Uterine fibroids (leiomyomas): Open abdominal myomectomy procedure

INTRODUCTION — Uterine fibroids (leiomyomas or myomas) are the most common type of pelvic tumor in females. Treatment options for fibroid-related symptoms include expectant management, medical therapy, nonexcisional procedures (eg, endometrial ablation, uterine artery embolization, magnetic resonance guided focused ultrasound), and surgery (eg, myomectomy, radiofrequency ablation, hysterectomy).

Myomectomy is the surgical removal of leiomyomas from the uterus, leaving the uterus in place. This can be accomplished using an open abdominal, laparoscopic, hysteroscopic, or vaginal approach.

The open abdominal myomectomy procedure will be reviewed here. General principles of the treatment of uterine leiomyomas, techniques to reduce blood loss during myomectomy, as well as laparoscopic (conventional and robotic approaches), hysteroscopic, and vaginal myomectomy, are discussed separately. (See "Uterine fibroids (leiomyomas): Treatment overview" and "Techniques to reduce blood loss during abdominal or laparoscopic myomectomy" and "Uterine fibroids (leiomyomas): Laparoscopic myomectomy and other laparoscopic treatments" and "Uterine fibroids (leiomyomas): Hysteroscopic myomectomy" and "Uterine fibroids (leiomyomas): Prolapsed fibroids".)

INDICATIONS AND ALTERNATIVES — The indications for, and alternatives to, open abdominal myomectomy are presented elsewhere. (See "Uterine fibroids (leiomyomas): Treatment overview".)

In general, open abdominal myomectomy is performed for patients with symptomatic intramural, transmural, or subserosal leiomyomas in whom future childbearing is desired and a hysteroscopic or laparoscopic myomectomy is not feasible. The abdominal approach is also reasonable for some type 2 fibroids (figure 1).

For patients who do not plan future childbearing but prefer to preserve their uterus, the choice of procedure (eg, myomectomy, nonexcisional procedures, medical therapy) must be individualized. For patients with symptomatic fibroids who prefer definitive surgery, hysterectomy is a reasonable option. This is reviewed in detail separately. (See "Uterine fibroids (leiomyomas): Treatment overview", section on 'Patients not desiring fertility'.)

Open abdominal myomectomy is contraindicated in patients in whom laparotomy is contraindicated (eg, medical comorbidities). Myomectomy is also contraindicated in patients with coexisting cervical or uterine carcinoma. (See "Overview of the principles of medical consultation and perioperative medicine" and "Invasive cervical cancer: Staging and evaluation of lymph nodes" and "Overview of resectable endometrial carcinoma".)

PREOPERATIVE ISSUES

Informed consent — The surgeon provides detailed explanation of all applicable medical, interventional, and surgical treatment options. A discussion of anticipated benefits and potential complications, including the likelihood of recurrent fibroids and symptoms, and reproductive issues and expectations helps patients make informed decisions. (See "Uterine fibroids (leiomyomas): Treatment overview".)

This discussion should be documented on the surgical consent form and in the medical record.

Preparing for potential blood loss — While myomectomy does not usually result in significant blood loss, life-threatening hemorrhage can occur [1]. (See 'Hemorrhage' below.)

Risk factors for increased blood loss include fibroids that are large, multiple in number, or those located low in the pelvis (eg, cervical fibroid). In a prospective study including 2050 patients with symptomatic fibroids undergoing laparoscopic myomectomy, major complications (eg, hemorrhage, visceral injury, failure to complete the planned procedure) occurred in 2 percent of patients and were associated with fibroid size ≥5 cm (odds ratio [OR] 6.9) or removal of >3 fibroids (OR 1.3) [2].

Techniques to reduce blood loss (eg, intramyometrial vasopressin, tranexamic acid) and methods to reduce the risk of allogenic blood transfusion (eg, autologous blood donation, intraoperative blood salvage) are discussed in more detail separately. (See "Techniques to reduce blood loss during abdominal or laparoscopic myomectomy".)

