Uterine fibroids are a benign tumor that can subsequently degenerate into cancer. Myomectomy is an operation in which fibroids are removed and the uterus is preserved. Due to the fact that such surgical intervention allows a woman to preserve her reproductive organ, in the future she can become pregnant and give birth to a child without any problems.
After myomectomy, the chances of pregnancy increase, however, confidence in positive result is still missing. IN medical practice There are several types of myomectomy, but their main goal is to remove nodular formations in the uterine cavity in the most gentle way, and to prevent violations reproductive function female body. Reviews about various types Myomectomies are quite diverse, because each of them has its own characteristics and consequences.
Features of fibroids
Uterine fibroids can range in size from a small nodule to a tumor weighing about a kilogram, when it is easily identified by palpation of the abdomen.Uterine fibroids are often diagnosed in women of reproductive age, however, this does not exclude the possibility of its development at any period of life.
The danger of this disease lies in its asymptomatic course, which does not allow a woman to promptly seek help from a specialist and undergo treatment.
Only a small proportion of patients exhibit signs of fibroids and changes in the uterine cavity that require emergency treatment. surgical intervention.
We can highlight the most clear signs diseases that indicate the need for surgery:
- periodic bleeding from the uterine cavity and heavy menstruation;
- the appearance of pain in the lower abdomen;
- a feeling of heaviness and pressure on nearby organs;
- unpleasant and uncomfortable sensations during sexual intercourse;
- the tumor grows very quickly.
In the event that uterine fibroids cause various changes in the myometrium and heavy menstruation, this gradually leads to the development of anemia. In addition, there are such unpleasant symptoms, How:
- increased weakness of the body;
- severe dizziness;
- decline protective functions body;
- disruption of the cardiovascular system.
Diagnosis uterine fibroids leads to pregnancy occurring with various complications. In addition, when the tumor is localized under the uterine mucosa, the process of embryo implantation is disrupted and the likelihood of spontaneous miscarriage increases. Myomatous nodes can cause blockage and deformation fallopian tubes, as a result of which pregnancy may not occur a long period time. If pregnancy does occur, the risk of premature birth increases.
Often uterine fibroids are removed along with the uterus, however, this type of operation is not suitable for everyone. Experts do not use this treatment in young women who do not have children and are planning a pregnancy in the future.
The most effective and gentle treatment method in this situation is considered to be myomectomy, which involves only removing the tumor while preserving the uterus.
In the event that a scar remains on the uterus, then childbirth after it can take place either independently or by cesarean section.
Laparoscopy of fibroids
Laparoscopic myomectomy is one of the methods for removing benign neoplasms myometrium in the uterine cavity, one of which is fibroids. Most often, such a benign tumor is localized in the uterine cavity and only in some cases does it affect the cervix of the organ or the area of the associated apparatus. The scar after the operation is hardly noticeable and childbirth after such an operation most often goes away on its own.
Benefits of the procedure
Reviews about this procedure among women are mostly positive and the popularity of this method is explained by its following features:
- such an operation is performed with minimal blood loss;
- the risk of injury to nearby organs is very low;
- after such an operation, the seam and scar are almost invisible;
- the likelihood of formation of adhesions is reduced;
- recovery takes only a few days;
The woman retains the opportunity to become pregnant soon and childbirth usually occurs without complications.
Indications for laparoscopy
The laparoscopic myomectomy operation is performed in cases where a woman is diagnosed with large myometrial nodes, as well as single neoplasms with a specific structure. The consequences of their presence are not entirely pleasant and their presence in the uterine cavity does not allow a woman to become pregnant. In addition, labor may begin ahead of schedule and the development of some pathological processes is possible:
- fibroids cause pain and changes in the myometrium of the uterine cavity and disrupt contractile function, which leads to the development of anemia, and frequent bleeding and heavy menstruation are observed;
- observed fast growth benign tumor;
- pain appears and this is due to poor circulation in the area where it is localized;
- the growth of fibroids puts pressure on nearby organs and this disrupts their normal functioning;
- the likelihood that the pregnancy may end in spontaneous miscarriage or premature birth increases
- the threat of reproductive dysfunction increases.
