Do uterine polyps cause pain


  • By nason
  • On 10/09/2020

Complications of uterine fibroids and their treatment, natural treatment, surgical treatment of fibroids, laparoscopy and hemorrhage, adhesions and complications


A critical review of the surgical treatment of fibroids compares all available techniques of myomectomy. Different statistical analyzes reveal the advantages of the laparoscopic and hysteroscopic approaches. Complications can arise from the location of fibroids. They range from intermittent bleeding to continuous bleeding over several weeks, from simple pain episodes to severe pain, from dysuria and constipation to chronic bladder and bowel spasms. Peritonitis occurs very rarely. Infertility can result from a continuous metro and menorrhagia. The difficulty with laparoscopic and hysteroscopic myomectomy lies in obtaining satisfactory hemostasis using the appropriate sutures.

1. Introduction

Fibroids are diagnosed in 25-30% of women. Although the pathogenesis is not fully understood, we do know that myomas are hormone-dependent and are derived from individual myoma cells and not from a metastatic process. Myomas are the most common benign solid tumors of the female reproductive system. Although they are often asymptomatic, they can cause menorrhagia, metrorrhagia, infertility, pain, bleeding under pressure, and repeated abortions. While open abdominal myomectomy results in limited morbidity, similar to that of hysterectomy, laparoscopic myomectomy offers remarkable medical, social and economic benefits to the patient, with less postoperative pain and shorter recovery time. Semm and Mettler published their first article on laparoscopic myomectomy in 1980 [1]. Today, all myomas can be enucleated by this technique. Conventional laparoscopic surgery is supplemented with robotic support and abdominal entry often changed to NOS (natural orifice surgery) and NOTES (natural orifice transluminal endoscopic surgery), also referred to as single port entry.

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2. Materials and methods


Conventional and laparoscopic myomectomy

Depending on the extent of the fibroid, the optic trocar is placed in the umbilicus or 10 cm higher in the midline or at Palmer's point. Under vision, 2 or 3 additional ports are placed in the lower abdomen. The technique for resection of fibroids varies depending on the position and size of the myoma.

(1) Pedunculated myomas

The myoma pedicle is coagulated with bipolar forceps and cut with laparoscopic scissors or resected after the placement of loops or staplers. Sutures are not always necessary.

(2) Suberous and intramural myomas

After injection of the wall of the fibroid (extracapsular) with a vasopressin derivative solution, an incision is made vertically or horizontally away from the appendix. The incision is extended until it reaches the pseudocapsule; myoma dissection is then performed strictly in the plane of the capsule using two pairs of grasping forceps. Continuous hemostasis is performed with the bipolar forceps (ultracision). Following the enucleation of the myoma, the uterus is sutured along a seromuscular plane (edge ​​to edge) using one or two layers of separate Poly Dioxanol Suture (PDS) stitches with extra or intracorporeal knots. The suture pedicles should be in the wound. Continuous suction and irrigation are performed to minimize adhesion formation.

The myomas are then extracted suprapubic by morcellation with an electric morcellator, followed by laparoscopic control and careful cleaning of the peritoneal and hemostasis.

(3) cervical myomas

These myomas can be easily reached and enucleated by the transvaginal route; However, combined laparoscopic vaginal excision is sometimes necessary.

(4) focal adenomyosis

In the case of dysmenorrhea resulting from clearly discernible adenomyotic lesions, careful enucleation or resection of these areas is advised. Hysteroscopic ultrasound assistance can guide the resection.

(5) Submucosal myomas

Submucosal myomas located in the uterine cavity are classified into 3 categories according to their myometrial infiltration. Hysteroscopic resection of these fibroids is easy and is performed with the resectoscope loop in a sharp manner with the bipolar or monopolar current.

