This video demonstrate Laparoscopic Myomectomy for Large Intramural Fibroid Uterus. Despite the increased operation time and blood loss, laparoscopic myomectomy can be safely performed in the treatment of large uterine fibroid. However, high risk of blood transfusion in these patients has to be kept in mind. With laparoscopic approach, there is minimal tissue handling which reduces risk of adhesions. Saline irrigation is also constantly in use which prevents drying of tissues and blood clots from sticking to the tissues. Meticulous control of bleeding also is essential. Finally, adhesion prevention barrier such as Adept solution or Interceed is used at the end of the procedure.

Fibroids, medically known as uterine leiomyomas, are common benign tumors of the uterus. Among these, intramural fibroids, which grow within the muscular wall of the uterus, can cause significant symptoms such as heavy menstrual bleeding, pelvic pain, infertility, and pressure on adjacent organs. When these fibroids are large, surgical intervention is often necessary. Laparoscopic myomectomy has emerged as a minimally invasive and effective option for managing large intramural fibroids.

What is Laparoscopic Myomectomy?

Laparoscopic myomectomy is a minimally invasive surgical procedure that removes fibroids from the uterus using small incisions in the abdomen. Unlike traditional open surgery (laparotomy), laparoscopy offers benefits such as reduced pain, shorter hospital stay, faster recovery, and minimal scarring. The procedure is particularly challenging for large intramural fibroids, but with modern techniques and advanced laparoscopic instruments, it is feasible and safe in experienced hands.

Indications for Laparoscopic Myomectomy

Laparoscopic myomectomy is recommended in patients with:

• Large or symptomatic intramural fibroids

• Infertility related to fibroids

• Recurrent pregnancy loss due to fibroids

• Severe pelvic pain or pressure symptoms

• Desire for uterine preservation (as opposed to hysterectomy)

Preoperative Evaluation

Before surgery, thorough evaluation is essential:

• Ultrasound and MRI: Determine the size, number, and location of fibroids.

• Blood tests: Complete blood count, coagulation profile, and hemoglobin level (especially if there is heavy bleeding).

• Medical optimization: Correction of anemia, if present.

• Counseling: Discuss risks, benefits, and the possibility of conversion to open surgery if needed.

Surgical Technique: Step-by-Step

1. Anesthesia and Patient Positioning
   The patient is placed under general anesthesia in a dorsal lithotomy position with slight Trendelenburg tilt to allow better visualization of the pelvic organs.

2. Port Placement
   Typically, a 10–12 mm umbilical port is used for the camera, with 5 mm accessory ports on either side for instruments. Placement may vary depending on the size and location of the fibroid.

3. Uterine Manipulation
   A uterine manipulator helps mobilize the uterus and improve access to the fibroid.

4. Incision and Fibroid Enucleation
   A careful incision is made on the uterine wall overlying the fibroid. Using laparoscopic instruments, the fibroid is dissected and removed. Large fibroids may require morcellation for extraction, either transvaginally or via specialized containment systems to prevent tissue dissemination.

5. Hemostasis and Suturing
   The uterine defect is meticulously sutured in layers using laparoscopic suturing techniques to ensure hemostasis and preserve uterine integrity.

6. Closure and Recovery
   Ports are closed, and the patient is monitored postoperatively. Early mobilization and pain management facilitate a quicker recovery.

Advantages of Laparoscopic Approach

• Less postoperative pain

• Reduced hospital stay

• Faster return to daily activities

• Minimal scarring

• Better visualization of the pelvis and multiple fibroids

Challenges and Considerations

• Large fibroids increase operative complexity

• Risk of bleeding, especially with highly vascular fibroids

• Skilled laparoscopic suturing is required to repair the uterine wall

• Morcellation carries a risk of tissue dissemination; containment systems are recommended

Postoperative Care

• Pain management and early mobilization

• Monitor for signs of infection or bleeding

• Follow-up imaging if needed to ensure complete removal

• Advice on pregnancy planning, as future pregnancies require careful monitoring

Conclusion

Laparoscopic myomectomy for large intramural fibroids is a safe and effective minimally invasive technique when performed by experienced surgeons. It combines the benefits of uterine preservation with the advantages of modern laparoscopy, offering patients relief from symptoms and improving fertility outcomes in a shorter recovery time. With careful patient selection, preoperative planning, and advanced laparoscopic skills, even large fibroids can be successfully managed without resorting to open surgery.