The treatment of uterine fibroids includes follow-up observation, pharmacological treatment, surgical treatment and minimally invasive treatment, with surgery being the main treatment method. This article introduces the basic overview of surgical treatment of uterine fibroids and transabdominal and transvaginal surgical methods, and please refer to other literature for transhieroscopic and translaparoscopic consultation and treatment.
I. Indications for surgery for uterine fibroids
Asymptomatic fibroids generally do not require treatment. Surgical treatment should be considered when the following indications are present.
1, excessive menstruation secondary to anemia and ineffective drug treatment.
2, acute abdominal pain caused by severe abdominal pain, painful intercourse or chronic abdominal pain, or twisting of a tipped fibroid.
3, with symptoms of bladder and rectal compression.
4, those who can determine that leiomyoma is the sole cause of infertility or recurrent miscarriage
5.The fibroids are growing fast and malignancy is suspected.
The surgical route of fibroids
The surgical route for fibroids can be transabdominal, transvaginal or hysteroscopic and laparoscopic.
Surgical procedures for fibroids
The surgical methods for uterine fibroids are
1.myomectomy: It is suitable for patients who wish to preserve their reproductive function. Interstitial fibroids can be removed transabdominally, transvaginally or laparoscopically; submucosal fibroids can be removed vaginally or hysteroscopically.
2.Hysterectomy: Hysterectomy or subtotal hysterectomy is feasible for those who do not require preservation of reproductive function or suspected malignant change. Preoperative cervical scraping cytology should be performed to exclude malignant cervical lesions.
Introduction of common surgical methods for uterine fibroids
(A) Total hysterectomy
Total hysterectomy is the main surgical procedure for the treatment of uterine fibroids, which can be performed transabdominally, transvaginally or laparoscopically. Each of the three surgical approaches has its own advantages and disadvantages, as well as suitable indications. Transabdominal surgery has a wide range of indications, is safe, convenient and easy to master, and is still the mainstay. The disadvantage is that the abdomen is scarred and the chance of forming adhesions after surgery may be greater than that of transvaginal and translaparoscopic; transvaginal surgery has no scars on the abdomen, less interference with the intestine, less possibility of postoperative adhesions, and faster recovery after surgery, but the disadvantage is that it is limited by the small space of the vagina, more difficult to operate, more difficult to deal with adnexal lesions, narrower indications, and relatively more surgical complications such as damage to the bladder and rectum. With laparoscopic surgery, the pelvic cavity can be clearly seen, and lesions coexisting in the pelvic cavity can be treated at the same time, and the patient recovers faster after surgery. For combined pelvic adhesions, endometriosis and other lesions that require hysterectomy, laparoscopic surgery has advantages over transvaginal surgery. However, laparoscopy and transvaginal surgery still have their limitations, i.e., they cannot complete hysterectomy in patients with huge uterus or severe pelvic adhesions. Therefore, for each patient, a full preoperative estimate should be made to choose the most suitable surgical method for that patient, and the choice of surgical method should not be based on the personal preference of the surgeon, let alone the inclusion of some non-medical factors. At the same time, when laparoscopic or transvaginal surgery is chosen, if intraoperative difficulties are encountered and it is estimated that the surgery cannot be completed microscopically or transvaginally, the patient should be promptly transferred to open surgery, all with the patient’s safety in mind.
In general, transabdominal surgery is appropriate for those with a large uterine volume, poor mobility, suspected adhesions, no history of vaginal delivery, adnexal lesions requiring excision or treatment, and potential for malignancy. Conversely, transvaginal surgery is appropriate for those with a small uterus, good mobility, no adhesions, a history of vaginal delivery, no adnexal treatment, and no potential for malignancy. When choosing transabdominal or transvaginal surgery, the limit of uterine size is generally defined by the size of the uterus at 10 weeks of gestation, but it also varies depending on the skill and experience of the surgeon. Some surgeons dare to remove the uterus vaginally even if it is flat at the base of the uterus or even above the umbilicus, because the uterus can be cut into pieces and removed vaginally after the uterine artery has been severed. This is a practice that is occasionally called “daring” and often tried as “daring”! Because this practice has many disadvantages: first, the operation takes a long time, the second bleeding, the third to increase the chance of surgical injury, why not change to a simple and quick open surgery?
