Background Information:

What are the other Names for the Procedure?

• Fibroidectomy
• Myomectomy
• Uterine Fibroid Tumor Removal

What is Fibroid Tumor Removal surgical procedure?

Fibroid Tumor Removal (or Myomectomy) is the surgical removal of fibroids from the uterus. Fibroids are non-cancerous growths that often appear in the uterus, during childbearing years.

What part of the Body does the Procedure involve?

A Fibroid Tumor Removal procedure involves the uterus.

Why is the Fibroid Tumor Removal surgical procedure Performed?

The presence of a fibroid does not indicate that it needs to be surgically removed

A Fibroid Tumor Removal (Myomectomy) is performed, when the fibroid causes pain, pressure, abnormal bleeding, or interferes with reproduction

What are some Alternative Choices for the Procedure?

The use of alternative treatment methods depends on several factors, including:

• Age of the individual
• Their general health
• Severity of symptoms
• Type of fibroids
• Whether, you are pregnant
• If you plan on having children in the future

Some women may only need pelvic exams or ultrasounds, every once in a while, in order to monitor the fibroid's growth.

Treatment for the symptoms of uterine fibroids may include:

• Birth control pills (oral contraceptives) to help control heavy periods
• Intrauterine devices (IUDs) that release the hormone progestin, to help reduce heavy bleeding and pain
• Iron supplements to prevent or treat anemia, caused due to heavy periods
• Non-steroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or naprosyn, for cramps or pain
• Short-term hormonal therapy injections, to help shrink the fibroids

What are the Recent Advances in the Procedure?

Robotic Myomectomy and high-intensity focused ultrasound ablation are recent advancements in the procedure.

What is the Cost of performing the Fibroid Tumor Removal surgical procedure?

The cost of Fibroid Tumor Removal surgical procedure depends on a variety of factors, such as the type of your health insurance, annual deductibles, co-pay requirements, out-of-network and in-network of your healthcare providers and healthcare facilities.

In many cases, an estimate may be provided before the procedure. The final amount depends upon the findings during the surgery/procedure and post-operative care that is necessary.

When do you need a Second Opinion, prior to the Procedure?

• It is normal for a patient to feel uncomfortable and confused with a sudden inflow of information regarding Uterine Fibroid Tumor Removal surgical procedure and what needs to be done
• If the patient needs further reassurance or a second opinion, a physician will almost always assist in recommending another physician
• Also, if the procedure involves multiple surgeries or has many alternatives, the patient may take a second opinion to understand and choose the best one. They can also choose to approach another physician independently

What are some Helpful Resources?

http://www.mayoclinic.com/health/myomectomy/MY00501 (accessed on 05/16/2014)

http://www.davincisurgery.com/gynecology/gynecology-procedures/myomectomy.html (accessed on 05/16/2014)

http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001912/ (accessed on 05/16/2014)

Prior to Fibroid Tumor Removal surgical procedure:

How is the Fibroid Tumor Removal surgical procedure Performed?

A Fibroid Tumor Removal procedure can be performed in a number of ways. It depends on the location and number of lesions, and the experience and preference of the surgeon. The different methods include:

• Laparotomy
• Laparoscopy
• Hysteroscopy
• Robotic surgery

Laparotomy: Open approach

• An incision is made on the abdomen, either vertically or horizontally
• The incision is carried down through different layers of the abdominal wall, and the abdominal cavity is opened
• The uterus is identified, incised, and the lesion(s) removed
• The open approach is often preferred for larger lesions, multiple fibroids, or fibroids that have grown deep into the uterine wall

Laparoscopy:

• Using a narrow tube-like instrument (cannula), the surgeon enters the abdomen in the area of the belly button
• A laparoscope (a tiny telescope) connected to a special camera is inserted through the cannula, giving the surgeon a magnified view of the patient's internal organs on a television screen
• Other cannulas are inserted, which allow your surgeon to identify the uterus and remove the fibroids
• This method is not generally used on very large fibroids

