Uterine fibroids, also known as leiomyomas, are the most common benign tumors of the uterus and are found in up to 70% of women by the age of 50. They differ in size, location, and number, and may cause a wide range of symptoms such as heavy menstrual bleeding, pelvic pain, pressure on adjacent organs, infertility, and recurrent miscarriage. Among them, intramural fibroids—those arising within the muscular wall of the uterus—are the most frequent and often the most symptomatic. When an intramural fibroid becomes very large, it not only distorts uterine anatomy but also significantly compromises quality of life. Laparoscopic myomectomy has become the preferred surgical option for women desiring uterine conservation, even in the presence of big fibroid uteri.

Clinical Presentation of Big Intramural Fibroids

Women with large intramural fibroids commonly present with:

Menorrhagia and dysmenorrhea, leading to anemia.

Pelvic pain and pressure, often radiating to the back or thighs.

Urinary frequency or constipation from pressure on bladder or rectum.

Abdominal distension, mimicking pregnancy or an ovarian tumor.

Infertility and miscarriage, due to disruption of uterine contractility and implantation.

On examination, the uterus may be enlarged to the size of a 14–20 week pregnancy. Imaging with ultrasound or MRI confirms the size, number, and location of fibroids and helps plan the surgical approach.

Why Laparoscopic Myomectomy?

Historically, big intramural fibroids were treated by open abdominal myomectomy or hysterectomy. However, laparoscopic myomectomy has been shown to be safe and feasible in experienced hands, offering several advantages:

Smaller incisions with superior cosmetic outcomes.

Reduced intraoperative blood loss due to magnified visualization and precise dissection.

Shorter hospital stay and faster return to daily activities.

Lower postoperative pain and minimal need for narcotics.

Reduced adhesion formation, which is especially important for fertility preservation.

For women of reproductive age who want to retain their uterus, laparoscopy provides a minimally invasive yet effective solution, even for large fibroids.

Preoperative Preparation

Patients with large fibroid uterus often require special preparation:

Correction of anemia through iron therapy or transfusion.

Preoperative imaging to assess fibroid characteristics and exclude sarcomatous changes.

GnRH analogs may be given for 2–3 months to shrink fibroid size and reduce vascularity, though this is optional and depends on surgeon preference.

Counseling regarding the possibility of conversion to laparotomy in rare cases of uncontrolled bleeding or technical limitations.

Surgical Technique

Anesthesia and Positioning

General anesthesia is administered.

The patient is placed in lithotomy position with Trendelenburg tilt to displace bowel loops.

Port Placement

A 10 mm umbilical port is introduced for the laparoscope.

Two or three additional 5 mm working ports are inserted under vision.

For a very large uterus, ports may be placed higher to provide better access.

Vasopressin Injection

Diluted vasopressin is injected into the myometrium around the fibroid to minimize bleeding.

Uterine Incision

A vertical or transverse incision is made over the fibroid using monopolar scissors or harmonic scalpel.

Enucleation of the Fibroid

The fibroid is dissected out from its pseudocapsule using a combination of blunt and sharp dissection.

Bipolar energy or advanced vessel sealing devices are used for hemostasis.

Uterine Reconstruction

The myometrial defect is sutured in multiple layers using laparoscopic intracorporeal suturing techniques.

This step is critical to restore uterine strength and prevent rupture during subsequent pregnancies.

Specimen Retrieval

The fibroid is removed by contained morcellation or via a small laparotomy incision, depending on size and safety protocols.

Intraoperative Challenges

Managing big intramural fibroids laparoscopically can be technically demanding. Challenges include:

Limited working space in the abdomen due to enlarged uterus.

Increased vascularity, raising the risk of blood loss.

Difficulty in enucleation, as larger fibroids are embedded deep within the myometrium.

Specimen extraction, requiring safe morcellation techniques.

Only skilled laparoscopic surgeons with advanced suturing expertise should attempt very large fibroids.

Postoperative Care and Recovery

Patients are mobilized within hours of surgery.

Oral intake is resumed the same day.

Hospital discharge typically occurs within 24–48 hours.

Analgesic requirements are minimal compared to open surgery.

Women are advised to avoid pregnancy for at least 6 months to allow adequate uterine healing.

Outcomes

Studies and clinical experience confirm that laparoscopic myomectomy for big intramural fibroids results in:

Significant improvement in symptoms of bleeding and pelvic pain.

Restoration of normal uterine anatomy and fertility potential.

High patient satisfaction due to quick recovery and minimal scarring.

Low rates of recurrence when fibroids are completely removed.

Conclusion

Laparoscopic myomectomy for an intramural big fibroid uterus represents the pinnacle of minimally invasive gynecologic surgery. It combines the benefits of uterine preservation with the advantages of laparoscopy—small incisions, faster recovery, less pain, and improved fertility outcomes. Though technically challenging, especially for large fibroids, with careful preoperative planning, meticulous surgical technique, and advanced laparoscopic skills, it is a safe and effective option. For women suffering from symptomatic large intramural fibroids, this procedure offers not only relief from distressing symptoms but also the promise of restored reproductive health and improved quality of life.