Features of the operation
Laparoscopic myomectomy requires certain preparation, which consists of prescribing a course of certain medicines. Their action is aimed at reducing the size of uterine nodes and reducing blood loss during surgery. Often hormonal treatment is prescribed only if the size of the myometrial fibroid nodes exceeds 4-5 cm. In the event that the fibroid node is subserous localized, then preoperative preparation is not carried out in this case. Reviews from patients indicate that this type of surgery is well tolerated by the female body.
During the operation, a special device is used - a laparoscope, which is directly inserted into the abdominal cavity.
To do this, four punctures are made on the anterior abdominal wall, into one of which a laparoscope is inserted. The remaining three punctures are intended for the introduction of surgical manipulators. In addition, for the convenience of laparoscopy, carbon dioxide is injected into the abdominal cavity.
Contraindications to laparoscopy
Despite the fact that reviews of laparoscopic myomectomy are almost all positive, such an operation often has some limitations. This kind surgical intervention It is not recommended for women in the following cases:
- diagnosing pathologies that are accompanied by disorders respiratory function and cardiovascular activity;
- complicated hemorrhagic diathesis;
- renal failure of acute and chronic nature;
- there is a suspicion of progression to female body malignant neoplasms;
- identification of a large number of fibroids, the location of which is the myometrial region.
Only a specialist makes a decision to perform laparoscopic myomectomy and he does this taking into account the complexity of the pathology and individual characteristics female body.
Reviews from women indicate that the rehabilitation period lasts about three months, and a woman can plan a pregnancy six months after the procedure. Childbirth after laparoscopy can proceed as follows: naturally, and by caesarean section.
Hysteroscopy of fibroids
Hysteroscopic myomectomy is an operation to remove a benign tumor through the vagina and cervix.
Indications for surgery
Most often, this type of surgical intervention is performed in the following cases:
- diagnosing a woman with submucous fibroids;
- identification of fibroids on the leg, which causes severe pain;
- heavy bleeding and menstruation, leading to the development of anemia;
- pregnancy does not occur for a long time or ends in spontaneous miscarriage;
- in the uterine cavity there is a single node, the location of which is the posterior or anterior wall of the reproductive organ;
- there are no pathological changes in the uterine appendages.
Hysteroscopic myomectomy is performed in outpatient setting, and requires the use of local or general anesthesia.
Features of the operation
This treatment involves the use of a special device - a hysteroscope, which is inserted through the woman's cervix. It is through it that a benign myometrial tumor is removed using additional surgical instruments.
Today in medical practice, treatment with hysteroscopy is carried out in the following ways:
- The mechanical method is used if the tumor with nodes is localized under the mucous membrane of the uterine cavity and its penetration into the myometrial area does not exceed 50%. In addition, attention is paid to the size of the fibroid and it should not exceed 5 cm. Mechanical treatment significantly reduces the duration of the operation, eliminating the need for additional equipment and a special liquid medium. Reviews from specialists about this method of operation are much better than about electrosurgical surgery, which causes changes and burns to neighboring organs and tissues.
- Electrosurgical treatment is used if submucosal nodes with a pronounced intramural component are observed. In addition, this method of surgical intervention is performed if a woman is diagnosed with benign tumors in the corners of the uterine cavity, which makes it much more difficult to remove them mechanically.
Content
Uterine fibroids are one of the most common pathologies of female reproductive sphere. The disease primarily affects women of childbearing age.
Doctors call uterine fibroids the growth of a tumor-like neoplasm in the myometrium. The size of uterine fibroids corresponds to the increase in the size of the uterus during pregnancy, so the progression of this tumor is assessed in weeks.
The disease occurs in one of several varieties. Myoma happens:
- single, multiple;
- nodular, diffuse;
- uterine, cervical;
- large, medium, small;
- intramural, submucosal, subserous, intraligamentary, submucosal;
- simple, proliferating, presarcoma;
- on a pedicle, on a wide base.
Doctors consider a defect in the formation of the myometrium during embryonic development as the main reason for the development of a myomatous node.
The trigger mechanism for the formation of fibroids is hormonal imbalance. Scientists also consider the following as additional risk factors for the occurrence of pathology:
- previous surgical interventions;
- absence of pregnancies before the age of thirty;
- excess weight and physical inactivity;
- hypertension in young women;
- early menarche;
- disharmony of sexual life.
