-Negotiable

MRI is the preferred imaging modality: it defines fibroid number, size, location, vascularity, and - critically - the path of the endometrial cavity, which guides incision placement
GnRH agonists may be used preoperatively to:
- Shrink larger fibroids (≥5-6 cm), sometimes enabling hysteroscopic rather than abdominal removal
- Reduce intraoperative blood loss and correct preoperative anemia
- Caveat: GnRH agonist treatment can make fibroid capsule planes less distinct
Anemia correction (iron, transfusion) before elective surgery reduces transfusion risk

4. Minimize Blood Loss

Hemorrhage is the dominant intraoperative risk. All myomectomy approaches share the principle of proactive, multi-modal blood loss control:

Vasopressin (dilute: 20 units in 100 mL normal saline) injected into the myometrium overlying the fibroid - causes local vasoconstriction. Total dose should remain <5 units to avoid cardiovascular collapse
Tranexamic acid (1,000 mg IV) - antifibrinolytic, given at time of incision
Misoprostol (400-800 mcg rectally) - promotes uterine contraction, tamponade effect
Tourniquets around the lower uterine segment (Penrose drain, feeding tube, or suture after opening the broad ligament bilaterally) - impedes uterine blood flow; leave in place no longer than 60 minutes
Cell saver - particularly for large cases (uterus >16 weeks); avoids risks of allogeneic transfusion
Consent for possible blood transfusion is mandatory

5. Medial Uterine Incisions

The uterine arteries run along the lateral sides of the uterus. Hysterotomy incisions must therefore be placed medially to avoid vascular injury. This principle is especially important when uterine anatomy is distorted by large or multiple fibroids - in these cases, the location of the adnexal structures serves as a landmark to identify where the uterine arteries lie.

Sabiston Textbook of Surgery, p. 2798

6. Enucleation Within the Pseudocapsule

The fibroid is dissected along its natural plane of cleavage - the fibroid pseudocapsule - using blunt dissection, sharp dissection, monopolar current, or harmonic scalpel. Direct incision into the surrounding healthy myometrium is avoided to:

Minimize blood loss
Preserve myometrial integrity
Reduce adhesion-forming injury

7. Meticulous, Layered Closure

The myometrial defect is closed in multiple layers with delayed absorbable suture (barbed suture is commonly used). This principle is critical for two reasons:

Hemostasis - obliterates dead space and controls bleeding from the bed
Future pregnancy safety - adequate closure prevents uterine rupture in subsequent pregnancy. The depth and extent of myometrial entry determines the mode of delivery; if the endometrial cavity was entered, cesarean delivery is generally recommended

A final serosal layer is placed to approximate edges and achieve hemostasis at the surface.

8. Cavity Integrity - Avoid Inadvertent Entry

Entry into the endometrial cavity must be recognized intraoperatively and closed carefully in layers. Unrecognized or poorly repaired cavity entry increases the risk of:

Asherman syndrome (intrauterine adhesions)
Isthmocele or uterine defect
Placenta previa/accreta in future pregnancy

9. Adhesion Prevention

Adhesion formation after myomectomy is well documented and is a significant source of morbidity (infertility, chronic pain):

Posterior uterine incisions carry higher adhesion risk than anterior
Adhesion barriers (Interceed, Seprafilm) reduce adhesion incidence and severity; a prospective RCT of 127 women showed Seprafilm significantly reduced adhesions at second-look laparoscopy
Minimizing tissue trauma, desiccation, and ischemia during closure also reduces adhesion formation
Berek & Novak's Gynecology, p. 531

10. Myomectomy vs Hysterectomy - Risk Equivalence

Myomectomy is a safe alternative to hysterectomy. A retrospective comparison of 197 myomectomies vs 197 hysterectomies (uterine size ~14-15 weeks) found:

Operating time slightly longer with myomectomy (200 vs 175 min)
Blood loss actually greater with hysterectomy (484 vs 227 mL)
Rates of hemorrhage, febrile morbidity, life-threatening events, and rehospitalization were comparable

This supports offering myomectomy to any woman who wishes to retain her uterus, not only those desiring fertility.

Berek & Novak's Gynecology, p. 521

11. Morcellation Awareness

When fibroids are removed laparoscopically, morcellation is required to extract tissue through ports. Key principles:

The risk of occult leiomyosarcoma in women undergoing myomectomy is very low (~4/10,000 to 2/1,000)
There is no convincing evidence that morcellation worsens prognosis for leiomyosarcoma
Leiomyoma cells have been found in the peritoneal cavity prior to morcellation, suggesting disease may already be disseminated before surgery
Contained (in-bag) morcellation systems are an option to mitigate theoretical risk of peritoneal dissemination
Berek & Novak's Gynecology, p. 1295

12. Counsel on Conversion

All patients must be counseled preoperatively that:

Conversion to hysterectomy may be necessary for uncontrolled hemorrhage
Informed consent must explicitly include this possibility

Summary Table

Principle	Core Goal
Uterine conservation	Restore function; preserve fertility
Route selection	Match technique to fibroid FIGO type
Preoperative MRI + optimization	Safe surgical planning
Multi-modal hemostasis	Prevent hemorrhage
Medial incisions	Avoid uterine artery injury
Pseudocapsule dissection	Minimize myometrial damage
Layered closure	Hemostasis + uterine integrity for pregnancy
Cavity protection	Prevent Asherman syndrome
Adhesion barriers	Reduce postoperative adhesion morbidity
Morcellation awareness	Oncologic safety
Hysterectomy consent	Safety net for hemorrhage

Sources: Berek & Novak's Gynecology; Sabiston Textbook of Surgery; Goldman-Cecil Medicine

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