Determining the Route of Surgery for Leiomyomas

Selecting the Route of Surgery for Leiomyomas: General considerations

The determination of the surgical route for leiomyomas undertaken considering the patient's symptoms, fertility desires, the size,  location, and number of the fibroids, the surgeon’s expertise and experience, and the patients preferences. Uterine-sparing surgical options is  myomectomy and less invasive procedures such as uterine artery embolization and MRgFUS. Interestingly, while hysterectomy is the only definitive solution, it is not without risks, and alternative treatments are available that may align better with the patient's quality of life and fertility goals. Minimally invasive surgery options are preferred by many patients due to factors such as quicker recovery and smaller incisions, despite the potential risks associated with power morcellation. The patient's informed consent is crucial, and the decision should be made collaboratively with the healthcare provider to ensure the best possible outcome.


Vaginal Surgery


Considerations for appropriateness for vaginal surgery include prior vaginal delivery, prior abdominal surgery, potential intraabdominal adhesions, concern for underlying malignancy, pelvimetry assessment, and uterine descent.  Advantages of vaginal surgery include lack of abdominal incisions, minimal morbidity, enhanced recovery, ability to perform under regional anesthesia, no need for Trendelenburg positioning, and no increase in intraabdominal pressure.  This can prove exceptionally advantageous for patients with cardiopulmonary comorbid conditions.  Disadvantages of vaginal surgery include the potential need for uterine morcellation or ovarian cyst rupture if enlarged pathology, inability to assess the entire peritoneal cavity, difficulty accessing the adnexal structures, and possible decreased visualization.


Hysteroscopic Surgery


Considerations for the appropriateness of hysteroscopic surgery primarily center on the presence or absence of pathology that can be dealt with appropriately with intrauterine techniques.  Other considerations include patient symptomatology and the goals of the surgery. Advantages of hysteroscopic surgery include the ability to perform in the office (dependent on pathology and resources available), minimal surgical risk and time for recovery, lack of abdominal incisions, minimal morbidity, and ability to perform under local, regional, or intravenous anesthesia.  This can prove exceptionally advantageous for patients desiring to return to normal activities quickly following surgery.  Disadvantages of hysteroscopic surgery include the inability to assess or treat pathology deep within the myometrium or the peritoneal cavity, the risk of excessive fluid absorption and fluid overload, and the potential need for staged procedures with large or challenging pathology.


Laparoscopic Surgery


Similar to laparotomic surgery, considerations for laparoscopic or robotically assisted laparoscopic surgery include prior abdominal surgery, intraabdominal adhesive disease, suspected or known malignancy, and size of pathology (uterine or adnexal).  Advantages of laparoscopic surgery include decreased surgical risk and faster recovery compared to the laparotomic approach, the ability to assess the entire peritoneal cavity, and magnified visualization.  Laparoscopic surgery's disadvantages include general anesthesia, steep Trendelenburg positioning, and intraabdominal insufflation.  This can pose challenges for patients with cardiopulmonary comorbidities, increased intraocular pressure, or morbid obesity. 

Laparotomic Surgery


Considerations for appropriateness for laparotomic surgery include prior abdominal surgery, intraabdominal adhesive disease, suspected or known malignancy requiring a debulking procedure, and size of pathology (uterine or adnexal).  Advantages of laparotomic surgery include directly palpating pathology, thoroughly assessing the entire peritoneal cavity, and removing pathology en bloc.  Disadvantages of laparotomic surgery include prolonged recovery, increased morbidity, postoperative adhesive disease, and increased surgical risk. 


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