This video demonstrates Laparoscopic myomectomy instead of hysteroscopic myomectomy for large submucous fibroids. Laparotomy, laparoscopy, and hysteroscopy are the three main procedures employed by gynecologists to remove uterine fibroids. The abdominal approach (laparotomy and laparoscopy) is used to treat subserousal and intramural lesions, and the vaginal approach (hysteroscopy) is used for submucous fibroids. With the advent of hysteroscopic surgery, operative hysteroscopies can manage most intrauterine surgical problems with fast recovery. However, hysteroscopic myomectomy for large deeply intramural extension submucous fibroid has still deemed a challenge for hysteroscopists. It involves issues of longer operating time, fluid overload, uterine perforation, and incomplete resection in one surgery. In conclusion, even hysteroscopic myomectomy offers several benefits to the patient. We must bear in mind that hysteroscopic removal of large deeply intramural invasion submucous fibroids is still a technically challenging procedure and might be associated with higher surgical morbidity and incidence of additional surgery. To avoid these tough situations, the vaginal approach should be shifted to the abdominal approach with laparoscopy, which can remove fibroids and still meet the principle of minimally invasive surgery; however, this particular approach should be performed only by those surgeons who are skilled in laparoscopic suturing.

Fibroids, also known as leiomyomas, are benign tumors of the uterine muscle that can significantly impact a woman’s health and fertility. Among them, submucous fibroids, which grow just beneath the uterine lining, are particularly notorious for causing heavy menstrual bleeding, infertility, and recurrent miscarriages. While hysteroscopic myomectomy is the standard minimally invasive approach for removing smaller submucous fibroids, it has limitations when dealing with large fibroids. In such cases, laparoscopic myomectomy emerges as a safer and more effective alternative.

Limitations of Hysteroscopic Myomectomy for Large Fibroids

Hysteroscopic myomectomy involves removing fibroids through the cervix using a hysteroscope. While it is minimally invasive and effective for small fibroids (<4–5 cm), its limitations include:

Incomplete Removal: Large submucous fibroids may extend deep into the uterine wall (intramural component), making complete removal challenging through the hysteroscope.

Risk of Complications: Excessive resection increases the risk of uterine perforation, fluid overload, and intraoperative bleeding.

Multiple Procedures: Large fibroids often require staged procedures, increasing patient discomfort and prolonging recovery.

Because of these challenges, alternative surgical approaches are considered for fibroids that are large or deeply embedded.

Advantages of Laparoscopic Myomectomy

Laparoscopic myomectomy is a minimally invasive surgery performed through small abdominal incisions using a camera and specialized instruments. Its advantages for large submucous fibroids include:

Complete Removal: Surgeons can excise large and deeply embedded fibroids entirely, reducing recurrence.

Uterine Reconstruction: After removing fibroids, the uterine wall can be reconstructed under direct vision, preserving structural integrity and fertility.

Reduced Complications: The laparoscopic approach allows better control of bleeding and reduces the risk of uterine perforation compared to hysteroscopic removal.

Faster Recovery: Despite being abdominal surgery, laparoscopic procedures result in smaller scars, less pain, and quicker return to normal activities compared to open surgery.

Fertility Preservation: By reconstructing the uterus meticulously, laparoscopic myomectomy offers better outcomes for women planning pregnancy.

Indications for Laparoscopic Myomectomy Over Hysteroscopy

Laparoscopic myomectomy is generally preferred for submucous fibroids when:

Fibroid size exceeds 4–5 cm.

There is a significant intramural component.

Multiple fibroids are present.

Prior hysteroscopic attempts were incomplete.

Procedure Overview

Preoperative Assessment: Imaging (ultrasound or MRI) determines size, number, and location of fibroids.

Anesthesia and Positioning: General anesthesia is used; the patient is positioned for optimal laparoscopic access.

Port Placement: Small abdominal incisions are made for the camera and instruments.

Fibroid Enucleation: The fibroid is carefully separated from the uterine wall.

Uterine Repair: The defect in the uterine wall is sutured in layers to ensure structural strength.

Fibroid Removal: The excised fibroid is removed, often using a morcellator or contained extraction technique.

Recovery: Most patients can return home within 1–2 days, with minimal postoperative pain.

Conclusion

While hysteroscopic myomectomy is effective for small submucous fibroids, laparoscopic myomectomy offers a safer, more complete, and fertility-preserving option for large or complex fibroids. Women with large submucous fibroids should consult experienced minimally invasive surgeons to choose the approach that ensures optimal outcomes and preserves uterine function.

For more https://www.laparoscopyhospital.com/