Laparoscopic Myomectomy Lecture By Dr R K Mishra
Laparoscopic myomectomy has transformed the management of uterine fibroids, offering a minimally invasive alternative to traditional open surgery while preserving fertility and uterine integrity. Dr. R K Mishra, a globally recognized laparoscopic surgeon and founder of the World Laparoscopy Hospital, has delivered numerous lectures emphasizing the principles, techniques, and benefits of laparoscopic myomectomy. His teachings provide valuable insights for surgeons, residents, and gynecologists aiming to master advanced minimally invasive procedures.
Introduction to Laparoscopic Myomectomy
Uterine fibroids, or leiomyomas, are the most common benign tumors in women of reproductive age. They can be located subserously, intramurally, or submucosally. Symptoms such as abnormal uterine bleeding, pelvic pain, pressure effects on the bladder or bowel, and infertility often necessitate surgical intervention.
While hysteroscopic myomectomy is suitable for small submucosal fibroids, laparoscopic myomectomy is preferred for large, intramural, or multiple fibroids. The minimally invasive approach ensures reduced postoperative pain, faster recovery, shorter hospital stays, and excellent cosmetic results, making it the procedure of choice in carefully selected patients.
Key Highlights from Dr. Mishra’s Lecture
Dr. Mishra emphasizes that laparoscopic myomectomy requires a structured approach combining surgical precision, advanced instrumentation, and an understanding of uterine anatomy. Some of the key teaching points from his lecture include:
Preoperative Assessment:
Comprehensive imaging using transvaginal ultrasound and MRI to determine fibroid size, number, location, and relation to the uterine cavity.
Laboratory investigations including hemoglobin, coagulation profile, and general health assessment.
Consideration of preoperative GnRH analog therapy to reduce fibroid size and vascularity, especially for large or multiple fibroids.
Patient counseling about fertility preservation, recovery, and potential risks.
Patient Positioning and Anesthesia:
The procedure is performed under general anesthesia.
The patient is positioned in the dorsal lithotomy position with Trendelenburg tilt, allowing bowel loops to move away from the pelvis.
A Foley catheter is inserted to keep the bladder decompressed.
Port Placement and Laparoscopic Access:
Pneumoperitoneum is established using a Veress needle or open technique.
A 10 mm umbilical port is used for the laparoscope, with two or three 5 mm accessory ports placed in the lower abdomen to provide optimal instrument triangulation for enucleation and suturing.
Fibroid Identification and Enucleation:
The uterus is inspected, and fibroids are localized.
Diluted vasopressin is injected into the myometrium overlying the fibroid to reduce intraoperative bleeding.
A linear incision is made over the fibroid, and enucleation is performed using traction-countertraction technique along the natural cleavage plane.
Large or multiple fibroids may be removed in pieces (piecemeal excision) for safe retrieval.
Hemostasis:
Bleeding from the myoma bed is controlled using bipolar cautery or advanced energy devices.
Meticulous hemostasis is critical to reduce postoperative hematoma formation and adhesion development.
Uterine Reconstruction:
Multilayer closure of the uterine wall is essential, especially for large or deep fibroids.
Deep myometrial layer: Closed with delayed absorbable sutures to restore uterine strength.
Serosal layer: Approximated with continuous or interrupted sutures, often using barbed sutures to minimize adhesions and reduce operative time.
Proper closure ensures uterine integrity for future pregnancies and reduces the risk of rupture.
Specimen Retrieval:
Excised fibroids are removed via contained morcellation or a mini-laparotomy incision depending on size.
Contained morcellation prevents tissue dissemination and parasitic fibroid formation.
Final Inspection and Adhesion Prevention:
The pelvis is irrigated, hemostasis confirmed, and adhesion barriers may be applied over the uterine repair site.
Ports are removed and skin incisions closed meticulously.
Advantages Highlighted by Dr. Mishra
Minimally invasive approach with faster recovery and minimal scarring.
Preservation of fertility and uterine function.
Ability to remove large, multiple, or deep intramural fibroids safely.
Reduced intraoperative blood loss and postoperative complications.
Shorter hospital stay and early return to daily activities.
Dr. Mishra emphasizes that the success of laparoscopic myomectomy depends not only on surgical technique but also on careful patient selection, preoperative planning, and postoperative care.
