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{{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 =
| considerations_intraoperative = Hemorrohage, uterine rupture
| considerations_postoperative = PONV
}}


Myomectomy is a surgical procedure involving the removal of parts of the muscular layers of the uterus. Indications include abnormal bleeding, infertility, 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>
== 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
|-
|Renal
|
|-
|Endocrine
|
|-
|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
* 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
* 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 (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 laparoscopy
* Monitor blood loss, transfuse if needed
=== 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
*** Local anesthetic at trocar sites
*** TAP blocks
*** Epidural analgesia
=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===
* Bleeding
* Uterine rupture
* Bowel/bladder injury
== 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
|
|
|
|-
|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
|}
== References ==
[[Category:Surgical procedures]]

Revision as of 11:22, 19 January 2022

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

Article quality
Editor rating
Comprehensive
User likes
0

Myomectomy is a surgical procedure involving the removal of parts of the muscular layers of the uterus. Indications include abnormal bleeding, infertility, and pain[1]

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

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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