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
Article quality
Editor rating	Comprehensive
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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. 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