Uterine fibroids are the most common benign tumors of the female genital tract, affecting women in their reproductive years. While many fibroids remain asymptomatic, intramural fibroids, particularly those located in the posterior uterine wall, may produce significant symptoms such as heavy menstrual bleeding, dysmenorrhea, pelvic pain, or pressure on the rectum. Management becomes especially challenging in unmarried girls, where preserving uterine integrity and avoiding compromise to reproductive potential is paramount. In such cases, laparoscopic myomectomy provides a minimally invasive, fertility-sparing surgical option.

Clinical Significance of Posterior Intramural Fibroids

Posterior wall intramural fibroids can cause unique clinical problems due to their location. They often:

Distort the endometrial cavity, contributing to infertility and menstrual irregularities.

Cause backache or rectal pressure, leading to constipation and painful defecation.

Make the uterus bulky and retroverted, complicating future conception.

In unmarried patients, the psychological distress of abdominal distension or pelvic pain adds to the clinical concern. Early intervention helps preserve normal anatomy and improve future fertility prospects.

Diagnostic Evaluation

Accurate diagnosis is crucial before surgical planning:

Ultrasound (transabdominal or transrectal in unmarried girls) identifies the fibroid’s size, location, and number.

MRI is particularly useful for posterior intramural fibroids, providing detailed mapping and helping differentiate fibroids from adenomyosis.

Blood tests assess hemoglobin levels, as menorrhagia is common.

Since vaginal instrumentation may be culturally sensitive in unmarried girls, non-invasive diagnostic methods are preferred.

Rationale for Laparoscopic Myomectomy

Traditionally, open myomectomy was considered for large or deep intramural fibroids. However, laparoscopy offers several advantages:

Cosmetic benefits with tiny scars, important for young unmarried women.

Faster recovery and minimal hospital stay.

Reduced adhesion formation, preserving fertility potential.

Precise dissection and suturing, aided by magnified visualization.

Most importantly, it allows uterine preservation, ensuring reproductive capacity is maintained.

Preoperative Preparation

Correction of anemia with iron supplementation or blood transfusion.

Bowel preparation to improve surgical field visibility.

Counseling the patient and family about fertility-sparing intent, surgical risks, and possibility of laparotomy conversion in rare cases.

GnRH analogs may be used selectively to shrink large fibroids and reduce vascularity, though routine use is debated.

Surgical Technique

Anesthesia and Positioning

The patient is placed under general anesthesia in lithotomy position with Trendelenburg tilt.

Port Placement

A 10 mm umbilical port for the laparoscope and two or three accessory ports are inserted under vision.

High port placement may be required in case of a large uterus.

Exposure of Posterior Uterus

The uterus is manipulated to expose the posterior wall. Care is taken to avoid vaginal instrumentation in unmarried girls, so uterine manipulators are replaced with alternatives such as myoma screws or external uterine handling techniques.

Vasopressin Injection

Diluted vasopressin is injected around the fibroid to minimize bleeding.

Uterine Incision and Fibroid Enucleation

A vertical incision is made over the posterior uterine wall.

The fibroid is carefully dissected out from its pseudocapsule using blunt and sharp dissection.

Hemostasis is achieved with bipolar coagulation.

Uterine Reconstruction

The myometrial defect is sutured in multiple layers with absorbable sutures to restore uterine integrity.

Proper closure is essential to prevent uterine rupture in future pregnancies.

Specimen Retrieval

The fibroid is removed using contained morcellation or through a small incision, depending on size.

Challenges in Posterior Intramural Fibroid Surgery

Difficult access to the posterior uterine wall.

Risk of rectal injury, given the proximity to the rectum.

Increased bleeding, as posterior wall fibroids are often highly vascular.

Absence of uterine manipulator, requiring alternative exposure techniques in unmarried girls.

These challenges demand advanced laparoscopic expertise and careful intraoperative planning.

Postoperative Care

Early mobilization and resumption of diet within hours of surgery.

Hospital discharge within 24–48 hours.

Analgesics are required only for a short duration.

Long-term follow-up ensures proper healing and monitoring for recurrence.

Patients are advised to delay conception for at least six months to allow complete myometrial healing.

Fertility and Psychological Benefits

For an unmarried girl, the procedure provides not just physical relief but also psychological reassurance. The uterus is preserved, cosmetic scars are minimal, and the chances of normal conception in the future remain intact. Laparoscopic myomectomy helps avoid stigma, protects body image, and maintains reproductive potential—factors of immense importance in this group of patients.

Conclusion

Laparoscopic myomectomy for posterior intramural fibroid in an unmarried girl is a safe, effective, and fertility-sparing surgical approach. While technically demanding due to fibroid location and limitations in uterine manipulation, it offers distinct benefits of minimal invasiveness, quicker recovery, and superior cosmetic results. With meticulous surgical technique and careful preoperative planning, laparoscopic myomectomy ensures symptom relief, preserves reproductive health, and addresses the unique social and emotional needs of unmarried women with fibroids.