Minimally Invasive Surgery for Fibroids

Minimally invasive gynecologic (MIG) techniques have generated significant improvement in surgical outcomes. The advent of laparoscopic and robotically assisted laparoscopic (L/RAL) method (surgery through 0.25-0.5 inch “holes”) made the greatest contribution in that positive trend. Employing MIG techniques, patients undergoing major surgeries, such as hysterectomies and myomectomies, are able to go home the same day and return to normal activities in only 2-3 weeks. Major complications, such as clot formation (DVT), infection, scar formation, bowel obstruction and incisional hernias are reduced remarkably as well. Unfortunately, the majority of patients are still undergoing the traditional laparotomy (open abdominal incision). This makes them to stay 2-3 days in the hospital, postpones their return to normal activities by 6-8 weeks and increases the rate of major complications.

Thousands of patients afflicted with large fibroids needing a hysterectomy or myomectomy can benefit from L/RAL. Large fibroids are being extracted through small (0.5-0.8 inch) “holes” using special devices called morcellators. These tools are able to cut fibroids into smaller fragments enabling their removal through these small incisions.

Recently (4/17/2014) and surprisingly, the FDA issued a safety communication stating “FDA discourages the use of laparoscopic power morcellation during hysterectomy or myomectomy for the treatment of women with uterine fibroids”. It’s important to note that the FDA didn’t ban morcellation. The FDA continues it’s investigation and will issue final recommendations later this year. The concern expressed by the FDA stems from a possible risk of spreading sarcomatous (certain cancerous) tissue that could be inside these morcellated fibroids throughout the abdomen. The FDA stated that risk of sarcoma in fibroids is 0.3%. The Society of Gynecologic Oncologists (SGO) reported that the risk to be 0.1%. This means that out of every 1000 patients with fibroids, 1-3 will have sarcoma within a fibroid. There is no reliable way to diagnose sarcoma prior to surgery.

Sarcoma is known to spread through blood vessels and, unfortunately, at the time of diagnosis, the distant dissemination has already occurred. Therefore, if sarcoma is unknowingly morcellated, the possible detrimental impact of intraabdominal spread is at best, questionable. On the other hand, banning morcellation from 99.7-99.9% of patients who have benign fibroids, will cause them to undergo traditional laparotomy surgery (instead of L/RAL) and subject them to significantly longer hospital stays, longer recovery at home and higher risk of complications. These complications could be deadly as well. Patients afflicted with obesity, diabetes, risk for clotting or desiring to preserve fertility could suffer especially.

Any surgery is not without risk. Therefore, all conservative measures need to be exhausted before deciding to undergo an operation. Once a decision to proceed with surgery is made, careful risk/benefit analysis needs to be done. If the benefit outweighs the risk, then the least potentially harmful operation has to be chosen. MIG in general and L/RAL in particular can minimize complications. The 0.1-0.3% risk of sarcoma in fibroids with questionable morcellation harm needs to be weighed against well proven complication reduction in 99.7-99.9% of patients with benign fibroids.

Author

Dr. Nathan Mordel, MD Nathan Mordel, MD, is a board-certified gynecological surgeon at Atlanta Minimally Invasive Gynecologic Surgery Center in Atlanta, Georgia. He specializes in advanced robotic, laparoscopic, vaginal pelvic surgery, including for fibroids, endometriosis, heavy and/or painful menstrual periods, pelvic organ prolapse, and urinary incontinence.