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
Intraoperative	Hemorrohage, uterine rupture
Postoperative	PONV
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Myomectomy is a surgical procedure involving the removal of parts of the muscular layers of the uterus. Indications include abnormal bleeding, infertility, and pain

Preoperative management

Patient evaluation

System	Considerations
Respiratory
Gastrointestinal
Hematologic	Assess for anemia secondary to menorrhagia
Renal
Endocrine
Other

Labs and studies

• Type and screen

Patient preparation and premedication

• IV midazolam for anxiety
• PO Acetaminophen for pain
• 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
• 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 (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 laparoscopy
• Monitor blood loss, transfuse if needed

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
    • Local anesthetic at trocar sites
    • TAP blocks
    • Epidural analgesia

Potential complications

• Bleeding
• Uterine rupture
• Bowel/bladder injury

Procedure variants

	Open myomectomy	Laparscopic myomectomy	Vaginal myomectomy
Unique considerations
Position	Supine	Steep Trendelenburg	Lithotomy
Surgical time
EBL
Postoperative disposition	Floor
Pain management	Severe, multimodal, consider epidural	Mild to moderate, multimodal	Mild to moderate, multimodal
Potential complications	Bowel/bladder injury, bleeding	Bowel/bladder injury	Uterine rupture