There are often no symptoms of fibroids. At knots large sizes The following symptoms may appear:
- increased volume and duration of bleeding during menstruation;
- the occurrence of intermenstrual bleeding;
- development of anemia;
- increased pain during menstrual periods;
- squeezing Bladder and intestines;
- infertility with submucous fibroids or large intramural fibroids;
- complications of pregnancy and childbirth;
- increase in abdominal circumference.
Myoma is often accompanied by various complications. With increased physical activity or if the formation is large, torsion of the leg may occur, which will cause the development of symptoms such as nausea, vomiting, fever, and severe pain.
Absence surgical treatment at torsion of the leg of the node leads to necrosis.
Detection of fibroids occurs during gynecological examination and ultrasound of the pelvic organs. When treating uterine fibroids, doctors use three main tactics:
- expectant (observant);
- conservative;
- surgical
In modern gynecology, surgical tactics are used as the main method of treatment. Removal of uterine fibroids can be carried out within the framework of:
- conservative myomectomy;
- hysterectomy.
A hysterectomy involves removing the body of the uterus. This is the most common operation for women who have reached menopause. In some cases, the cervix and appendages are amputated. Such an intervention is traumatic and has a difficult postoperative period. However, at the end of the postoperative period, the development of long-term consequences is also possible:
- osteoporosis;
- vegetative disorders;
- intimate disorders;
- hormonal and psycho-emotional imbalance.
Hysterectomy is a radical treatment for uterine fibroids, leading to the impossibility of reproductive function.
Conservative myomectomy means enucleation or removal of uterine formations while preserving the organ and its anatomical structure. This organ-preserving intervention is often recommended for young women in order to preserve reproductive function.
However, conservative myomectomy is not always technically possible. This is due to the type and size of the nodes, as well as the peculiarity of their location. In some cases, myomectomy is accompanied by the risk of inflammation and subsequent adhesions, which can also lead to infertility.
Indications and contraindications for
Any operation, including myomectomy, is performed if there are certain indications. This approach avoids unpleasant complications and consequences in the postoperative period.
Indications for conservative myomectomy include:
- intermenstrual and menstrual bleeding causing anemia;
- reproductive dysfunction in the presence of a tumor larger than 4 centimeters in volume;
- the need to take hormonal medications;
- increase in the size of nodes up to 12 weeks or more;
- dysfunction internal organs due to their compression;
- pressure of the neoplasm on the nerve plexuses;
- atypical localization of nodes;
- submucous type of tumors and severe symptoms;
- risk of torsion with pedunculated subserous nodes;
- necrosis of uterine fibroid tissue;
- birth of a submucosal node;
- rapid tumor growth.
In some cases, doctors have to resort to myomectomy during a woman's pregnancy. Indications for myomectomy during pregnancy are:
- torsion of the leg and necrosis of uterine fibroids;
- disruption of the functioning of neighboring organs caused by their compression by a large-volume node;
- rapid tumor growth.
Although conservative myomectomy is the preferred method of treatment, there are contraindications to the use of this type of surgery.
Among the contraindications to myomectomy, doctors identify:
- spicy inflammatory processes in the reproductive sphere;
- necrosis of the node tissue with signs of infection;
- malignant tumor of the genital organs;
- oncological alertness regarding uterine fibroids;
- combination of myomatous node and internal endometriosis;
- multiple uterine fibroids, characterized by neoplasms different types and volume.
In some cases, contraindications to myomectomy are temporary, for example, acute inflammatory diseases. If conservative myomectomy is not possible, radical treatment is usually required.
Carrying out using different surgical tactics
Conservative myomectomy is usually performed from the sixth to the eighteenth day of the cycle. During pregnancy, intervention is recommended from the fourteenth to the nineteenth week.
The success of conservative myomectomy depends on the choice of the incision area and the correct enucleation of the formation. These criteria allow the formation of a full-fledged scar on the uterus and prevent the appearance of adhesions due to the introduction of special solutions. The capsule of the myomatous node is cut in the upper pole, which prevents disruption of the integrity of large vessels.
