Abdominal Hysterectomy as a Surgical Approach in Large Fibroids
Table of Contents
Uterine fibroids, also known as leiomyomas, are usually benign masses that are most commonly found in women of reproductive age. Fibroids are usually asymptomatic and tend to be incidental findings on ultrasound. When clinically relevant, however, patients report symptoms such as menorrhagia, pelvic pain, and bulk-related symptoms. Treatment of symptomatic fibroids may be pharmaceutical with gonadotropin-releasing hormone agonists, radiological using MRI-guided focused ultrasound surgery (or magnetic resonance-guided focused ultrasound), or minimally invasive uterine artery embolization, but the treatment is largely surgical. There are many different surgical approaches that can be utilized, including myomectomy or hysterectomy. Treatment of choice depends on multiple factors, including the severity of symptoms, size of fibroids, and patient’s desire to preserve fertility. However, out of all of the different surgical techniques available, hysterectomy is the only definitive treatment for these patients. Here, an abdominal hysterectomy was performed on a 45-year-old patient with symptomatic uterine fibroids.
Leiomyomas, also known as fibroids, are the most common benign tumors in women of reproductive age. According to Boosz et al., fibroids can be seen in up to 80–90% of females.1 Due to its high prevalence, it also poses a large economic burden; estimated health care costs for management of fibroids are as high as two billion dollars annually in the United States.2
These tumors originate from the myometrium of the uterus, and thus its growth is affected by female hormones, estrogen and progesterone. As a result, increased age until menopause is one of the risk factors for fibroid development.3 Other risk factors, such are African American race, early menarche, nulliparity, obesity, and family history of fibroids.3 Fibroids are treated when symptomatic in patients. Treatment of symptomatic fibroids may be pharmaceutical with gonadotropin-releasing hormone agonists, radiological using MRI-guided focused ultrasound surgery (or magnetic resonance-guided focused ultrasound), or minimally invasive uterine artery embolization, but the treatment is largely surgical, to include myomectomy or hysterectomy. Hysterectomy is the most effective treatment.2 Symptomatic fibroids account for up to 39% of all hysterectomies performed in the United States annually.3 In this case, an abdominal hysterectomy was performed on a 45-year-old female who presented with symptomatic leiomyomas.
Symptoms in patients with fibroids are diverse, depending on the size and location of these masses. Symptoms can range from asymptomatic to significant complications such as infertility. The pathogenesis of fibroids involves local anatomical changes in the uterus that cause a disruption in endometrial function, such as increased contractility and impairment of uterine blood supply.2 These functional changes manifest clinically as heavy menstrual bleeding and pelvic pain, which are the most common symptoms that patients present with.1 When these masses grow large enough, these patients can also present with bulk-related symptoms, such as pelvic pressure, bowel dysfunction, urinary frequency and urgency or retention, low back pain, constipation, and protuberant abdomen. Sometimes, fibroids can be palpated during a routine pelvic exam. However, these masses can also be detected with imaging, which is used instead to make an official diagnosis.
Transvaginal ultrasound is the gold standard for diagnosing leiomyomas.3 Fibroids detected on ultrasound are typically incidental findings due to their asymptomatic nature. As a result, it is not recommended for physicians to screen for fibroids in asymptomatic patients.1 Hysteroscopy is another diagnostic tool that can be particularly helpful in differentiating intracavitary myomas from polyps.2 Regardless, detection of fibroids with imaging coupled with patient symptoms and physical exam findings are sufficient to confirm a diagnosis of fibroids.
Fibroids that are left untreated not only lead to a worsening of symptoms but also cause significant complications such as iron deficiency anemia and infertility. The pathophysiology of infertility secondary to fibroids involves hormonal changes that may impair gamete transport and/or reduce blastocyst implantation.2 Female patients who present with infertility should therefore be evaluated for fibroids and have them removed. Multiple studies have shown that women with uterine fibroids have an increased risk of complications such as cesarean delivery, breech presentation, preterm premature rupture of membranes (PPROM), delivery before 37 weeks gestation, and postpartum hemorrhage secondary to uterine atony.3 Therefore, it is recommended that pregnant patients who have fibroids be monitored closely to prevent these complications.
Fortunately, these benign masses have a very small risk of developing into malignant tumors. Prevention of malignancy alone is therefore not an indication for hysterectomy.
