Progress in myomectomy

Abstract Myomectomy was begun a little over one hundred years ago as a bold surgical venture for the removal of a pedunculated tumor which was erroneously believed to spring from the ovary. If there were other similar embedded tumors they were considered inoperable. The operation has gradually developed technically so that today multiple myomectomy is done as a conservative plastic operation upon the uterus with the specific object of not only removing all of the fibroids but of conserving the uterus with retention of menstruation and possible reproduction. Three dangers attending the operation to an appreciable degree, namely, hemorrhage, postoperative morbidity, and mortality, were gradually reduced by improvements in surgical technique. Hemorrhage has been controlled by temporary constriction of the uterine vessels by the fingers of an assistant, by rubber covered clamps, and finally by use of an elastic rubber tourniquet circumscribing the cervix and constricting the uterine vessels on either side. This elastic tourniquet has made possible the bloodless removal of many fibroids which previously would have indicated hysterectomy. The reduction of morbidity and mortality was further brought about by careful planning of the uterine incisions which were placed mostly on the anterior and superior surface of the uterus and removing as many fibroids as possible through one incision. By providing adequate peritoneal protection of the wound, covering them with vesicouterine peritoneum, anterior parietal peritoneum, sigmoid epiploica and omentum according to the requirements of the conditions met in the individual cases, intestinal agglutinations, intestinal adhesions, postoperative distress, and morbidity were further reduced. The mortality has been reduced in fairly large series of cases to 1 per cent and below, comparing favorably with the best statistics on hysterectomy. The complete planning of myomectomy includes diagnostic measures by which to exclude or demonstrate the presence of intrauterine lesions, chiefly, retained products of conception in incomplete abortion, submucous myoma, polyps, and carcinoma. These can be diagnosed by exploratory curettage done before the myomectomy. Practically all intrauterine lesions are amenable to demonstration by means of radiopaque media injected into the uterine cavity. A viscous soluble crystalloid iodine solution has been found useful and safe and may replace diagnostic curettage. Uterine polyps may be removed by curettage and the polyp forceps, and submucous myomas may be removed by vaginal or abdominal hysterotomy at the same time as other fibroids are removed. If the operation is designed to relieve sterility the uterine incision and suture should guard against implicating the insertion of the Fallopian tubes. Recurrences are relatively rare and arise from seedling fibroids overlooked at the time of operation or escaping inspection because of their embedded location. The choice of a second myomectomy is left in such cases to the patient, provided she is young enough and still desires children or resort may be had to hysterectomy or radiotherapy. In from 25 to 35 per cent of the cases, myomectomy has been followed by pregnaney. This would appear to justify the pains taken by the surgeon in conserving the uterus. Myomectomy is the ideal and at present the only conservative treatment for uterine fibroids which preserves menstruation and the possibility of reproduction.