Myomectomy

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, hemorrhage/hematoma
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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. 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 laparoscopic approach, abdomen is insufflation. For vaginal approach, the uterus is infused with fluids. 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
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 2 ( at least 1 large bore for open)

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
• 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
• 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
    • IV/PO acetominophen
    • IV/PO opioids
    • IV/PO NSAIDs based on discussion with surgical team
    • IV lidocaine
    • IV ketamine
    • 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		1-4 hours	1-4 hours
EBL	1-1.5 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