Management of fibroids is largely surgical, with hysterectomy serving as the only definitive treatment for this condition.2 However, indications for surgical intervention depend on a variety of different factors such as the severity of symptoms as well as the desire to maintain fertility. Therefore, patients must be consulted on their desire to preserve fertility before determining the treatment of choice.
Other therapeutic techniques include uterine artery embolization (UAE), a minimally invasive procedure for patients that involves injecting occluding agents into the uterine arteries to limit blood supply to the fibroids.3 Additionally, procedures such as MR-guided focused ultrasound and myomectomy are alternative treatment options that are particularly indicated for patients who are planning to conceive in the future.3
Drug therapies are occasionally used as a pretreatment to surgical intervention. Due to the pathogenesis of fibroid development, medications such as gonadotropin-releasing hormone (GnRH) analogs and selective progesterone receptor modulators (SPRMs) that antagonize the effects of estrogen and progesterone, respectively, can be given to help shrink these masses before surgical intervention.2
The goal of treatment is to remove fibroids when indicated in order to relieve symptoms and other complications that may impact the patient’s quality of life.
Patients should always be asked whether or not they would like to preserve their fertility before determining the treatment of choice. For patients who would like to preserve their fertility, MR-guided focused ultrasound or myomectomy is the best option. Otherwise, interventions such as hysterectomy and UAE are the preferred treatment options.
In this case, a successful abdominal hysterectomy with preservation of the ovaries was performed on a 45-year-old patient who presented with symptomatic leiomyomas. Hysterectomy is the second most commonly performed surgery in the world following cesarean section.4 It is the most effective treatment for symptomatic fibroids and can be performed via three different approaches: laparoscopic, vaginal, and abdominal.2 Choice of surgical technique depends on several factors such as the size and location of fibroids. Vaginal hysterectomy is associated with positive outcomes such as shorter operative time, decreased blood loss, shorter hospitalization, reduced postoperative pain, and earlier return to normal activity.3-4 Alternatively, laparoscopic hysterectomy is becoming a more popular technique and is also associated with positive outcomes similar to vaginal hysterectomy. In fact, rates of laparoscopic hysterectomies performed have increased over the last twenty years, increasing from 0.3% in 1990 to 11.8% in 2003.5 It should be noted that laparoscopic removal of the uterus is sometimes performed with morcellation. As a result, laparoscopic hysterectomy should be performed only in patients without suspected or known uterine cancer in order to prevent the dissemination of potentially malignant tissue.
However, these approaches are not indicated when patients present with larger fibroids, due to their increased risk of complications. Laparoscopic extraction of the uterus can be especially challenging, as trocar insertion is more difficult and can directly injure the uterus and/or intraabdominal organs, causing excessive bleeding and thus prolonged operative time. According to Hwang et al., uterine fibroids that are greater than 13 cm are contraindicated in both vaginal and laparoscopic hysterectomy, and abdominal hysterectomy, which was performed in this video, is instead the treatment of choice.4
UAE is an alternative procedure that has several indications: multiple fibroids, very large fibroids, restricted operability, a history of multiple operative procedures in the abdomen, and the patient’s desire to preserve her uterus.3 UAE is associated with several positive patient outcomes, such as reduced blood loss, shorter procedural times, and shorter hospital stays.1 On the other hand, UAE has also been associated with a higher risk of reintervention and unwanted effects such as complete amenorrhea, abdominal pain from ischemic necrosis of fibroids, and risk of infection.2 In a study conducted by van der Kooij et al., reintervention or secondary hysterectomy rates were as high as 26–34% during a 5-year follow-up period.6 Furthermore, UAE is may be associated with subclinical deterioration of ovarian function. As a result, this procedure is not recommended for patients who would like to preserve their fertility. Other contraindications include pregnancy, active uterine or adnexal infections, IV contrast allergy, and renal insufficiency.3
MR-guided focused ultrasound is another treatment option for those who want to maintain their fertility. MRI is used to help visualize and target the mass before ultrasound energy is utilized to induce coagulation tissue necrosis.2 This procedure is generally well tolerated; however, patients are at risk for developing complications such as skin burns, pain, nausea, and allergic reactions.1 Another drawback to performing this procedure is its relatively high rate of recurrence. In a five-year follow-up study, the reoperative rate for patients who underwent this procedure was as high as 59%.3 This procedure is also contraindicated in pregnant patients or those who have pre-existing contraindications to MRI.
