Does myoma need to remove the cervix. Should uterine fibroids be removed? Video: Evaporation of fibroids using FUS ablation

When diagnosing a tumor, the first thing the patient asks the doctor is whether it is necessary to remove the fibroid.

The causes of the appearance of pathology

Doctors identify several main reasons for the appearance of such a tumor, these are:

1. Hormonal disbalance.
2. Low immunity.
3. Genetic predisposition.

Tumor types

There are three types of fibroids:

• Submucous - means that the pathology grows inside the uterus.
• Subserous - trying to get out of the organ.
• Interlinking.

On average, pathologies are diagnosed with a size of about fifty millimeters, although it can grow up to one hundred millimeters. But tumors that are large in size are very rare.

Symptoms of the disease

It should be noted that in the early stages, the disease does not show any symptoms, so it is very difficult to diagnose it. Although this can happen if a woman undergoes a routine examination by a gynecologist.

But if the disease is started, the tumor has already reached a sufficiently large size, then certain symptoms appear, namely:

• Profuse and prolonged periods.
• Pain in the lower abdomen.
• Infertility (spontaneous miscarriages or premature birth in which the baby does not survive).

If the fibroid does not pose any danger to a woman's health, doctors recommend treatment with medication. However, in rare cases, it gives a positive result and ultimately, you have to remove the tumor surgically.

Is it possible to cancel the operation

If we talk specifically about the removal of the uterus, then such an operation is recommended to be carried out when a woman has crossed the line of forty years. At this age, women already have children, they no longer plan to give birth, so they no longer "need" the uterus.

If a woman has agreed to such an operation, then before carrying out it, the doctor should observe the development of pathology for some time. Find out at what speed it grows and only after that make a decision about removal.

For the operation to take place, certain indications are required:

1. The patient is over forty years old.
2. The size of the pathology is more than twelve weeks of pregnancy.
3. Fibroids develop more than four weeks a year.
4. Degeneration of a neoplasm into a cancerous tumor. The patient's age will not be taken into account, as well as the presence of children. Because the emphasis will be on her life.

In medicine, there are cases when myoma resolves itself, during the period when a woman reaches menopause. At this time, the body stops producing estrogen, which feeds the pathology, and over time, the tumor disappears. It doesn't happen in one month, it can take years. If everything goes well, then the operation can be skipped.

If the patient is diagnosed with many fibroid nodes, then she is sent for examination. Having studied its results, the doctor will be able to clearly understand the whole picture of the pathology, and only after that he will make a decision about the removal.

If the disease is found in a woman who is under forty, then the decision to remove it will be made in order to preserve the organ and remove only the tumor.

The question whether it is necessary to remove uterine fibroids can be answered as follows: if a woman's age has crossed the forty-year border, then the entire organ must be removed. Thus, doctors will protect a woman from possible relapses and cancer pathologies.

The main indications for surgical intervention

So, there are certain indications that indicate the need to remove pathology, regardless of the woman's age:

• The size of the tumor is more than twelve weeks.
• Rapid growth of pathology.
• When profuse bleeding occurs, not only during menstruation, but also between it.
• Development of anemia.
• The appearance of fainting.
• With painful sensations that arise due to the fact that the neoplasm begins to squeeze neighboring organs or nerve endings.
• Negative changes in the structure of pathology.
• With a formation growing on a thin, long base with which it is connected to the uterus. In this case, the leg may twist and bleed.
• The location of the tumor in the cervical region.
• Infertility due to this pathology.

Any disturbances in the functioning of organs located near the neoplasm can affect the removal:

1. Impaired emptying of the bladder. Because of this, urine can accumulate in it, and this leads to inflammation, sand and stones.
2. The ingress of urine into the ureter, which causes inflammation and pyelonephritis.
3. Due to constriction of the rectum, defecation does not go well. The consequence of this is constant constipation, and then poisoning of the body.
4. Squeezing of nerve endings near the rectum, because of this, pain in the heart, lower back and legs occurs.

Surgical removal of fibroids

Before determining which method will remove the pathology, it is necessary to consider the factors:

If the patient is not yet forty years old, then only the neoplasm is removed, without touching the uterus. After forty, the removal of the organ - perhaps because it has already fulfilled its main role in a woman's life.

• The tumor size is twelve weeks.
• The area of \u200b\u200bthe neoplasm, if it is found on the back of the uterus.

If the removal is directed only to the tumor itself, then the pathology may appear again, after a while.

With a small tumor, it is imperative to monitor its further development. If it does not increase and does not cause discomfort to the patient, then the operation is not required. A woman needs to undergo regular preventive examinations in order to see changes in time and make the right decision.

Varieties of operations

There are several types of surgical treatment:

• Laparotomy ... To perform excision of the tumor in this way, you will have to make an incision in the patient's abdomen. The main indications for this method are a large or multiple neoplasm, which deforms the organ itself. A good prevention will be a woman's pregnancy two years after the operation.
• Laparoscopy ... To do this, you do not need to cut the stomach, you only need to pierce it, which will not leave scars as a result. The most appropriate indication would be a small tumor, about nine weeks. If this method is applied to a large pathology, then bleeding from the uterus may occur.
• Hysteroscopy ... There is no need to make incisions and punctures during this process. The operation is performed through the vagina. Indications are small neoplasms, pathology on the basis, pathology that degenerates into a cancerous tumor.
• Hysterectomy ... Excision not only of neoplasms, but also of the uterus, which can be carried out through an incision in the abdomen or vagina. This method is used if the tumor is critical and can threaten a woman's life. Such removal is carried out mainly for women after forty years, but if the situation is critical, then it can be prescribed to patients who have not reached this age.
• Embolization ... In this case, the blood vessels are clogged and the neoplasm, due to lack of nutrition, slowly dies off.

