Laparoscopic Myomectomy

Fibroids are benign (non-cancerous) knots of muscle arising in the wall of the womb. They are common, and often women are unaware that they have them. Treatment for fibroids is only recommended where they are causing symptoms that have an impact on your day-to-day life.  

The most common problems are heavy periods, abdominal bloating, pain or pressure symptoms (for example causing your bladder to feel full very quickly). Some women are recommended to have large fibroids removed as part of fertility treatment.

Compared to open surgery (where there is a bigger cut on your tummy), laparoscopic myomectomy may result in: 

• Less pain after the operation. 
• A lower risk of infection.  
• A lower risk of blood clots in the legs (DVTs) or lungs (Pes). 
• A shorter hospital stay.  
• Quicker recovery and return to work. 

All treatments and procedures have risks, and we will talk to you in detail about the risks of laparoscopic myomectomy. Serious complications are thankfully rare. 

Problems that may happen during the operation

During the operation, there may be accidental injury to the ureters (the tubes that drain urine from the kidney into the bladder), the bladder or the bowel. Repairing these injuries may require conversion to an open procedure (with a bigger cut on the tummy) and a longer operation time, as well as a more prolonged recovery.   

Usually these injuries are identified at the time of the operation and repaired immediately. However, sometimes these injuries are small and are missed, and only get noticed when you become unwell in the days following the operation. If this is the case you may need a second operation. 

You may bleed heavily during the operation.  

Problems that may happen after the operation

Sometimes you may develop an infection of the wound sites, or deeper inside the pelvis. You may need antibiotics to treat this. After any operation, you are more at risk of developing blood clots in your legs or lungs.  

Some women develop scar tissue within the womb or in the pelvis. You may also develop new fibroids over time. There is a small risk of developing a hernia at the site of the cuts. 

Depending on your operation, you may be recommended to have a planned Caesarean delivery if you become pregnant. 

What additional procedures may be required?

Occasionally, if you bleed heavily, you will need a blood transfusion (donated blood given through a drip) during, or soon after, the operation.  

If bleeding is very heavy, or if there is concern about injury to other organs, the surgery may be converted from keyhole to open surgery. This can be associated with more pain and a longer recovery. 

If you are bleeding so heavily that your life is at risk, we may have to remove the womb (a hysterectomy) to control the bleeding. The risk of this happening is small: approximately one in every 100 laparoscopic myomectomies.

What are the risks of laparoscopic morcellation?

During morcellation, there is a risk that small pieces of benign (non-cancerous) fibroid tissue may be left inside your abdomen. These may then attach to the internal organs in your abdomen where they can continue to grow. It is difficult to know how common this is, but it is thought to affect between 1 out of every 120 and 1200 women. You may then require additional surgery to remove these fibroids. 

Although most fibroids are benign (non-cancerous), in a very small number of cases fibroids may contain cancerous cells, known as sarcoma. Before considering morcellation, your healthcare professional will have offered you investigations which may include: an ultrasound scan; a magnetic resonance imaging (MRI) scan; a biopsy of the womb lining; or a cervical smear test. These investigations may assist us in diagnosing sarcoma, but there is currently no single reliable test to rule out sarcoma before surgery. This means that in a very small number of patients sarcoma may only be diagnosed when we look at the fibroids under a microscope after surgery.  

Morcellation of a fibroid that contains an unexpected sarcoma may cause the cancer to spread and worsen your chances of survival.  

The risk of unexpected uterine sarcoma in fibroids depends on your age and is higher around the time of and after your menopause. Various studies have quoted this risk as ranging from:  

• 1 in 65 to 1 in 278 (if you are over 60) 
• 1 in 158 to 1 in 303 (if you are between 50 to 59) 
• and 1 in 304 to 1 in 1250 (if you are under 50 years of age).  

(RCOG Consent Advice No 13 – Morcellation for myomectomy or hysterectomy, October 2019) 

If you are over 50 years of age your risk is higher and continues to increase as you get older. 

What might affect my risk of having a uterine sarcoma?

