With the advances in minimally invasive surgery, performing multiple laparoscopic procedures in a single operative session has become both feasible and safe. Combining laparoscopic cholecystectomy, appendectomy, and small myomectomy allows patients to address multiple pathologies at once, reducing overall anesthesia exposure, hospital stay, recovery time, and healthcare costs. However, careful patient selection, preoperative planning, and meticulous surgical technique are crucial to ensure safety and optimal outcomes.

Indications and Patient Selection

Patients suitable for combined laparoscopic procedures include those with symptomatic gallstones, appendicular pathology (such as chronic or recurrent appendicitis), and a small, accessible uterine fibroid causing symptoms such as menorrhagia, pelvic pain, or infertility. Contraindications include uncontrolled systemic illnesses, severe cardiopulmonary compromise, extensive abdominal adhesions, or large fibroids not amenable to laparoscopic removal.

Preoperative evaluation involves a detailed history, physical examination, and laboratory investigations. Imaging studies such as ultrasound or MRI of the abdomen and pelvis help assess gallbladder stones, appendix status, and fibroid size, number, and location. Counseling the patient about the benefits, risks, and postoperative expectations is essential, and informed consent must cover all three procedures.

Surgical Preparation and Sterilization

Preparation begins with standard preoperative fasting, anesthesia assessment, and prophylactic antibiotics to prevent infection. Sterilization of laparoscopic instruments is critical, including autoclaving of trocars, graspers, scissors, and energy devices, to prevent contamination between the gastrointestinal and gynecological components of the surgery. Proper positioning of the patient in the supine or slight Trendelenburg position allows optimal access to the upper abdomen for cholecystectomy and lower abdomen for myomectomy and appendectomy.

Port Placement and Access

Typically, a four-port technique is employed for cholecystectomy, with a camera port at the umbilicus and working ports in the epigastrium and right upper quadrant. These ports can be slightly modified to allow access to the lower abdomen for appendectomy and myomectomy. In some cases, an additional port in the left lower quadrant may facilitate uterine manipulation and safe excision of the fibroid. Using existing ports for multiple procedures minimizes abdominal trauma, reduces postoperative pain, and avoids the need for additional incisions.

Laparoscopic Cholecystectomy

The procedure begins with cholecystectomy. The gallbladder is mobilized from the liver bed after careful dissection of Calot’s triangle to identify the cystic duct and artery. These structures are securely clipped and divided. The gallbladder is then removed in a retrieval bag to prevent spillage of bile or stones into the peritoneal cavity. Complete hemostasis is ensured before moving on to the next procedure.

Laparoscopic Appendectomy

Next, attention is turned to the appendix. The cecum and appendix are identified, and the mesoappendix is dissected to control the appendicular artery. The appendix is ligated at its base and removed using a retrieval bag to avoid contamination of the peritoneal cavity. Laparoscopic appendectomy following cholecystectomy ensures that any potential infection is controlled and that port placement can be optimized for the subsequent myomectomy.

Laparoscopic Small Myomectomy

The final step is the myomectomy. The uterus is visualized, and the fibroid is localized. Using laparoscopic graspers and energy devices, a small incision is made over the fibroid, and it is carefully enucleated. Hemostasis is achieved with bipolar cautery or suturing as required. The fibroid is removed through the umbilical port using a morcellation technique if necessary. The uterine wall is then meticulously closed with absorbable sutures to preserve uterine integrity and reduce the risk of adhesion formation.

Advantages of Combined Procedures

Performing all three procedures in a single session offers multiple advantages. Patients undergo a single exposure to general anesthesia, reducing perioperative risk. Hospital stay is shortened, and overall healthcare costs are reduced. Postoperative recovery is faster, with less cumulative pain and trauma compared to separate surgeries. Additionally, addressing all pathologies simultaneously improves patient satisfaction and allows quicker return to daily activities.

Postoperative Care

Postoperatively, patients are monitored for pain, signs of infection, bleeding, or organ injury. Early ambulation and gradual resumption of oral intake are encouraged. Pain management usually involves oral analgesics, and patients with uncomplicated procedures can be discharged within 24–48 hours. Follow-up includes wound care, monitoring recovery, and counseling regarding reproductive health and gallbladder function.

Conclusion

Laparoscopic cholecystectomy, appendectomy, and small myomectomy performed in the same patient are safe and effective when executed by experienced surgeons with careful planning and strict adherence to sterilization protocols. This combined approach minimizes surgical trauma, reduces hospitalization, and ensures faster recovery while maintaining the safety and efficacy of each individual procedure. With proper patient selection and meticulous surgical technique, multiple laparoscopic interventions can be performed successfully in a single operative session, offering excellent outcomes and improved patient satisfaction.