Woman's condition after removal of the uterus

After removal of the organ, consequences may arise:

1. Depressive states of a woman.
2. Mental disorders.
3. Pain syndrome in the pelvic region.
4. Violations of the genitourinary system.
5. Lack of orgasm.
6. Loss of interest in sex.
7. Early menopause (if ovaries remain).

The main thing is for doctors to remember that there are no "extra" organs in the body, so you should think about it before completely removing the uterus.

When is it necessary to remove uterine fibroids?

A uterine fibroid is a neoplasm that has grown in the myometrium (muscle layer) and consists of connective tissue and veins. A woman who has been diagnosed with one or more myomatous nodes first of all asks the attending physician about whether it is necessary to remove the organ.

The main reasons for the appearance of fibroids are:

• hormonal imbalance;
• failures in immunity;
• heredity.

There are three types of myomatous nodes:

• sumbucous (spreading inside the body);
• subserous ("crawl out" in the peritoneum);
• interlinkage.

The average node size is 5 cm, sometimes it reaches 10 cm, large fibroids are rare.

The main symptoms of fibroids (especially multiple or large) are divided into three categories:

• failures of menstrual bleeding;
• lower abdominal pain;
• infertility (sometimes miscarriages or premature birth, as a result of which the child rarely survives).

For non-hazardous fibroids, conservative treatment is indicated. But, unfortunately, in most cases it turns out to be ineffective and the patient is recommended to have an operation.

Is it possible to do without surgery?

Basically, it is necessary to remove the uterus after the age of 40, when the woman does not plan to give birth to children anymore, and the organ is no longer needed. In this case, doctors are obliged to observe the condition of the tumor (s) in advance, find out how much they are progressing, and whether it is worth intervening surgically. The main indication for the operation is the patient's age after 40 years and the size of the myomatous nodes, which exceeds the gestational age of 12 weeks and grows rapidly over time (more than 4 weeks per year). It is also necessary to remove the organ in the case when doctors suspect that the uterine fibroids have begun to degenerate into a malignant cancerous tumor (sarcoma). Then hysterectomy is allowed in young women (up to 40 years old) who have not had children in order to preserve their life.

If one or more myomatous nodes are found, it is necessary to undergo a complete examination in order for the doctor, having a complete picture of the patient's health, to decide on the advisability of performing a surgical operation. In women under the age of 40, surgeons try to remove fibroids while preserving the organ or most of it.

After 40 years, doctors agree that the best option during menopause is the complete removal of the uterus in order to avoid relapses (reappearance of fibroids) and cancer.

Indications for surgery

The following are situations when it is worth performing an operation to remove a fibroid or an organ in general (regardless of how old the woman is):

• If the size of the myomatous node corresponds to the gestational age after the 12th week;
• If the uterine myoma grows catastrophically quickly (for 4 or more weeks of pregnancy);
• When myomatous nodes manifest themselves with frequent and profuse bleeding (both menstrual and intermenstrual), the patient, against the background of blood loss, develops general anemia, accompanied by pallor of the skin, poor health and fainting;
• If the myoma causes severe pain (severe cramps during menstrual bleeding, abdominal pain due to squeezing by the tumor of adjacent organs and nerve endings in the spine);
• If the ultrasound examination revealed irreversible changes in the myoma node (its necrosis, rupture, infection);
• When the patient has a subserous or sumbucous uterine myoma, growing on a long stem, through which it connects to the organ. There is a high probability of torsion of the leg, as a result of which severe uterine bleeding (if the myoma is submucous) or peritonitis (if the peritoneal node) may begin;
• If the fibroid is located in the neck area;
• If the myomatous node is located submucosally on a thin long leg and is visible in the lumen of the neck, begins to "be born", it can be removed surgically by twisting the leg;
• In preparation for IVF;
• If the patient is diagnosed with infertility associated with the myomatous node, its size or location;
• When fibroids cause miscarriages or freezing of pregnancy.

If disorders in the functioning of neighboring vital organs are diagnosed:

• Urination is impaired, urine stagnates in the bladder, which may cause inflammation or sand with stones;
• The back wall of the bladder is compressed, urine is thrown back into the ureter, which can provoke pyelonephritis and other inflammatory diseases, cause enlargement of the renal pelvis (hydronephrosis);
• The process of defecation is disrupted (the rectum is pinched), due to which the patient experiences prolonged constipation, which threatens to poison the body;
• There is compression of the nerve endings near the rectum, which causes radiculitis (severe pain in the lower back) and pain in the heart and lower extremities.

Surgical treatment of myomatous nodes

The choice of the method and amount of surgical intervention directly depends on several factors:

• At a young age, the uterus is tried to be preserved, only the myomatous node can be removed;
• After 40 years, the uterus can be removed - it has fulfilled its main function in the female body. In this case, menstrual and reproductive functions will be suppressed;

The size of the neoplasm (more than 12 weeks - surgery is indicated).

Localization of the tumor (fibroids located on the back wall can provoke miscarriages).

An important nuance of myomectomy is that in a certain percentage of cases, there is a relapse of the disease (tumors return, reappear in other areas).