In the case of conservative myomectomy in pregnant women, doctors try to ensure insignificant blood loss, avoid injury to the fetus and the development of the inflammatory process. Unlike normal operation When performing myomectomy in pregnant women, doctors aim to remove only large tumors. In the future, the patient is recommended for surgical delivery, which prevents uterine rupture.
Uterine myomectomy can be performed using several techniques.
- Hysteroscopic. Such removal is recommended for intrauterine or cervical fibroids. The permissible size of the uterus is 12 centimeters, while the volume of the neoplasm does not exceed five centimeters. Conservative myomectomy is performed by inserting a hysteroscope into the uterus.
- Laparoscopic and laparotomy. Removal using a laparoscope is characterized by the absence of an incision, less blood loss and an easier postoperative period. However, with large tumors, stopping bleeding is difficult. Damage to healthy tissue may also occur. In the postoperative period, this can lead to scar failure and the formation of adhesions, which can negatively affect reproductive function.
The laparotomy method involves abdominal surgery for significant size nodes. This method also recommended for pregnant patients.
The risk of complications both during the intervention and in the postoperative period, depends on the volume of formation, their quantity and location.
Features of the postoperative period
In the early postoperative period there are bloody issues, which can bother the patient for up to a month. The cycle is usually established immediately after conservative myomectomy. The day of manipulation is considered the first day of the cycle.
The postoperative period takes place both in a hospital setting and on an outpatient basis. During the postoperative period it is necessary to ensure:
- prevention of the occurrence of the inflammatory process, which is achieved by prescribing antibacterial agents and enzyme preparations;
- reducing the risk of various psychological and physiological disorders;
- reducing the possibility of relapses, for which the woman is prescribed hormonal correction with specially selected drugs;
- restoration of reproductive function.
The objectives of the postoperative period are achieved by:
- early activation of patients;
- applications medications;
- leg compression;
- performing breathing exercises.
In the postoperative period there is restoration of the uterine cavity and formation of a wealthy scar.
Therefore, in the postoperative period it is important to prevent any complications, for example, a purulent process. Adhesions are formed due to individual characteristics, injuries and infections. Properly performed conservative myomectomy and the use of medications can reduce the risk of complications.
Treatment is indicated for women hormonal agents during the postoperative period. This treatment promotes rehabilitation and prevents relapses of the disease in the postoperative period.
The postoperative period is carried out under the supervision of the attending physician. The first ultrasound is recommended one week after conservative myomectomy, and subsequent examinations are recommended in the third and seventh months of the postoperative period.
Doctors note that wait-and-see tactics and refusal of surgical treatment for a benign uterine tumor can lead to serious consequences, the most dangerous of which is the need to remove the reproductive organ and subsequent loss of reproductive function. Women with reproductive plans are recommended to undergo conservative myomectomy within three years after determining the tumor during its growth.
Laparoscopic conservative myomectomy– endoscopic removal of myomatous nodes through punctures in the anterior abdominal wall, providing for the preservation of the uterus, menstrual and reproductive functions of the woman. Along with vaginal myomectomy, laparoscopic myomectomy is an organ-preserving intervention and is characterized by low morbidity, short terms recovery, absence of visible postoperative scars and preservation of the anatomy of the pelvic floor.
Indications for laparoscopic myomectomy
Laparoscopic myomectomy is performed in the presence of a single or several nodes with a diameter of more than 2 cm, located intramurally or subserosally and accessible for enucleation by laparoscopy, as well as the need to preserve the uterus for subsequent pregnancy. When nodes are unavailable endoscopic removal(interstitial, intraligamentary or low-lying myomatous nodes), a combination of laparoscopy with supravaginal access or transection is possible.
Laparoscopic myomectomy is often preceded by conservative hormonal preparation aimed at reducing the size of the myomatous node and reducing blood loss. Hormonal preparation is carried out when the size of the fibroid node is over 4-5 cm. If present subserous node on the leg, hormonal preparation is not prescribed.
