Robotic & Laparoscopic: myomectomy & Hysterectomy

Robotic technology has expanded the limits of gynecologic surgery by enabling surgeons to better visualize and more precisely perform highly technical laparoscopic procedures than would otherwise be possible. Robotic technology in association with the laparoscope allows surgeons to view anatomical structures - including small blood vessels, nerves and nearby organs - from a magnified, three-dimensional perspective. Robotics significantly enhances depth perception and range of motion, which enables surgeons to safely perform complex operations by remotely manipulating robotic arms while sitting at a console similar to a pilot's cockpit. Robotic technology adds no risks beyond those associated with laparoscopic hysterectomy.While the use of robotics in the field of gynecology is increasing, it is estimated that only 2 percent of hysterectomies currently performed in the U.S. employ this technology. UCLA is one of only a few centers in Southern California with the technology and surgical expertise to offer robotic laparoscopic myomectomy and hysterectomy as an alternative for women who might otherwise face the increased risk of complications associated with open abdominal hysterectomysurgery.

 

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Surgery may be your best treatment option

A uterine fibroid is a common type of benign (non-cancerous) tumor that develops within the uterine wall. Uterine fibroids occur in up to one third of all women and are actually the leading reason for hysterectomy (removal of the uterus) in the United States. Uterine fibroids occur in 20-40% of all women during reproductive years.

Uterine fibroids may grow as a single tumor or clusters. They often increase in size and frequency with age, but may also revert in size after menopause. While not all women with fibroids experience symptoms, these may include excessive menstrual bleeding, pelvic pain and difficulty getting pregnant.

The Treatment: myomectomy

A common alternative to hysterectomy for fibroids is myomectomy, the surgical removal of fibroid tumors and a procedure considered standardof- care for removing fibroids and preserving the uterus. It therefore may be recommended for women who wish to become pregnant. myomectomy is most often performed through a large abdominal incision. After removing each fibroid, the surgeon repairs the uterus to minimize potential bleeding, infection and scarring. Proper repair is critical to reducing the risk of uterine rupture during a future pregnancy. Fibroid embolization is a newer, non-invasive treatment available but, there are limited studies showing its long-term success. Another approach, laparoscopic myomectomy, offers a minimally invasive alternative to open surgery but is usually not an option for women with large fibroids, multiple fibroids or with fibroids in difficultto- reach areas.

myomectomy: A Less Invasive Surgical Procedure

If your doctor recommends surgery to treat uterine fibroids, you may be a candidate for a uterine-preserving, minimally invasive procedure – da Vinci myomectomy. Using the most advanced technology available, da Vinci myomectomy enables surgeons to perform this delicate operation with unmatched precision, vision and control using only a few small incisions. For women who want a uterine-sparing procedure, da Vinci myomectomy offers numerous potential benefits over open abdominal surgery, including:

  • Significantly less pain
  • Less blood loss and need for blood transfusions
  • Shorter hospital stay
  • Faster recovery and quicker return to normal activities
  • Less scarring
  • Associated Risks 

    Many physicians who are untrained in performing a myomectomy will opt for a hysterectomy because their lack of experience increases the risk of complications.

    Although complications are rare when a myomectomy is performed properly, women considering this procedure should be aware of the possible risks. Possible complications include blood loss, ileus (bowel obstruction), anemia, pain, late intestinal obstruction, infertility, possible conversion to hysterectomy during myomectomy, and subsequent surgery.

    Although pregnancy is still possible after a myomectomy, women who become pregnant following a myomectomy face the possible necessity of a cesarean section due to a potential weakening in the uterine wall.

    Although more than 99 percent of fibroids are benign, your physician should also discuss the rare possibility of cancer before your myomectomy.

    Types and General Procedure

    There are several ways to perform a myomectomy. It can be performed vaginally or abdominally, using a variety of different methods. The type of myomectomy chosen depends on the size and location of the fibroid tumors.

     

    After a woman is under anesthesia, a catheter is inserted into the bladder to keep it empty during the procedure. Another catheter is then inserted into the uterus and a blue dye is injected to stain the uterine cavity; this staining of the uterine cavity is necessary to help the physician determine the location of the fibroids, which often are so large they are indistinguishable from the tissue of the uterus.

     

    The blue dye also runs into the fallopian tubes and allows the physician to determine whether they are blocked or open. Repairs to the fallopian tubes can also be made during this procedure.

    Next, a drug is injected into the first fibroid slated for removal, causing the blood supply to stop for 20 minutes and allowing the physician to remove the fibroid with less risk of excessive bleeding and transfusion.

    Special care must be taken when closing up the defect (space) left where the fibroid was removed. Each layer of tissue must be sutured individually to prevent clots and other complications. As each fibroid is removed, this procedure is repeated.

     

    All women undergoing a minimally invasive myomectomy technique should be aware of the possible need to convert to a traditional abdominal procedure while the myomectomy is in progress.

    As previously mentioned, there are several ways to perform myoa mectomy.

    Trans-cervical Myomectomy

    This is performed during a hysteroscopy with the aid of a resectoscope to treat submucosal fibroids. Other types of myomectomy may be performed during this procedure if intramural or subserosal fibroids are present.

    Laparoscopic Myomectomy

    This is a procedure that removes the fibroids and repairs the defect left where the fibroid was located. Proper repair of the defect is of extreme importance in the prevention of complications. A small incision is made, usually in the navel, and a laparoscope is inserted where the myomectomy is performed. This type of myomectomy offers the fastest recovery time.

    Laparoscopic Myomectomy with Colpotomy

    This is a procedure that involves an incision in the vagina to remove large pieces of fibroids. This procedure does not close the defect left by the fibroid and must be performed in conjunction with another procedure.

    Laparoscopic Minilap Myomectomy

    This is a procedure that also includes a small traditional abdominal incision to remove the fibroids. This type of procedure can be used for any size of fibroid. Because the incision is only 4-5 cm, recovery is quicker than from a conventional myomectomy.

    Conventional Myomectomy

    This is still the most commonly performed type of myomectomy, as laparoscopic myomectomies are more difficult to perfor requires a 5-7 inch abdominal incision, three to five days of hospitalization, and six to eight weeks for recovery.

    What to Ask Your Physician

  • Why is your doctor recommending a myomectomy now?
  • What are the risks of deciding against myomectomy? 
  • How often does your doctor perform myomectomies?
  • Can a myomectomy be performed without regard to the size or location of fibroids? 
  • What type of myomectomy is your doctor recommending? Why? 
  • Will you require blood transfusions
  • Remember, your physician should explain all possible options before you make your decision. If your physician does not offer myomectomy for fibroids and insists on hysterectomy, it is most likely because he is not experienced enough to safely perform a myomectomy, and you should ask him for a referral to a physician who is experienced in performing a myomectomy. A good physician will gladly give you such a referral and a second opinion is always a wise choice before any major surgery.