Types of operations performed

1. Fibroid laparotomy is performed through an incision in the abdominal cavity. The main indications for its implementation are large tumor sizes or a large number of them, as a result of which the uterus is severely deformed. Before the operation, you must undergo special training, after which you need to avoid physical activity for about 2-3 months and monitor the condition of the seam. Ideally, a couple of years after the laparotomic myomectomy, you can start planning the baby;
2. Laparoscopic removal of myomatous nodes - removal of neoplasms through puncture holes in the peritoneum (there are no scars after surgery). The optimal indications for laparoscopy of myoma is its average size (about 8-9 weeks), with laparoscopy of large tumors, uterine bleeding is frequent;
3. Hysteroscopy of fibroids is a procedure performed without punctures or incisions in the abdominal cavity. All manipulations are performed through the cervix and vagina. Indications: small nodes, submucosal fibroids on the pedicle, sumbucous neoplasms, accompanied by severe bleeding, myoma degenerating into a cancerous tumor;
4. Hysterectomy - removal of an organ along with tumors, performed either through incisions in the peritoneum or through the vagina. Hysterectomy can be performed in extreme cases for women after 40 years of age for additional indications with the permission of the attending physician (cancer, necrosis of the myomatous node, the huge size of the neoplasm, squeezing adjacent organs);
5. Embolization of the veins of the tumor (blockage of the main vessels), as a result of which it dies and decreases in size.

Postcastration syndrome or consequences of hysterectomy

The consequences of removing the uterus can be:

This question is very often asked to a gynecologist by a patient diagnosed with uterine myoma - a tumor that is an accumulation of bundles of muscle and connective tissue that grows inside or outside the organ. The causes of its occurrence are not fully understood, but there is no doubt that the growth of this benign tumor is pushing the hormone estrogen. Hormonal imbalance, disorders in the cellular immunity system, as well as hereditary predisposition are also important.

Since myoma occurs in the thickness of the muscular wall of the uterus, at the beginning of its development it is always intermuscular. In the future, if the growth of the myomatous node occurs outward towards the serous membrane of the uterus, the node turns into subperitoneal on a wide base or on a narrow leg. With the subperitoneal (subserous) variant, the fibroid node can sometimes be located far from the uterus, in its ligaments (intraligamentary). In rare cases, such fibroids can separate from the uterus and remain free in the abdominal cavity. If the growth of the fibroid node occurs in the direction of the uterine cavity, the node turns into submucous (submucous). The myomatous node can be single with sizes from a few millimeters to 8-10 cm, rarely more.

Multiple myoma of the uterus consists of two or more myomatous nodes, the relative position of which can give the uterus an irregular shape. Numerous symptoms of uterine fibroids, depending on the location, size, state of blood circulation in the node can be reduced to 3 groups: menstrual dysfunction, pain, reproductive dysfunction.

In what cases can myoma be observed and not operated on?

There is no universal answer. When solving this issue, we take into account the woman's desire, the presence and severity of complaints, the woman's age and reproductive plans (the desire to have children in the future), a decrease in the quality of life, the size, location of myomatous nodes, etc. The decision is made jointly with the woman on the basis of a thorough discussion and consideration of possible alternatives. You can resort to conservative treatment methods. However, today they are not effective enough. Hormonal drugs of the new generation can stop the growth of fibroids if the tumor consists mainly of muscle fibers and when there are receptors in the muscle layer of the uterus that allow them to "catch" these hormones and give a response. For some, this therapy will help, for others it will not. Treatment with non-steroidal anti-inflammatory drugs somewhat reduces pain and bleeding.

As menopause begins, fibroids usually decrease. And if a woman with this disease, who is approaching menopause, comes to the specialists of the Department of Gynecology and Oncogynecology of EMC, we usually suggest not rushing into the operation. She should be monitored and checked every six months to make sure there is no rapid growth of fibroids.

Uterine fibroids: indications for surgery

The absolute indications for surgical treatment of uterine fibroids, regardless of the patient's age, are:

the size of myoma exceeding the size of the uterus during pregnancy 12-14 weeks;

rapid growth of uterine fibroids (per year by an amount corresponding to 4-5 weeks of gestation);

uterine bleeding with a decrease in hemoglobin due to profuse blood loss;

pronounced pain syndrome;

secondary changes in the node (necrosis, infection);

the presence of submucous or subserous nodes of any size on long legs, with a high probability of being prone to twisting;

cervical, interconnective, "nascent" node;

infertility, miscarriage, incl. as preparation for the IVF program;

severe dysfunctions of neighboring organs (frequent urination, prolonged constipation). Due to pressure on the back wall of the bladder, reflux occurs (urine flow into the ureter), the risk of inflammatory diseases increases (for example, exacerbation of chronic pyelonephritis), dilation of the ureters and renal pelvis up to secondary hydronephrosis.

Surgical treatment of uterine fibroids

The choice of the volume and access of the surgical intervention depends on the size and localization of the myomatous node, the patient's age, her desire to preserve the reproductive and menstrual functions. In any case, when treating young women, we are guided by the principle: "Remove myoma - save the uterus!" However, we must not forget that myomectomy, being a conservative, organ-preserving, reconstructive plastic surgery, has a certain percentage of fibroids recurrence, which in some cases requires a second operation.