Role of GnRH agonists — In our practice, we do not routinely administer GnRH agonist prior to open myomectomy. We reserve these agents for patients who strongly prefer a transverse rather than a vertical incision and in whom uterine size reduction is anticipated to enable adequate surgical exposure through such an incision. (See 'Skin incision' below.)

In a meta-analysis including 13 randomized trials evaluating patients undergoing abdominal myomectomy, surgical pretreatment with a GnRH agonist compared with placebo or no treatment reduced uterine size (uterine volume: mean difference [MD] -175 mL; fibroid volume: MD -6 to -155 mL), and was associated with a modest increase in hemoglobin (MD 0.88 g/dL) [3]. In a single trial evaluating incision choice, GnRH agonist use (13 patients) compared with no treatment (15 patients) was associated with fewer vertical incisions (0 versus 33 percent) [4]. However, GnRH agonists result in little effect on surgery time or blood transfusion rates [3,5]. (See 'Preparing for potential blood loss' above.)

In our experience, post GnRH histologic changes, including necrosis of the myometrial-myoma junction, may obscure the tissue plane between the fibroid and normal myometrium and make enucleation more challenging. GnRH effects on smaller fibroids may also obscure identification during surgery, and these persistent myomas may cause symptoms in the future.

The effects of GnRH agonists on blood loss and operative difficulty during myomectomy are discussed in more detail separately. (See "Techniques to reduce blood loss during abdominal or laparoscopic myomectomy", section on 'GnRH agonists'.)

Prophylactic antibiotics — In our practice, we give prophylactic antibiotics (table 1) for open abdominal myomectomy. Limited evidence supports administration of antibiotic prophylaxis prior to clean (ie, not involving entry into the vagina or intestine) laparotomy [6]. (See "Pelvic inflammatory disease: Long-term complications", section on 'Infertility'.)

The American College of Obstetricians and Gynecologists advises that prophylactic antibiotics may be considered for laparotomy procedures in which the bowel or vagina are not entered [7]. Some experts believe the risk of surgical site infection with myomectomy is similar to that of hysterectomy, for which antibiotic prophylaxis is universally recommended [7,8]. Furthermore, intraabdominal infection may adversely affect future fertility.

Thromboprophylaxis — Patients undergoing open abdominal myomectomy (major open surgery [>45 minutes]; Caprini risk score: 2 points) are at least at low risk for venous thromboembolism and require appropriate pharmacologic or mechanical thromboprophylaxis (table 2). For such patients, we use sequential compression devices during surgery and until fully ambulatory following surgery. Those at higher-than-average risk may require medical anticoagulation.

Calculation of the Caprini score to assess individual risk of thromboembolism and selection of thromboprophylaxis is reviewed in detail separately. (See "Prevention of venous thromboembolic disease in adult nonorthopedic surgical patients" and "Overview of preoperative evaluation and preparation for gynecologic surgery", section on 'Thromboprophylaxis'.)

Anesthesia — Open abdominal myomectomy is typically performed under general anesthesia, but regional anesthesia may be used. (See "Overview of anesthesia", section on 'Types of anesthesia'.)

Indwelling or single administration transverse abdominis plane (TAP) blocks may also be used to provide prolonged postoperative analgesia. (See 'Closure' below and 'Postoperative care' below.)

PROCEDURE

Skin incision — A low transverse abdominal incision (eg, Pfannenstiel, Maylard) is used whenever possible. Compared with a large vertical incision (eg, to the umbilicus or above), transverse incisions decrease postoperative pain and improve scar cosmesis [9]. (See "Incisions for open abdominal surgery", section on 'Incisions for pelvic operations'.)

Large fibroids that displace the abdominal wall attenuate the rectus muscles and fascia, making them more pliable. Therefore, a transverse incision may permit access to the enlarged uterus and be a reasonable choice even in patients with very large uteri. In such patients, extending the lateral borders of the incisions cephalad (to avoid the ilio-inguinal nerves), can make the myomectomy feasible. Use of gonadotropin-releasing hormone (GnRH) agonists to decrease uterine size to permit a transverse rather than vertical incision may be a reasonable option in some patients. (See 'Role of GnRH agonists' above.)