Contraindications
Removal of uterine fibroids by laparoscopic method is contraindicated if:
- the diameter of a single myomatous node exceeding 15 cm after hormonal preparation;
- the presence of multiple (more than three) nodes with a diameter > 5 cm;
- uterine size over 16 weeks of pregnancy;
- any pathology abdominal cavity, eliminating the possibility of increasing intra-abdominal pressure;
- severe diseases in the stage of decompensation;
- malignant neoplasms of the genitals.
Methodology
To perform laparoscopic myomectomy, surgical gynecology uses various techniques. The choice of surgical technique depends on the number of myomatous nodes (single or multiple), their size, subserous or intramural localization.
When removing fibroids, general endotracheal anesthesia is usually used. After applying pneumoperoneum in the area of the anterior abdominal wall, skin incisions and 3 trocar punctures are made: one near the navel (for inserting a laparoscope with a video camera) and two above the womb (for inserting instruments - biopsy forceps, scissors, clamps, needle holders, etc.) Progress The surgeon has the opportunity to observe laparoscopy operations for uterine fibroids on the monitor screen.
Using a monopolar coagulator or scissors, the serous membrane of the uterus is dissected to the capsule of the myomatous node, identified by its whitish color. The node is securely fixed in toothed clamps and is peeled off or cut off with simultaneous coagulation of all bleeding areas of tissue. The bed of the removed myomatous node is washed with a sterile solution and cauterized with a bipolar coagulator.
After removal of fibroids, myometrial defects are restored by applying endoscopic sutures. The myomatous node is removed outward, and if it is large in size, it is preliminarily cut into pieces. Blood clots are removed from the abdominal cavity, hemostasis, its sanitation and revision are carried out. Trocar punctures are sutured with intradermal sutures using absorbable thread.
After myomectomy
After the intervention, a hospital stay of 3-5 days is required. On the first postoperative day, it is possible to prescribe narcotic analgesics. In the future, it is appointed hormone therapy for restoration of postoperative defects in the uterus. Dynamic examination by a gynecologist and ultrasound control are carried out after 1, 3 and 6 months. Planning a pregnancy is possible after 6-9 months. Management of pregnancy and childbirth in patients after laparoscopic myomectomy requires increased attention; childbirth can be either natural or as a result of cesarean section.
Complications after laparoscopic myomectomy
Laparoscopic complications may include damage to organs (intestines, bladder and ureters), as well as large vessels during the insertion of trocars; bleeding from the uterus during or after surgery; hematomas due to inadequate suturing of uterine wall defects; hernia of the anterior abdominal wall due to the extraction of macropreparations through it.
Cost of laparoscopic conservative myomectomy in Moscow
This technique is one of the low-traumatic modern organ-preserving operations, however, due to the need for hospitalization, the risk of damage to internal organs and the availability of alternative minimally invasive procedures, it is used infrequently. The intervention is performed in small quantities medical institutions capital Cities. The price of laparoscopic conservative myomectomy in Moscow varies depending on the organizational and legal status of the clinic, the qualifications of the endoscopist, the type of anesthesia and the length of hospital stay.
The gold standard for the treatment of uterine leiomyomas in women of reproductive age remains conservative myomectomy. Introduction of minimally invasive surgical methods treatment of many gynecological diseases led to a significant advantage for the patient from both a medical and social, as well as economic point of view (shorter hospitalization time, faster restoration of working capacity, better cosmetic effect).
It has been shown repeatedly that laparoscopy is an absolute alternative to the standard open surgical technique with comparable long-term results, more short time hospital stay, earlier recovery and best quality life.
What are the indications for myomectomy?
A mandatory stage of laparoscopic myomectomy in modern gynecology is suturing the uterine wall after removal of the node (Fig. 1). If this is not done - the risk of uterine rupture during subsequent pregnancy and childbirth increases significantly (up to 9%!!!). Therefore, it is unacceptable to leave the wound without suturing for women planning childbearing in the future.
Rice. 1. Main stages of laparoscopic myomectomy
During myomectomy with opening of the uterine cavity, the reproductive prognosis and results of the operation significantly worsen due to deterioration of the healing of the uterine scar, a decrease in the surface of the endometrium, the risk of developing adenomyosis, and synechiae in the uterine cavity. Solution:
- It is easier to prevent the opening of the uterine cavity by remembering the distance from the edge of the node to the endometrium (high risk of entering the cavity at a distance of less than 3 mm);
- Refusal of excessive traction and blunt enucleation of intramural nodes in the final stages - most cases of opening the uterine cavity occur due to rupture of the delicate endometrium due to excessive tension;
- Staining the uterine cavity with a solution of methylene blue or inserting a balloon into the cavity makes it clear that the surgeon is working close to the uterine cavity;
- The few studies evaluating the need for separate endometrial closure have shown no benefit of suturing versus not suturing.
