By Dr. Manas Chakrabarti, FRCOG
Senior Gynaecological Oncologist, Kolkata
Before you read on: This article focuses on surgical options for fibroids. If you have not yet read the companion piece on medical and drug treatments for fibroids, it is worth reading that first - it will give you the full picture before you reach the surgical section.
ℹ️ Why Surgery Is Often the Most Effective Route
Medicine has made quiet, steady progress in managing fibroid symptoms. There are drugs that keep symptoms under control, and a handful that can reduce fibroid size modestly. But no medication currently available can make fibroids disappear completely.
Surgery does what medicine, so far, cannot.
That said, the right type of surgery - its suitability, the patient’s own preferences, and what the treatment needs to achieve - can only be understood through a face-to-face conversation between patient and doctor. This article is a guide, not a prescription.
🔷 The Two Paths: The Question That Shapes Everything
Surgical treatment for fibroids divides into two broad categories, and the single question that determines which path is right for you is this:
Do you wish to have children in the future?
Your answer to that question shapes every surgical decision that follows.
🔷 When Future Pregnancy Is Not Planned
🔹 Hysterectomy: The Definitive Answer for Fibroids
If future pregnancy is not a consideration, the standard surgical treatment for problematic fibroids is hysterectomy - the surgical removal of the uterus. Research consistently shows that, in appropriate cases, hysterectomy delivers the best long-term symptom control and the highest rates of patient satisfaction.
Of all the reasons hysterectomies are performed worldwide, fibroids are the leading cause.
It is important to understand clearly: having a hysterectomy means that natural pregnancy will not be possible in the future.
There are three types of hysterectomy, and the most appropriate one for any individual patient depends on the size of the fibroids, the structure of the pelvis, and the surgeon’s assessment.
🔹 Type 1: Vaginal Hysterectomy
In a vaginal hysterectomy, the entire operation is performed from below - the uterus is removed through the vagina, without any incision on the abdomen.
This is generally the preferred approach where it is technically feasible, because it involves no abdominal wound and typically means a faster recovery.
However, if the fibroids are very large, or if there is insufficient vaginal space, this approach may not be safe and another method will be recommended.
🔹 Type 2: Laparoscopic (Keyhole) Hysterectomy
In a laparoscopic hysterectomy, the uterus is removed without opening the abdomen. Instruments are inserted through small, narrow incisions - often called ‘ports’ - in the abdominal wall, and the surgeon operates using a camera and specialised tools.
Because the abdomen is not opened, there are two methods for actually removing the uterus and fibroids once they have been detached:
Via the vagina: The uterus is guided out through the vagina after the laparoscopic work above is complete.
Via morcellation: The uterus and fibroids are divided into smaller pieces inside the abdomen and removed through one of the laparoscopic port sites.
Morcellation makes it possible to remove even large fibroids without an abdominal incision. However, contemporary research has identified specific risks associated with this technique. These are discussed fully in the companion article on fibroid precautions - please read that section before drawing conclusions about this option.
A note on robot-assisted laparoscopic hysterectomy: You may have seen this advertised on hoardings or hospital websites. It is not a separate operation - it is a variant of laparoscopic hysterectomy in which some of the instruments are guided by machine assistance rather than held by a surgical assistant. The surgical goals are identical. The cost is higher. Whether the additional cost offers additional benefit for your specific situation is a conversation worth having with your surgeon.
🔹 Type 3: Abdominal (Open) Hysterectomy
In an abdominal hysterectomy, the surgeon makes a direct incision in the abdomen and removes the uterus and fibroids through that opening.
This approach is used when the fibroid size, position, or other clinical factors make the keyhole or vaginal routes impractical or unsafe. It is a well-established, highly effective operation - and for complex cases, it may be precisely the right choice.
🔷 When Future Pregnancy Is Planned
🔹 Myomectomy: Removing the Fibroid, Preserving the Uterus
The word ‘myoma’ means fibroid. The suffix ‘-ectomy’ means removal. A myomectomy, therefore, is a surgical procedure in which only the fibroids are removed whilst the uterus remains in place.
This is the operation of choice for patients who wish to preserve their fertility.
There are three methods, and the correct one depends on where the fibroid is located within or on the uterus.
🔹 Method A: Laparoscopic Myomectomy
Fibroids that grow on the outer surface of the uterine wall, protruding towards the abdominal cavity, can be seen clearly through a laparoscopic camera and removed using keyhole techniques.
This approach avoids an abdominal incision and is appropriate for externally positioned fibroids of suitable size and number.
🔹 Method B: Open (Abdominal) Myomectomy
Where the laparoscopic approach is not suitable - for example, if morcellation is not appropriate for that patient - the fibroids are removed through a direct abdominal incision.
This is called open myomectomy. It is a straightforward, well-practised surgical approach that remains the right answer in many clinical situations.
🔹 Method C: Hysteroscopic Myomectomy
Some fibroids grow inward, projecting into the inner cavity of the uterus rather than outward. These cannot be reached by a camera inserted from the abdomen, nor by open abdominal surgery.
To remove these fibroids, a thin camera is passed through the vagina and into the uterine cavity from below. The fibroids are then carefully sliced away and removed.
This procedure is called Hysteroscopic Myomectomy.
🔷 What You Should Know Before Choosing Myomectomy
Myomectomy preserves the uterus and removes the fibroid - but it is important to understand the full picture before deciding.
Fibroids can return. The uterine wall muscle is capable of developing new fibroids after surgery. Studies show that approximately one in three women will develop new fibroids within the uterus following myomectomy.
One in every 200 women undergoing myomectomy may require an emergency hysterectomy during the operation due to excessive bleeding. With precaution this can be even lower.
Advances in surgical technique, combined with specific pre-operative medications and intraoperative injections, have significantly reduced the likelihood of this complication. The risk exists - but it is manageable in experienced hands.
Every surgical procedure carries both benefits and risks. These are not reasons to avoid a decision; they are reasons to make an informed one.
🔷 Making Your Decision
No two fibroid cases are identical. The right surgery for one patient may be entirely wrong for another - even if the fibroids look similar on a scan.
What matters is the conversation between you and your surgeon: your priorities, your plans, your body, and the clinical findings specific to you.
Read everything you can. Then ask everything you need to ask.
Dr. Manas Chakrabarti, FRCOG
Senior Gynaecological Oncologist, Kolkata
Cochrane Author | Specialist in Complex Gynaecological and Gynaecological Oncological Surgery
🔹 Further Reading
Fibroid Treatment Guide: 9 Steps Before Going to Doctor
Masterclass: Fibroid
This is an impartial , unsponsored health information. For public awareness and not a replacement of Medical Advice.