Abdominal Myomektomi
Özet
Abdominal myomektomi, kadınlarda en sık görülen pelvik tümör olan benign karakterli miyomların (leiomyomlar) tedavisinde kullanılan köklü bir cerrahi yöntemdir. En sık 35-45 yaş aralığında görülen miyomlar, derin anemiye yol açan anormal uterin kanama, ağrı ve infertilite gibi semptomlara neden olduğunda kesin tedavi olarak cerrahiye başvurulur. Operasyon öncesinde ultrason veya MR ile detaylı değerlendirme yapılır ve aneminin düzeltilmesi gibi önlemler alınır. Cerrahi süreçte, miyomun boyutuna göre Pfannenstiel veya Maylard transvers insizyonları tercih edilerek postoperatif ağrı ve kozmetik kaygılar azaltılır. Kan kaybını kontrol altına almak için turnike veya vazopressin enjeksiyonu uygulanır; insizyonların avasküler düzlem olan psödokapsül altına kadar uzatılması kritiktir. Miyomların eksizyonunun ardından miyometrium, hemostazın tam sağlanması amacıyla yuvarlak uçlu iğne ve uygun süturlar kullanılarak katlar halinde dikkatle kapatılır. Operasyon sonrasında kanama, febril morbidite, enfeksiyon ve adhezyon gibi komplikasyonlar gelişebilir; özellikle koter kullanımı ve tek kat kapatma sonraki gebeliklerde uterin rüptür riskini artırır. Gebelikte miyom dejenerasyonu geliştiğinde ilk tercih medikal takip olup, yanıt alınamayan durumlarda cerrahi uygulanır. İyileşme süreci yaklaşık 1-1.5 ay süren bu operasyon sonrasında gebelik planlayan hastalara miyometriumun sağlıklı onarımı için 3-6 ay beklemeleri önerilir ve karmaşık vakalarda sonraki doğumlar için sezaryen tavsiye edilir.
Abdominal myomectomy is an established surgical method used in the treatment of benign myomas (leiomyomas), which are the most common pelvic tumors in women. When myomas, most frequently observed in the 35-45 age range, cause symptoms such as abnormal uterine bleeding leading to profound anemia, pain, and infertility, surgery is utilized as the definitive treatment. Prior to the operation, a detailed evaluation is performed using ultrasound or MR, and preoperative measures like correcting anemia are implemented. During the surgical procedure, transvers incisions such as Pfannenstiel or Maylard are preferred based on the size of the myoma to minimize postoperative pain and cosmetic concerns. To control blood loss, a tourniquet or vasopressin injection is utilized, and extending the incisions beneath the pseudocapsule, which is an avascular plane, is critical. Following the excision of myomas, the myometrium is carefully closed in layers using round-bodied needles and appropriate sutures to ensure complete hemostasis. Postoperative complications including hemorrhage, febrile morbidity, infection, and adhesions may develop; particularly, the use of cautery and single-layer closure increases the risk of uterine rupture in subsequent pregnancies. When myoma degeneration occurs during pregnancy, medical follow-up is the primary choice, and surgery is performed only in cases unresponsive to treatment. Patients planning a pregnancy after this operation, which requires a recovery period of approximately 1-1.5 months, are advised to wait for 3-6 months to ensure proper healing of the myometrium, and cesarean delivery is recommended for future births in complex cases.
Referanslar
Rodriguez-Triana VM, Kwan L, Kelly M, Olson TH, Parker WH. Quality of Life after Laparoscopic and Open Abdominal Myomectomy. J Minim Invasive Gynecol. 2021 Apr;28(4):817-823. doi: 10.1016/j.jmig.2020.07.023. Epub 2020 Jul 26. PMID: 32721469.
Bhave Chittawar P, Franik S, Pouwer AW, Farquhar C. Minimally invasive surgical techniques versus open myomectomy for uterine fibroids. Cochrane Database Syst Rev. 2014 Oct 21;(10):CD004638. doi: 10.1002/14651858.CD004638.pub3. PMID: 25331441.
Takeda S, Ota T, Kaneda H, Terao Y, Kuwatsuru R. Abdominal Myomectomy for Huge Uterine Myomas with Intra-arterial Balloon Occlusion: Approach to Reduce Blood Loss. Surg J (N Y). 2019 Aug 5;6(Suppl 1):S11-S21. doi: 10.1055/s-0039-1693041. PMID: 32399486; PMCID: PMC7214084.