Myomectomy is another option for patients who wish to conceive in the future. Hysteroscopic myomectomy, in particular, is a standard minimally invasive procedure for submucosal myomas smaller than 2 cm and can be done in an outpatient setting.2 Alternatively, laparoscopic myomectomy can also be indicated for smaller fibroids and is associated with shorter recovery and reduced postoperative morbidity compared to abdominal myomectomy. However, several studies have reported no differences in outcomes between the two approaches.2 There are several contraindications for laparoscopic myomectomy, such as intramural myomas greater than 10–12 cm and multiple myomas (>4) in different sites of the uterus that would require multiple incisions.2 However, as with UAE and MR-guided focused ultrasound, studies have shown that recurrence of symptomatic fibroids post-myomectomy can occur in up to 10% of patients within the next decade.3
In some circumstances, drug hormonal therapy such as GnRH analogs, selective estrogen receptor modulators (SERMs), aromatase inhibitors, and SPRMs is used in patients in addition to surgical intervention. In a study published by Boosz et al. medications such as GnRH analogs have been shown to lead to a volume reduction in fibroids; however, they also come with a plethora of side effects including dizziness, hot flushes, and loss of bone mineral density, which preclude them from being used long-term.1 Additionally, when these medications are stopped in patients due to their adverse effect profiles, studies have shown that fibroids will grow back to their original size.1 Other medications, antagonizing estrogen effects, such as aromatase inhibitors and SERMs come with similar side effects due to hypoestrogenism.3 On the other hand, SPRMs, notably ulipristal acetate, have a much better side effect profile and also have a sustained effect in reduced fibroid size after discontinuation.2 As a result, these drugs are typically favored over GnRH analogs.
However, there is little evidence that shows that pretreatment with these drug therapies improves resectability or reduces operative time.1 Furthermore, it is still too early to determine whether or not these drugs can be used as monotherapy over surgical intervention. As a result, further research is needed to determine the role that these therapies play, if at all, in the treatment of fibroids.
Nothing to disclose.
The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.
- Boosz AS, Reimer P, Matzko M, Römer T, Müller A. The conservative and interventional treatment of fibroids. Dtsch Arztebl Int. 2014;111(51-52):877-883. https://doi.org/10.3238/arztebl.2014.0877
- Donnez J, Dolmans MM. Uterine fibroid management: from the present to the future. Hum Reprod Update. 2016;22(6):665-686. https://doi.org/10.1093/humupd/dmw023
- De La Cruz MS, Buchanan EM. Uterine Fibroids: Diagnosis and Treatment. Am Fam Physician. 2017;95(2):100-107. PMID: 28084714
- Hwang JL, Seow KM, Tsai YL, Huang LW, Hsieh BC, Lee C. Comparative study of vaginal, laparoscopically assisted vaginal and abdominal hysterectomies for uterine myoma larger than 6 cm in diameter or uterus weighing at least 450 g: a prospective randomized study. Acta Obstet Gynecol Scand. 2002;81(12):1132-1138. https://doi.org/10.1034/j.1600-0412.2002.811206.x
- Jacoby VL, Autry A, Jacobson G, Domush R, Nakagawa S, Jacoby A. Nationwide use of laparoscopic hysterectomy compared with abdominal and vaginal approaches. Obstet Gynecol. 2009;114(5):1041-1048. https://doi.org/10.1097/AOG.0b013e3181b9d222
- van der Kooij SM, Bipat S, Hehenkamp WJ, Ankum WM, Reekers JA. Uterine artery embolization versus surgery in the treatment of symptomatic fibroids: a systematic review and metaanalysis. Am J Obstet Gynecol. 2011; 205(4).
Table of Contents
- 1. Introduction
- 2. Incision and Access to the Abdominal Cavity
- 3. Exposure of Uterus
- 4. Division of Right Utero-Ovarian Pedicle
- 5. Division of Left Utero-Ovarian Pedicle
- 6. Division of Right Uterine Vessels
- 7. Division of Left Uterine Vessels
- 8. Ligation and Tagging of Uterosacral Ligaments
- 9. Excision of Uterus
- 10. Excision of Cervix
- 11. Closure of Vaginal Cuff
- 12. Closure
- Division of Round Ligament
- Separation of Anterior Layer of Peritoneum
- Transection of Pedicle
- Extension of Incision
- Division of Round Ligament
- Separation of Anterior Layer of Peritoneum
- Transection of Pedicle
- Examination of Specimen
Okay, we're going to do a - an abdominal hysterectomy through a midline abdominal incision - a low-midline. The patient is a 45-year-old with a symptomatic leiomyomata uteri. And, she was scheduled for surgery, and after a workup she said she wanted to proceed with the operation, and we're going to do that right now. The first thing we do - she's had a spinal anesthetic - and then we're going to always check to make sure that she doesn't have any pain. And does she have any pain up there? So… The skin is here, so Dr. Perez is going to put a little tension on his side, and I'm going to put a little tension on my side. We're ready to go guys.
