Obstetrician and Gynaecologist
What is an abdominal myomectomy?
Abdominal myomectomy is an operation to remove fibroids through a cut made along the bikini line or from your belly button to the bikini line. A myomectomy is performed under general anaesthetic and is offered for symptoms such as heavy periods (menorrhagia) or infertility, and pressure symptoms such as passing urine frequently, constipation and pain.
What are fibroids?
Fibroids are benign (non-cancerous) growths called tumours, made up of muscle fibres. Fibroids range in size and can be single or multiple. It is estimated that 20 to 40 in every 100 women have, or will have, fibroids at some time in their lives. They are rare in women under the age of 20 and can decrease in size after menopause. The cause of fibroids is not known.
Why should I have the operation?
The benefits of having a myomectomy may vary depending on the symptoms you experience. Symptoms such as pain, discomfort and heavy menstrual bleeding can be relieved by this operation.
You may consider a myomectomy if:
· your bleeding during your periods is so heavy that you are feeling unwell or have a low haemoglobin (red blood cells) level, or that you are unable to go to work during your period
· your fibroids are pressing on your bladder and make you pass urine frequently
· you are finding it difficult to get pregnant due to very large fibroids, and have been advised to have them removed before having assisted conception · medicines have not reduced your symptoms.
What are the risks?
As with any operation, there are risks of having abdominal myomectomy:
· Risk associated with a general anaesthetic
There is always a small risk associated with having a general anaesthetic, whatever the procedure (for more information about anaesthesia and the side effects and complications, please see our leaflet, Having an anaesthetic).
As with all operations, there is a risk of bleeding (haemorrhage) which may require you to have a blood transfusion. This risk varies, depending on the number and the size of the fibroids removed. A transfusion of your own blood is possible and this will be discussed with you in greater detail before the operation.
There is a small risk that a hysterectomy (removal of womb) may be required during a myomectomy. This will only be performed if there is very heavy bleeding that cannot be stopped any other way, and your life is at serious risk.
· Damage to bladder
This is very rare and would be repaired immediately if it happened. You would need to have a temporary catheter (a small plastic tube) to drain the urine from your bladder to allow it to heal. If you would like more information about this, please ask a member of staff for our leaflet, Having a urinary catheter – information for women.
· Damage to the bowel
There is a very small risk of damage to the bowel as a result of a myomectomy. If this happens, the bowel will need to be repaired and you may have a temporary colostomy (an opening that drains into a bag on your abdomen (tummy) to allow your bowel movement to pass into it while the damaged bowel is healing). In this case you may wake from the general anaesthetic to find a fine tube going down your nose into your stomach, with a drainage bag attached to drain fluid. This will stay in place for a few days and you will not be able to eat and drink for a longer time than usual after your operation.
Potential complications following the operation
As with all operations, there are a number of potential complications that may arise following abdominal myomectomy.
Following any operation, there is a risk of developing an infection. This can be a urine infection, a chest infection or an infection of the wound. If this happens, it can be treated with antibiotics. It is therefore important that you tell your nurse or doctor if you are allergic to any antibiotics. You should avoid lying in bed for long periods of time, and ensure you drink plenty of fluids, as this will reduce the risk of chest and urine infection.
· Deep vein thrombosis (DVT) and pulmonary emboli (PE)
DVT is a blood clot that forms inside the vein in your leg and interferes with your normal circulation. A pulmonary embolus (PE) is a clot that forms in your lungs and can affect your breathing. The risk of either DVT or PE occurring is increased when you do not move for long periods of time. To help prevent this, we will give you thrombo-embolic device (TED) stockings to wear, and a daily injection of an anticoagulant medicine that helps to prevent blood clots from forming. We will also encourage you to start moving around and assist you in getting out of bed on the day after the operation. For more information about blood clots, please ask a member of staff to give you our information leaflet, Preventing deep vein thrombosis (DVT) and pulmonary embolism (PE) following some types of major surgery and fractures (extended prevention).
Sometimes small nerves are cut or damaged during surgery. This may cause pain but it will usually improve over time as the nerves re-grow. Internal scar tissue (adhesions) may also cause pain following surgery, which may persist. These problems are rare and unpredictable, but you will be given painkillers to take home with you. Any pain usually improves over time.
