Principal Director & Unit Head, Obstetrics and Gynaecology, Max Hospital, Gurugram
Part 7 of 9 in Benign Growth in Uterus Causing Gynaecological Problems
Surgical Removal: Hysteroscopic, Laparoscopic and Robotic Myomectomy
August 25, 2024
For women who want to preserve fertility, myomectomy, removal of the fibroid while leaving the uterus intact, is the standard surgical approach, and the technique chosen depends heavily on the fibroid's location.
Hysteroscopic removal for cavity fibroids
A small fibroid inside the uterine cavity (submucosal) can be removed hysteroscopically, entering through the vagina with no external cut at all. It's a day-care procedure: the patient is admitted in the morning and goes home the same evening, with essentially no blood loss.
Laparoscopic and robotic myomectomy
For fibroids in the muscle wall or on the outer surface, laparoscopic or robotic myomectomy uses small keyhole incisions to remove the fibroid, offering minimal blood loss, less pain and quicker recovery than open surgery. Robotic myomectomy specifically, performed using a console-based system with two hand-controlled instruments, gives fine surgical control but requires intensive training and skill to perform well. Open surgery is still used in select cases where minimally invasive access isn't feasible.
This article is based on a Jivo Masterclass session conducted by Dr. Suman Lal, Principal Director & Unit Head, Obstetrics and Gynaecology, Max Hospital, Gurugram. The article has been summarised with the assistance of an AI tool from the original masterclass recording. Watch the full Masterclass recording
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This guide is based on a live Jivo Masterclass: Dr. Suman Lal taught doctors across Africa on August 25, 2024.
FROM THE LIVE Q&A
Moderator
What is the role of the gonadotropin agonists used in India, Lupron and Goserelin?
Dr. Suman Lal
Both are effective at reducing fibroid size, by around 40-50%. Different centres use different ones, but either can be used.
Frequently Asked Questions
Do you suggest that a scan measuring a 5cm fibroid should be surgically removed?▼
Not automatically. If the 5cm fibroid is inside the uterus causing heavy bleeding or obstruction, yes. If it's outside the uterus and not causing any problem, there's no need to operate. If it's in the muscle layer and the patient is trying to conceive or undergo IVF, removal is often needed. Symptoms, location and fertility goals all have to be weighed together, not size alone.
What is the relationship between fibroids and menstrual pain?▼
A fibroid inside the uterine cavity acts like a foreign body. When menstrual contractions begin, the uterus tries to expel the fibroid the same way labour contractions try to expel a baby, causing cramping. An intramural fibroid also increases the uterus's surface area, independently increasing both pain and bleeding.
What is the fate of myoma nuclei after embolization, and why is it contraindicated in women wishing to conceive in the future?▼
Embolization blocks the artery supplying the uterus, so blood flow to the entire uterus decreases, not just to the fibroid. That reduced blood flow is exactly why the procedure is contraindicated for women planning pregnancy afterward, since it can compromise the nutrition and growth of a future baby. For these patients, myomectomy (surgical removal) is the right choice instead.
In cases of infertility, is there any actual management in terms of medication?▼
Infertility has several possible causes, blocked tubes, inadequate egg count, or structural issues like fibroids, adenomyosis or endometriosis, and each needs a different treatment. For a woman with fibroids who wants to avoid surgery before conceiving, a GnRH agonist can shrink the fibroid over six to nine months, after which medication can be given to support pregnancy.
Can endometriosis be cured completely, and how can someone with endometriosis get pregnant easily?▼
Complete cure of endometriosis is mostly not possible, but early detection and adequate treatment are key. If an endometrioma is found, a thorough cystectomy removing all endometriotic tissue at the first surgery is the most important step; getting this first surgery right substantially reduces recurrence and preserves the chance of pregnancy.
How is a submucosal fibroid removed?▼
Hysteroscopically, through the vagina with no external cut, as a day-care procedure with essentially no blood loss.
What is the benefit of robotic myomectomy?▼
Minimal blood loss, less pain, and quicker recovery than open surgery, with fine surgical control, though it requires intensive training and skill.
In This Series: Benign Growth in Uterus Causing Gynaecological Problems
- 1.Uterine Fibroids
- 2.What Are Uterine Fibroids? Risk Factors and Symptoms
- 3.Diagnosing and Classifying Fibroids by Location
- 4.Fibroids, Fertility, Pregnancy Risk and Menstrual Pain
- 5.Medical Management: Painkillers, Progesterone and GnRH Agonists
- 6.Uterine Artery Embolization: When It Works and When It's Contraindicated
- 7.Surgical Removal: Hysteroscopic, Laparoscopic and Robotic Myomectomy
- 8.Beyond Fibroids: PCOS, Endometriosis and Infertility
- 9.Preventing Adhesions After Myomectomy: What Actually Works