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{{Infobox surgical procedure
{{Infobox surgical procedure
| anesthesia_type = General vs Neuraxial
| anesthesia_type = General or neuraxial
| airway = ETT vs LMA vs non-invasive O2
| airway = ETT, LMA, or Noninvasive O2
| lines_access = PIV x 2 (at least 1 large bore), +/- arterial line
| lines_access = Large bore IV
| monitors = Standard, 5-lead EKG, temperature
± Arterial line
| monitors = Standard
5-lead ECG
Temperature
| considerations_preoperative = Type and screen
| considerations_preoperative = Type and screen
| considerations_intraoperative = Hemorrohage, uterine rupture, CO2 air embolism
| considerations_intraoperative = Hemorrohage
Uterine rupture
CO<sub>2</sub> air embolism
| considerations_postoperative = PONV
| considerations_postoperative = PONV
}}
Hemorrhage/hematoma
}}A '''myomectomy''' is a surgical procedure involving the removal of uterine fibroids.


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.
== Overview ==


== Preoperative management ==
===Indications ===
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>
===Surgical procedure===
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. For the laparoscopic approach, the abdomen is insufflated. For the vaginal approach, the uterus is infused with fluids. In order to minimize bleeding, vasoconstrictors such as epinephrine or vasopressin are injected into the myometrium or a tourniquet can be used to minimize uterine blood flow. Fibroids are removed and defects are sutured and closed.


=== Patient evaluation<!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --> ===
==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"
{| class="wikitable"
|+
|+
!System
!System
!Considerations
!Considerations
|-
|Respiratory
|
|-
|Gastrointestinal
|
|-
|-
|Hematologic
|Hematologic
Line 30: Line 35:
|Renal
|Renal
|Assess for volume status as abdominal insufflation decreases preload
|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. --> ===
===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
*Type and screen


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


* IV midazolam for anxiety  
*IV midazolam for anxiety
* PO Acetaminophen for pain  
*PO acetaminophen for pain
* PO gabapentin
*PO gabapentin
* PO celecoxib
*PO celecoxib
* Scopolamine patch for PONV  
*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. --> ===
=== 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  
*Spinal and/or epidural mainly for vaginal approach or for supplementation of analgesia with general for open approach


== Intraoperative management ==
==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. --> ===
===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
*Standard ASA monitors
* 5-lead EKG  
*5-lead EKG
* +/- arterial depending size/extent of myomectomy  
*+/- arterial depending size/location/approach of myomectomy
* OG/NGT to decompress stomach prior to trocar placement to decrease risk of injury
*OG/NGT to decompress stomach prior to trocar placement to decrease risk of injury
* PIV x 2 ( at least 1 large bore)  
*PIV x 1-2 (at least 1 large bore for open or laparoscopic)


=== 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. --> ===
===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  
*If general is chosen, standard induction
** ETT vs LMA  
**ETT vs LMA
* If neuraxial is chosen, minimal to deep sedation is reasonable
*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. --> ===
===Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. -->===


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


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


* PONV prophylaxis  
*PONV prophylaxis


== Postoperative management ==
==Postoperative management==


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


* PACU
*PACU
* Usually discharged home
*Home likely for laparoscopic or vaginal approach
*Most likely floor for open approach


=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===
===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  
*Pain ranges from mild to severe depending on surgical approach
** Multimodal analgesia  
*Multimodal analgesia
*** IV/PO acetominophen
*NSAIDs based on discussion with surgical team
*** IV/PO opioids
*Local anesthetic at trocar sites
*** IV/PO NSAIDs pending surgical team approval
*TAP blocks
*** IV lidocaine
*Epidural analgesia
*** IV ketamine
*** Local anesthetic at trocar sites
*** TAP blocks
*** Epidural analgesia


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


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


== 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). --> ==
==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"
{| class="wikitable wikitable-horizontal-scroll"
Line 135: Line 137:
!
!
!Open myomectomy
!Open myomectomy
!Laparscopic myomectomy
!Laparoscopic myomectomy
!Vaginal myomectomy
!Vaginal myomectomy
|-
|-
|Unique considerations
|Unique considerations
|
|
|Minimizes blood lost
*Increased bleeding risk
|
|
*Minimizes blood lost
*May require mini-laparotomy or posterior culdotomy to retrieve fibroids
|
*Requires hysteroscopy
*Fluid shifts
|-
|-
|Position
|Position
|Supine
|Supine  
|Steep Trendelenburg
|Steep Trendelenburg +/- lithotomy
|Lithotomy  
|Lithotomy  
|-
|-
|Surgical time
|Surgical time
|
| Up to 4 hours
|1-4 hours
|1-4 hours  
|1-4 hours
| 1-4 hours
|-
|-
|EBL
|EBL
|1-1.5 L
|Up to 1 L
|100-600 mL
|100-600 mL
|
| 0-100 mL
|-
|-
|Postoperative disposition
|Postoperative disposition
|Floor
|Floor
|PACU and usually discharged home
| PACU and usually discharged home
|PACU and usually discharged home
|PACU and usually discharged home
|-
|-
|Pain management
| Pain management
|Severe, multimodal, consider epidural
|Severe, multimodal, consider epidural
|Moderate, multimodal
|Moderate, multimodal
Line 170: Line 178:
|Potential complications
|Potential complications
|Bowel/bladder injury, bleeding
|Bowel/bladder injury, bleeding
|Bowel/bladder injury
|Bowel/bladder injury, complications of abdominal CO2 insufflation
|Uterine rupture
|Uterine rupture, pulmonary edema, electrolyte abnormalities
|}
|}