After the incision is made, the linea alba is separated from its attachment to the rectus fascia up to the level of the umbilicus (figure 2). Once detached, the rectus muscles can be easily separated, allowing room for abdominopelvic exploration and exteriorization of the uterus.

Exteriorize the uterus — The uterus is exteriorized. If the uterus is difficult to exteriorize, a towel clamp is placed on an identified fibroid and upward traction applied to deliver the uterus without the added bulk of the surgeon's hand in the abdomen. If the abdominal fascia restricts the delivery of the uterus, a vertical incision can be made from underneath the fascia to allow more room (and is closed prior to closing the transverse fascia at the end of surgery). Alternatively, the uterus is left in situ until it is debulked enough to allow delivery.

Vesicouterine dissection is not performed unless the bladder is covering the fibroid or near the planned uterine incision. (See 'Uterine incision' below.)

Tourniquet — A tourniquet is placed around the lower uterine segment to limit blood loss, even if the uterus is left in situ. (See "Techniques to reduce blood loss during abdominal or laparoscopic myomectomy", section on 'Tourniquets'.)

Vascular clamps on the infundibulopelvic ligaments may also be used, but we do not routinely do this in our practice.

Uterine incision — The uterus is palpated to locate the leiomyomas, which are then injected with vasopressin (we use 20 units in 100 mL saline) just below the pseudocapsule. (See "Techniques to reduce blood loss during abdominal or laparoscopic myomectomy", section on 'Vasopressin and other vasoconstrictors'.)

The uterine incisions may be either:

●Vertical or transverse. Careful planning can avoid inadvertent extension of the incision into the cornua or ascending uterine vessels. However, as fibroids distort normal vascular architecture, it is often impossible to avoid the arcuate arteries of the uterus [10]. (See "Techniques to reduce blood loss during abdominal or laparoscopic myomectomy", section on 'Vascular anatomy of the uterus and leiomyomas'.)

●Anterior or posterior. Anterior uterine incisions are associated with fewer adnexal adhesions than posterior incisions [11]. However, if the fibroids are in the posterior uterine wall, it is usually preferable to make a posterior rather than anterior incision to avoid entry into the uterine cavity when extracting the fibroids.

●Single or multiple. A single uterine incision can sometimes be made at a location through which all, or most, of the myomas can be removed. Limiting the number of incisions may reduce the likelihood of adhesions to the uterine serosa, although there are no data to support this theory [12] (see 'Adhesive disease' below). However, burrowing through a single incision to extract distant myomas causes tunneling defects in the myometrium that can be difficult to close, interfering with hemostasis. Alternatively, creating an incision directly over each myoma (or group of nearby or apposing myomas) facilitates easy fibroid removal and hemostasis due to prompt closure of the myometrial defects to secure hemostasis [13].

The uterine incision is extended through the myometrium including the entire fibroid pseudocapsule (figure 3). We use a needle-tip monopolar electrosurgical instrument in order to limit lateral tissue devascularization, although no data exist to show that this is associated with improved wound healing. Fibroids are surrounded by a dense blood supply, without distinct vascular pedicle exists at the base of the fibroid [14]. Thus, it is important to extend the myomectomy incisions below the entire pseudocapsule to an avascular surgical plane. At this point, the myoma will clearly be visible and may bulge slightly.

Removal of myomas — There are many techniques to enucleate myomas. In our practice, we grasp the fibroid with a towel clamp and apply upward traction. The pseudocapsule is then bluntly dissected off the fibroid, until it is removed (figure 4). Areas of myometrium adherent to the fibroid are lysed with an electro-surgical needle tip (figure 5).

Closure — We close the myometrial defects with running unlocked layers of 0-Vicryl (polyglactin 910) suture on a circle taper (ie, CT1) needle (figure 6). Closure of a myometrial defect that is >2 cm deep often requires two layers to achieve adequate tissue apposition and hemostasis. The serosa is closed as a baseball stitch with 0- or 2-0 Monocryl (poliglecaprone 25) to decrease exposure of suture and adhesion formation (figure 7). (See 'Adhesive disease' below.)

