Uterine fibroids, also known as leiomyomas, are the most common benign tumors of the female reproductive tract, affecting up to 40% of women during their reproductive years. While subserosal and submucosal fibroids are often straightforward to manage, intramural fibroids (embedded within the uterine wall) and broad ligament fibroids (arising from the connective tissue of the broad ligament) present unique surgical challenges. These fibroids can cause symptoms ranging from menorrhagia, pelvic pain, infertility, and pressure effects on adjacent organs such as the bladder and rectum. With advances in minimally invasive gynecologic surgery, laparoscopic myomectomy has become the preferred approach for selected intramural and broad ligament fibroids, offering patients less pain, faster recovery, and excellent cosmetic results.

Clinical Features

Intramural fibroids often cause:

Heavy menstrual bleeding

Dysmenorrhea (painful menstruation)

Pelvic pressure or bloating

Infertility or recurrent pregnancy loss

Broad ligament fibroids, due to their location in the lateral pelvic wall, may remain asymptomatic for long periods. When symptomatic, they can present with:

Pelvic pain

Urinary frequency or retention (due to bladder compression)

Constipation or rectal pressure

Rarely, acute pain from torsion or degeneration

Because of their deep pelvic location and proximity to vital structures like ureters, pelvic vessels, and nerves, surgical management of broad ligament fibroids is technically demanding.

Preoperative Assessment

Dr. R. K. Mishra and other experts emphasize the importance of preoperative imaging using transvaginal ultrasonography and MRI to determine fibroid size, number, location, and relation to surrounding structures. Ureteral stenting may be considered in large broad ligament fibroids to avoid ureteral injury. Blood tests, anemia correction, and optimization of general health are standard preparatory measures.

Indications for Laparoscopic Myomectomy

Symptomatic fibroids causing bleeding, pain, or pressure effects

Fibroids associated with infertility or recurrent miscarriage

Rapidly enlarging fibroids

Patient preference for uterus-preserving minimally invasive surgery

Fibroids with significant distortion of the uterine cavity or extensive adhesions may require open surgery.

Surgical Technique

Patient Positioning and Anesthesia

General anesthesia is administered.

The patient is placed in the lithotomy position with Trendelenburg tilt for optimal pelvic exposure.

Port Placement

A 10 mm umbilical port for the laparoscope is placed.

Two or three 5 mm working ports are introduced laterally, ensuring proper triangulation and access to the fibroids.

Exposure and Identification

The uterus and broad ligaments are carefully inspected.

For intramural fibroids, the uterine serosa overlying the myoma is identified and marked.

Broad ligament fibroids are visualized within the lateral pelvic wall, and the ureters are traced to prevent injury.

Myoma Enucleation

A serosal incision is made over intramural fibroids, and blunt dissection is used to enucleate the myoma.

Broad ligament fibroids are dissected carefully, keeping in mind proximity to the ureter and pelvic vessels.

Hemostasis is achieved using bipolar coagulation or harmonic energy devices.

Uterine and Ligament Repair

The myoma bed is closed with intracorporeal absorbable sutures to restore uterine contour and prevent hematoma formation.

Broad ligament defects are also sutured to maintain anatomy and avoid pelvic adhesions.

Specimen Retrieval

Fibroids are removed via contained morcellation through the umbilical port or, if large, via mini-laparotomy or posterior colpotomy.

Final Inspection and Closure

Hemostasis is confirmed, and the pelvic cavity is irrigated.

Ports are removed, and fascial closure is performed for ports larger than 10 mm. Skin incisions are closed with absorbable sutures.

Advantages of Laparoscopic Removal

Minimally invasive: Reduced postoperative pain and smaller scars.

Faster recovery: Early mobilization and discharge within 1–2 days.

Enhanced visualization: Magnification allows precise dissection and preservation of ureters, vessels, and surrounding structures.

Uterus preservation: Critical for women desiring future fertility.

Reduced adhesion formation: Compared to open surgery, precise laparoscopic dissection minimizes pelvic adhesions.

Challenges and Limitations

Technical difficulty: Deep pelvic location and vascularity of broad ligament fibroids require advanced laparoscopic skills.

Risk of ureteral injury: Careful identification and tracing of ureters is essential.

Bleeding: Intramural and broad ligament fibroids may be highly vascular; meticulous hemostasis is crucial.

Learning curve: Laparoscopic enucleation and suturing demand expertise in intracorporeal techniques.

Postoperative Care and Outcomes

Patients generally experience minimal pain and rapid recovery. Follow-up includes ultrasonography to detect residual fibroids and assessment of menstrual and fertility outcomes. With skilled surgical technique, recurrence is uncommon, and most patients experience significant improvement in symptoms, including relief from pain, bleeding, and pressure effects. Fertility outcomes are favorable in women desiring conception.

Conclusion

Laparoscopic removal of intramural and broad ligament myomas is a safe, effective, and minimally invasive approach for managing complex uterine fibroids. By combining careful preoperative planning, advanced laparoscopic dissection, and meticulous suturing, surgeons can achieve excellent symptomatic relief while preserving uterine function and fertility. Though technically demanding, this procedure offers patients the benefits of reduced pain, shorter hospital stay, minimal scarring, and rapid return to normal activities. With increasing expertise in advanced laparoscopic gynecology, management of these challenging fibroids is shifting toward minimally invasive techniques, enhancing both surgical outcomes and patient satisfaction.