Hello, how are you? Good morning. We have been asked a lot about laparoscopic surgery… Why don’t we upload videos? And second, how risky is fibroid surgery? So, we will answer you right now and take advantage of it we will upload the video of the last myomectomy we had for a degenerated cyst with large elements and also why to perform laparoscopic surgery or not and the risk of surgery depending on each patient, remember that knowledge is success.

Ok, let’s start with the first question about laparoscopy… We actually do very few laparoscopies at Creafam for two small reasons: first: The patients who come to us for fibroids are patients who already have very large fibroids, over 8 or 10 cm, and they are generally multiple fibroids.

Here it is important to highlight that doing a laparoscopy would take a little longer to perform the surgical procedure, but it also increases the cost of the surgery, and second: Laparoscopy is indicated for medium to small fibroids, preferably less than 6 cm, and it can also be used for ovarian tumors, depending on the type of cyst or ovarian tumor. The main problem we have with laparoscopy is that patients do not have many more financial resources or do not have health insurance, and so the difference between doing an open surgery and a laparoscopy represents over $25,000 pesos more for the same technique and obviously for using the laparoscope technology.

Now, it is also true that there are patients who do have the financial means or health insurance to undergo surgery with a laparoscopy, however, being able to perform surgery with a fibroid larger than 12 cm or 15 cm, which are the ones we normally perform, would represent a greater surgical risk because when performing the laparoscope technique we can perforate some organ, that is, some intestine, or damage the fibroid and cause internal bleeding and have to go in urgently. Second, and most importantly: The surgical time is not the same for a 20 cm fibroid; it can take me 2 hours, 2 and a half hours for an open surgery, but for a laparoscopy it could take up to twice as long, that is, 5 to 6 hours, and it doesn’t make any sense because remember that in a laparoscopy we would have to do general anesthesia with intubation.

So, there are always precise indications for both the patient, the tumor, and obviously, whether or not we have the financial means to perform a laparoscopy. But don’t worry, we will try to upload some laparoscopic surgeries, but always remember that the indication for a laparoscopy must be based on a study, an analysis, a review, and above all, gathering all the parameters to know if it is feasible to do a laparoscopy and if it is also economically possible to do that laparoscopy.

Here we are going to show you the surgery we performed. Apparently, this patient had been having problems with these fibroids for only 6 months, with a lot of pain during menstruation and a lot of distension. However, if we look at the surgery, the cyst or the fibroid is a degenerated cystic one, but it has a lot of vascularity. Let’s imagine that I put in a tube, a little thicker than a straw, through laparoscopy, and in theory I have to extract the tumor… It is feasible, but it would greatly increase the surgical time, increase the risk of bleeding, and with the so-called morcellation, there could also be bleeding and end up in open surgery. In fact, due to the distension of the fibroid, we had to make a slightly wider incision to be able to extract the tumor.

Look at a 32-year-old patient with a tumor in the left ovary, it looks like endometriosis but she has elevated CA-215 and 19-9, there are already inflammatory lesions of endometriosis in the prevesical, so it is surely an endometriotic cyst and she has a huge myoma, so there are adhesions in the colon on the left side. We are going to infiltrate the myoma, it is a very large myoma, almost completely subserous intramural. We removed 2 subserous from the posterior face but she has several bilobed ones, these myomas are very bloody, fortunately she has 15 hemoglobin but even so we are going carefully and the most important thing is: She already has crossed bundles.

Look, she has a completely subserous myoma in the right ovary, here it is on top, it is all attached, there are the adhesions and this is the left ovary with the endometriotic cyst completely attached to the bottom of the sacrum, uterosacral… Let’s see if we can resect something, not this is the right one, another myoma and here is the left ovary fixed on the posterior face. We are already removing the myomas but they are bilobed myomas, which have many compartments but look at the very important blood vessels, so with this we have to be very careful because sometimes the clamp does not grab it, see how it makes a kind of fibers there within myomas but they are degenerated cystic myomas.

Look how we are already externalizing it but see it looks like a brain because they are bilobed, bands are formed like amniotic ones we could say but they are fibroid bands and then a very irregular structure is formed, half vascular and bleeding but we are almost finished. Look at the myoma, how ugly it is, it is a bilobed cerebraloid, also a degenerated cystic, cousin of the other one, but this one was in another way. There is another myoma here, so we are almost finished with the surgery, then we will show you how the uterus is.

This is the bilobed myoma, but we had already removed 1, 2, 3, 4… 5 medium-sized and large elements here, so look at how the cavity is, in fact here you can see the cavity, see how it is globose, it is like a little bag, we are going to start to deal with hemostasis, then we remove these and the somewhat complicated surgery is over. Ready, we are already washing, see these are the flame lesions that are called or gunpowder lesions of endometriosis, but the incision was in front of the uterus, the entire anterior fundic surface was gone, here are the other incisions behind but we were able to perfectly preserve the uterus, we could not move the left ovary because it was fixed and the right ovary is perfect. It is very important that laparoscopy only has specific indications, and open surgery sometimes has a better prognosis both for the evolution and also for preserving the uterus and avoiding bleeding.

The second question is: How risky is fibroid surgery? We often get a lot of questions on social media about: “I have a subserous fibroid. How risky is it?”, “I have a hemoglobin of 10. How risky is it?”, “I have bleeding and I have fibroids. How risky is it?”. Remember that this is very vague information. What we are analyzing is: What increases the surgical risk of fibroids?

• First: The time of evolution is important, but the number of fibroids and the size of the fibroids are much more important.
• Second: If we have low hemoglobin levels, that is, anemia, from mild to moderate or severe anemia, the risk is also different in mild anemia to severe anemia or in a patient who does not have anemia.
• Third: If we are obese or not overweight.
• Fourth, which is also very important: If there is heavy bleeding or not.
• It can also increase the risk if the patient is diabetic or hypertensive.

So, it’s not just about saying “I have a 20 cm fibroid, so the surgical risk is higher.” No! You can have a 20 cm fibroid and be 32 years old and have normal hemoglobin and not have a chronic disease such as diabetes or hypertension, then your surgical risk is very low, but if you are 45 years old, obese and hypertensive, and have a hemoglobin of 8 or 9, then the surgical risk is going to be higher. And last but not least… The doctor’s expertise also matters, that is, at Creafam we perform around 120 to 150 myomectomies per year. If you go to a doctor who only does one or two or ten surgeries a year, then obviously the volume gives you more experience. I mean, it’s true that going to someone who operates on one or two fibroids a year is not the same as going to someone who does more than a hundred myomectomies a year… Because that gives you the ability to make decisions or to be able to diagnose in advance how risky a surgery is or not, and even with all that experience and all those surgeries, we do ultrasounds on all of our patients, we evaluate all of our patients, we generally do MRIs, and every woman over 40 years of age has a pre-anesthetic evaluation before surgery.

Also, normally in a fibroid surgery we enter: the instrumentalist, first assistant, second assistant, and the surgeon, and the anesthesiologist. On many occasions, as in this video, we have two people helping me to do the myomectomy but sometimes there are up to three doctors in the surgery. It is very important not to have surgery with the first doctor if he tells you that he is going to operate on you in any hospital, it cannot be like that, remember the important thing is not the cost of the surgery but where you are going to have the surgery and who is going to operate on you.