All materials on the site were prepared by specialists in the field of surgery, anatomy and specialized disciplines.
All recommendations are indicative in nature and are not applicable without consulting a doctor.
Laparoscopy of uterine fibroids is a fairly common treatment method. tumor process, which has a lot of advantages over . The laparoscopic technique has been successfully used in many clinics in Russia and abroad for many years.
When diagnosing uterine fibroids, there is a need for prompt removal tumor nodes, because their presence entails not only a lot of inconvenience in the form constant pain, heavy bleeding, disorders menstrual cycle, but is also fraught with serious complications - anemia, infertility, compression of neighboring organs and adhesive disease.
Uterine fibroids are increasingly affecting women young, so what will the treatment be - abdominal surgery or laparoscopy is a very significant point in its planning. The desire to undergo laparoscopic myomectomy is dictated not only by the excellent cosmetic result of the operation and fast recovery, but also the need to preserve the uterus and fertility.
Preservation of the reproductive organ and subsequent pregnancy may be the goal of laparoscopy, along with ridding the woman of the fibroids themselves, which may not cause significant discomfort in themselves due to their small size. Laparoscopy is an excellent way out of the situation, provided that the operation is performed by a highly qualified surgeon in early stage diseases.
Benefits of laparoscopy for uterine fibroids
The laparoscopy technique has become firmly established in everyday surgical practice, specialists know the necessary techniques, operating rooms are equipped with equipment, and patients know the advantages of the method and therefore strive to be operated on minimally invasively.
The cosmetic effect after surgery is very important for a woman, because no one wants to walk around with a noticeable scar, and after laparoscopy, barely noticeable scars will remain on the anterior wall of the abdomen. However, in addition to the purely aesthetic side, laparoscopy has many other, more serious, advantages that make it much more attractive than usual surgery.
laparoscopy
The advantages of laparoscopy include:
- Minor surgical trauma, respectively, and pain syndrome, and the adhesive process will be minimal;
- Low blood loss and safety for nearby organs;
- Low incidence of complications during the intervention and rare tumor relapses subsequently;
- Short rehabilitation period;
- Possibility of preserving both the uterus and childbearing ability.
Laparoscopy also has disadvantages, although they are few. These include the impossibility of removing submucosal and intersitial nodes due to the difficulty of access and probable massive bleeding, as well as the not always feasible condition of having both equipment and a qualified surgeon.
Indications and contraindications for surgery
Laparoscopic technique, with all its undoubted advantages, cannot be used for all women who want to get rid of a tumor in a minimally invasive way. Taking into account the peculiarities of the anatomy and blood supply of the uterus, the extreme variability in the structure and location of the nodes, the high risk of serious complications, the doctor always determines not only the advisability of performing laparoscopy, but also evaluates possible contraindications to surgery, of which there are many in the case of fibroids.
Myomectomy using laparoscopic technology is possible for large and multiple tumors, and for single small tumors, which, nevertheless, prevent pregnancy. In other words, the number and size of myomatous nodes are not always decisive when choosing a specific surgical technique.
Indications for laparoscopy of uterine fibroids are:
Thus, the indications for laparoscopy of uterine fibroids differ little from those when planning open laparotomy. Modern specialists are “moving away” from the tactics of monitoring nodes, since further growth is inevitable, no conservative methods will not stop or eliminate the tumor. When a decision on surgery is made in a timely manner, smaller fibroids are removed, the number of advanced forms of the disease is reduced, which significantly expands the possibilities of using laparoscopy.
The main reason why a gynecologist seeks to perform laparoscopic surgery is the woman’s desire to preserve the uterus and realize reproductive function. In this regard, minimally invasive treatment is mostly performed on patients of reproductive age who plan to have children in the future.
