View source for Myomectomy

{{Infobox surgical procedure
| anesthesia_type = General vs Neuraxial
| airway = ETT vs LMA vs non-invasive O2
| lines_access = PIV x 2 (at least 1 large bore), +/- arterial line
| monitors = Standard, 5-lead EKG, temperature
| considerations_preoperative = Type and screen
| considerations_intraoperative = Hemorrohage, uterine rupture, CO2 air embolism
| considerations_postoperative = PONV
}}

Myomectomy is a surgical procedure involving the removal of fibroids of the uterus in patients who have not completed childbearing. Indications include abnormal bleeding, infertility, ureteral compression, hydroureter/hydronephrosis and pain<ref>{{Cite book|url=https://www.worldcat.org/oclc/1117874404|title=Anesthesiologist's manual of surgical procedures|date=2020|others=Richard A. Jaffe, Clifford A. Schmiesing, Brenda Golianu|isbn=978-1-4698-2916-6|edition=Sixth edition|location=Philadelphia|oclc=1117874404}}</ref>. There are several approaches to the surgery that is dictated by the size, number and location of the fibroids. The procedure begins with Pfannenstiel (open), low midline abdominal laparoscopic incision(laparoscopic) with placement of trocars, or with hysteroscopy. In order to minimize bleeding, vasoconstrictor such as epinephrine or vasopressin is injected to the myometrium or a tourniquet can be used to minimize uterine blood flow. Fibroids are removed and defects are sutured and closed. 

== Preoperative management ==

=== Patient evaluation<!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --> ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Respiratory
|
|-
|Gastrointestinal
|
|-
|Hematologic
|Assess for anemia secondary to menorrhagia or menometrorrhagia
|-
|Renal
|Assess for volume status as abdominal insufflation decreases preload
|-
|Other
|
|}

=== Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> ===

* Type and screen

=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> ===

* IV midazolam for anxiety 
* PO Acetaminophen for pain 
* PO gabapentin
* PO celecoxib
* Scopolamine patch for PONV 

=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> ===

* Spinal and/or epidural 

== Intraoperative management ==

=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> ===

* Standard ASA monitors
* 5-lead EKG 
* +/- arterial depending size/extent of myomectomy 
* OG/NGT to decompress stomach prior to trocar placement to decrease risk of injury
* PIV x 2 ( at least 1 large bore) 

=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===

* If general is chosen, standard induction 
** ETT vs LMA 
* If neuraxial is chosen, minimal to deep sedation is reasonable

=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===

* Lithotomy (laparoscopic, vaginal approach)
* Supine (open approach)
* Steep Trendelenburg (laparoscopic approach)

=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===

* Maintenance with volatile anesthetic supplemented with opioid analgesic 
** Consider TIVA is high risk for PONV
** Maintain neuromuscular blockade if open or laparoscopy
* Physiologic of abdominal insufflation
** Decreased FRC
*** May require adjustment of PEEP to prevent alveolar collapse
** CO2 retention
*** May require adjustment of MV to decrease absorbed CO2 from insufflation
** Increase HR, MAP, PVR and SVR
** Decreased venous return from IVC collapsed, preload, and cardiac output
** Bradycardia and systole
*** May need to decompress abdomen from insufflation, and proceed abdominal insufflation slowly 
*** Treat with atropine or glycopyrrolate 
* Monitor blood loss, transfuse if needed
** Vascular injury 
* CO2 air embolism 
* Subcutaneous/mediastinal emphysema 
* Uterine rupture
* Bowel/bladder injury

=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===

* PONV prophylaxis 

== Postoperative management ==

=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> ===

* PACU
* Usually discharged home

=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===

* Pain is mild to severe depending on surgical approach 
** Multimodal analgesia 
*** IV/PO acetominophen
*** IV/PO opioids 
*** IV/PO NSAIDs pending surgical team approval
*** IV lidocaine 
*** IV ketamine 
*** Local anesthetic at trocar sites
*** TAP blocks
*** Epidural analgesia

=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===

* Bleeding/hematoma
* Pregnancy complications
* Infections
* Peroneal nerve damage 
* Adhesion formation
* Fistula formation
* Pulmonary embolism

== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Open myomectomy
!Laparscopic myomectomy
!Vaginal myomectomy
|-
|Unique considerations
|
|Minimizes blood lost
|
|-
|Position
|Supine
|Steep Trendelenburg
|Lithotomy 
|-
|Surgical time
|
|1-4 hours
|1-4 hours
|-
|EBL
|1-1.5 L
|100-600 mL
|
|-
|Postoperative disposition
|Floor
|PACU and usually discharged home
|PACU and usually discharged home
|-
|Pain management
|Severe, multimodal, consider epidural
|Moderate, multimodal
|Mild to moderate, multimodal
|-
|Potential complications
|Bowel/bladder injury, bleeding
|Bowel/bladder injury
|Uterine rupture
|}

== References ==

[[Category:Surgical procedures]]