(6) Hysteroscopy

Although the first exploration of the uterine cavity dates back to Bozzini, hysteroscopy (resectoscope) with CO2, fluid and the modern office was developed by Hans Lindemann in Hamburg in 1972 and improved and modified by Bettocchi et al., Loffer et al., Loffer et al. al., Cooper et al., Gallinat and Campo et al. [2–8]. Recently, vaginoscopy has again been applied to guide the diagnostic hysteroscope from the vagina to the cervix without any traction of the cervical tenaculum. With saline as a means of distension and under exact control of pressure and flow, visualization of the uterine cavity and its pathology is visible, including synechiae, septum, endometrium, cervical canal, uterine cavity with uterine Ostia, polyps and fibroids. The most modern system offers continuous aspiration of the resected material.

2.2. Enucleation of myoma at one port

Enucleation of Myoma can easily be performed via all kinds of single port inputs (SILS: single-incision laparoscopic surgery, LESS: single site laparoendoscopic surgery), natural orifice surgery (NOS) and surgery transluminal endoscopic with a natural orifice (NOTES). The problem, however, lies in the fragmentation of the material and the extraction. The answer could be found in powder homogenization.

2.3. Robotic myomectomy

Once the learning curve is over, the da Vinci robot offers a more precise technique for each surgical procedure, including myomectomies. Robotic suturing is easier and faster. In my opinion, one day all surgeries will be carried out robotic.

After 30 years of experience in performing and teaching laparoscopic myomectomies, Professor Mettler has had the opportunity to perform a number of robot-assisted myomectomies with the da Vinci robot. The procedure is easy, can be done with less blood loss than with laparoscopy, and the suture can be done more precisely. However, three-dimensional vision and articulated instruments can also serve the same purpose. Robotic surgery is fascinating, but it would take a financial revolution for it to be accepted around the world, not only for cancer surgery but also for procedures such as myomectomy.

2.4. Myomectomie laparotomique

A laparotomic myomectomy may be done if the myoma is more than 8 inches in diameter, if it is located at a very critical point, or if it is suspected of being a sarcoma. More than 10 fibroids may require laparotomy. The decision is made by the surgeon.

2.5. Hysterectomy

(1) Classic intrafascial supracervical hysterectomy (CISH)

In cases of adenomyosis or diffuse myomatosis of the uterus without cervical pathology, CISH or LASH should be the method of choice for hysterectomy [10]. At CISH, the transformation zone of the cervix is ​​hollowed out in addition to the subtotal uterine resection.

(2) Laparoscopic subtotal hysterectomy (LASH)

LASH has been shown to be a safe, rapid, and very atraumatic hysterectomy technique. The advantage of the LASH procedure is that it can be performed in nulliparous patients, patients who have not yet given birth vaginally, and patients who have previously had abdominal surgery. In these cases, the uterus is fragmented, but no colpotomy is performed.

(3) Laparoscopic Total Hysterectomy (TLH)

Indications for TLH include benign gynecologic changes such as fibroids, endometriosis, and abnormal uterine bleeding in patients for whom vaginal surgery is contraindicated or cannot be performed. TLH can be performed for possible malignant indications, such as early endometrial cancer, small early cancers localized early (trachelectomy), as well as in the early stages of ovarian cancer with lymphadenectomy. The laparoscopic part includes the preparation of the uterus, the cervix and the complete dissection of the vaginal stump.

(4) vaginal hysterectomy

When Langenbeck first performed a vaginal hysterectomy in 1813, the discipline of gynecology was founded. Since then, vaginal access has been the privilege of the gynecological surgeon. According to the French surgical expert Doyen, in 1939, no one could call himself a gynecologist if he had not performed vaginal hysterectomy [11].

Vaginal hysterectomy remains a central element of the gynecological discussion. The gynecologist only considers other access routes for exploring the small pelvis if vaginal access does not allow a clear diagnosis and the possibility of treatment to be established. Today, however, it appears that only highly skilled vaginal surgeons still operate on vaginal fibroids using vaginal fragmentation with a knife.

(5) Abdominal hysterectomy

Abdominal hysterectomy is now a safe technique. There is no longer any fear of infection, thrombosis or other morbidities. In the last 40 years of the 20th century, the number of hysterectomies has exploded. Even in Germany, laparotomy and hysterectomy was still the method of choice for bleeding, myoma and other conditions. Large diffuse fibroids and multiple fibroids sometimes require an abdominal hysterectomy.


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