Surgical techniques of open myomectomy

Although surgical technique varies from surgeon to surgeon because of training and familiarity with procedures, the following are some general principles of good myomectomy practice: If the patient is not acutely hemorrhaging, correct any preoperative anemia from fibroid-induced menorrhagia. Increase blood volume through the use of leuprolide acetate and iron therapies; consider autologous blood donation. Ensure adequate uterine exposure; if the uterine size is greater than 16 to 18 weeks, a midline or a Maylard abdominal incision is advisable. Pay attention to microsurgical and atraumatic tissue handling throughout the operation to decrease inadvertent uterine damage and to reduce adhesion formation. Use vasopressin injection and mechanical vascular compression to diminish uterine blood loss. Vasopressin is better suited for patients who have several well-defined fibroids that need removal. If the uterus is heavily affected by myomas, tourniquet placement is preferable; again, vasopressin and tourniquets are not mutually exclusive and may be used in concert with one another. Choose uterine incisions that will minimize blood loss yet will maximize the number of myomas that can be removed through them. Reapproximate the uterine serosa in an inverting fashion to eliminate any protruding edges that may act as foci for adhesion formation. Use an anti-adhesive agent, especially if a posterior uterine incision is necessary.