This video demonstrate Laparoscopic Myomectomy for Intramural Myoma with Submucosal Extension. For fibroids that distort the cavity there is consensus of a negative impact on both the clinical pregnancy rate and delivery rate together with dysfunctional uterine bleeding. Uterine leiomyomas are present in 30-70% of women of reproductive age. In addition to causing menstrual disorders and pain, uterine fibroids negatively affect fertility and pregnancy outcome for patients pursuing assisted reproduction. The two questions that have to be addressed are: which fibroids should be treated, and how they should be treated? Submucosal fibroids are associated with a 70% reduction in delivery rate. Intramural fibroid had a lesser effect and reduced the delivery rate approximately 30%. In contrast, studies on subserosal fibroids did not negatively impact fertility. Furthermore, both submucosal and intramural fibroids were associated with an increased risk of spontaneous miscarriage. Myomectomy is considered the treatment of choice to alleviate these detrimental effects. Further research is needed before alternative treatments can be recommended.

Uterine fibroids, also known as leiomyomas, are benign smooth muscle tumors of the uterus that affect a significant number of women in their reproductive years. Among them, intramural myomas with submucosal extension pose unique clinical challenges due to their location within the uterine wall and partial protrusion into the endometrial cavity. These fibroids can cause abnormal uterine bleeding, pelvic pain, and infertility. Laparoscopic myomectomy has emerged as a minimally invasive, fertility-preserving surgical approach for managing these complex fibroids.

Indications

Laparoscopic myomectomy is indicated in patients with:

• Symptomatic intramural fibroids with submucosal extension

• Heavy menstrual bleeding or menorrhagia

• Infertility or recurrent pregnancy loss associated with fibroids

• Pelvic pain or pressure symptoms

Preoperative Evaluation
A thorough evaluation is critical for optimal outcomes:

• Ultrasound and MRI: To determine fibroid size, location, vascularity, and the degree of submucosal extension.

• Hysteroscopy: Useful in evaluating endometrial cavity involvement.

• Laboratory tests: Complete blood count, coagulation profile, and preoperative optimization if anemia is present.

Surgical Technique

1. Patient Positioning and Anesthesia
   The patient is placed in the dorsal lithotomy position under general anesthesia. Pneumoperitoneum is established, and trocars are placed for laparoscopic access.

2. Uterine Manipulation
   A uterine manipulator helps in mobilizing the uterus for better visualization of the myoma.

3. Identification of the Myoma
   The intramural myoma with submucosal extension is identified. Vasopressin may be injected locally to reduce intraoperative bleeding.

4. Incision and Enucleation
   A precise incision is made over the myoma. Using laparoscopic instruments, the fibroid is carefully dissected and enucleated, taking care not to breach the endometrial cavity extensively.

5. Repair of Uterine Wall
   The uterine defect is closed in multiple layers using absorbable sutures. This step is crucial to restore uterine integrity, especially for patients desiring future fertility.

6. Extraction
   The fibroid is removed from the abdominal cavity. Morcellation or mini-laparotomy may be used depending on size.

7. Hemostasis and Closure
   Hemostasis is confirmed, and the abdominal incisions are closed.

Postoperative Care

• Early ambulation and pain management

• Monitoring for signs of bleeding or infection

• Follow-up imaging in selected cases to ensure complete removal

Advantages of Laparoscopic Approach

• Minimally invasive with smaller incisions

• Reduced blood loss

• Shorter hospital stay and faster recovery

• Preservation of fertility

• Better cosmetic outcome

Challenges

• Difficulty in cases with large or multiple fibroids

• Risk of breaching the endometrial cavity

• Requires advanced laparoscopic skills

Conclusion
Laparoscopic myomectomy for intramural myomas with submucosal extension is a safe and effective procedure that combines the benefits of minimally invasive surgery with fertility preservation. Careful preoperative planning, surgical expertise, and meticulous intraoperative technique are key to achieving optimal outcomes.