Myomectomy
Anesthesia type |
General vs Neuraxial |
---|---|
Airway |
ETT vs LMA vs non-invasive O2 |
Lines and access |
PIV x 2 (at least 1 large bore), +/- arterial line |
Monitors |
Standard, 5-lead EKG, temperature |
Primary anesthetic considerations | |
Preoperative |
Type and screen |
Intraoperative |
Hemorrohage, uterine rupture, CO2 air embolism |
Postoperative |
PONV |
Article quality | |
Editor rating | |
User likes | 0 |
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[1]. 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
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
- 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
Intraoperative management
Monitoring and 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
- 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 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
- Decreased FRC
- Monitor blood loss, transfuse if needed
- Vascular injury
- CO2 air embolism
- Subcutaneous/mediastinal emphysema
- Uterine rupture
- Bowel/bladder injury
Emergence
- PONV prophylaxis
Postoperative management
Disposition
- PACU
- Usually discharged home
Pain management
- 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
- Multimodal analgesia
Potential complications
- Bleeding/hematoma
- Pregnancy complications
- Infections
- Peroneal nerve damage
- Adhesion formation
- Fistula formation
- Pulmonary embolism
Procedure variants
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
- ↑ 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.
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Top contributors: Cornel Chiu, Chris Rishel and Riley Hales