== References ==
== References==


[[Category:Surgical procedures]]
[[Category:Surgical procedures]]
<references />
[[Category:Obstetric and gynecologic surgery]]

Latest revision as of 18:09, 30 June 2022

Myomectomy
Anesthesia type

General or neuraxial

Airway

ETT, LMA, or Noninvasive O2

Lines and access

Large bore IV ± Arterial line

Monitors

Standard 5-lead ECG Temperature

Primary anesthetic considerations
Preoperative

Type and screen

Intraoperative

Hemorrohage Uterine rupture CO2 air embolism

Postoperative

PONV Hemorrhage/hematoma

Article quality
Editor rating
Comprehensive
User likes
0

A myomectomy is a surgical procedure involving the removal of uterine fibroids.

Overview

Indications

Abnormal bleeding, infertility, ureteral compression, hydroureter/hydronephrosis, and pain[1]

Surgical procedure

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. For the laparoscopic approach, the abdomen is insufflated. For the vaginal approach, the uterus is infused with fluids. In order to minimize bleeding, vasoconstrictors such as epinephrine or vasopressin are injected into 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

System Considerations
Hematologic Assess for anemia secondary to menorrhagia or menometrorrhagia
Renal Assess for volume status as abdominal insufflation decreases preload

Labs and studies

  • Type and screen

Patient preparation and premedication

  • IV midazolam for anxiety
  • PO acetaminophen for pain
  • PO gabapentin
  • PO celecoxib
  • Scopolamine patch for PONV

Regional and neuraxial techniques

  • Spinal and/or epidural mainly for vaginal approach or for supplementation of analgesia with general for open approach

Intraoperative management

Monitoring and access

  • Standard ASA monitors
  • 5-lead EKG
  • +/- arterial depending size/location/approach of myomectomy
  • OG/NGT to decompress stomach prior to trocar placement to decrease risk of injury
  • PIV x 1-2 (at least 1 large bore for open or laparoscopic)

Induction and airway management

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

Positioning

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

Maintenance and surgical considerations

  • Maintenance with volatile anesthetic supplemented with opioid or neuraxial for analgesic
    • Consider TIVA is high risk for PONV
    • Maintain neuromuscular blockade if open or laparoscopy
  • Physiology 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
  • Monitored fluid infused and fluid retrieved and assess for fluid shifts and electrolytes imbalance if vaginal approach

Emergence

  • PONV prophylaxis

Postoperative management

Disposition

  • PACU
  • Home likely for laparoscopic or vaginal approach
  • Most likely floor for open approach

Pain management

  • Pain ranges from mild to severe depending on surgical approach
  • Multimodal analgesia
  • NSAIDs based on discussion with surgical team
  • Local anesthetic at trocar sites
  • TAP blocks
  • Epidural analgesia

Potential complications

  • Bleeding/hematoma
  • Pregnancy complications
  • Infections
  • Peroneal nerve damage
  • Adhesion formation
  • Fistula formation
  • Pulmonary embolism
  • Pulmonary edema
  • Electrolyte imbalances

Procedure variants

Open myomectomy Laparoscopic myomectomy Vaginal myomectomy
Unique considerations
  • Increased bleeding risk
  • Minimizes blood lost
  • May require mini-laparotomy or posterior culdotomy to retrieve fibroids
  • Requires hysteroscopy
  • Fluid shifts
Position Supine Steep Trendelenburg +/- lithotomy Lithotomy
Surgical time Up to 4 hours 1-4 hours 1-4 hours
EBL Up to 1 L 100-600 mL 0-100 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, complications of abdominal CO2 insufflation Uterine rupture, pulmonary edema, electrolyte abnormalities

References

  1. ↑ Anesthesiologist's manual of surgical procedures. Richard A. Jaffe, Clifford A. Schmiesing, Brenda Golianu (Sixth edition ed.). Philadelphia. 2020. ISBN 978-1-4698-2916-6. OCLC 1117874404. |edition= has extra text (help)CS1 maint: others (link)

Top contributors: Cornel Chiu, Chris Rishel and Riley Hales

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