The following things may mean that you have a higher risk of uterine sarcoma. Your healthcare professional will check for these and discuss with you before considering morcellation.   

• Bleeding after your menopause, or irregular vaginal bleeding.  
• Fibroids that are growing quickly.  
• Findings suspicious of uterine sarcoma on your ultrasound or MRI scan. 
• If certain types of breast, ovarian or bowel cancer run in your family. 
• Your age as your risk is higher around the time of and after your menopause.  
• Your ethnicity: fibroids are more common in black women and the chances of uterine sarcoma may also be higher. 
• If you have ever used the drug Tamoxifen.  
• If your fibroid continues to grow despite medical treatment.  
• If you have had radiotherapy to your pelvis.  

We are unlikely to recommend laparoscopic myomectomy with morcellation if your risk of sarcoma is considered to be high. 

Nowadays we commonly perform morcellation within a bag to contain the spread of the small fibroid pieces, which could otherwise attach to the inside of the abdomen and grow. This may also be beneficial if the fibroid was unknowingly a cancer, but we don’t yet know this for sure.

1. Watching and waiting; in this case any symptoms are likely to continue, but may improve after the menopause when fibroids usually become smaller. 
2. Taking medical treatments: These can be effective at controlling pain and bleeding, but do not remove the fibroid and can sometimes have side-effects. Your doctor will advise which options might be suitable for you. 
3. Uterine artery embolisation: This is a procedure that blocks the blood vessels to the fibroids, causing them to shrink. It is performed via a small incision in the groin or wrist. 
4. Open myomectomy – this involves a bigger (15-20cm) cut to your tummy and may allow the removal of all fibroids if you have many. It also avoids morcellation of an unsuspected sarcoma. Open surgery may result in a longer hospital stay and longer recovery compared to a laparoscopic approach. 
5. Hysterectomy – this involves complete removal of your uterus (womb) and can be done either laparoscopically or as open surgery. The advantage of this procedure is that your menstrual bleeding will stop, and fibroids cannot grow back.  

The risks and benefits of each treatment option will vary depending on your individual situation and will be fully discussed with you by your health care professional. More information is available on our page on “Fibroids”. 

We want to involve you in all the decisions about your care and treatment.  Your doctor will discuss the reasons for having the procedure, and its risks, and record this on a ‘consent form’. They will then sign this form themselves, and ask you to sign it, as confirmation that you would like to go ahead, and as a record of these discussions.   

If you are unsure about any aspect of your proposed treatment, please don’t hesitate to speak with a senior member of staff again.

GnRH injections

Some women may be recommended hormonal (GnRH analogue) injections for around 3 months to reduce the size of the fibroids or control bleeding (see our page entitled “Gonadotrophin-releasing hormone analogue injections”). The medication may cause temporary menopausal side-effects including hot flushes, night sweats, tiredness and mood changes. 

Iron

If you are anaemic (have a low blood count, usually as a result of heavy periods), you may be recommended to take iron supplements. Iron can be given by tablet, or by an infusion.  

Contraception

It is important that there is no possibility of pregnancy when you have this operation. For this reason, we ask you to either abstain from having sex, or use reliable contraception, in the month before your surgery (from the first day of your last period before your operation).  

Combined oral contraceptive pills slightly increase your risk of blood clots on the legs or lungs (DVTs or PEs) after surgery. For this reason, you will usually be advised to change to an alternative e.g. condoms or the progesterone only pill, four weeks before the procedure.  

Preparing your body for surgery

Some changes can have a really big impact on your recovery, for example: 

• Increasing your exercise: try to do 30 minutes of activity which makes you feel out of breath, at least three times each week.   
• Eating a healthy, balanced diet before surgery and planning easy to cook meals for your recovery. 
• Stopping smoking and alcohol can be hard, but quitting or cutting down before surgery can reduce your hospital stay and improve wound healing. 

More information is available in our “Preparing for gynaecology surgery and your recovery” page.  