At the EMC Clinic of Gynecology and Oncogynecology, laparoscopic myomectomy is performed, which has practically no restrictions on the size of uterine fibroids, hysteroresectoscopic removal of submucous uterine myomas, combined laparoscopic-hysteroscopic myomectomy. The question of hormonal preoperative preparation of patients is decided individually. With multiple myomatous nodes above the surface of each of them, the uterine wall is incised, the nodes are fixed with special instruments and removed. The vessels in the bed of the node are coagulated (turn into clots), after which a complete layer-by-layer reconstruction of the uterine wall is performed by suturing using modern absorbable suture material. Adequate layered restoration of the integrity of the uterine wall is the key to the success of laparoscopic myomectomy. Patients who have undergone myomectomy will be able to start preparing for pregnancy 6-12 months after the operation (the issue is decided individually). Most of these procedures can be performed laparoscopically, with the exception of very large nodules that span the entire abdominal cavity.

In some cases, the method of choice may be embolization (blockage) of the vessel feeding the myoma, as a result of which the growth of the node stops, and it “shrivels”. It is also possible to target the site with focused high-energy ultrasound. Women in pre- and postmenopausal women are shown uterine artery embolization, extirpation (complete removal) of the uterus with or without appendages. If the fibroid does not grow and does not cause discomfort, then treatment is not recommended.

Uterine fibroids is the most common gynecological disease. According to medical statistics, it is diagnosed in at least 25-30% of women aged 35-50 years.

Moreover, in the last decade all over the world there has been a tendency towards "rejuvenation" of this disease. Increasingly, fibroids are detected in 25-30-year-old patients, which negatively affects their reproductive health and fertility. And the frequent neglect of regular gynecological examinations leads to a rather late diagnosis of myomatosis, already at the stage of development of complications.

Treatment can be conservative or surgical. In this case, the operation to remove uterine fibroids is performed only if there are certain indications. The choice of the surgical technique and the determination of the scope of the intervention depend on many factors.

What is myoma and what is it like?

Myoma is a benign hormone-dependent nodular neoplasm originating from the myometrium - the muscular layer of the uterus. In this case, the serous membrane of the organ (peritoneum) and the internal mucous membrane (endometrium) are not involved in the pathological process, but cover the surface of the tumor.

Such a neoplasm does not germinate, but pushes the surrounding healthy tissue apart. This feature makes it technically possible to remove relatively small myomatous nodes while maintaining the integrity and functional usefulness of the uterine wall.

Tumor tissue may consist only of hypertrophied muscle fibers or include additional layers of connective tissue. In the latter case, the term "fibroids" is valid. Soft enough homogeneous muscle tissue formations are called leiomyomas.

The growth of such a tumor of the uterus can occur in several directions:

• with prolapse into the lumen of the organ, while the myoma is called submucosa or;
• with stratification of the muscle layer, thickening and deformation of the uterine wall (interstitial variant);
• with protrusion of the node into the abdominal cavity ();
• with stratification of the sheets of the broad ligament of the uterus (intraligamentary myomatous node).

The nodes protruding beyond the contours of the organ can have a pedicle of various diameters or "sit" on a wide base, sometimes immersed in the middle muscle layer.

Fibroids rarely undergo malignancy, malignancy is diagnosed in less than 1% of patients. But in many cases, such a tumor of the uterus is accompanied by various complications. They are usually the basis for making a decision about surgical treatment.

When is uterine fibroid removal required?

Removal of uterine fibroids (myomectomy) refers to organ-preserving operations. Therefore, in women of reproductive age with unrealized fertility, preference is given, if possible, to this option of surgical treatment.

In some cases, surgery even becomes a key step in fertility treatment. This is possible if difficulties with conception or prolongation of the onset of pregnancy are caused by deformation of the uterine cavity by submucous or large interstitial nodes.

Indications

Removal of fibroids is necessary when conservative therapy does not lead to a decrease in the size of the tumor and does not allow it to restrain its growth. Also indications for surgery are:

• recurrent uterine bleeding;
• persistent pain syndrome;
• signs of displacement and dysfunction of adjacent organs;
• with submucous and subserous nodes, especially prone to ischemic necrosis and with a risk of torsion of the leg.

Contraindications

Myomectomy is not performed under the following conditions:

• in the presence of large or multiple myomatous nodes;
• with the cervical location of the tumor;
• profuse and uncorrected uterine bleeding (menometrorrhagia), which leads to severe anemization of the patient and even threatens her life;
• with massive tumor necrosis, especially if it is accompanied by the addition of a secondary bacterial infection, septic, thrombosis, or threatens the development of peritonitis;
• active growth of fibroids in a patient who is in;
• severe disruption of the functioning of neighboring organs (bladder, ureters, intestines), due to their displacement and compression by a large myomatous node or the entire enlarged uterus.

All these conditions are indications for radical surgical treatment of fibroids. This is done.

Limitations for myomectomy are also the patient's severe physical condition, the presence of current infectious and septic diseases, and the identification of contraindications for general anesthesia. In such cases, surgery can be temporarily postponed or replaced with alternative treatments in combination with active conservative therapy.

Ways to remove uterine fibroids

Surgical removal of fibroids can be done in several ways. Their fundamental difference is the type of online access. In accordance with this, laparotomy, laparoscopic and hysteroscopic myomectomy are distinguished.

• Laparotomy

This is a classic abdominal surgery to remove uterine fibroids. It is accompanied by the imposition of incisions on the anterior abdominal wall of the patient using a scalpel or modern instruments - for example, an electric knife. This access gives the operating doctor the opportunity to have a fairly wide direct view of the abdominal cavity, but is the most traumatic for the patient.