On the other hand, preservation of the uterus may be an important condition treatment also for those women who no longer plan to have children, if the prospect of total organ removal brings them serious psychological discomfort. In these cases, the doctor will also try to do everything possible for gentle treatment.
The third situation is the removal of not only nodes, but also the affected uterus through laparoscopic access. In this case, when planning laparoscopy, the doctor is based on its other significant advantages than preserving the uterus - fast rehabilitation and recovery, excellent cosmetic results, low trauma and pain for the patient.
Laparoscopic removal of uterine fibroids is still an operation, although it is performed through small punctures, so it requires anesthesia and has certain risks and contraindications:
Obesity and adhesive disease are considered relative contraindications to laparoscopy, so the issue of access is resolved individually if they exist. The doctor may go for laparoscopy, but if necessary, switch to open surgery.
Laparoscopy can be risky if the tumor is located between the broad ligament of the uterus and along the posterior surface of the organ due to the possibility of massive bleeding, since the growing tumor changes the anatomy vascular bed pelvis, and in conditions of insufficient visibility, the surgeon can damage a large artery.
The number of contraindications is determined by how well the patient is prepared for the operation (prevention of bleeding, careful preoperative diagnosis), as well as the skills of the surgeon, since the high professionalism and skill of the doctor in many difficult cases help to perform laparoscopy and preserve the uterus.
Until recently, one of the contraindications to laparoscopy was the size of fibroids more than 10 cm. Today, thanks to the introduction into practice of special instruments that crush any tissue or even organ (morcellators), the large size of the tumor has ceased to be an obstacle to such an operation, therefore Laparoscopy of large uterine fibroids is performed. Moreover, the surgeon can remove during surgery not only tumor foci up to 15-17 cm in diameter, but also the uterus itself, when there is no point in preserving it.
Preparation and technique for performing the operation
Preparation for surgery includes undergoing a comprehensive examination, and if there is accompanying illnesses, then they should be brought to such a course as not to provoke complications, or, if possible, cured.
In some cases, before removing the tumor, hormone therapy is prescribed for several months to curb the growth of the tumor and reduce its size, and embolization of the arteries supplying the node is also possible, facilitating laparoscopy for large tumor sizes.
Before the intervention, the patient passes a general and biochemical tests blood, urine, undergoes a blood clotting test, determination of group affiliation and Rh factor. Upon admission to the hospital, it will be necessary to present the result of fluorography and a cytological smear of the cervix. If indicated, an ECG is performed (mandatory after 45 years), and all women undergo an ultrasound of the abdominal and pelvic organs.
Before the operation, the woman visits a gynecologist in the clinic, who examines her, palpates the nodes, determines their size and location, takes smears from the cervix and cervical canal for the presence of atypical cells, as well as from the genital tract to exclude inflammation and infection. Infections and inflammatory processes can become an obstacle to surgery. For accurate topical diagnosis of fibroids, ultrasound is indicated.
The results of examinations completed before hospitalization are valid for no more than 10 days. After completing all the procedures, the patient visits the therapist, who signs his permission to intervene. At this point, all medications that may cause bleeding or adversely affect the course of the operation are discontinued.At the appointed time, the woman comes to the clinic, where she is consulted by a surgeon, once again making sure that the operation can be carried out according to the previously determined plan. On the eve of the intervention, a cleansing enema is carried out, the last meal and water is taken no later than six o’clock in the evening. Before going to bed, it is recommended to take a shower, change clothes and calm down, even if this means taking a sedative or sleeping pill.
Before the operation, the anesthesiologist talks with the woman, talks about the expected anesthesia and administers necessary appointments. To prevent thromboembolic complications, elastic bandaging of the lower extremities is indicated.
Laparoscopy technique
Laparoscopy of uterine fibroids is performed under general anesthesia and lasts on average from 40 minutes to one and a half to two hours, depending on the number of tumor nodes and their location. The operation can be performed on any day of the cycle, except menstruation due to increased bleeding during this period, optimal time The interval between 15 and 25 days is considered, that is, after ovulation and before menstruation.