· Recurrent fibroids
There is a risk of new fibroids growing within five years of surgery. This risk is very difficult to predict, but is higher in younger women. The new fibroids may be picked up on an ultrasound scan, but will only be significant if they cause problems. This is because any future surgery may be more difficult due to the scar tissue that may have formed after the myomectomy. There is also a possibility that fibroids that were small at the time of the operation become bigger with time. This will only be a problem if they cause symptoms.
Are there any alternatives?
Below are some of the alternatives to abdominal myomectomy, although they may not be suitable for all women. If you would like more information, please talk to your doctor.
During hysterectomy, a cut is made on your abdomen, generally across below the bikini line or vertically up towards your belly button, and the entire womb is removed. This procedure may be performed as a vaginal hysterectomy or through keyhole surgery (laparoscopically) if the fibroids are small. The advantages are that your periods will stop and the fibroids do not regrow. The main disadvantage is that you will not be able to have children after the operation. Taking medicines If your fibroid is causing heavy menstrual bleeding, there may be the option to take medicines to reduce the amount of bleeding you experience. They include tranexamic acid or hormonal contraceptive pills. An intrauterine system (Mirena®) releasing a hormone (levonorgestrel) may also help to reduce menstrual bleeding. There are also medicines that can temporarily shrink fibroids before the operation, such as GnRH analogues or selective progesterone modulators (Zoladex®). There is no medicine that can permanently shrink fibroids.
Uterine artery embolization
This is a technique used to treat fibroids. It involves putting a catheter (thin flexible tube) into an artery (blood vessel) in the groin, which is then guided to the arteries of the uterus using x-ray pictures. The treatment blocks the blood vessels supplying the fibroids and causes them to shrink. A general anaesthetic is not necessary, but some sedation is given and a local anaesthetic is used on the area where the catheter is inserted. Once the fibroid blood supply has been identified, a special fluid is injected into the catheter and delivered to the small arteries of the fibroid. No stitches are necessary. After the procedure, you may have uterine pain and vaginal bleeding or discharge that can continue for a few months. For more information, please ask for a copy of our leaflet, Having a fibroid embolisation. Not having an operation If you do not wish to have any procedures performed, you can choose not to. Your doctor will be able to discuss with you the risks and benefits of this, and any other treatments that can help to manage your symptoms.
How can I prepare for my operation?
You will need to attend a pre-assessment appointment to ensure that you are well enough to undergo the operation. Before you come in for your operation, there are some things you can do to reduce the risk of complications.
We recommend that you:
· cut down or give up smoking
· maintain a healthy diet
· maintain some form of exercise if you can
· try to lose weight if you are overweight.
We will send you information with your admission letter about how to prepare for your hospital visit. You may be given an injection, such as goserelin, or a medicine called ulipristal acetate to shrink the fibroids before your surgery. Your doctor will discuss this with you in more detail. Your medicines Please let us know if you are taking any regular medicines and if you have any allergies to any medicines. If you are taking any antiplatelet medicines (such as aspirin or clopidogrel), or anticoagulants (such as warfarin or rivaroxaban), you may need to stop them temporarily before you have the procedure. If you have diabetes and are taking any medicines (including insulin) to help control your blood sugar levels, you may need to alter the dose around the time of your surgery. Further information on stopping any medicines will be given to you when you come for pre-assessment. Please ask us if you have any questions.
You will need to fast before your operation. Fasting means that you cannot eat or drink anything (except non-fizzy water) for six hours before surgery. You can drink clear non-fizzy water up to two hours before surgery. We will give you clear instructions when to start fasting and it is important that you follow them. If there is food or liquid in your stomach during the anaesthetic, it could come up to the back of your throat and damage your lungs.
Consent – asking for your consent
We want to involve you in decisions about your care and treatment. If you decide to go ahead, you will be asked to sign a consent form. This states that you agree to have the treatment and you understand what it involves. If you would like more information about our consent process, please speak to a member of staff caring for you.
What happens before the operation?
You will most likely be admitted to hospital on the morning of the operation and the nurses and doctors will answer any questions you may have. Your blood pressure and pulse will be checked, and you will be given an ID band to wear and a gown and slippers to put on. Your nurse will go through a checklist with you to make sure that you are well prepared for your surgery. They will also give you TED stockings to wear to prevent blood clots in your legs during your operation. When it is time for you to be taken to the operating theatre, your nurse or porter will escort you down.
