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| lines_access = PIV x 2 (at least 1 large bore), +/- arterial line
| lines_access = PIV x 2 (at least 1 large bore), +/- arterial line
| monitors = Standard, 5-lead EKG, temperature
| monitors = Standard, 5-lead EKG, temperature
| considerations_preoperative =  
| considerations_preoperative = Type and screen
| considerations_intraoperative = Hemorrohage, uterine rupture
| considerations_intraoperative = Hemorrohage, uterine rupture, CO2 air embolism
| considerations_postoperative = PONV
| 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>
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.


== Preoperative management ==
== Preoperative management ==
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|-
|-
|Hematologic
|Hematologic
|Assess for anemia secondary to menorrhagia  
|Assess for anemia secondary to menorrhagia or menometrorrhagia
|-
|-
|Renal
|Renal
|
|Assess for volume status as abdominal insufflation decreases preload
|-
|Endocrine
|
|-
|-
|Other
|Other
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* IV midazolam for anxiety  
* IV midazolam for anxiety  
* PO Acetaminophen for pain  
* PO Acetaminophen for pain  
* PO gabapentin
* PO celecoxib
* Scopolamine patch for PONV  
* Scopolamine patch for PONV  


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* 5-lead EKG  
* 5-lead EKG  
* +/- arterial depending size/extent of myomectomy  
* +/- 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)  
* PIV x 2 ( at least 1 large bore)  


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=== 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 (vaginal approach)
* Lithotomy (laparoscopic, vaginal approach)
* Supine (open approach)
* Supine (open approach)
* Steep Trendelenburg (laparoscopic approach)
* Steep Trendelenburg (laparoscopic approach)
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* Maintenance with volatile anesthetic supplemented with opioid analgesic  
* Maintenance with volatile anesthetic supplemented with opioid analgesic  
** Consider TIVA is high risk for PONV
** Consider TIVA is high risk for PONV
** Maintain neuromuscular blockade if laparoscopy
** 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
* Monitor blood loss, transfuse if needed
** Vascular injury
* CO2 air embolism
* Subcutaneous/mediastinal emphysema
* Uterine rupture
* Bowel/bladder injury


=== 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. --> ===
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* Pain is mild to severe depending on surgical approach  
* Pain is mild to severe depending on surgical approach  
** Multimodal analgesia  
** Multimodal analgesia  
*** IV/PO acetominophen  
*** IV/PO acetominophen
*** IV/PO opioids  
*** 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
* Bleeding/hematoma
* Uterine rupture
* Pregnancy complications
* Bowel/bladder injury
* Infections
* Peroneal nerve damage
* Adhesion formation
* Fistula formation
* Pulmonary embolism


== 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). --> ==
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|Unique considerations
|Unique considerations
|
|
|
|Minimizes blood lost
|
|
|-
|-
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|Surgical time
|Surgical time
|
|
|
|1-4 hours
|
|1-4 hours
|-
|-
|EBL
|EBL
|
|1-1.5 L
|
|100-600 mL
|
|
|-
|-
|Postoperative disposition
|Postoperative disposition
|Floor
|Floor
|
|PACU and usually discharged home
|
|PACU and usually discharged home
|-
|-
|Pain management
|Pain management
|Severe, multimodal, consider epidural
|Severe, multimodal, consider epidural
|Mild to moderate, multimodal
|Moderate, multimodal
|Mild to moderate, multimodal
|Mild to moderate, multimodal
|-
|-

Revision as of 12:22, 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

Type and screen

Intraoperative

Hemorrohage, uterine rupture, CO2 air embolism

Postoperative

PONV

Article quality
Editor rating
Comprehensive
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
  • 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

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

  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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