Kongnyuy EJ, Wiysonge CS. Interventions to reduce haemorrhage during myomectomy for fibroids. Cochrane Database Syst Rev. 2014 Aug 15;2014(8):CD005355. doi: 10.1002/14651858.CD005355.pub5. PMID: 25125317; PMCID: PMC9017065.
Vilos GA, Allaire C, Laberge PY, Leyland N; SPECIAL CONTRIBUTORS. The management of uterine leiomyomas. J Obstet Gynaecol Can. 2015 Feb;37(2):157-178. doi: 10.1016/S1701-2163(15)30338-8. PMID: 25767949.
Laberge PY, Murji A, Vilos GA, Allaire C, Leyland N, Singh SS. Guideline No. 389-Medical Management of Symptomatic Uterine Leiomyomas - An Addendum. J Obstet Gynaecol Can. 2019 Oct;41(10):1521-1524. doi: 10.1016/j.jogc.2019.01.010. PMID: 31548041.
Lethaby A, Puscasiu L, Vollenhoven B. Preoperative medical therapy before surgery for uterine fibroids. Cochrane Database Syst Rev. 2017 Nov 15;11(11):CD000547. doi: 10.1002/14651858.CD000547.pub2. PMID: 29139105; PMCID: PMC6486044.
Murji A, Whitaker L, Chow TL, Sobel ML. Selective progesterone receptor modulators (SPRMs) for uterine fibroids. Cochrane Database Syst Rev. 2017 Apr 26;4(4):CD010770. doi: 10.1002/14651858.CD010770.pub2. PMID: 28444736; PMCID: PMC6478099.
Abu Hashim H, Al Khiary M, El Rakhawy M. Laparotomic myomectomy for a huge cervical myoma in a young nulligravida woman: A case report and review of the literature. Int J Reprod Biomed. 2020 Feb 27;18(2):135-144. doi: 10.18502/ijrm.v18i2.6421. PMID: 32259008; PMCID: PMC7097170.
Brennan A, Hickey M. Abnormal uterine bleeding: managing endometrial dysfunction and leiomyomas. Med J Aust. 2018 Feb 5;208(2):90-95. doi: 10.5694/mja17.00726. PMID: 29385977.
Tian Y, Chen J. The effects of laparoscopic myomectomy and open surgery on uterine myoma patients' postoperative immuno-inflammatory responses, endocrine statuses, and prognoses: a comparative study. Am J Transl Res. 2021 Aug 15;13(8):9671-9678. PMID: 34540094; PMCID: PMC8430179.
Rakotomahenina H, Rajaonarison J, Wong L, Brun JL. Myomectomy: technique and current indications. Minerva Ginecol. 2017 Aug;69(4):357-369. doi: 10.23736/S0026-4784.17.04073-4. Epub 2017 Apr 26. PMID: 28447445.
Brun JL, Legendre G, Bendifallah S, Fernandez H. Myomectomie [Myomectomy]. Presse Med. 2013 Jul-Aug;42(7-8):1117-21. French. doi: 10.1016/j.lpm.2013.02.317. Epub 2013 Apr 9. PMID: 23582900.14.. Wong L, Brun JL. Myomectomy: technique and current indications. Minerva Ginecol. 2014 Feb;66(1):35-47. PMID: 24569403.
Nause SL, Schröer A, Diedrich K, Weichert J. Atypischer myometraner Flüssigkeitsverhalt in graviditate--intramurale Schwangerschaft oder degeneriertes Myom? [Atypical myometric fluid accumulation in graviditate--intramural pregnancy or degenerated fibroid?]. Z Geburtshilfe Neonatol. 2012 Oct;216(5):226-9. German. doi: 10.1055/s-0032-1323792. Epub 2012 Oct 29. PMID: 23108967.
Thubert T, Demoulin G, Lamazou F, Rivain AL, Trichot C, Faivre E, Deffieux X. Une prise en charge qui répond à un algorithme précis. Ménométrorragies [Menometrorrhagia]. Rev Prat. 2014 Apr;64(4):531-9. French. PMID: 24855791.
Ertunc D, Uzun R, Tok EC, Doruk A, Dilek S. The effect of myoma uteri and myomectomy on sexual function. J Sex Med. 2009 Apr;6(4):1032-1038. doi: 10.1111/j.1743-6109.2008.01086.x. Epub 2008 Nov 19. PMID: 19040618.
Ferrero S, Abbamonte LH, Giordano M, Parisi M, Ragni N, Remorgida V. Uterine myomas, dyspareunia, and sexual function. Fertil Steril. 2006 Nov;86(5):1504-10. doi: 10.1016/j.fertnstert.2006.04.025. PMID: 17070199.