Transabdominal or transabdominal hysterectomy is distinguished between extrafascial and intrafascial hysterectomy. Currently, most hospitals still use extrafascial hysterectomy, which involves complete removal of the uterine body and cervix, as well as severing the main and uterosacral ligaments and a small segment of the superior vaginal segment. Intrafascial hysterectomy is performed by severing the uterine artery and part of the main ligament while preserving part of the outer layer of the cervical fascia, without severing the uterosacral ligament and the upper vaginal segment. Intrafascial hysterectomy theoretically has less impact on the structure and function of the pelvic floor, but to date there is no conclusive evidence of its superiority, so it remains a non-mainstream procedure.
The key steps in transvaginal hysterectomy are finding the cystoperitoneal reflex and rectoperitoneal reflex. My teacher, Prof. Pan Guoquan, used to say, “If the anterior and posterior peritoneum are opened, the cervical resection is equivalent to half of the operation being completed”. There are 2 points to note when opening the bladder peritoneal reflex.
The correct position of incision is 3mm-5mm above the vaginal cervical attachment point, with transverse incision and cutting through the whole vaginal wall.
2. When separating the bladder-vaginal space, it is advisable to use scissors to hold the cervix tightly open instead of cutting it open. It is better to separate the vesicovaginal gap by using scissors to close to the cervix to avoid damaging the bladder and to open it without cutting into the cervical tissue. After opening the bladder peritoneal reflex, there is no urgency to open the rectal peritoneal reflex. A circular incision can be made along the incision of the anterior vaginal fornix to both fornix and posterior fornix vaginal wall, and the posterior vaginal wall and rectum can be pushed downward immediately behind the cervix to expose both sides of the uterosacral ligament, at this time, both sides of the uterosacral ligament and the main ligament can be cut off immediately after the cervix, and after cutting off the sacral and main ligaments because the uterus can be pulled outward some, in most cases, the recto-peritoneal reflex is disconnected by itself, and even if it is not disconnected, it is easy to find the recto-peritoneal reflex immediately after the cervix. The rectal reflex peritoneum can be found easily by cutting into the rectal fossa.
(ii) Subtotal hysterectomy
Secondary total hysterectomy is performed at the level of the isthmus, after cutting off the uterine arteries, veins and parametrial tissues, a circular incision is made at the isthmus, penetrating the mucosal layer of the cervical canal, cutting out the body of the uterus and preserving the cervix. The advantage of this procedure is that it preserves the integrity of the main ligament, the uterosacral ligament and the vagina and has less impact on the pelvic floor and vaginal function. The disadvantage is that the preserved cervix is still subject to future pathology, and cervical cancer of the stump can occur from time to time. Therefore, for those who want to preserve the cervix, preoperative tests such as cervical smears should be done routinely and the results should be normal before preserving the cervix. In fact, after years of follow-up, total hysterectomy does not have any effect on postoperative sexual life. With the increasing incidence of cervical cancer and cervical lesions, the author has been advising patients not to opt for subtotal hysterectomy for many years, except for those who have difficulty in removing the cervix due to severe adhesions during surgery.
In general, subtotal hysterectomy is done transabdominally or laparoscopically. However, subtotal hysterectomy has also been performed vaginally. In cases with a small uterus, the anterior and posterior vaginal fornix and vesico-peritoneal reflexes and the recto-peritoneal reflexes are opened, the uterine body is turned out of the anterior or posterior vaginal fornix, and the parametrial tissue is cut in stages from the bottom of the uterus toward the cervix using the same method as the transabdominal subtotal hysterectomy, to the level of the uterine isthmus where the cervix is cut, the uterine body is removed, the cervix is preserved, and finally the cervical stump and the incisions in the anterior and posterior vaginal fornix are sutured respectively.
