The field of gynecological surgery has undergone a tremendous transformation over the last two decades with the evolution of minimally invasive techniques. Among these, laparoscopic myomectomy and laparoscopic ovarian cystectomy have gained widespread acceptance as safe, effective, and fertility-preserving procedures. When a patient presents with multiple uterine myomas along with an associated paraovarian cyst, laparoscopic management offers the unique advantage of addressing both pathologies in a single surgical session. This not only reduces the need for multiple procedures but also ensures faster recovery, minimal postoperative pain, and better cosmetic outcomes.

Understanding the Pathologies

Uterine Myomas (Fibroids):
Myomas are benign smooth muscle tumors of the uterus that can occur in various locations such as subserosal, intramural, or submucosal. Multiple myomas can distort the uterine architecture, causing symptoms such as heavy menstrual bleeding, pelvic pain, pressure symptoms, infertility, and recurrent miscarriages. For women desiring future fertility or uterine conservation, myomectomy remains the treatment of choice.

Paraovarian Cyst:
Paraovarian cysts arise from the broad ligament, separate from the ovary itself. They are usually benign and asymptomatic, but larger cysts may cause pelvic pain, pressure symptoms, or complications such as torsion. Surgical excision is indicated when the cyst is symptomatic, enlarging, or raises suspicion for malignancy.

Indications for Combined Laparoscopic Surgery

Patients with both multiple uterine myomas and a paraovarian cyst often present with a combination of menorrhagia, dysmenorrhea, infertility, and pelvic discomfort. Indications for a combined laparoscopic approach include:

Symptomatic multiple myomas causing uterine enlargement or menstrual disturbances.

Infertility related to uterine distortion by fibroids.

Paraovarian cysts larger than 5 cm, symptomatic, or with sonographic features requiring excision.

Desire for fertility preservation and minimally invasive management.

Preoperative Evaluation

A thorough evaluation is essential to plan surgery. This includes:

Ultrasound and MRI for mapping the number, size, and location of fibroids, and to characterize the paraovarian cyst.

Complete blood count to assess anemia due to heavy bleeding.

Hormonal profile and tumor markers (such as CA-125) if ovarian pathology is suspected.

Counseling regarding the risks of recurrence, adhesion formation, and potential need for conversion to laparotomy in rare cases.

Surgical Technique

Anesthesia and Positioning:
The patient is placed in lithotomy position under general anesthesia. After establishing pneumoperitoneum, trocars are introduced, typically using a three or four-port technique.

Step 1: Assessment of Pelvis and Mapping of Pathologies
Initial laparoscopic survey identifies the number and position of uterine myomas and localizes the paraovarian cyst.

Laparoscopic Myomectomy

A uterine incision is made over the most prominent myoma, usually with monopolar energy or harmonic scalpel.

The fibroid is enucleated using traction and countertraction with myoma screw and graspers.

The myoma bed is sutured laparoscopically in layers using delayed absorbable sutures to restore uterine integrity and prevent hematoma.

Multiple fibroids are removed sequentially through similar incisions.

Laparoscopic Ovarian Cystectomy for Paraovarian Cyst

The paraovarian cyst is carefully dissected from the broad ligament while preserving surrounding structures, especially the fallopian tube and ovary.

The cyst is excised without spillage, and the peritoneum is closed if required.

Specimen Retrieval:
Morcellation is employed to remove fibroids, while the paraovarian cyst is usually retrieved in an endoscopic bag to prevent spillage.

Hemostasis and Adhesion Prevention:
Meticulous hemostasis is ensured. Adhesion prevention strategies, such as copious irrigation and application of anti-adhesion barriers, may be employed, especially in fertility-preserving cases.

Postoperative Care

Patients undergoing combined laparoscopic myomectomy and cystectomy typically recover quickly. Early ambulation is encouraged within hours after surgery. Oral intake can usually be resumed the same day. Hospital stay is generally limited to 24–48 hours. Postoperative analgesic requirement is minimal compared to open surgery. Patients are advised to avoid conception for at least 3–6 months to allow proper healing of the uterus.

Advantages of Combined Laparoscopic Approach

Single anesthesia and surgery for both pathologies.

Minimally invasive with reduced postoperative pain and shorter hospital stay.

Fertility preservation by restoring normal uterine anatomy and conserving ovarian tissue.

Excellent cosmetic outcome due to small incisions.

Faster return to normal activities.

Conclusion

Laparoscopic myomectomy combined with ovarian cystectomy for multiple myomas and a paraovarian cyst represents a comprehensive, minimally invasive surgical solution. It allows simultaneous management of uterine and adnexal pathology with preservation of reproductive potential and improved quality of life. With advances in laparoscopic instrumentation and surgical expertise, such combined procedures have become safe, efficient, and increasingly preferred by both surgeons and patients. Proper patient selection, preoperative planning, and meticulous surgical technique are the cornerstones of successful outcomes in these complex but rewarding procedures.