Myomectomy (Fibroid Removal Surgery) in India and UAE | Complete Patient Guide

• Women with symptomatic uterine fibroids causing heavy menstrual bleeding (defined as >80 mL/cycle or PBAC score >100), pelvic pain, bulk symptoms, or urinary/bowel dysfunction

• Patients with submucosal fibroids (FIGO Types 0–2) distorting the uterine cavity who have experienced implantation failure, recurrent miscarriage, or are planning IVF/ICSI

• Women who desire uterine preservation (ruling out hysterectomy) and are not yet in menopause

• Patients with incidentally found fibroids growing rapidly (>1 cm/year on serial ultrasound), particularly to exclude rare uterine sarcoma

• Intramural or subserosal fibroids ≥3 cm causing documented symptoms, or ≥5 cm even with mild symptoms if fertility is desired

Required Pre-Operative Diagnostics:

• Transvaginal and transabdominal pelvic ultrasound (TVS/TAS): fibroid mapping — number, size, FIGO type, relationship to endometrial cavity and serosa

• MRI pelvis with contrast (gadolinium): mandatory for fibroids >6 cm, suspected adenomyosis, pre-operative robotic/laparoscopic planning, and to exclude degenerated or atypical fibroids suggestive of sarcoma

• Saline infusion sonohysterography (SIS) or diagnostic hysteroscopy: to evaluate cavity distortion in submucosal fibroids

• Complete blood count (CBC), serum ferritin, iron studies: quantify anemia burden

• Coagulation profile (PT, aPTT, platelet count): bleeding risk assessment

• Renal and liver function tests, blood group and cross-match

• Endometrial biopsy (Pipelle): in women >40 or with irregular bleeding, to exclude endometrial hyperplasia/malignancy before surgery

• CA-125 serum level: as a baseline marker; elevated levels may prompt additional workup for leiomyosarcoma or concurrent endometriosis

• ECG and anesthesia fitness assessment for all patients; echocardiography (ECHO) for those with severe anemia-related cardiac symptoms or known cardiac disease

Contraindications / Factors Favoring Alternative Management:

• Postmenopausal status with new or enlarging fibroids (raises sarcoma concern; hysterectomy preferred)

• Confirmed or strongly suspected uterine leiomyosarcoma on imaging or biopsy

• Pregnancy (myomectomy performed only in exceptional circumstances in the second trimester)

• Uncorrectable coagulopathy or inability to tolerate general anesthesia

• Women who have completed childbearing and are better served by hysterectomy or uterine artery embolization (UAE interventional radiology) as definitive therapy

• Fibroids fully amenable to medical management (e.g., perimenopausal women with small fibroids responding to levonorgestrel-releasing IUS or GnRH agonist therapy)

1. HYSTEROSCOPIC MYOMECTOMY (FIGO Types 0, 1, and selected Type 2 submucosal fibroids)

Performed under general or regional anesthesia as a day-case or overnight procedure. A resectoscope (26–28 Fr) with a monopolar or bipolar electrosurgical loop is introduced transcervically; no abdominal incisions are made. The STEP-W (Submucosal Myoma ESGE Classification) score guides feasibility: scores 0–4 are favorable for complete single-session resection. Advanced platforms include the Truclear Elite and MyoSure REACH tissue-removal systems, which use reciprocating mechanical blades to resect and extract fibroid tissue simultaneously, reducing fluid absorption risk compared to traditional loop resection. For larger Type 1–2 fibroids (>3 cm), a two-stage procedure may be planned 2–3 months apart, with intervening GnRH agonist therapy.

2. LAPAROSCOPIC MYOMECTOMY (FIGO Types 3–7; fibroids ≤10–12 cm; ≤4–5 in number)

Performed under general anesthesia through 3–4 port sites (5–12 mm). A vasopressin solution (0.2–0.4 units/mL, maximum 30 units total) is injected into the myometrium at the pseudocapsule plane to minimize blood loss. Fibroids are enucleated along the pseudocapsule — a fibronectin-rich plane — and the myometrial defect is repaired with multilayer barbed suture (e.g., V-Loc 180 or STRATAFIX) to ensure uterine wall integrity for future pregnancy. Specimen extraction is performed via a mini-laparotomy (2–3 cm) using a contained manual morcellation bag system (e.g., PneumoLiner, Espiner) — this approach complies with FDA and MHRA guidance against open power morcellation due to the theoretical risk of disseminating occult leiomyosarcoma. Blood loss is further minimized with intraoperative tranexamic acid 1 g IV and cell-salvage autotransfusion when estimated blood loss is anticipated to exceed 500 mL.

3. ROBOTIC-ASSISTED MYOMECTOMY (Da Vinci Xi / Da Vinci SP platform)

Robotic myomectomy offers 10× magnification with 3D-HD vision, 7-degree-of-freedom EndoWrist instruments, and tremor filtration — critical advantages for multilayer uterine reconstruction in complex or deep intramural fibroids and for surgeons managing high fibroid burden. Studies (Gilabert-Aguilar 2021, JMIG) demonstrate non-inferiority to conventional laparoscopy in blood loss and operating time, with a steeper learning curve overcome at centers performing >50 robotic gynecological cases annually. The Da Vinci SP (single-port) platform, available at select centers in India and the UAE, allows the entire procedure through a single 2.5 cm umbilical incision. Leading hospitals in India (e.g., Apollo Hospitals Chennai, Fortis Gurugram, Manipal Bangalore) and the UAE (Cleveland Clinic Abu Dhabi, American Hospital Dubai) have active robotic gynecology programs with dedicated fellowship-trained surgeons.

