Myomectomy
Abdominal myomectomy is performed as an alternative to hysterectomy. The indications for myomectomy are collateral and consist of the desire to preserve the uterus together with the presence of symptomatic intramural or subserosal myomata uteri. Typical symptoms experienced by women in whom no submucous component exists are pressure on the bladder or bowel, partial obstruction of the ureters, and pain. Although this operation has been performed laparoscopically, most surgeons consider laparotomy to be the route of choice.
The uterus is typically distorted (Fig. 14–1). Although the arterial supply to myomata is relatively sparse, the venous return is large, thin-walled, and anomalous (Figs. 14–2 through 14–4). The surgeon must cut through the capsule to reach the core of the myoma to remove it, and must traverse tissue planes that contain these venous sinuses. Because of the increased vascularity, many surgeons prefer to use an energy source to diminish bleeding (e.g., carbon dioxide [CO2] laser, electrosurgical needle electrode). The author additionally uses a 1 : 200 solution of vasopressin (20 units). Approximately 20 to 30 mL of this solution is injected just beneath the capsule (Fig. 14–5A). The anesthesiologist should be alerted to monitor the patient’s blood pressure and pulse during injection of vasopressin. Next, an outline is made for the incision. This may be performed with cold steel, CO2 laser, or needle electrode (Fig. 14–5B). The author prefers to limit the posterior extent of the incision to diminish subsequent adhesion formation (Fig. 14–5C). In the case illustrated, a slightly defocused CO2 laser handpiece is utilized with power set at 50W and a laser spot 1.5 to 2.0 mm in diameter (power density 1250–2200 W/cm2) (Fig. 14–6). The edges of the capsule are retracted, and the myoma is dissected peripherally off the capsule (Fig. 14–7). The operator’s index finger can actually be used to separate the myoma from the capsule. The laser, needle electrode, or scissors may be used to cut away adhesions (Fig. 14–8). Care should be taken to carry out the dissection gently and carefully to avoid entry into the uterine cavity and injury to the interstitial portion of the oviduct (Fig. 14–9A–C).
When the base of the myoma is reached, the arterial pedicle should be clamped and suture-ligated (Fig. 14–9D, E). The specimen is then removed. Typically, the author cuts the myoma to determine whether there is any gross suspicion of sarcoma or infection. A pulpous, rotting interior suggests the need for a frozen section or at least a careful postoperative histologic assessment. Some excess capsule may be trimmed away (Fig. 14–9F). The uterus is reconstructed by bringing muscle to muscle together with interrupted 0 Vicryl (Fig. 14–10A, B). This may require a two-layered closure. Next, the serosa is closed with running or interrupted 2-0 or 3-0 Vicryl sutures. At the completion of closure, the author prefers to cover the exposed suture line with a parietal peritoneal graft or a patch of Interceed absorbable adhesion barrier or other suitable material. Typically, the surgeon measures and cuts the specimen (Fig. 14–11A, B). Submucous myomata are responsible for 90% of the bleeding associated with these common tumors and should be treated hysteroscopically. If the myoma is too large for hysteroscopic extirpation, even after 3 to 4 months of gonadotropin-releasing hormone (GnRH) agonist suppression, the patient should undergo a hysterectomy (Fig. 14–12).
Occasionally, a myomectomy is performed and no suspicion of malignancy is evidenced (Fig. 14–13A–D), but it is surprising to note that the permanent histopathologic sections reveal leiomyosarcoma (Fig. 14–14A, B). In this circumstance, the patient must be promptly notified of these findings and strongly advised to undergo total abdominal hysterectomy (Fig. 14–15A, B).
Cervical myomata may be excised via the vaginal route with the use of a microscope-mounted CO2
