Uterine fibroids, or leiomyomas, are the most common benign tumors affecting women of reproductive age. While most fibroids develop within the uterine wall (intramural), on the outer surface (subserosal), or inside the uterine cavity (submucosal), a small percentage arise in unusual locations such as the broad ligament. Broad ligament myomas, also known as extrauterine or parametrium fibroids, are rare but pose unique surgical challenges due to their proximity to major pelvic vessels, ureters, and adjacent organs.

Laparoscopic myomectomy has become the preferred minimally invasive approach for managing broad ligament myomas, offering reduced postoperative pain, faster recovery, shorter hospital stay, and excellent cosmetic results while preserving uterine and reproductive function.

Anatomy and Challenges of Broad Ligament Myomas

The broad ligament is a peritoneal fold that attaches the uterus to the lateral pelvic walls and contains important structures including the uterine artery, veins, ureters, and pelvic nerves. Broad ligament myomas are classified as true broad ligament fibroids if they arise from the connective tissue of the ligament, or as false broad ligament fibroids if they originate from the lateral uterine wall and extend into the ligament.

Surgical removal of broad ligament myomas is challenging because:

They are closely related to major vessels and ureters, increasing the risk of injury.

They may distort pelvic anatomy, making laparoscopic access more difficult.

Large myomas can compress surrounding organs, complicating dissection.

Preoperative Evaluation

Comprehensive preoperative assessment is essential for safe surgery. Imaging studies such as ultrasound, MRI, or CT scans are used to determine the size, location, and relationship of the myoma with surrounding structures, particularly the ureters and pelvic vessels. Blood tests are conducted to check hemoglobin, coagulation profile, and overall fitness for surgery.

Preoperative counseling covers the procedure, potential risks (such as ureteral or vascular injury), postoperative recovery, and implications for future fertility. In selected cases, GnRH analog therapy may be administered to reduce fibroid size and vascularity.

Patient Preparation and Positioning

The procedure is performed under general anesthesia. The patient is placed in the dorsal lithotomy position with Trendelenburg tilt to allow bowel loops to move away from the pelvis. A Foley catheter is inserted to decompress the bladder. Standard aseptic preparation and prophylactic antibiotics are administered.

Laparoscopic Access and Port Placement

Pneumoperitoneum is created using either a Veress needle or an open (Hasson) technique. A 10 mm umbilical port is used for the laparoscope, and two or three 5 mm accessory ports are placed in the lower abdomen to allow optimal triangulation for enucleation, dissection, and suturing.

Identification and Enucleation of Broad Ligament Myoma

The uterus and broad ligament are inspected, and the myoma is carefully localized. Special care is taken to identify the ureters and uterine vessels. Diluted vasopressin is injected into the myoma capsule to reduce intraoperative bleeding.

A careful incision is made over the myoma, and traction-countertraction technique is used to enucleate the tumor. Broad ligament myomas often require meticulous dissection from surrounding structures to avoid ureteral injury or vascular compromise.

Hemostasis

Bleeding is controlled using bipolar cautery or advanced energy devices. Maintaining precise hemostasis is critical given the proximity of major pelvic vessels and the potential for significant blood loss.

Uterine and Broad Ligament Reconstruction

After enucleation, any defect in the uterus is repaired with multilayer suturing, particularly if the myoma had a significant uterine attachment. The broad ligament peritoneum is approximated carefully to restore anatomy and prevent adhesions. Barbed sutures or delayed absorbable sutures are often used for efficiency and strength.

Specimen Retrieval

The excised myoma is removed through contained morcellation or mini-laparotomy depending on size. Contained morcellation is preferred to avoid intra-abdominal tissue dissemination and reduce the risk of parasitic fibroid formation.

Final Inspection and Adhesion Prevention

The surgical field is irrigated with warm saline, hemostasis is confirmed, and adhesion barriers such as oxidized regenerated cellulose or hyaluronic acid gel may be applied. Ports are removed, and skin incisions are closed meticulously.

Postoperative Care

Recovery after laparoscopic myomectomy for broad ligament myomas is usually rapid. Most patients are discharged within 24–48 hours. Pain is managed with oral analgesics, and early ambulation is encouraged. Patients are advised to delay conception for 3–6 months to allow complete healing, especially if the uterus was involved. Follow-up imaging may be performed to assess uterine integrity and ensure complete removal of the myoma.

Advantages of Laparoscopic Myomectomy for Broad Ligament Myomas

Minimally invasive with smaller incisions and faster recovery

Preservation of fertility and uterine function

Safe removal of large or complex myomas with careful dissection

Reduced intraoperative blood loss through vasopressin injection and meticulous hemostasis

Lower risk of adhesion formation with precise reconstruction

Shorter hospital stay and early return to normal activities

Conclusion

Laparoscopic myomectomy for broad ligament myomas is a safe and effective minimally invasive procedure when performed by experienced surgeons. With careful preoperative planning, meticulous identification of ureters and vessels, precise enucleation, and multilayer reconstruction, excellent surgical outcomes can be achieved. This approach ensures symptom relief, preservation of reproductive potential, and faster recovery, making it the preferred choice for women with rare and complex broad ligament fibroids.