Conclusion
The laparoscopic myomectomy lecture by Dr. R K Mishra provides a comprehensive roadmap for performing minimally invasive fibroid surgery with precision and safety. His structured approach, attention to detail, and focus on fertility preservation make this procedure accessible and reproducible for surgeons worldwide. With proper training, laparoscopic myomectomy offers women an effective, minimally invasive solution for fibroid-related symptoms while ensuring optimal reproductive outcomes.
Introduction to Laparoscopic Myomectomy
Uterine fibroids, or leiomyomas, are the most common benign tumors in women of reproductive age. They can be located subserously, intramurally, or submucosally. Symptoms such as abnormal uterine bleeding, pelvic pain, pressure effects on the bladder or bowel, and infertility often necessitate surgical intervention.
While hysteroscopic myomectomy is suitable for small submucosal fibroids, laparoscopic myomectomy is preferred for large, intramural, or multiple fibroids. The minimally invasive approach ensures reduced postoperative pain, faster recovery, shorter hospital stays, and excellent cosmetic results, making it the procedure of choice in carefully selected patients.
Key Highlights from Dr. Mishra’s Lecture
Dr. Mishra emphasizes that laparoscopic myomectomy requires a structured approach combining surgical precision, advanced instrumentation, and an understanding of uterine anatomy. Some of the key teaching points from his lecture include:
Preoperative Assessment:
Comprehensive imaging using transvaginal ultrasound and MRI to determine fibroid size, number, location, and relation to the uterine cavity.
Laboratory investigations including hemoglobin, coagulation profile, and general health assessment.
Consideration of preoperative GnRH analog therapy to reduce fibroid size and vascularity, especially for large or multiple fibroids.
Patient counseling about fertility preservation, recovery, and potential risks.
Patient Positioning and Anesthesia:
The procedure is performed under general anesthesia.
The patient is positioned in the dorsal lithotomy position with Trendelenburg tilt, allowing bowel loops to move away from the pelvis.
A Foley catheter is inserted to keep the bladder decompressed.
Port Placement and Laparoscopic Access:
Pneumoperitoneum is established using a Veress needle or open technique.
A 10 mm umbilical port is used for the laparoscope, with two or three 5 mm accessory ports placed in the lower abdomen to provide optimal instrument triangulation for enucleation and suturing.
Fibroid Identification and Enucleation:
The uterus is inspected, and fibroids are localized.
Diluted vasopressin is injected into the myometrium overlying the fibroid to reduce intraoperative bleeding.
A linear incision is made over the fibroid, and enucleation is performed using traction-countertraction technique along the natural cleavage plane.
Large or multiple fibroids may be removed in pieces (piecemeal excision) for safe retrieval.
Hemostasis:
Bleeding from the myoma bed is controlled using bipolar cautery or advanced energy devices.
Meticulous hemostasis is critical to reduce postoperative hematoma formation and adhesion development.
Uterine Reconstruction:
Multilayer closure of the uterine wall is essential, especially for large or deep fibroids.
Deep myometrial layer: Closed with delayed absorbable sutures to restore uterine strength.
Serosal layer: Approximated with continuous or interrupted sutures, often using barbed sutures to minimize adhesions and reduce operative time.
Proper closure ensures uterine integrity for future pregnancies and reduces the risk of rupture.
Specimen Retrieval:
Excised fibroids are removed via contained morcellation or a mini-laparotomy incision depending on size.
Contained morcellation prevents tissue dissemination and parasitic fibroid formation.
Final Inspection and Adhesion Prevention:
The pelvis is irrigated, hemostasis confirmed, and adhesion barriers may be applied over the uterine repair site.
Ports are removed and skin incisions closed meticulously.
Advantages Highlighted by Dr. Mishra
Minimally invasive approach with faster recovery and minimal scarring.
Preservation of fertility and uterine function.
Ability to remove large, multiple, or deep intramural fibroids safely.
Reduced intraoperative blood loss and postoperative complications.
Shorter hospital stay and early return to daily activities.
Dr. Mishra emphasizes that the success of laparoscopic myomectomy depends not only on surgical technique but also on careful patient selection, preoperative planning, and postoperative care.
Conclusion
The laparoscopic myomectomy lecture by Dr. R K Mishra provides a comprehensive roadmap for performing minimally invasive fibroid surgery with precision and safety. His structured approach, attention to detail, and focus on fertility preservation make this procedure accessible and reproducible for surgeons worldwide. With proper training, laparoscopic myomectomy offers women an effective, minimally invasive solution for fibroid-related symptoms while ensuring optimal reproductive outcomes.
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