This video demonstrates Laparoscopic Management of Posterior Intramural Fibroid performed by Dr. R K Mishra at World Laparoscopy Hospital. Uterine fibroids (also known as leiomyomas or myomas) are the most common form of benign uterine tumors. Clinical presentations include abnormal bleeding, pelvic masses, pelvic pain, infertility, bulk symptoms, and obstetric complications. Almost a third of women with leiomyomas will request treatment due to symptoms. Current management strategies mainly involve surgical interventions, but the choice of treatment is guided by the patient's age and desire to preserve fertility or avoid ‘radical’ surgery such as hysterectomy. The management of uterine fibroids also depends on the number, size, and location of the fibroids. Other surgical and non-surgical approaches include myomectomy by hysteroscopy, myomectomy by laparotomy or laparoscopy, uterine artery embolization, and interventions performed under radiologic or ultrasound guidance to induce thermal ablation of the uterine fibroids.

Laparoscopic Management of Posterior Intramural Fibroid
 
Fibroids, also known as leiomyomas, are benign smooth muscle tumors of the uterus that can cause significant symptoms, including heavy menstrual bleeding, pelvic pain, and infertility. Among them, intramural fibroids, which grow within the uterine wall, can significantly impact a woman’s reproductive and overall health. Posterior intramural fibroids, located at the back wall of the uterus, can be particularly challenging to treat due to their location and potential impact on surrounding structures, such as the rectum and sacral nerves. Laparoscopic myomectomy has emerged as a highly effective minimally invasive approach for managing posterior intramural fibroids, offering numerous advantages over traditional open surgery.
 
Indications for Laparoscopic Management
Laparoscopic myomectomy is recommended for patients with symptomatic posterior intramural fibroids that cause:
- Heavy menstrual bleeding (menorrhagia)
- Chronic pelvic pain or pressure
- Infertility or recurrent pregnancy loss
- Bladder or rectal pressure symptoms
- Enlargement of the uterus leading to discomfort
 
Preoperative Evaluation
A thorough preoperative assessment is essential for successful laparoscopic management. This includes:
- Imaging Studies: Transvaginal ultrasound and MRI help determine fibroid size, location, and number.
- Hormonal and Hematologic Assessment: Evaluating anemia and hormone levels aids in optimizing patient readiness for surgery.
- Endometrial Assessment: To rule out other uterine pathologies.
- Bowel and Bladder Preparation: Necessary in some cases to ensure clear access to the posterior uterus.
 
Laparoscopic Myomectomy Procedure
1. Patient Positioning and Anesthesia: The patient is placed in a lithotomy position under general anesthesia, with a steep Trendelenburg tilt to enhance visibility of the pelvic organs.
 
2. Port Placement: Typically, a 10-mm umbilical port is used for the laparoscope, with additional 5-mm accessory ports placed for instrument manipulation.
 
3. Uterine Mobilization: Proper mobilization of the uterus is achieved using a uterine manipulator to optimize surgical access to the posterior uterine wall.
 
4. Fibroid Enucleation:
- A serosal incision is made over the fibroid using monopolar or harmonic energy.
- Blunt and sharp dissection is employed to enucleate the fibroid while preserving healthy myometrial tissue.
- Hemostasis is meticulously achieved using bipolar coagulation or suturing to minimize blood loss.
 
5. Myometrial Closure: The myometrial defect is closed in layers using absorbable sutures to restore uterine integrity and reduce the risk of rupture in future pregnancies.
 
6. Specimen Removal: The fibroid is morcellated and extracted via the umbilical or accessory port, ensuring minimal trauma to surrounding tissues.
 
7. Peritoneal Lavage and Closure: The surgical site is irrigated, and ports are closed meticulously to prevent adhesions.
 
Postoperative Care and Recovery
- Patients are typically discharged within 24 hours.
- Mild postoperative pain and bloating are managed with analgesics.
- Early ambulation is encouraged to prevent deep vein thrombosis (DVT).
- Return to routine activities within 1-2 weeks, with avoidance of strenuous exercises for about 4-6 weeks.
- Follow-up imaging may be conducted after a few months to assess uterine healing.
 
Advantages of Laparoscopic Management
- Minimally Invasive: Reduced surgical trauma and quicker recovery.
- Lower Blood Loss: Advanced hemostatic techniques minimize intraoperative bleeding.
- Reduced Adhesion Formation: Compared to open surgery, laparoscopy decreases the risk of postoperative adhesions.
- Enhanced Fertility Outcomes: Preserving the uterus and minimizing scarring improve reproductive potential.
- Shorter Hospital Stay: Most patients recover within a day and resume normal activities sooner.
 
Conclusion
Laparoscopic myomectomy is a safe and effective approach for managing posterior intramural fibroids, providing excellent outcomes with minimal morbidity. Advances in laparoscopic techniques, including improved suturing methods and hemostasis control, continue to enhance patient safety and reproductive outcomes. Proper patient selection, meticulous surgical technique, and comprehensive postoperative care are key to ensuring successful treatment and optimal recovery.
 

For more information:

World Laparoscopy Hospital
Cyber City, Gurugram, NCR Delhi
INDIA: +919811416838

World Laparoscopy Training Institute
Bld.No: 27, DHCC,
Dubai UAE: +971525857874

World Laparoscopy Training Institute
8320 Inv Dr, Tallahassee, Florida
USA: +1 321 250 7653