Uterine fibroids, or leiomyomas, are the most common benign tumors of the uterus, affecting women in their reproductive years. Among the different types—subserosal, submucosal, and intramural—intramural fibroids are the most prevalent. They originate within the myometrium and can enlarge the uterine wall, sometimes distorting the uterine cavity. Intramural fibroids are frequently associated with infertility, heavy menstrual bleeding, pelvic pain, and pressure symptoms. With the advancement of minimally invasive surgery, laparoscopic myomectomy has emerged as the gold standard for the management of intramural fibroids in women who wish to preserve fertility or retain their uterus.

Clinical Significance of Intramural Fibroids

Intramural fibroids account for a majority of symptomatic cases. Their clinical relevance lies in their potential to:

Cause menorrhagia and dysmenorrhea due to disruption of uterine contractility.

Lead to infertility by altering endometrial receptivity and impairing implantation.

Exert pressure on adjacent pelvic organs, producing urinary frequency, retention, or constipation.

Increase the risk of miscarriage, especially when they distort the endometrial cavity.

Thus, surgical removal is often recommended in women with significant symptoms or those seeking pregnancy.

Diagnosis

Accurate diagnosis and characterization are essential before proceeding with surgical management.

Ultrasound: Transvaginal ultrasound is the first-line investigation, useful in assessing the size, number, and location of fibroids.

MRI: Provides precise mapping, particularly in cases of multiple or large intramural fibroids, and is valuable in surgical planning.

Hysterosonography or Hysteroscopy: Useful to evaluate cavity distortion in intramural fibroids with submucosal extension.

Indications for Laparoscopic Myomectomy

Laparoscopic management of intramural fibroid is indicated when:

Fibroid is symptomatic (pain, pressure, abnormal bleeding).

Infertility is associated with fibroid-induced cavity distortion.

Size of fibroid is moderate to large (>4–5 cm) and accessible laparoscopically.

Patient desires fertility preservation or wishes to avoid hysterectomy.

Surgical Technique of Laparoscopic Myomectomy

Preoperative Preparation

Patients are optimized with hemoglobin correction and, if needed, preoperative GnRH analogs to shrink fibroids and reduce vascularity.

Prophylactic antibiotics are administered before induction of anesthesia.

Patient Positioning and Port Placement

The patient is placed in the lithotomy position under general anesthesia.

Pneumoperitoneum is established, and three to four laparoscopic ports are placed strategically to facilitate instrument movement and suturing.

Uterine Incision and Myoma Enucleation

A dilute vasopressin solution is injected into the myometrium overlying the fibroid to minimize blood loss.

A linear serosal incision is made using monopolar energy or harmonic scalpel.

The fibroid is grasped with a myoma screw and carefully enucleated by blunt and sharp dissection, ensuring minimal damage to surrounding myometrium.

Hemostasis and Myometrial Closure

Meticulous hemostasis is achieved using bipolar energy.

The myometrial defect is closed in multiple layers with delayed absorbable sutures to restore uterine integrity and reduce the risk of rupture in subsequent pregnancies. Intracorporeal suturing skills are critical at this stage.

Morcellation and Specimen Retrieval

The excised fibroid is typically removed by morcellation through a trocar site.

In select cases, contained morcellation or mini-laparotomy is performed to avoid tissue spillage.

 Final Inspection and Adhesion Prevention

The uterine surface is inspected for bleeding.

Copious irrigation is performed, and adhesion-prevention barriers may be applied to minimize postoperative adhesion formation.

Postoperative Management

Patients are usually discharged within 24–48 hours due to the minimally invasive nature of the procedure.

Analgesics and antibiotics are administered as required.

Normal activity can resume within a week, though heavy lifting and strenuous activity are avoided for 4–6 weeks.

Patients are advised to delay conception for at least 3–6 months to allow complete myometrial healing.

Advantages of Laparoscopic Management

Minimally invasive: Smaller incisions, less postoperative pain, and faster recovery.

Cosmetic benefit: Minimal scarring compared to laparotomy.

Reduced blood loss: With vasopressin infiltration and meticulous hemostasis.

Preservation of fertility: Restores normal uterine anatomy, enhancing reproductive outcomes.

Short hospital stay: Faster return to normal life and work.

Lower adhesion formation: Compared to open myomectomy.

Challenges and Considerations

Requires advanced laparoscopic skills, especially for suturing large defects.

Risk of intraoperative bleeding, particularly with large or multiple fibroids.

Recurrence is possible, as fibroids may develop again in future years.

Uterine rupture in future pregnancy, though rare, is a recognized complication if myometrial repair is inadequate.

Morcellation raises concerns about the rare possibility of disseminating undiagnosed malignancy, making patient selection and counseling vital.

Conclusion

Intramural fibroids, although benign, can significantly impair a woman’s quality of life and reproductive potential. Laparoscopic myomectomy is the gold standard for their surgical management, offering the dual benefit of symptom relief and fertility preservation. With precise preoperative evaluation, meticulous surgical technique, and careful postoperative care, laparoscopic management ensures excellent outcomes. While challenges such as recurrence and surgical expertise remain, the advantages of minimally invasive surgery make it the preferred option in modern gynecology for women with symptomatic intramural fibroids.