Myomectomy
Anesthesia type General vs Neuraxial
Airway ETT vs LMA vs non-invasive O2
Lines and access PIV x 1-2 (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


Myomectomy is a surgical procedure involving the removal of uterine fibroids 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. For the laparoscopic approach, the abdomen is insufflated. For the vaginal approach, the uterus is infused with fluids. In order to minimize bleeding, vasoconstrictors such as epinephrine or vasopressin are injected into 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 1-2 (at least 1 large bore for open or laparoscopic)

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 Up to 4 hours 1-4 hours 1-4 hours
EBL Up to 1 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

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)