Preoperative Assessment Clinic

A few weeks before your surgery you will be asked to attend a preoperative assessment appointment. This can be by telephone, or in person in the hospital.   

You will be asked questions about your health, medical history and home circumstances.  Some tests may also be required, for example blood tests, or an ECG (a tracing of your heart rhythm).  

You will be given information about the morning of your surgery: when to stop eating and drinking, and if you need to stop taking any of your regular medications. 

The day of your surgery

You will receive instructions about the time of your admission, and where to go. If you do not receive these, please contact your team using the contact details below.  

More information about what to bring to hospital, and what to expect once you arrive, can be found in the “Preparing for gynaecology surgery and your recovery” leaflet.

You will be put to sleep (have a general anaesthetic) for the procedure.  

The surgery involves making a number of small cuts on the abdomen. Usually you will have four cuts, between 0.5cm and 2cm big.  

Thin surgical instruments are inserted through the cuts and the operation is carried out with the aid of a thin telescope. The fibroids are separated from the uterus and the area that has been cut is then repaired. The fibroids are then cut into smaller pieces using a morcellator and removed through the keyhole incision. Occasionally fibroids may be removed through a cut in the vagina or a slightly bigger cut in the abdomen.  

The operation usually lasts two to three hours.

Detailed information about what to expect in hospital after an operation, and about your longer-term recovery, can be found in our “Preparing for gynaecology surgery and your recovery” leaflet.  

When you wake up from the operation, you will have a drip in your arm and a catheter in your bladder. These will usually stay in for about 24 hours. You may also have a drain placed in your tummy to allow additional body fluids (e.g blood) to drain out, but this is not common. 

You may feel drowsy and nauseous from the anaesthesia. Your abdomen may feel painful and bloated. You may also have pain around the shoulders from the gas that is used within the abdomen for the procedure. This will settle within a few days, and can be improved by moving around and taking pain killers.  

You will be discharged once you are eating, drinking, passing urine and moving around safely, and when your pain is well-controlled with tablets. This is usually after one to three nights. Occasionally your surgeon may recommend that you stay in hospital a little longer, especially if your surgery was difficult, or if there were complications.   

It is important that someone is available to help you get home when you are discharged (e.g. to help carry your bag). You will need to plan in advance for the fact that you won’t immediately be able to do things you usually would do at home, including driving. Our leaflet “Preparing for gynaecology surgery and your recovery” explains in more detail about what to expect, and what plans you may need to make.  

We would suggest that you plan to be off work for six weeks. You may feel able to go back sooner, or you may need longer if your job is very active, or if there were complications.

If you develop the following symptoms once you get home, you should go to your nearest Accident and Emergency Department. They can be signs of complications, for which you may need urgent treatment. 

• High fever.
• Pain in the abdomen that is getting worse. 
• Swelling of the abdomen that is getting worse. 
• Being unable to pass urine, or passing very little. 
• Swelling, redness, or tenderness in the lower legs. 
• Difficulty breathing, or chest pain.

Fibroids - NHS 

British Fibroid Trust 

Royal College of Obstetricians and Gynaecologists: Morcellation for myomectomy or hysterectomy 2019  

Royal College of Obstetricians and Gynaecologists. Recovering well: Information for you after a laparoscopy; 2015   

UCLH cannot accept responsibility for information provided by other organisations.

Gynaecology Diagnostic Unit  

Telephone: 0203 447 9411 

Email: uclh.gynaeadmissions@nhs.net 

Website: www.uclh.nhs.uk 

Ward T7 South (if your next of kin wants an update on how you are immediately after the operation, or if you have non-urgent queries when you go home) 

Tel: 020 3447 7828 or 020 3447 0712 

Pre-operative assessment clinic (PAC) (if you have questions about how to prepare for the operation) 

Tel: 020 3347 2504 

Surgical reception (if you are running late on the day of your operation) 

Tel: 020 3447 3184 or 07939 135323

The Gynaecology Diagnostic Unit is located on the lower ground floor of the Elizabeth Garrett Anderson Building. Follow signs to “Clinic 3”.