Indwelling catheters for continuous transverse abdominis plane (TAP) block are placed at this time if planned for prolonged postoperative analgesia. This technique is described in detail separately (see "Transversus abdominis plane (TAP) blocks procedure guide", section on 'Continuous TAP block'). The peritoneum is closed with 2-0 Vicryl (polyglactin 910) when TAP block catheters are placed to keep bupivacaine in proximity to the severed nerves. The fascia is closed with 0-Vicryl (polyglactin 910) over one infusion catheter and the subcutaneous layer is closed with 3-0 plain suture over the second infusion catheter.

The skin is reapproximated in standard fashion. (See "Principles of abdominal wall closure", section on 'Skin'.)

SPECIAL CIRCUMSTANCES

Large uterus — Open abdominal myomectomy can be performed safely for patients with a large uterus (≥16 weeks size), but surgical expertise is required. In a retrospective study including 91 patients with uterine fibroids ≥16 weeks size who underwent open abdominal myomectomy, the average operative time was 236 minutes (range 120 to 390 minutes) and average blood loss was 794 mL (range 50 to 3000 mL) [13]. Intraoperative blood salvage was used in patients with blood loss >300 mL (70 patients, 77 percent) and only 7 patients (8 percent) received a blood transfusion. (See "Techniques to reduce blood loss during abdominal or laparoscopic myomectomy", section on 'Autologous blood transfusion'.)

Submucosal myomas — Hysteroscopic myomectomy is the procedure of choice for patients with primarily intracavitary leiomyomas (FIGO type 0, type 1, or some type 2 (figure 1)) (see "Uterine fibroids (leiomyomas): Treatment overview", section on 'Submucosal fibroids only'). However, for those with submucosal myomas and myomas in multiple other locations, both hysteroscopic and abdominal/laparoscopic myomectomy may be required. Removal of submucosal myomas during open abdominal myomectomy requires transmural myometrial dissection, and the uterine cavity is often entered during this process. In our practice, we repair the myometrium at the interface with the cavity, taking care to avoid entry of suture into the cavity, since this may cause a foreign body reaction and adhesions [15].

Cervical or broad ligament myomas — Uterine leiomyomas originate within the myometrium, but may extend close to, or displace, adjacent structures as they grow. Cervical or broad ligament myomas are a common finding and are often proximal to the ureter or major pelvic vessels.

The first step in removing a cervical or broad ligament fibroid is identification of a clear area of peritoneum overlying the fibroid where the peritoneum can be incised. With careful attention to staying in the proper surgical plane, the fibroid can be removed with traction and blunt dissection in a direction away from vital structures. Sharp dissection, especially where the tips of the instrument cannot be seen, should be avoided. If the surgeon stays inside the fibroid pseudocapsule, the ureters will always be lateral to the pseudocapsule. The only exception is intravenous leiomyomatosis, which may involve the blood supply of the uterus near the ureters. We dissect out the ureters when necessary, but this is rarely the case. (See "Uterine fibroids (leiomyomas): Variants and smooth muscle tumors of uncertain malignant potential", section on 'Intravenous leiomyomatosis'.)

Closure of the uterine defect should also be carefully planned after identification of the ureter and uterine vessels, to avoid injury, kinking, or ligation of these structures. If necessary, ligation of the uterine vessels may be performed to avoid bleeding.

Removal of a cervical fibroid through a vaginal colpotomy incision is rarely performed; vaginal myomectomy for a prolapsed submucosal fibroid is described in detail separately. (See "Uterine fibroids (leiomyomas): Prolapsed fibroids".)

Myomectomy during pregnancy — Myomectomy is performed rarely during pregnancy and is discussed in detail separately. (See "Uterine fibroids (leiomyomas): Issues in pregnancy".)