(iii) Myomectomy
There is a 50% chance of recurrence after myomectomy, and about 1/3 of patients need to be operated again, which should be clearly explained to patients before surgery. Different surgical approaches can be used to remove fibroids according to their different growth sites. Subplasmaline and interstitial fibroids are usually removed transabdominally or laparoscopically. Submucosal fibroids or smaller interstitial fibroids close to the uterine cavity can be removed hysteroscopically. Submucosal fibroids with a tip that protrudes into the vagina can be removed directly through the vagina.
In recent years, some hospitals have also performed transvaginal resection of submucosal and intermucosal myomas, which is the same as transvaginal subtotal hysterectomy. Depending on whether the myoma is located in the anterior or posterior wall of the uterus, the anterior or posterior vaginal fornix and vesico-peritoneal reflex or recto-peritoneal reflex are opened, and the uterine body is turned out of the anterior or posterior vaginal fornix. The fibroids are then removed and the wall is sutured. Transvaginal myomectomy is usually indicated for small fibroids, low growth, cervical fibroids, etc.
There are three key surgical steps in myomectomy.
1, determination of the location of the myoma.
2. full excision of the pseudo-envelope.
3.Reducing bleeding during resection and suturing to stop bleeding.
When fibroids are located between the muscle walls near the uterine cavity, sometimes the uterus is near uniformly enlarged and it is not easy to determine whether the fibroids are located in the anterior or posterior uterine wall. When the location of the myoma cannot be determined, it is not known where to start the uterine incision. At this point, palpation by hand is very important. The anterior and posterior uterine walls should be carefully palpated to feel where the harder fibroid nodules are located. Also observe the interstitial tubules for any deviation. If the interstitial part of the fallopian tube is posterior, the fibroid nodule may be in the anterior wall of the uterus, and if the interstitial part is anterior, the fibroid nodule may be in the posterior wall of the uterus.
In the process of increasing the size of the fibroid nodule, the nucleus of the fibroid gradually compresses the fibroid to form a pseudo-envelope, and there is a gap between the pseudo-envelope and the nucleus, which must be cut open during surgery to reach the surface of the nucleus and lift the nucleus to remove the fibroid quickly. There is no need to worry about cutting too deep when cutting through the pseudoperitoneum. If the nucleus itself is cut a little deeper, it will not cause any damage or bleeding, and the nucleus can be lifted once the grayish-white nucleus is seen, and the gap between the nucleus and the pseudopapillary membrane can be easily found.
One is to clamp both sides of the pelvic funnel ligament with two toothless oval forceps, and the other is to punch holes in the front and back pages of the broad ligament on both sides of the uterus and pass a rubber tube through it, and tighten the rubber tube in front of or behind the uterus to temporarily block the blood supply to the upper branches of the uterine artery. Uterine constrictors can also be injected into the myometrium to make the uterus contract.
Suturing to stop bleeding is the biggest headache in myomectomy, and often more time is spent on stopping bleeding than on removing the myoma. Often, either the sutures tear the muscle layer or the incision oozes blood. After a lot of effort, the bleeding from the incision is stopped, but the suture eye is still bleeding. When the bleeding stitches are closed again, the result is that the bleeding stitches change from one to two!
I have a few points for your reference regarding culling and suturing to stop bleeding.
1, use the electric knife electrocoagulation this gear to cut the surface of the fibroids of the uterine pulpy muscle layer and fibroid pseudo-envelope, the bottom of the fibroids can be clamped and ligated to reduce the bleeding when removing. Unless there is significant vascular bleeding, the incision should be made without the use of a rat-tooth clamp. Because the clamp marks of the rattooth clamp will also bleed.
2. Abolish the pulpy myometrium continuous decubitus embedding method because myoma removal is not like the uterus during cesarean section, which has a softer myometrium and easier decubitus embedding. The muscle layer of the uterus is hard when the myoma is removed, and the sutures are stretched tightly when the muscle layer is suitable for tearing, but not stretched tightly, so the continuous mattress embedding is often futile.