4. OPEN (ABDOMINAL) MYOMECTOMY — Pfannenstiel or Midline Laparotomy

Reserved for: uteri >20 weeks' size, >10 fibroids, fibroids >15 cm requiring complex reconstruction, or cases where MIS is technically not feasible. The uterus is exteriorized, fibroids excised, and the myometrium closed in 3 layers. A temporary uterine tourniquet (Bonney or rubber tourniquet) reduces intraoperative blood loss. Recovery is longer (4–6 weeks return to full activity) but allows the most thorough survey and removal of fibroid burden.

5. PRE-OPERATIVE MEDICAL OPTIMIZATION

• GnRH Agonists (leuprolide, goserelin): 2–3 months pre-op to reduce fibroid volume by 30–50% and correct anemia. Limitation: fibroids may become softer and harder to enucleate.

• GnRH Antagonists (elagolix/relugolix + add-back therapy): newer class (FDA-approved ORIAHNN regimen) offering rapid suppression without the initial flare seen with agonists; increasingly used at advanced centers pre-operatively.

• IV Iron (ferric carboxymaltose or iron sucrose): corrects iron-deficiency anemia within 3–4 weeks, reducing transfusion requirement.

• Tranexamic acid: antifibrinolytic, administered intraoperatively and in the immediate post-operative period.

PHASE 1 — PRE-TRAVEL & WORKUP (Weeks 1–4 before arrival)

• Submit medical records, prior imaging, and pathology reports to GAF Healthcare for specialist review and surgical planning.

• Remote video consultation with the assigned gynecologic surgeon to discuss fibroid map, surgical approach, fertility goals, and consent.

• Complete preliminary blood work and imaging at home if advised; share digital DICOM files of pelvic MRI/ultrasound.

• Begin GnRH agonist/antagonist therapy or IV iron supplementation if prescribed by the receiving team (coordinated with your local physician).

• Obtain e-Medical Visa for India (typically processed in 1–5 business days) or arrange UAE entry visa through GAF Healthcare.

PHASE 2 — ARRIVAL & PRE-OPERATIVE ASSESSMENT (Days 1–2 in country)

• GAF Healthcare airport transfer to hospital or partnered accommodation.

• Pre-admission clinic: repeat CBC, coagulation profile, renal function, cross-match, anesthesia evaluation, ECG/ECHO if indicated.

• Diagnostic or confirmatory hysteroscopy (if submucosal component is being assessed) may be performed on Day 1.

• Pre-operative optimization: IV iron infusion, bowel preparation if required, thromboprophylaxis planning (enoxaparin dosing).

• Informed consent, anesthesia consent, and surgical site marking completed.

PHASE 3 — SURGERY (Day 2 or 3)

• Hysteroscopic myomectomy: 45–90 minutes; performed as day-case or overnight stay.

• Laparoscopic/robotic myomectomy: 90–180 minutes (variable with fibroid burden); 1–3 nights hospital stay.

• Open myomectomy: 2–4 hours; 3–5 nights hospital stay.

• Intraoperative: vasopressin injection, tranexamic acid 1 g IV, cell-salvage autotransfusion on standby, multilayer barbed suture closure of myometrial defect.

• Immediate post-operative monitoring in recovery unit: vital signs, urine output, drain output (if placed), pain control via multimodal analgesia (IV paracetamol + ketorolac + opioid PCA).

PHASE 4 — HOSPITAL RECOVERY (Days 3–7)

• Early mobilization commencing 6–12 hours post-operatively (critical for DVT prevention).

• Thromboembolic prophylaxis: low-molecular-weight heparin (enoxaparin 40 mg SC daily) + TED stockings until fully mobile.

• Oral intake resumed within 6–24 hours; transition from IV to oral analgesics.

• Drain (if placed) removed on Day 1–2 post-op when output <50 mL/24 h.

• Repeat CBC on post-op Day 1 to assess for significant blood loss.

• Discharge when: afebrile ×24 h, tolerating oral intake, pain controlled with oral medications, voiding normally.

PHASE 5 — POST-DISCHARGE IN-COUNTRY RECOVERY (Days 7–28)

• Remain near the hospital facility in partnered accommodation arranged by GAF Healthcare.

• First post-operative outpatient review at Day 7: wound inspection, suture/staple removal (open cases), histopathology review of excised fibroid specimens (to exclude leiomyosarcoma — results typically available 5–7 days post-op).

• Pelvic rest strictly maintained: no vaginal intercourse, tampons, or douching for 6–8 weeks.

• Light walking encouraged from Day 3 onward; no lifting >5 kg for 4–6 weeks.

• Laparoscopic/robotic patients may be cleared for an international flight at 2–3 weeks post-op (following DVT risk assessment — long-haul flights >6 hours may require enoxaparin prophylaxis for the journey).

• Open myomectomy patients are generally cleared to fly at 4–6 weeks, once abdominal wall healing is confirmed.

PHASE 6 — LONG-TERM MILESTONES

• Return to desk work: 1–2 weeks (laparoscopic); 4–6 weeks (open).

• Return to full physical activity/exercise: 6–8 weeks.

• Attempting pregnancy: surgeons typically advise waiting 3–6 months post-myomectomy for myometrial healing; mandatory waiting period may extend to 12 months if a deep transmural defect was repaired (cesarean section recommended for delivery).

• Follow-up pelvic ultrasound at 3 months and 12 months to confirm cavity normalization and monitor for fibroid recurrence (cumulative 5-year recurrence rate approximately 15–30% depending on number of fibroids removed and patient age).