For good visibility of the pelvic organs, the first trocar is inserted into the abdomen, through which carbon dioxide is pumped. Gas lifts abdominal wall, and the surgeon examines the area of interest using a video camera inserted through another trocar along with a light source. During the examination, the doctor specifies the location of the nodes, their sizes, the configuration of the uterus and appendages, the presence of adhesions, etc. In total, to remove fibroids, you will need to insert 4 trocars through 4 punctures in the abdominal wall.
Using endoscopic instruments, the surgeon can dissect adhesions, cut the outer tissue of the uterus above the node, remove the formation from the capsule, coagulate bleeding vessels and apply sutures to the cut tissue. The sequence and technique for removing nodes varies in each case, since the location and number of nodes are always individual, and the surgeon acts based on the specific clinical situation.
If the myomatous nodes are small, then they can be removed through the punctures through which the instruments were inserted. If there is a large tumor or the entire uterus is removed by laparoscopy, it will be problematic to get the cut-off tissue out, so there is a need to grind it. Device morcellator helps to crush the removed formations by cutting them with knives different sizes. It is inserted instead of one of the trocars. The fragmented nodes and the uterus can then be easily brought out without resorting to additional incisions.
At the end of the operation, the surgeon once again examines the operating area, makes sure that there is no bleeding, removes the instruments from the abdomen and sutures the trocar punctures, covering the wounds with sterile napkins. Drainage of the pelvic cavity is usually not required.
Postoperative period
The postoperative period, as a rule, proceeds favorably. Four small incisions up to 1 cm wide are left on the patient’s abdomen, the sutures from which are removed 7-10 days after the intervention. Every day, the wounds are examined by the attending physician, and the nurse changes the dressings or plasters.
On the first day after laparoscopy, it is recommended to become more active and get out of bed. This measure helps prevent the occurrence of adhesions, postoperative paresis intestines and circulatory disorders. Drinking and easy intake liquid food.
In connection with postoperative pain, analgesics and anti-inflammatory drugs are prescribed. At high risk infectious complications Antibiotic therapy is indicated, and anticoagulants (heparin, Clexane) are used to combat thrombosis in women at risk.
Complications after laparoscopy occur infrequently, the most dangerous of them are bleeding, but other consequences are also likely - adhesions, infection, infertility. In the case of large fibroids, massive bleeding may be a reason to remove the entire organ, so it is better not to wait for this and remove only the fibroid while it is completely controlled.
Recovery after laparoscopy of uterine fibroids is rapid, and by the 4th day after surgery the patient can be discharged home. Stitches can be removed at a local clinic. Before removing sutures, you should exclude water treatments, it is better to postpone visiting the pool, bathhouse and sauna for several months. If you have varicose veins, your doctor will recommend wearing compression garments for a while.
Physical activity and heavy lifting are contraindicated until the scars have completely healed, but it is better to avoid them for the first six months, since the healing of internal scars occurs more slowly. Over the next two years after laparoscopy, you should not lift more than 10 kg.
Condition is important gastrointestinal tract and restoration of intestinal function. In the first days, there may be abdominal pain, constipation, and bloating associated with the operation and the injection of gas into the abdomen. To prevent such phenomena, it is necessary to follow a diet that excludes strong tea and coffee, chocolate, and an abundance of fresh vegetables and legumes that cause flatulence. Physical activity is useful.
Young women who have undergone surgery due to the inability to have children are worried about whether and when pregnancy is possible after laparoscopy of fibroids. If the intervention was successful, the uterus remained in place, then pregnancy is possible, but it is better to plan it together with your doctor no earlier than six months later.
The first menstruation after tumor removal usually occurs after 28-30 days, but if this does not happen, then there is no need to panic. A delay in menstruation may be associated with stress, unnecessary worries, hormonal imbalances in a woman’s body, so first of all you need to visit a gynecologist and undergo an ultrasound to determine the condition of the endometrium and ovaries. If necessary, appointed hormonal drugs, normalizing the menstrual cycle.
Pregnancy after laparoscopy of uterine fibroids is usually recommended to be planned after a year, since during this time all internal scars will heal and an increase in the size of the uterus will become safe. The choice of contraception method in the postoperative period lies with the attending physician based on the condition reproductive system female patients (hormonal drugs, barrier methods). In the first month after laparoscopy, complete sexual rest is recommended.