What happens during the operation?
The operation is performed under general anaesthesia. This means that you will be asleep for the entire procedure.
· While you are asleep, a urinary catheter will be passed up the urethra into your bladder to drain off urine (please see our leaflet, Having a urinary catheter – information for women). A drip will also be put into your arm to give you fluids. The surgeon will then clean your skin with antiseptic and make a cut in your abdomen.
· The surgeon will remove the fibroids from your uterus, and may use a plastic tube to drain the blood from your pelvis if necessary. Both the urinary catheter and the plastic tube will be left in place for 24 to 48 hours.
· The cut will then be closed with stitches or clips and the wound covered with a sterile dressing. The duration of the operation depends on the number and size of the fibroids to be removed, but it usually takes between one and two hours.
What happens after the operation?
You will wake up in the recovery room and you will stay there for about 30 to 60 minutes. You may have an oxygen mask to help you breathe properly. When you are more conscious and stable from the anaesthetic, your nurse will take you to the ward where you will be looked after until you leave hospital. Following your operation, you may wake up with:
· a drip in your arm, which usually stays in place for a day until you are drinking normally again.
· one or two drains (plastic tubes) situated under your skin near the wound to remove any excess blood. These will remain for one or two days.
· a catheter to drain urine from your bladder, which will be removed after one or two days.
· a dressing covering your wound.
· a sanitary towel in place. While you are on the ward, your nurse will check your blood pressure, wound and sanitary towel regularly. They will also assess your pain and give you painkillers as you need them. If you have a patient-controlled analgesia (PCA) pump, they will remind you how to use it. If you feel sick after the anaesthetic, please tell your nurse so that they can give you medicine to relieve this. You will need to stay in hospital for one to three days after your operation, and you can usually return to normal activities within six to eight weeks, depending on your recovery. This will be discussed with you in detail at your pre-assessment appointment.
Will I feel any pain?
Although there will be some discomfort following surgery, this will be controlled with painkillers. We will discuss pain relief with you during your pre-assessment appointment. Here are some of the methods we use to control pain:
· regular injection of painkillers
· patient-controlled analgesia (PCA). This is a pump that gives a dose of painkiller into your bloodstream when you press a button, which means that you are in control of your pain relief. The pump is programmed to allow only a set amount of the painkiller to be delivered, no matter how many times you press the button, so you cannot overdose
· an epidural infusion via a pump that injects painkillers into your spine to block the nerve endings that cause pain · oral (by mouth) painkillers once you are able to eat and drink. Some painkillers can cause nausea and vomiting but we can give you medicines to prevent this. You will be given painkillers to take home with you, so please take them as prescribed. You will also be advised on how to take any other medicines before leaving hospital.
What do I need to do after I go home?
This advice is only a guide, as your recovery is specific to you as an individual and also depends on your condition. Your nurse or doctor will be happy to address any concerns you may have and to answer your questions. You will need someone to be with you at home and help you with your domestic activities, such as cleaning and cooking, as you may not be able to do these things in the first few weeks after your surgery. Everyone is different, so you will know in yourself when you feel well enough.
The following list offers advice on when you may be able to get back to your normal activities:
· Going back to work – This is usually between four and six weeks after surgery, depending on the type of surgery you had, the type of work you do and how you are feeling after your operation.
· Exercise and lifting – Before leaving hospital, you will be given information on exercises you can do at home. You should not go swimming until your wound is healed and the vaginal discharge has stopped. You should only lift light objects for the first few weeks.
· Driving – It is not advisable to drive until you feel comfortable, usually no sooner than four weeks after your surgery. You should be able to put on your seat belt yourself and do an emergency stop. Check if you are covered by your insurance policy.
· Sex – As a guide, you should wait until you have no vaginal discharge and feel comfortable and relaxed before having sex, usually up to four weeks after surgery. However, it is your choice how long you would like to wait and you can discuss this with your nurse before leaving hospital. · Contraception – You will still need to use contraception following a myomectomy if you do not wish to get pregnant.
· Tampons – Due to the risk of infection, we recommend that you do not use tampons immediately after your operation, and that you wait until you no longer have postoperative vaginal discharge. More information will be given to you before leaving hospital.