Advances in minimally invasive surgery have made it possible to manage multiple pathologies in a single operative setting. Performing laparoscopic myomectomy for a large fibroid uterus and laparoscopic cholecystectomy for gallbladder disease in the same patient, using only three ports, demonstrates the versatility and precision of modern laparoscopic techniques. This combined approach minimizes patient morbidity, reduces operative time, and shortens hospital stay, while avoiding the need for two separate surgeries.

Clinical Considerations

Patients with a large fibroid uterus often present with symptoms such as abnormal uterine bleeding, pelvic pain, pressure symptoms, and infertility. Simultaneously, gallbladder disease, most commonly cholelithiasis, may cause right upper quadrant pain, dyspepsia, nausea, or episodes of acute cholecystitis.

Traditionally, these conditions would have required two separate operations, but laparoscopic surgery allows for safe, effective, and minimally invasive management of both in the same sitting. However, careful patient selection, preoperative planning, and advanced surgical expertise are crucial to avoid complications.

Preoperative Evaluation

Imaging studies: Transvaginal ultrasound or MRI for fibroid assessment and abdominal ultrasound for gallbladder pathology.

Laboratory tests: Complete blood count, liver function tests, renal function, coagulation profile, and hormonal evaluation when necessary.

Anesthesia assessment: Given that two procedures will be performed in one sitting, a thorough pre-anesthetic evaluation is essential.

Counseling: Patients should be counseled regarding the benefits of combined surgery, risks of prolonged anesthesia, and fertility implications of myomectomy.

Patient Positioning and Anesthesia

The procedure is performed under general anesthesia. The patient is placed in the supine lithotomy position with a slight reverse Trendelenburg tilt during cholecystectomy and a Trendelenburg tilt during myomectomy. A Foley catheter is inserted for bladder decompression.

Three-Port Technique

Unlike conventional multiport laparoscopic procedures, this combined surgery is performed with only three ports, optimizing access and minimizing abdominal trauma.

Umbilical port (10 mm): For the laparoscope.

Epigastric port (5 mm or 10 mm): For dissection instruments or energy devices.

Lateral port (5 mm): For retraction, suturing, and assistance.

This port configuration allows surgeons to access both the upper abdomen for gallbladder surgery and the pelvis for fibroid removal without requiring additional incisions.

Laparoscopic Cholecystectomy

The gallbladder is visualized, and the Calot’s triangle is carefully dissected to identify the cystic duct and cystic artery.

Critical view of safety is ensured before clipping and dividing the cystic duct and artery.

The gallbladder is separated from the liver bed using electrocautery or harmonic scalpel.

The specimen is retrieved in an endobag through the umbilical or epigastric port.

Hemostasis is checked, and the operative field is irrigated if necessary.

By addressing the gallbladder first, the upper abdominal field is completed, allowing focus to shift to the pelvic surgery.

Laparoscopic Myomectomy for Large Fibroid Uterus

The uterus is inspected, and the large fibroid is identified.

A diluted vasopressin solution is injected into the myometrium to reduce blood loss.

A linear incision is made over the fibroid using monopolar scissors or harmonic scalpel.

The fibroid is enucleated with a traction-countertraction technique, exposing the cleavage plane.

Bleeding from the myoma bed is controlled using bipolar cautery.

Uterine reconstruction: Multilayer intracorporeal suturing is performed to restore uterine integrity. Barbed sutures are often used to reduce operative time.

The fibroid specimen is retrieved using contained morcellation through one of the existing ports.

Specimen Retrieval

Both the gallbladder and fibroid specimens are removed in containment bags to prevent tissue spillage. In some cases, the umbilical port may be slightly extended to facilitate safe retrieval.

Postoperative Care

Patients are monitored for hemodynamic stability, urine output, and signs of bleeding.

Pain management typically requires only oral analgesics due to the minimally invasive approach.

Early ambulation is encouraged to reduce thromboembolic risk.

Most patients are discharged within 48–72 hours.

Follow-up includes monitoring wound healing, liver function recovery, and uterine healing for those planning future pregnancies.

Advantages of Combined Three-Port Surgery

Single anesthesia exposure: Avoids the risks of two separate operations.

Fewer incisions: Reduced postoperative pain, minimal scarring, and lower risk of port-site complications.

Shorter hospital stay: Faster recovery and earlier return to normal activities.

Cost-effectiveness: Reduces overall healthcare expenditure.

Fertility preservation: Myomectomy restores uterine anatomy for women desiring pregnancy.

Conclusion

Laparoscopic myomectomy for a large fibroid uterus combined with laparoscopic cholecystectomy using three ports is a technically advanced yet highly effective procedure that demonstrates the potential of minimally invasive surgery. With meticulous planning, precise execution, and expertise in advanced laparoscopy, surgeons can safely treat two distinct pathologies in a single session. This approach not only reduces surgical trauma and hospital stay but also enhances patient satisfaction, making it a valuable option in select patients requiring management of both fibroid uterus and gallbladder disease.