Indications for surgery for uterine fibroids.
1. Significant symptoms leading to secondary anemia.
2.Submucosal uterine fibroids.
3.Suspected fibroid sarcoma.
4.Uterus larger than the size of two and a half months of pregnancy.
5.Uterine fibroids leading to infertility.
Indications for myomectomy.
Those who have fertility requirements or are young and have small children who need to preserve the uterus.
Indications for hysterectomy.
Total hysterectomy is indicated for those who are older than 40 years old and have no childbearing requirements.
Secondary hysterectomy is indicated for patients younger than 40 years of age with no childbearing requirements.
Removal of one ovary may be recommended for patients older than 45 years of age.
Bilateral removal of both ovaries is recommended for patients older than 50 years of age or for those who are menopausal.
Age of adnexal hysterectomy
Myomectomy – mainly for patients under 45 years of age, especially those under 40 years of age.
Indications.
Infertile women for childlessness; existing children with large fibroids larger than 6 cm in diameter; excessive menstrual flow and ineffective conservative medication; or symptoms of pressure; submucosal fibroids; fast-growing fibroids.
Contraindicated: myoma with malignancy, with severe pelvic adhesions, such as tuberculosis or endometriosis.
Those with highly suspicious malignancy in cervical cytology.
Precautions: pathological examination of the endometrium is preferable before myoma excision to exclude precancerous or cancerous endometrial lesions.
Intraoperative attention should be paid to whether the myoma is malignant or not, and if there is suspicion, rapid biopsy should be performed.
Principles of myoma excision incision.
1, the upper uterine incision is preferable to the anterior wall of the uterus, with as few incisions as possible and as many myomas as possible to be excised from each incision.
2.Determine the uterus according to the fallopian tube and round ligament, and make an incision at least 1 cm away from the interstitial part.
3.Determine the direction of incision according to the long diameter of the myoma.
4.The incision should avoid penetrating the endometrium as much as possible. Hemostasis should be complete, paying special attention to the closure of the tumor cavity, avoiding damage to the interstitial tubules, and trying to achieve peritonization of the uterine incision.
The main risk of myomectomy is bleeding, and later pregnancy should be guarded against uterine rupture and placental implantation, so an elective cesarean section should be performed at full term.
Hysterectomy – age 45 years or older
Total hysterectomy is generally recommended, especially in cases with cervical hypertrophy, laceration or severe erosion.
The advantages of total hysterectomy are the elimination of cervical cancer and the disadvantages of total hysterectomy are the impact on the support of the pelvic floor and the impact on sexual life, as the loss of glandular secretion causes vaginal dryness and affects the length of the vagina.
Broad ligament uterine fibroids, cervical fibroids and retroperitoneal fibroids are closely related to the ureter, so special attention should be paid during surgery to avoid accidental injury.
Hysterectomy, mainly transabdominal.
Individuals with small tumors, no inflammatory adhesions in the adnexa, too obese abdominal wall, eczema in the abdominal wall, and submucosal myomas can be considered transvaginal.
The advantages of transabdominal are: technical operation is simpler than transvaginal, less bleeding; large tumors and adnexal adhesions can be handled more easily. The disadvantage is that in cases of rectal bladder distention and vaginal wall laxity, separate vaginal surgery is required.
Adnexal management – for those under 50 years of age, the ovaries should be preserved if they can be.
After 50 years of age, the normal ovaries of non-menopausal patients should also be preserved (normal post-menopausal ovaries still have some endocrine function and will work for another 5-10 years. The uterus also has an endocrine role and is a target organ for the ovaries, which should not be removed casually).
If both sides can be preserved, it is better to preserve both sides than only one side. The incidence of ovarian cancer is 0.15% if the ovaries are preserved, which is not higher than that of the uncut uterus.
Submucosal fibroids: Large submucosal fibroids cause severe anemia secondary to bleeding and are usually treated with blood transfusions to improve the body’s condition before surgery (simple myomectomy or hysterectomy). If the condition does not allow, and the fibroid has protruded outside the cervical opening or near the vaginal opening, the fibroid should be removed vaginally, which is often more helpful to stop the bleeding and correct the general condition.
Those who have prolapsed from the cervix can be removed transvaginally, avoiding excessive traction during removal to avoid damage to the uterine wall during excision, by first feeling the root with hemostatic forceps as far as possible along the tip and then cutting it from below with scissors, or if the myoma is large, by first wedge-cutting the tumor.
If it is not detached, it can also be removed by transabdominal hysterotomy.
Postoperative treatment should be given hemostatic drugs with antibiotics, hemostatic forceps wrapped with gauze and fixed for 24-48h.
Those who are not pregnant should use contraception for 1 to 2 years; later pregnancies should be wary of uterine rupture and placental implantation, and elective cesarean delivery is advisable at term. There is a possibility of recurrence after myomectomy, and regular checkups are recommended.
There are four types of surgical methods for submucosal myoma.
1, transvaginal resection.
2.Transcatheter hysteroscopic resection.
3.Transcatheter laparoscopic resection.
4. transabdominal resection.
Submucosal fibroids should be resected with a hysteroscopy – a pathological examination of the endometrium and fibroids.
Infection in the lower genital tract and uterine cavity is present in all submucosal myomas, so broad-spectrum antibiotics should be given to control infection during the perioperative period; preoperative local treatment and cleaning are more important than systemic medication to prevent postoperative infection.
Submucosal fibroids are often accompanied by varying degrees of uterine base involution, so the tip should be severed slightly below the root of the tip, and if there is a lot of bleeding during surgery, we should be alert to any damage to the uterine wall or uterine vessels; to prevent bleeding from the tip, sutures or gauze strips can be added to the uterine cavity to stop bleeding.
Fibroids combined with pregnancy
If there are no fibroids embedded in the pelvic cavity or cervical fibroids that prevent the fetus from being delivered vaginally, the principle should be vaginal delivery and the fibroids should be re-examined after the puerperium and dealt with according to the situation; for multiple fibroids and if the patient does not want to keep the uterus, elective hysterectomy by cesarean section can be done if the surgical technique is adequate. Red degeneration of uterine fibroids during pregnancy should be differentiated from other acute abdominal pain disorders. In most cases, the patient can rest in bed, take painkillers and observe closely, and the patient will gradually improve. If myoma is removed during pregnancy, there are more chances of miscarriage and premature delivery. If the fetus is full term and in good condition, cesarean section should be considered and the uterus can be preserved or not according to the above principles.