Hysteroscopy:

• The surgeon accesses and removes the fibroids using instruments inserted through the vagina and cervix, into the uterus
• This method is generally used to remove smaller fibroids (less than 5 cm), located on the inner wall of the uterus, which have not grown deep into the uterine wall

Robotic surgery:

• This is a minimally-invasive robotic procedure for removal of the fibroids
• During this procedure, the surgeon sits at a console viewing 3-D, high-definition images, while using controls below the display to move robotic arms with attached surgical instruments
• The system translates the surgeon’s hand, wrist, and finger movements, into precise, real-time movements of the surgical instruments inside the patient
• In some centers, unlike traditional robotic surgeries that require 3-4 small incisions, used as access ports for the robotic arms, the new technology allows for a single incision at the belly button, where instruments are placed and the fibroid removed

Where is the Procedure Performed?

• Hysteroscopic and laparoscopic removal of fibroids are usually performed in an out-patient surgery center facility. Normally, the individual can go home, once the procedure is completed
• However, the physician may keep them under overnight observation, if necessary
• In some cases, the patient may be kept under observation for a period of time, under advice by the physician
• Laparotomy and fibroid removal is performed in a hospital. The patient is admitted, undergoes the procedure and discharged, as per the instruction of the physician

Who Performs the Procedure?

The Fibroid Tumor Removal procedure is performed, either by an obstetrician or a gynecologist, with assistance from an anesthesiologist.

How long will the Procedure take?

The Fibroid Tumor Removal surgical procedure may take anywhere between 1-3 hours, depending upon the type of approach used.

What do you need to tell your Physician before the Procedure?

It is very important to provide the following information to your healthcare provider. This enables your healthcare provider in assessing the risks for the Fibroid Tumor Removal surgical procedure and helps avoid unnecessary complications.

• Provide a complete list of medications you are currently, taking to your physician. This information is useful for a variety of reasons. For example, it can help your healthcare provider prevent complications due to a drug interaction
• If you are allergic to any specific medication or food items
• If you are taking blood thinners, such as aspirin, warfarin, herbal supplements, or any other such medications
• If you or your family members, have a history of bleeding disorders, or if there is a tendency to bleed more than normal
• If you have diabetes, high blood pressure, chest pains, or have previously suffered from a heart attack
• If you have ever been diagnosed with blood clots in your leg (deep vein thrombosis) or lung (embolism of lung)
• If you have a history of frequent bone fractures (this may affect bone-healing, if bones are involved as part of your procedure)
• A list of all previous surgical procedures you have undergone, like for example: Removal of appendix, gallbladder, or any other part, of your body; surgical repair of any body part, such as hernia repair, perforation of bowel wall, etc.

What Preparations are needed, prior to the Procedure?

• The physician may evaluate the individual’s medical history to gain a comprehensive knowledge of the overall health status of the patient, including information related to the medications that are being currently taken
• Some medications increase a person’s chances of bleeding and it may be recommended to discontinue them for a period of time, before the procedure is performed
• Blood tests may be performed to determine if there is a bleeding tendency or any other medical conditions that prevents the person from undergoing the procedure
• Normally, local anesthesia is not used; however, do inform the physician if you are allergic to any local anesthetics, lidocaine, etc.
• Avoid application of any cosmetics, deodorant, or topical medicines on the area, prior to the procedure
• It is advisable to quit smoking and the use of any nicotine based products, for a while, before the surgery
• Consumption of alcoholic drinks must also be avoided for a period of time, as instructed
• The patient must avoid eating or drinking at least 8 hours prior to the surgical procedure, depending on when the procedure is arranged
• For persons suffering from diabetes, it is important that the blood sugar stays within the normal range; if not their diabetologist may have to control blood sugar by recommending insulin and/or a combination of oral medicines

What is the Consent Process before the Procedure?

A physician will request your consent for Fibroid Tumor Removal procedure using an Informed Consent Form.