COMPLICATIONS

Hemorrhage — The average volume of blood loss for open abdominal myomectomy varies across studies from approximately 200 to 800 mL [13,16,17]. In studies of 100 or more open abdominal myomectomy procedures, blood transfusion rates varied widely from 2 to 28 percent [16-19]. Increasing size and number of myomas, as well as entering the uterine cavity, are associated with increased blood loss [20]. Severe hemorrhage, although uncommon, may be managed using intraoperative blood salvage, uterine artery ligation, or conversion to hysterectomy. Approximately 1 to 4 percent of open myomectomies are converted to hysterectomy [21,22].

Prevention and management of blood loss during myomectomy are discussed in detail separately. (See "Techniques to reduce blood loss during abdominal or laparoscopic myomectomy" and "Management of hemorrhage in gynecologic surgery".)

Fever and infection — Fever occurs within 48 hours after surgery in 12 to 67 percent of patients following myomectomy [19,22,23]. However, in one retrospective study including patients with postoperative unexplained fever, patients undergoing myomectomy (250 patients) compared with hysterectomy (341 patients) had similar rates of fever (39 percent within 24 hours), but fewer localized findings (eg, urinary tract infection or pneumonia: 14 versus 31 percent) [23]. Therefore, evaluation of fever after myomectomy in the absence of localizing symptoms may not be cost-effective. Proposed mechanisms for unexplained postmyomectomy fever include factors at the evacuated myoma sites: hematomas or release of inflammatory mediators [8].

Few studies report on specific sites of infection following open abdominal myomectomy. In the retrospective study above including 250 myomectomy patients, most infections occurred in the urinary (46 percent) or respiratory tracts (38 percent) [23]. Wound infection occurs less frequently, affecting 2 to 5 percent of patients after open abdominal myomectomy [19,22].

Evaluation and management of postoperative fever are discussed separately. (See "Fever in the surgical patient".)

Adhesive disease — Adhesion formation after myomectomy has been well documented; however, as these studies require second-look procedures, data are limited. In one prospective study including 45 patients undergoing second look laparoscopy following open abdominal or laparoscopic myomectomy, adhesions were found in 36 percent of patients [24]. Factors associated with adhesive disease were posterior location of a removed myoma and the presence of sutures. Adnexal adhesions, which may impact tubal fertility, were also associated with concurrent surgery (eg, ovarian cystectomy) and prior adhesive disease.

A detailed discussion of methods of adhesion prevention can be found separately. (See "Postoperative peritoneal adhesions in adults and their prevention".)

Other — Visceral injury is uncommon during open abdominal myomectomy. As an example, in one series including 197 patients undergoing abdominal myomectomy, there was one cystotomy and two small bowel obstructions [16].

The evaluation and management of these and other complications, such as ileus, wound infection, or incisional hernia, are discussed separately. (See "Postoperative ileus" and "Complications of abdominal surgical incisions" and "Management of ventral hernias".)

POSTOPERATIVE CARE — Routine postoperative care includes monitoring of a patient's hemodynamic and fluid status, pain control, and reintroducing normal diet and activity. Components of inpatient postoperative care specific to open abdominal myomectomy include:

●Use of a continuous transverse abdominis plane (TAP) block with catheters to provide prolonged postoperative analgesia (see 'Closure' above). The pump lasts approximately four days, at which time the catheters are removed. This is supplemented with parenteral administration of analgesics in the postanesthesia care unit which are then transitioned to the oral route as soon as a patient can tolerate oral intake, usually by the first postoperative day.

While TAP blocks are effective in managing postoperative pain in other patient subgroups, studies evaluating their use at time of open abdominal myomectomy are limited [25]. (See "Approach to the management of acute pain in adults".)

●Removal of the bladder catheter during the first 24 hours postoperatively. (See "Placement and management of urinary bladder catheters in adults".)

●Early feeding of a regular diet. (See "Overview of perioperative nutrition support".)

●Ambulation and other measures to prevent pulmonary complications. (See "Strategies to reduce postoperative pulmonary complications in adults".)

Enhanced recovery after surgery (ERAS) programs aimed at maximizing recovery and improving postoperative outcomes are discussed in detail separately. (See "Enhanced recovery after gynecologic surgery: Components and implementation", section on 'Postoperative'.)