And we're going to make the incision. She's not seeing if she's feeling this, is she? No. No. This - we're making an incision with this dull knife. And we're approaching the adipose tissue, the fat layer, and she's got a little bit excessive adipose tissue. We're cutting through the adipose tissue. It all looks normal. And we're approaching the fascia. Right here is the fascia - so we're going to open down to the fascia. We're separating the adipose tissue from the fascia. Do you have Metz? The fascia is the strong tissue that covers the muscle. And we're going to open the fascia with a knife. Kelly? No Kelly's. This knife is not quite sharp. And Dr. Perez is separating here, and I'm going to open the fascia with the cautery. Okay. So we've got the skin, adipose tissue, and fascia opened. And now what we can do is enter the peritoneal cavity, and - I can see where the midline is right here. And I'm separating it slightly - you got some Metzenbaums? And we're separating it very gently because we don't want to injure any of the internal organs. I see a vessel here, and we're going to cauterize it so it doesn't bleed. And we're getting close to the… Kelly? Abdominal contents here, and I'm going to just stretch it out a little bit more. Sometimes we can enter the peritoneal cavity with our fingers, but it looks like this one we're going to have to open it with scissors. Well Dr. Perez has just opened it with his fingers, and that's one of the ways to do it. Here… And he likes to stretch it out a little bit. We open the peritoneal layer, and the internal fascia. With these dull Metzenbaum scissors. Be very careful that we don't injure the internal organs. You see these scissors don't cut like they're made to cut, but that's okay, we'll make it work. We're going to stretch it out a little bit.
And then what we're going to do is push the adipose tissue onto what's called the omentum up toward her head, and then reach my hand inside to feel what we're dealing with. Kelly? Times two. Another Kelly. Tie. This is an adhesion. I'm going to reach down in, and I can feel - I'm feeling her left ovary right now, which is normal size. And I'm feeling her right overy, which has a cyst on it. You can see the ovary with the small cyst there. I'm getting behind the uterus. I can feel the fibroids. And it's - you can feel the fibroids in front, so we know exactly what we're dealing with. Normally, the uterus is the size of a lemon. And hers, as you'll see in a second, is much larger. Okay. Oh, wait. I think there's some… Adhesions? There you go, okay. Here's the fibroid uterus. Like I say, it's normally the size of a lemon, and hers is the size of a - a big mango maybe, huh? I'm looking on the right side, and you see that she's got a little cyst there. And she's got that cystic ovary. And then over here… I don't see any cyst on this side. But I think the best thing to do is put a retractor in. This is a - what's called a self-retaining retractor. And then we're going to put a bladder blade in here - to pull the bladder down. So we have a little better exposure now, so now we can get ready to do the operation. I'm just going to elevate it up a little bit. Yeah, but once we release the…
This instrument is not really adequate because the blades are too short, but what we're doing is we're going to try to release the right adnexa. So that will do two things - it'll kind of control part of the blood supply to the organ, and also release - so, we'll get a little more mobility of it. And this is the round ligament - the right round ligament - that he's ligating right now. And then we're going to tag the - the distal part of the round ligament. Okay, he's ligated part of the round ligament, now he's going to put another ligature around it, and we'll separate the round ligament. So he's got the round ligament ligated in two - two areas, now what he's going to do is separate it. Do you have that Metzenbaum that I used?
Now he's separating the - peritoneum from the portion of the uterus. Pickups. Give me a pickups. With teeth. Okay. Get the Heaney - get the cautery and… Heaney.
Another one. Okay, we just transected the - the right utero-ovarian pedicle, which includes the portion of the fallopian tube on the right side, and the the uterine-ovarian vessels And we're going to double-tie it, it's always good to double-tie it to make sure you don't have any bleeding. So this way the ovary will be preserved on that side, now we have to remember, we might end up taking it out at the end, depending on how things go and what it looks like, but right now we know the ovary has a small cyst on it. This suture we use is a relatively strong suture, and it's what we call a delayed-absorbable. It takes about three months before it absorbs and it's completely gone. But it does disintegrate in the abdomen. Do you have a Rochester-Pean clamp? Do I have a what? Do you have any Rochester-Pean, like those big…
We're going to extend this incision a little bit.