Consent for the Procedure: A “consent” is your approval to undergo a procedure. A consent form is signed after the risks and benefits of the procedure, and alternative treatment options, are discussed. This process is called informed consent.

You must sign the forms only after you are totally satisfied by the answers to your questions. In case of minors and individuals unable to personally give their consent, the individual’s legal guardian or next of kin, shall give their consent for the procedure.

What Tests are needed, before the Fibroid Tumor Removal surgical procedure?

Prior to a Fibroid Tumor Removal procedure, the patient may need to undergo certain tests, such as:

• A pelvic exam by a physician, which may show a change in the shape of the uterus. It can be difficult to diagnose fibroids, especially in obese patients
• An ultrasound may be done to confirm the diagnosis of fibroids
• In some cases, a pelvic MRI is performed

What are some Questions for your Physician?

Some of the basic questions that you might ask your physician are as follows:

• What is a Fibroid Tumor Removal procedure?
• Why is this procedure necessary? How will this procedure help?
• What does the procedure involve?
• How soon should I get it done? Is there an emergency?
• Who are the medical personnel involved in this procedure?
• What are the risks while performing the procedure?
• What are the possible complications that might take place, during recovery?
• How long will it take to recover? When can I resume normal work?
• How many such procedures have you (the physician) performed?
• Are there any lifestyle restrictions or modifications required, after the procedure is performed?
• Are there any follow-up tests, periodic visits to the healthcare facility required, after the procedure?
• Is there any medication that needs to be taken for life, after the procedure?
• What are the costs involved?

During the Fibroid Tumor Removal surgical procedure:

What kind of Anesthesia is given, during the Procedure?

General anesthesia or spinal anesthesia is administered, during the Fibroid Tumor Removal procedure.

How much Blood will you lose, during the Procedure?

• The amount of blood loss is generally minimal (especially when the procedure is performed via a hysteroscopy or a laparoscopy)
• But, if complications arise during the Fibroid Tumor Removal procedure, it could lead to a further loss of blood

What are the possible Risks and Complications during the Fibroid Tumor Removal surgical procedure?

There are general factors that increase the risk of getting complications during the Fibroid Tumor Removal surgery and they include:

• Obesity: Generally greater the degree of obesity, greater is the surgical risk
• Smoking: Longer the smoking history (in pack years smoked), greater the surgical risk
• Advancing age
• Poorly controlled diabetes, as evidenced by a high hemoglobin A1c and a high fasting glucose
• Poorly functioning kidney, as evidenced by increased BUN (blood urea nitrogen) and blood creatinine
• Poorly functioning liver, as evidenced by increased blood liver function tests
• Hypertension (increased blood pressure), especially if it is poorly controlled
• Poor nutritional status (malnutrition with mineral and vitamin deficiencies)
• Poor lung function, as evidenced by abnormal lung function tests
• History of bleeding disorders
• Longstanding illness, such as autoimmune disorders, chronic infections
• Poor immune system due to a variety of causes

The possible risks or complications that may arise during the Fibroid Tumor Removal surgery are:

• Bleeding
• Injury to the neighboring structures
• Anesthetic complications
• Need for further procedures
• Blood clot formation
• Inability to restore the structure of the uterus: Sometimes, in order to remove the embedded fibroids, the surgeon might cut into the muscular wall (myometrium), leaving a gap. Rarely, the surgeon may have to remove the uterus, if reconstruction is not possible, or if the bleeding is severe

What Post-Operative Care is needed at the Healthcare Facility after the Fibroid Tumor Removal surgical procedure?

At the healthcare facility, generally there is no requirement for any post-procedure care, unless any complications arise.

After the Fibroid Tumor Removal surgical procedure:

What are the possible Risks and Complications after the Fibroid Tumor Removal surgical procedure?