• Laparoscopy

A much more gentle method that requires endoscopic equipment. Manipulations are performed through punctures placed in certain places of the anterior abdominal wall. Recovery after such an operation is much faster than with classical laparotomy.

• Hysteroscopy

A minimally invasive technique that also requires special endoscopic equipment. At the same time, the doctor does not need to impose incisions and punctures; he uses the cervical canal to access the uterine cavity.

The choice of the method of surgery depends on the specific clinical situation. This takes into account the size, number and localization of myomatous nodes, the presence and severity of complications, the patient's age and the risk of tumor malignancy. The qualifications and experience of the operating doctor, the equipment of the medical institution with endoscopic equipment is also of great importance.

How long the operation to remove uterine fibroids takes depends on the chosen technique, the volume of the intervention and the presence of intraoperative complications and complications.

How is the operation carried out by the laparotomy method

The operation using the laparotomic approach is indicated for interstitial and deeply embedded subserous nodes. It is used for multiple myomatosis, complicated course of the disease, adhesive disease, in the presence of rough or insufficiently wealthy scars of the uterus. Removal of large uterine fibroids and cervical tumors is also usually performed laparotomically.

Incisions for laparotomy surgery to remove the uterus

To access the myomatous nodes on the anterior abdominal wall, a vertical or horizontal incision is applied, followed by layer-by-layer dissection and tissue expansion. The affected organ is removed outside the abdominal cavity. Only in the presence of well-visualized nodes on the anterior wall can the doctor decide to perform manipulations on the submerged uterus.

The serous membrane (visceral layer of the peritoneum) is dissected and stupidly exfoliated, the myomatous node is isolated with the minimum possible trauma to the surrounding healthy myometrium. The tumor is shed and removed. Sutures are applied to her bed, while serosa is sutured separately. Bleeding vessels are carefully ligated; it is also possible to use an electrocoagulator. The abdominal cavity is drained, and the quality of hemostasis is controlled. After that, all layers of the abdominal wall are sutured in layers.

Possible complications during laparotomy removal of fibroids are associated with technical difficulties or errors during the operation. Massive intraoperative bleeding, accidental damage to adjacent organs is possible.

Removal of uterine fibroids by laparoscopic method

Laparoscopic surgery is a gentle and at the same time highly effective way to remove subserous fibroids on a pedicle or on a wide base. It is performed under general anesthesia in a specially equipped operating room.

Access to the uterus during laparoscopy is through small punctures of the anterior abdominal wall in both iliac regions. The camera is inserted through the umbilical ring. The same puncture is used to inject carbon dioxide into the abdominal cavity, which is necessary to expand the spaces between the walls of the internal organs, to obtain sufficient visibility and space for the safe introduction of manipulators and instruments.

Laparoscopic surgery is a more gentle way to remove fibroids

The thin leg of subserous myoma is coagulated and cut off close to the uterine wall. In this case, sutures are usually not required on the serous membrane; the use of an electrocoagulator is sufficient.

If a node is removed on an interstitial base, the doctor decapsulates and enucleates it. Such manipulations are necessarily complemented by a step-by-step thorough hemostasis by electrocoagulation of all intersected vessels, regardless of their diameter.

The process of removing the node on the base ends with the imposition of double-row endoscopic sutures on its bed. This is not only an additional method of hemostasis, but also contributes to the formation of a full-fledged scar in the future, which will retain its integrity in the process of enlarging the pregnant uterus. Suturing the defect of the serous membrane also helps to reduce the risk of postoperative.

The cut off myomatous node is removed with the help of morcellators through the existing punctures. Sometimes an additional colpotomy hole is required.

After a control revision of the operation area and the entire abdominal cavity, the doctor removes the instruments and the camera, and, if necessary, evacuates the excess carbon dioxide. The operation is completed by suturing the laparotomy holes. The patient usually does not need to stay in the intensive care unit and, after recovering from anesthesia, can be transferred to the recovery room under the supervision of a doctor and medical staff.

Currently, only subserous nodes are removed laparoscopically. But if the wide base of the fibroid (its interstitial component) is more than 50% of the total tumor volume, such an operation is not performed. In this case, a laparotomy is required.

Hysteroscopic myomectomy

Removal of uterine fibroids by hysteroscopy is a modern, low-invasive method of surgical treatment of submucous nodes. Such an intervention does not violate the integrity of the uterine wall and surrounding tissues and does not provoke the scarring process.

In most cases, hysteroscopic myomectomy is not accompanied by clinically significant blood loss with the development of postoperative anemia. A woman who has undergone such an operation does not lose the ability to deliver naturally. It is also usually not considered a risk group for miscarriage.

Hysteroscopic variant of uterine fibroid removal

All manipulations with the hysteroscopic variant of the operation are performed transcervically using a hysteroscope. This is a special device with a camera, a source of local illumination and instruments, which is inserted into the uterine cavity through an artificially dilated cervical canal. At the same time, the doctor has the ability to accurately control the manipulations performed by him on the monitor, to accurately examine suspicious areas of the mucous membrane and, if necessary, take a biopsy, to quickly stop the incipient bleeding.

Hysteroscopy is performed under general anesthesia, although spinal anesthesia is possible. To cut off the myomatous node, instruments for mechanical transection of tissues (analogous to a scalpel), an electrocoagulator or a medical laser can be used. It depends on the technical equipment of the operating room, the skills and preferences of the operating doctor.