3, the general suture method is divided into two layers of sutures: namely, the deep layer of over the bottom interrupted suture and shallow layer of simple continuous suture, deep suture available 0/2 absorbable suture, suture shallow layer, such as sutures thicker, the eye must be larger, the eye of the needle has more chances of bleeding, and vice versa, the suture is too thin, continuous suture pull off easy to pull off, this layer with 0/3 absorbable suture is more appropriate;.
4. When bleeding from the eye of the needle cannot be stopped by compression and sutures are really needed to stop bleeding, the principle to be followed is: use smaller sutures and stitches. At this point, one of the things I always say to the instrument nurses is: “Please give me the smallest circular needle that can pass through a No. 1 silk thread”. Further, that the direction of the suture is perpendicular to the direction of the original suture.
5, “baseball suture” is a kind of suture method that some people call “magic”, used to close the uterine incision can really play a “magic” effect of hemostasis, you may want to try. Our regular suture method is to stitch in one direction, first from the outside to the inside, and then from the inside to the outside. The “baseball suture method”, however, has each stitch going inward and outward, like a “figure of 8”, and the incision looks like a baseball’s suture joint after continuous suturing and tightening of the sutures (the specific suturing method is described in “China (The specific suture operation method can be seen in the video “Uterine fibroid removal” in the video album of Professor Lin Zhongqiu’s surgery video on “China Obstetrics and Gynecology Network”).
6.Some small bleeding eyes can be stopped by compression, strengthening uterine contraction, using some spray hemostatic gel or hemostatic powder, not necessarily by suturing.
V. Myomectomy of special parts of the uterus
(I) Broad ligament fibroids
The broad ligament myoma is closely related to the ureter, so it must be separated from the surrounding lax space after opening the broad ligament and lift the myoma off the pelvic floor. If the ureter is found to be attached to the leiomyoma, the ureter and the leiomyoma node must be separated under direct vision to avoid damage to the ureter.
It is important to note that there is a pseudo-envelope outside the broad ligament leiomyosarcoma, so it is not possible to remove the leiomyosarcoma by opening the broad ligament. After seeing the leiomyosarcoma nodule, the pseudo-envelope of the leiomyosarcoma needs to be cut in a circular pattern near the lateral wall of the uterus to reach the surface of the nucleus to remove the leiomyosarcoma.
If the myoma is not separated in the correct loose anatomical space close to the wall of the fibroid, the fibroid bed fossa will bleed after the removal of the fibroid. In this case, special care must be taken to avoid damaging tissues such as the ureter and large pelvic vessels when stopping the bleeding. After these structures are seen and avoided, the myoma bed can be closed by staged circular sutures, starting at the base. If sutures are not available, then only hemostatic gels and hemostatic powders can be sprayed, followed by filling with hemostatic gauze and gelatin sponges, and then tightly suturing the broad ligament incision so that the bleeding in the fossa of the tumor bed forms a blood clot and stops bleeding by its own pressure. Of course, it is necessary to place a drainage tube in the pelvis at this time to observe the blood seepage in the abdominal cavity.
(ii) Cervical fibroids
Cervical fibroids are located low, and the enlarged cervix and its lateral ureter are close to each other, so suturing the cervical incision can easily lead to narrowing of the cervical canal, so either total hysterectomy or myoma removal is difficult. If total hysterectomy is used, when cutting the main ligament and the uterosacral ligament, special attention should be paid to see the direction of the ureter on both sides first, push it away and then remove the ligament, and if necessary, the lower part of the ureter should be freed first, and then the ligament should be removed. If the fibroids are large and hinder the operation, the fibroids can also be removed first, and the incision can be clamped with mouse teeth pliers without sutures, and the operation will be easier after the volume of the cervix is reduced. If cervical fibroids are removed, when the incision reaches the cervical canal, attention should be paid to the condition of the cervical canal after suturing, so as not to form stenosis, distortion or postoperative adhesions, and if necessary, a silicone tube tied to a birth control ring or a pediatric double-lumen catheter can be placed in the uterine cavity before suturing, and then sutured after being led out of the vagina through the cervical canal. It can be placed as a stent for 1-2 weeks after surgery to avoid or reduce cervical canal stenosis or adhesions.