FOLLOW-UP — In general, patients require four to six weeks for recuperation after abdominal myomectomy. Patients are encouraged to resume their normal daily activities (including lifting and climbing stairs) as quickly as is comfortable and may return to work as soon as they have regained sufficient stamina and mobility [26,27]. Decisions regarding resumption of vaginal intercourse are made by the patient; there are no medical restrictions on sexual activity.

We see patients for a follow-up visit at two weeks postoperatively. The follow-up visit includes an evaluation for potential complications and an examination of the abdomen and incision. We review the details of the surgery and pathology results with the patient.

Routine postoperative instructions for patients can be found separately. (See "Patient education: Care after gynecologic surgery (Beyond the Basics)".)

COUNSELING ABOUT FUTURE PREGNANCY

●Interval to conception – Patients who undergo myomectomy with significant uterine disruption should wait several months before attempting to conceive; recommendations for this interval range from three to six months [28].

●Infertility – If a patient is having difficulty conceiving following a myomectomy, early assessment of the uterine cavity and fallopian tubes with a hysterosalpingogram is advisable [29].

Issues of fertility and leiomyomas are discussed separately. (See "Female infertility: Causes", section on 'Uterus'.)

●Uterine rupture – Myomectomy appears to be associated with an increased risk of uterine rupture during subsequent pregnancy, but it is difficult to ascertain the degree of risk and whether entering the uterine cavity adds to this risk. Thus, timing and route of delivery must be individualized based on the degree and location of the prior myomectomy. In general, cesarean birth is recommended for patients in which the myomectomy was extensive or complicated; a trial of labor may be an option for patients in whom the myomectomy was unlikely to have significantly compromised the myometrium. This is discussed in detail separately. (See "Uterine fibroids (leiomyomas): Issues in pregnancy".)

OUTCOMES

Relief of symptoms — Myomectomy has been reported to relieve symptoms in 80 percent of patients [30,31]. Unfortunately, however, many large series of open myomectomies have not reported data for relief of symptoms, patient satisfaction, or quality of life following surgery [19,32-34].

In one prospective cohort study including 52 patients undergoing open abdominal myomectomy, symptom severity and health-related quality of life scores (as measured by validated questionnaires) improved during the 27-month follow-up period [35].

Persistent or new myomas — Many patients who undergo myomectomy will have leiomyomas on subsequent evaluation, with studies showing rates as high as 62 percent at 5 to 10 years postmyomectomy [36-38]. Considering the background prevalence of leiomyomas (77 percent in one study [39]), it is not surprising that new myomas continue to develop after excision. However, routine surveillance for postmyomectomy myomas is not necessary since imaging detects many clinically insignificant myomas.

These myomas, often referred to as recurrent, are more accurately referred to as persistent (when they are not removed or incompletely removed at the time of surgery) or newly developed. Most of these patients will not require additional treatment for fibroid-related symptoms.

Postmyomectomy myomas are more likely to occur in patients who have multiple versus single myomas at time of surgery (74 versus 11 percent in one study [40]), those who do not versus do have a pregnancy after myomectomy (30 versus 15 percent in one study [37]), and those pretreated with gonadotropin-releasing hormone (GnRH) agonists prior to the myomectomy procedure. (See 'Role of GnRH agonists' above and "Techniques to reduce blood loss during abdominal or laparoscopic myomectomy", section on 'GnRH agonists'.)

Subsequent treatment — After a first myomectomy, approximately 10 to 25 percent of patients will undergo a second major surgery [38,40-43]. In one nested case-control study including 568 patients with a history of myomectomy (open abdominal, laparoscopic, or hysteroscopic), 21 percent required subsequent surgery within 1 to 10 years [44]. The combination of surgical approaches, however, limits the ability to apply these data to open abdominal myomectomy. Other studies have reported higher rates [45].

Risk factors for subsequent surgery are not well established. In one study, uterine size <12 weeks was associated with an increased risk of a second surgery, while other data suggest that a larger uterus or multiple myomas are associated with a lower risk of re-operation [40,45].