Laser removal of uterine fibroids is the most modern and gentle option for hysteroscopic myomectomy. Indeed, in this case, there is no squeezing, twisting and deep necrosis of the surrounding tissues, no special measures are required to stop bleeding. Healing takes place quickly and without the formation of rough scars.

Transcervical hysteroscopic myomectomy is not used for nodes larger than 5 cm in diameter, which are difficult to evacuate through the cervical canal. Dense postoperative scars on the uterine wall, internal adhesions (synechiae) also significantly limit the use of this method.

Supporting operating technologies

To increase the effectiveness of the surgical intervention and reduce the risk of intraoperative complications, the doctor may use some additional techniques. For example, laparoscopic and laparotomy removal of fibroids is sometimes combined with preliminary ligation, clearing, or embolization of the uterine arteries. Such preparation for the operation is carried out several weeks before the main surgical treatment.

Forced restriction of blood supply to myomatous nodes is aimed not only at reducing their size. The conditions of artificially created ischemia lead to a reduction in the healthy myometrium, which is accompanied by the contouring of tumors and their partial isolation from the thickness of the uterine wall. In addition, surgical manipulations in the blood-depleted area significantly reduce the volume of intraoperative blood loss.

Preliminary temporary clamping and ligation (ligation) of the uterine arteries are performed from the transvaginal approach. After the completion of the main operation, the superimposed clamps and ligatures are usually removed, although sometimes with multiple myomas, a decision is made to permanently ligate the supply vessels.

Postoperative and recovery period

The postoperative period usually proceeds with pain syndrome of varying intensity, which may require the use of non-narcotic and even narcotic analgesics. The severity of pain depends on the type of operation performed, the amount of intervention and the individual characteristics of the patient.

With significant intraoperative blood loss in the first hours after the transfer of a woman to a ward of intensive blood loss, transfusion of blood and blood substitutes, the introduction of colloidal and crystalloid solutions, the use of funds to maintain an adequate level of blood pressure may be required. But the need for such measures is rare, usually myomectomy passes without clinically significant acute blood loss.

In the first 2 days, the doctor must monitor the functioning of the intestines, because any operation on the abdominal organs can be complicated by paralytic intestinal obstruction. It is also important to prevent the development of constipation, since excessive straining during bowel movements is fraught with failure of the stitches. That is why much attention is paid to the nutrition of the patient, getting up early and the rapid expansion of motor activity.

What can you eat after your surgery?

It depends on the type of surgical treatment, the presence of anemia and concomitant diseases of the digestive tract.

The diet after removal of fibroids by the laparotomy method does not differ from the diet of persons who have undergone other abdominal operations. On the first day, the patient is offered liquid and semi-liquid easily digestible food, in the subsequent menu they quickly expand. And by 5-7 days a woman is usually already on the common table, if she does not need to comply with the so-called "gastric" diet.

But laparoscopic and hysteroscopic myomectomy does not impose such strict restrictions even in the early postoperative period. In good condition, the patient can eat from a common table by the evening of the first day.

If the fibroid caused the development of chronic iron deficiency anemia or if the operation was accompanied by large blood loss, iron-rich foods must be introduced into the woman's diet. Additionally, antianemic iron-containing drugs can be prescribed.

Myomectomy allows you to remove existing nodes, but is not a prevention of the appearance of new uterine tumors. The fact is that myoma has a hormone-dependent development mechanism, and the operation does not affect the patient's endocrine profile. Therefore, in the absence of proper preventive therapy, a relapse of the disease is possible. So what treatment is prescribed after removal of uterine fibroids? The therapeutic scheme is selected individually, it often includes the use of hormonal drugs.

Removal of fibroids imposes some restrictions. It is advisable for a woman not to visit baths, saunas and solariums during the first few months, to avoid increased physical exertion.

In general, rehabilitation after removal of uterine fibroids takes about 6 months, then the woman returns to her usual way of life. But at the same time, she also needs to undergo a gynecological examination every six months, as prescribed by a doctor, to carry out an ultrasound of the pelvic organs.

Consequences of the operation

Is it possible to become pregnant after removal of uterine fibroids is the main question that worries patients of reproductive age. Myomectomy does not entail the disappearance of menstruation and the onset.

In the first few days, bloody discharge is possible, which cannot be considered monthly. When determining the length of the cycle, only the start date of the previous menstruation should be considered. Periods after this operation usually return within 35-40 days. In this case, lengthening or shortening of 1-2 subsequent cycles is permissible.

Preserving the patient's ovaries and uterus allows her to maintain her reproductive function. Therefore, pregnancy after removal of uterine fibroids is possible soon after the restoration of the functional usefulness of the endometrium.

But it is advisable for a woman who underwent such an operation to think about conception no earlier than 3 months after surgical treatment. And sexual intercourse is permissible only after 4-6 weeks. Compliance with these deadlines is especially important if laparotomy myomectomy with suturing of the uterine wall was performed.

Possible consequences of the operation include the risk of premature termination of pregnancy in the future, the pathological course of labor, the development of adhesive disease.

Alternatives to surgery

The possibilities of modern medicine allow the use of alternative methods of eliminating uterine fibroids. They can be minimally invasive or even non-invasive, that is, they go away without surgery.

