Uterine fibroids are the most common benign tumors of the female reproductive system. They arise from smooth muscle cells of the uterus and vary widely in size, location, and clinical presentation. Among the different types, cervical fibroids are relatively rare, accounting for about 1–2% of all fibroids. Even less common are posterior cervical fibroids, which develop at the back of the cervix and often pose unique surgical challenges due to their proximity to vital pelvic structures such as the rectum, ureters, and major blood vessels. With advances in minimally invasive gynecologic surgery, laparoscopic removal of posterior cervical fibroids has become a feasible and effective option, offering patients the benefits of reduced pain, faster recovery, and excellent outcomes.

Clinical Features and Challenges

Posterior cervical fibroids may remain asymptomatic for a long period, but when symptomatic, they can cause:

Pelvic pressure and pain, often due to compression of the rectum or sacral nerves.

Constipation or bowel dysfunction, because of direct rectal compression.

Dyspareunia and urinary symptoms, such as frequency or urgency, depending on size and location.

Heavy menstrual bleeding or irregular cycles, similar to other uterine fibroids.

Unlike fibroids located in the uterine body, posterior cervical fibroids are more difficult to access surgically. Their location in the deep pelvis, distortion of anatomy, and adherence to surrounding structures increase the complexity of removal. Traditional open surgery has been the standard approach for many years, but laparoscopy now provides a minimally invasive alternative with fewer complications.

Indications for Laparoscopic Removal

Not all posterior cervical fibroids require surgical intervention. The following scenarios warrant laparoscopic myomectomy:

Large fibroids causing obstructive symptoms (bowel or bladder dysfunction).

Severe pelvic pain or pressure not relieved by medical therapy.

Fibroids contributing to infertility or recurrent miscarriage.

Rapidly growing fibroids or those suspected of atypical features.

Patient preference for uterus-sparing treatment.

Preoperative Planning

Dr. R. K. Mishra and other laparoscopic experts emphasize that careful preoperative assessment is critical. Imaging techniques such as ultrasound and MRI help determine the size, location, and relationship of the fibroid to nearby organs. Preoperative ureteral stenting may be considered in very large or deeply situated fibroids to avoid ureteral injury. Patients are also counseled about the risks, benefits, and potential need for conversion to open surgery if safe laparoscopic dissection is not possible.

Surgical Technique

Anesthesia and Positioning

The procedure is performed under general anesthesia.

The patient is placed in the lithotomy position with Trendelenburg tilt to allow small bowel displacement.

Port Placement

Typically, a 10 mm umbilical port is used for the laparoscope.

Two or three additional working ports (5 mm or 10 mm) are placed laterally for instruments, ensuring triangulation and optimal access to the pelvis.

Exposure and Identification

The posterior cervical fibroid is visualized, often bulging into the pouch of Douglas.

Ureters are carefully traced to avoid injury. Adhesions, if present, are lysed.

Myomectomy

A serosal incision is made over the fibroid using monopolar or harmonic energy.

The fibroid is enucleated by blunt and sharp dissection, often requiring meticulous hemostasis.

The myoma bed is sutured with intracorporeal absorbable sutures to restore normal anatomy and minimize dead space.

Specimen Retrieval

Depending on fibroid size, retrieval may be performed via contained morcellation, posterior colpotomy, or through an extended port site.

Closure and Hemostasis

Meticulous irrigation and inspection are carried out to confirm hemostasis.

All ports greater than 10 mm are closed to prevent port-site hernia.

Advantages of Laparoscopic Removal

Minimally invasive: Smaller incisions, less blood loss, and reduced tissue trauma.

Faster recovery: Patients often return to daily activities within 1–2 weeks compared to 4–6 weeks for open surgery.

Reduced adhesions: Enhanced visualization and precise dissection minimize adhesion formation.

Cosmetic benefit: Small scars with excellent aesthetic results.

Uterus preservation: Allows women to retain reproductive potential, which is especially important for those desiring future fertility.

Potential Risks and Limitations

Technical difficulty: The posterior cervix is a narrow and deep surgical field, requiring advanced laparoscopic skills.

Injury to adjacent organs: Risk to the ureters, rectum, and uterine vessels is higher compared to uterine body fibroids.

Conversion to laparotomy: In cases of uncontrollable bleeding or unclear anatomy, open surgery may be necessary.

Recurrence: As with any myomectomy, new fibroids may develop over time.

Postoperative Care and Outcomes

Patients typically recover quickly after laparoscopic posterior cervical fibroid removal. Pain management is simpler, hospital stay is short (1–2 days), and fertility outcomes are generally favorable. With skilled surgical execution, recurrence and complication rates are low. The majority of patients experience significant improvement in symptoms such as pelvic pain, constipation, or menstrual irregularities.

Conclusion

Laparoscopic removal of posterior cervical fibroid is a technically demanding but highly rewarding procedure that combines the benefits of minimally invasive surgery with effective resolution of symptoms. By ensuring meticulous preoperative planning, careful dissection, and advanced laparoscopic skills, surgeons can manage these complex cases safely. For patients, it means reduced pain, faster recovery, improved fertility outcomes, and better quality of life. As laparoscopic techniques continue to advance, the management of rare and difficult fibroids like posterior cervical lesions is shifting away from open surgery toward safer and more efficient minimally invasive solutions.