Post Fibroid Tumor Removal procedure, the following complications may arise:

• Infection
• Bleeding
• Pain and discomfort
• Pneumonia (infection of the lungs)
• Blood clot formation (embolism and thromboembolism)
• Heart problems
• Scar tissue: Within the uterus, scar tissue may block implantation of a fertilized egg in the uterine lining; though, this occurs only rarely. Outside the uterus, scar tissue could entangle neighboring structures and lead to a blocked fallopian tube, or a trapped loop of bowel, causing bowel obstruction
• Development of new fibroids: Tiny tumors (seedlings) during surgery could eventually grow and cause symptoms; new tumors may also develop
• Childbirth complications: Having had Myomectomy can pose some risk factors during delivery. Hence, some doctors may recommend cesarean delivery, to avoid rupture of the uterus during labor

What is the Prognosis after the Surgery?

After Fibroid Tumor Removal (Myomectomy) surgery, a majority of the women can experience relief from the bothersome signs and symptoms, including excessive menstrual bleeding, pelvic pain and pressure.

• However, Myomectomy surgery is not a permanent fix for uterine fibroids. New fibroids could develop that may or may not require any treatment
• Fibroids that were larger and more numerous are most likely to recur
• Since, fibroids can grow back, it is best to try and conceive (plan for a child) after the Myomectomy procedure is performed, as soon as it is safely possible to do so and when recovery from the surgery is complete (per advise of your physician)
• When incisions have been made into the uterine wall to remove fibroids, future pregnancy may be affected; sometimes, the placenta may develop problems

When do you need to call your Physician?

Do contact your physician if you notice any of the following symptoms:

• Worsening pain around the surgical wound
• Swelling and redness
• Bleeding or fluid drainage around the spot
• Fever
• Dizziness
• Signs of infection

What Post-Operative Care is needed at Home after the Fibroid Tumor Removal surgical procedure?

At home, the following post-operative care is recommended, after a Fibroid Tumor Removal procedure:

• Gradually advance the diet, from liquids to solids, as the patients tolerate
• Avoid strenuous physical activities, while slowly getting back to your regular daily routine
• Keep incision wounds clean and dry
• Complete the prescribed course of medications
• Avoid pain killers, unless they are prescribed by your healthcare provider
• Avoid any possibilities of constipation; take stool-softening medications, if required
• Do not use tampons or have sexual intercourse for up to six weeks (per advise of your physician)

How long does it normally take to fully recover, from the Procedure?

Recovery time depends on the method used for the Myomectomy:

• Hysteroscopy requires from a few days to 2 weeks, to recover
• Laparoscopy requires 1-2 weeks
• Laparotomy requires 4-6 weeks

Additional Information:

What happens to tissue (if any), taken out during the Procedure?

The fibroid tissue is taken for further examination and later disposed, as per the standard medical procedure.

When should you expect results from the pathologist regarding tissue taken out, during the Procedure?

• The fibroid tissue removed is processed in the laboratory under a pathologist's supervision
• The slide(s) are prepared once the tissue is processed, and this is examined by a pathologist and a pathology report issued
• Depending on the complexity of the case, issue of the report may take anywhere between 72 hours to a week's time

Who will you receive a Bill from, after the Fibroid Tumor Removal surgical procedure?

It is important to note that the number of bills that the patient may receive depends on the arrangement the healthcare facility has with the physician and other healthcare providers.

Sometimes, the patient may get a single bill that includes the healthcare facility and the consultant physician charges. Sometimes, the patient might get multiple bills depending on the healthcare provider involved. For instance, the patient may get a bill from:

• The outpatient facility, physician’s office or hospital
• An anesthesiologist (if anesthesia was administered)
• A pathologist
• An obstetrician/gynecologist

Individuals are advised to inquire and confirm the type of billing, before the Removal of Fibroid Tumor surgical procedure is performed.

Thanks and Gratitude:

We sincerely acknowledge and thank Dr. Douglas J. Jones for reviewing the article. His valuable input and feedback has helped enrich the contents of this article.

Douglas J. Jones, MD FACS
Board Certified General Surgeon and Faculty Member
University of Illinois, College of Medicine at Urbana-Champaign
506 S. Mathews Ave., Urbana, IL 61801, USA