These include:

• ... Malnutrition of tumor tissues leads to its aseptic lysis with replacement of muscle cells with connective tissue. Embolization is performed using a catheter inserted under X-ray control through the femoral artery.
• (focused ultrasound ablation) of fibroids, causing local thermal necrosis of tumor tissue. But this technique can only be used to get rid of fibromyomatous and fibrous nodes. But leiomyoma is insensitive to FUS-ablation.

In some cases, such techniques are combined with laparoscopic myomectomy, which is necessary for multiple myomatosis and subserous nodes on the pedicle.

You should not refuse to remove uterine fibroids. This organ-preserving operation does not lead to irreversible consequences for the woman's body and allows you to get rid of all the complications associated with the presence of myomatous nodes.

Diseases of the female reproductive system in some cases are detected quite by accident, for example, during the next routine examination, or when diagnosing concomitant diseases.

In this case, the disease does not yet have pronounced symptoms due to the initial stage of the course. Symptoms begin to appear as the disease progresses.

What is this tumor

Myoma is a benign formation localized in the body of the uterus or in organ, which can have both a single formation and represent a mesh .

A benign tumor may grow rapidly or develop slowly.

The development of nodular formation begins with the cells of the myometrium - the cells of the inner mucous layer of the uterus. In addition, fibroids are of different types, have different symptoms and structure.

There are many types of fibroids. It can be classified according to various criteria.

Depending on the cellular structure, the tumor is:

• simple... Has a cellular structure that is unable to divide;
• proliferating... 25% of tumor cells are capable of dividing, the rest of the cells have a cellular composition similar to a simple myoma;
• pre-sarcoma... Many nodules are concentrated in one tumor, 75% of the cells of which have mitotic activity.

By location, a benign neoplasm is:

• (intramuscular)... Such myoma is large in size and is located in the muscular layer of the body of the uterus;
• ... This type of myoma is located in the myometrium, on the border with the serous layer. A feature of the growth of such an education is a strong proliferation into the abdominal cavity. A characteristic feature of the structure of such a tumor is a thin leg on which the growth is held;
• (submucosal) ... Such a tumor grows in the mucous layer of the uterus inside her body. When large, this tumor causes severe bleeding and pain.

A rare case when fibroids grows in the retroperitoneal region.

There are two types of fibroids depending on the cellular structure:

• fibroids... Consists of connective tissue;
• leiomyoma... The cellular structure of this species has a muscle-fibrous structure.

In accordance with the stage of development of fibroids, there are three types, each of which is characterized by the size of the node, depending on the growth and development time. The first stage has, the third is large, characterized by rapid growth.

Sizing principle

In order to designate the size of a benign formation, experts take as a basis not only its diameter, but also the corresponding increase in the uterus.

With the growth of a benign tumor, the uterus enlarges. An organ enlargement is recorded similarly to its growth during pregnancy - , and the growth of the tumor often becomes visible visually - the woman's belly grows like during pregnancy.

Heavy bleeding during menstruation, as well as between periods, can lead to post-hemorrhagic anemia, accompanied by fainting, fatigue, lack of vitamins and soreness.

The danger of pedicle formation is twisting of the pedicle, as a result of which the tumor may die. In this case, necrotic processes occur in the organ, which can cause peritonitis or general sepsis.

Very often, fibroids can provoke infertility (when the pathways for the passage of sperm are blocked), miscarriage or premature birth.

If the doctor shows the removal of myomatous nodes, you should not refuse the operation. Otherwise, the growth of a tumor can endanger the life and health of a woman.

At what size is removed

The size of the fibroid is one of the main indications for surgery to remove it. So at what size are fibroids removed?

An operation is performed when the size of the uterine fibroids exceeds 3 cm. A tumor of this size most often already manifests itself in the form of basic symptoms (severe bleeding, pain syndromes). The more actively the tumor grows, the faster it needs to be operated on.

However, there are cases that require surgical intervention for small fibroids. For example, a small neoplasm on the pedicle during torsion causes severe pain; in this case, you cannot do without removing the fibroid.

In extremely rare cases, when a biopsy scraping showed cancer cells even in a small tumor, immediate surgery is required.

Also read in what cases with myoma.

Symptoms

Symptoms of fibroids occur, as a rule, when the tumor has outgrown the latent growth period, its size is more than 2 cm.

In this case, the following signs of the disease may appear:

• violation of the menstrual cycle;
• bleeding not associated with menstrual periods;
• excessively heavy menstruation;
• frequent, sometimes painful urination;
• constipation;
• a feeling of fullness or pressure in the lower abdomen;
• pain in the abdomen, sometimes in the lower back.

The growth of the tumor over time becomes noticeable with the naked eye - in the absence of an increase in the total body weight, the abdomen increases in volume.

NOTE!

If any of the symptoms of myomatous nodes appear, you should consult a gynecologist.

It is impossible to diagnose fibroids on their own on the basis of indicators, since many other gynecological diseases can have similar symptoms. Diagnostic measures will help not only to correctly identify the disease, but also exclude deadly pathologies, such as cancers.

Diagnostic methods

What should be done to identify the mimic uterus?

The methods of conservative therapy include:

• reception;
• medicinal baths;
• taking vitamin complexes;

In addition, indicators for conservative treatment are:

• planning pregnancy;
• localization of nodes in the muscle layer of the organ;
• there is no submucous tumor.

In case of intolerance to anesthesia or the impossibility of performing an operation for health reasons conservative treatment is used involuntarily.