There are no data regarding how many patients require medical treatment for fibroids following myomectomy.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Gynecologic surgery".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Beyond the Basics topics (see "Patient education: Uterine fibroids (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Definition – Open abdominal myomectomy (performed via laparotomy) is the surgical removal of leiomyomas from the uterus, leaving the uterus in place. (See 'Introduction' above.)

●Candidates – Open abdominal myomectomy is most commonly performed for patients with symptomatic intramural, transmural, or subserosal leiomyomas (figure 1) in whom future childbearing is desired and a hysteroscopic or laparoscopic myomectomy is not feasible. For patients who do not desire future fertility but prefer to preserve their uterus, the choice of treatment (eg, myomectomy, uterine artery embolization, medical therapy) must be individualized. (See 'Indications and alternatives' above.)

●Preoperative issues

•Preparing for potential blood loss – Preoperative measures (eg, correction of anemia, autologous blood donation, preoperative use of gonadotropin-releasing hormone [GnRH] agonists) may reduce the likelihood of receiving a blood transfusion. (See 'Preparing for potential blood loss' above and 'Tourniquet' above and "Techniques to reduce blood loss during abdominal or laparoscopic myomectomy".)

•GnRH agonists – For patients undergoing open abdominal myomectomy, we do not typically pretreat with GnRH agonists. Use of these agents is generally limited to patients in whom treatment would allow a transverse rather than a vertical incision and those who place a high value on type of surgical incision. (See 'Role of GnRH agonists' above and "Techniques to reduce blood loss during abdominal or laparoscopic myomectomy", section on 'GnRH agonists'.)

•Prophylactic antibiotics – For patients undergoing abdominal myomectomy, we suggest antibiotics for surgical site infection prevention rather than no antibiotics (Grade 2C). Intraabdominal infection may adversely affect fertility. (See 'Prophylactic antibiotics' above.)

•Thromboprophylaxis – We use sequential compression devices during surgery and until fully ambulatory following surgery for all inpatients. Those at higher risk may require medical anticoagulation. (See 'Thromboprophylaxis' above and "Prevention of venous thromboembolic disease in adult nonorthopedic surgical patients" and "Overview of preoperative evaluation and preparation for gynecologic surgery", section on 'Thromboprophylaxis'.)

●Procedure

•A low transverse abdominal incision is used whenever possible, even for patients with very large fibroids, the uterus is exteriorized, and a tourniquet is placed. (See 'Skin incision' above and 'Exteriorize the uterus' above and 'Tourniquet' above.)

•The uterine incision is extended down through the myometrium and entire fibroid pseudocapsule. The myoma is then removed with blunt dissection. (See 'Uterine incision' above and 'Removal of myomas' above.)

•Myometrial defects are closed with running layers of 0-vicryl suture. The serosa is closed with a baseball stitch to help prevent adhesion formation. (See 'Closure' above.)

•Indwelling catheters may be placed as part of a continuous transverse abdominis plane (TAP) block to provide prolonged postoperative analgesia. (See 'Closure' above and 'Postoperative care' above.)

●Complications

•Hemorrhage – Increasing size and number of myomas, as well as entering the uterine cavity, are associated with increased blood loss. Severe hemorrhage, although uncommon, may be managed using intraoperative blood salvage, uterine artery ligation, or conversion to hysterectomy. (See 'Hemorrhage' above.)

•Fever and infection – While fever frequently occurs within 48 hours following myomectomy, many patients have no localized findings and do not have an infection. (See 'Fever and infection' above.)

•Adhesions – Adhesion formation occurs in approximately 36 percent of patients after myomectomy and are more common with posterior compared with anterior uterine incisions. (See 'Adhesive disease' above and 'Uterine incision' above.)

●Counseling – Patients should be counseled to wait three to six months before attempting to conceive and that a cesarean birth is advised for patients in which the myomectomy was extensive or complicated. (See 'Counseling about future pregnancy' above and "Uterine fibroids (leiomyomas): Issues in pregnancy", section on 'Patients with prior myomectomy'.)

●Outcomes – Myomectomy relieves symptoms in 80 percent of patients. Subsequent surgery is required in approximately 10 to 24 percent of patients. (See 'Outcomes' above.)