This is the left round ligament I'm approaching right now, I'm going to go around it with this suture. Then I'm going to come back and go through it with the same suture. Are you going to tag that? Yes. I'm going to snug it down until the tissue blanches - that means you control the flow of blood through it. And then I'm going to put a second suture in just like Dr. Perez did on the right side - on the left side. I got it. And again, I go around and then through it. Vicryl is easier to tie than this. This is Vicryl, isn't it? Yeah. This is Vicryl? That's Vicryl, yeah. 3-0. Okay, this Vicryl is easier to tie than the other. I'm transecting the left round ligament. Get the Metzenbaums ready.
And I'm going to do the same thing. I'm going to separate the anterior peritoneal layer. It's a relatively avascular layer. Maybe we should sponge stick? Would you cut down over here? What I'm trying to do is just make it where I have a little bit better exposure before I start putting instruments on. We call it deskeletonizing.
We can see the vessel there. Okay, get a couple of Haeneys ready. Okay. Okay, I've double-clamped the left - the left utero-ovarian ligament, incorporating with the fallopian tube and the major vessels. And I've just transected, so I'm going to put a free tie on it. Get ready to cut. And I'll take a stick tie. Okay, we put a free ligature around it, and I always double-tie it. So now I'm going to put a suture ligature around it. Because major vessels come through there. Okay, so now we have that taken care of. Now let's see what side we're going to work on first.
He's dissecting the tissue so we can get down to the right uterine artery, which we want to secure as quickly as we can. This is a very important bite of the operation. And we're going to double-clamp it. He's got the vessel double clamped, and he's cutting between the clamps. Do you have one of those - packs? Those lap sponges? Yeah. Yeah, when we're done here, we're going to see what it looks like. Oh, this isn't Vicryl, is it? That's Vicryl. Is it? Doesn't look like it. No, that's normal. Doesn't look like it. Look - no, he's using Vicryl. Okay, I see, I see.
Let me get a… Stay close to me. It's very important we ligate this good, this is the left uterine artery and vein.
Knife. We'll tag this too. Okay, ease it off. Okay, tag that, and cut this. I don't always do this, but I want to tag them because this is… I'm ligating the proximal portion of the uterosacral… This one. Okay, I have the proximal uterosacrals tagged with a suture, so we can always have control of that portion of the uterus. Tag? Okay. Knife. Tag. Knife. Okay. Good? Mm hmm.
Knife. I got it, I got it, I got it. Oh, you got the...? Okay, perfect. Yeah. I got a good grip. Here's the uterus without the cervix that we just removed. Watch this knife, John.
So we have a good view - there, much better. We'll just push it down, and then… Okay. There are certain instruments that would make this procedure a little bit easier, but they're not available right now, so we're improvising. Then we need a couple full-length sutures. Okay, put it inside...? Yeah, yeah.
Tag this one. If they're big, it's usually in these corners. We have the uterus and cervix removed. We did it in two parts because of the clinical situation we have here. And we have had no major bleeding, which was good. We're going to - right now we're closing the vagina. Cut, please. Okay. Cut. Ease it down, ease it down. Cut. Tag that. We want to stay out of bladder, here. That's bad… Tag. How much more? One more and then… If you have one of those partial sutures that's a little bit long, he can use that. Okay. One more and you got it. Best to leave them there. Cut this part before it. Cut the suture? The whole thing. Yeah. We're irrigating right now. Making sure there's no bleeding or leaks, and we'll go ahead and remove the irrigating fluid, which is saline. And it's nice and dry we call it. So we've removed the uterus, preserved the ovaries, and removed the uterus in two pieces because of the situation. You know what? I'm going to - I'll tell you what I'm going to do - I'm going to take these uterosacrals… I like to tag these uterosacrals to make sure that… Let's see, what is this on? That's the other tag.
We're removing the sponges that we put in. And then we're going to check for any bleeding before we terminate the procedure here, and it's nice and dry, everything looks good. So we're going to go ahead and remove the retractor, which is partially working. And we're going to prepare to close. I like to put the omentum, which is this flap of adipose tissue down, and cover the - the bowel and the internal organs. And we're going to close the abdomen in layers. I like to go about 1-1.5 cm…