The experts spoke about the curse of the courtesans

“One thirty-year-old patient, upon learning about uterine fibroids, lamented: perhaps someone cursed me! My career is going uphill, I make good money, - there are a lot of envious people, - says the professor of the Department of Obstetrics and Gynecology, Faculty of Medicine, Moscow State Medical University. A.I. Evdokimova Alexander Tikhomirov. - No one cursed her! It's just that the uterus should be used as intended. "

The entire women's world today is practically on the verge of a non-infectious epidemic of fibroids. The representatives of the fair half are paying for the fact that they postpone the birth of children almost to old age. And although today there is bloodless treatment for fibroids, in Russia the removal of the uterus remains the most popular abdominal operation.

At the beginning of the last century, fibroids were considered a disease of nuns, or, in extreme cases, courtesans. It was these categories of the female population that were at risk of facing the named disease. The rest actually lived from childbirth to childbirth, letting the uterus work as nature intended.

Now, as Professor Tikhomirov says, modern young ladies have dissertations, careers and so on in their heads. The birth of a dozen children is almost beyond anyone's plans. As a result, with each new period, the risk of fibroids increases - after all, nature has provided for this organ to rest during pregnancy and lactation.

Myoma has become one of the most common female diseases - occurs in at least a third of women aged 35+. According to some estimates, to one degree or another it can be found in as many as 72% of women over 40 (the peak incidence occurs at the age of 35-50).

“When women are diagnosed with fibroids for the first time, they have a lot of questions,” says Alexander Leonidovich. - For example, isn't it cancer? No, not cancer, and will never develop into cancer. Will the uterus have to be removed? The vast majority of women, with timely diagnosis, do not need such an operation. Although there are situations when it is better to live without a uterus than to die with a uterus. "

Unfortunately, fibroids tend to grow. Always. There is no such thing as myoma freezing in one size. But many doctors, having found a nodule, tell their patients: nothing needs to be done, come in half a year. Despite the advances in modern medicine, there are gynecologists who prefer to passively observe this tumor until a radical operation is required. “What is there to observe? How will the node grow? So that he grows up to 12 weeks, when will the patient be told: is it time to remove the uterus? " - Professor Tikhomirov is indignant.

He is sure that treatment for uterine fibroids should be started immediately. There are two groups of drugs for this - selective progesterone receptor modulators and gonadotropin-releasing hormone antagonists. If the nodes are very small, they may disappear with such treatment. If they are medium or large, they will gradually decrease. “However, when the symptoms - bleeding, pain, heaviness in the abdomen, difficulties with urination - disappear, no one will care whether there is a fibroid or not. The main thing is that it does not interfere with life, "says the professor.

In some cases, a conservative plastic method is required - removal of nodes. Today it is performed by anemic methods - laparoscopy, endoscopic instruments. There are other minimally invasive hardware techniques for getting rid of fibroids. For example, by exposure to X-rays the best. Or embolization of the uterine arteries (in the process of introducing special drugs through the femoral artery into the uterus, the tumor is deprived of the blood supply nodes). Another technique from this series - high-speed ultrasound - unfortunately, has many contraindications.

Meanwhile, hysterectomy - surgery to remove the uterus - is the most common abdominal surgery in our country. The average age of such an operation in Russia is 40.5 years plus 3.5 years. Of course, this procedure ends in infertility. But in fact, there are very few indications for it - either if the myoma is in a very advanced stage, or if it is combined with other tissue pathologies. “It is important to observe the principle of the four“ not ”: not to allow, not to miss, not to start the disease, not to allow the formation of a larger volume of myomatous tissue. Passive observation is not acceptable! " - Professor Tikhomirov repeats.

Many women worry - is it possible to give birth with fibroids? “Yes, good health! Get timely treatment and give birth, ”says our expert. As for prevention, besides childbirth and lactation, there is only one scientifically proven method of preventing this disease - the use of complex oral contraceptives. Everything else in terms of preventing this disease does not play any role.

Less than a third of Russian women of reproductive age (29%) undergo a preventive examination by a gynecologist, as recommended by experts. This was shown by the poll "Index of Women's Health" conducted by VTsIOM.

Although the majority of women (86%) aged 18 to 44 agree that it is necessary to visit a doctor regularly for preventive purposes, only one in three does it properly, once every six months. In addition, only every seventh woman of reproductive age (14%) goes to a gynecologist only in case of health problems. 40% wait several days to see if the alarming symptoms go away by themselves, and 26% are willing to endure long enough until the situation seriously worsens. 49% of Russian women consider themselves healthy; 39% say that since they have a permanent sexual partner, they have nothing to worry about; 38% have no time and 21% have a good doctor. 4% of women are ashamed or afraid that they, God forbid, will find something.

As says chief Researcher, Research Institute of Women's Health, First Moscow State Medical University THEM. Sechenova Irina Kuznetsova: “The culture of caring for women's reproductive health began to form not so long ago. Today this topic is considered a bit embarrassing. Even at an appointment with a specialist, they are embarrassed to talk about their problems using euphemisms. And doctors began to speak openly on these topics not so long ago. For example, interest in the PMS arose in the 70s of the last century, when lawyers tried to justify their clients that they were not in their best shape. It must be remembered that a preventive examination is not just an ordinary event. At a doctor's appointment, women can receive advice on preparing for pregnancy, adjusting nutrition and lifestyle, as well as on the prevention of reproductive system diseases. "