Uterine fibroids, also known as leiomyomas, are among the most common benign tumors of the uterus, often affecting women of reproductive age. Depending on their size and location, fibroids can cause heavy menstrual bleeding, pelvic pain, infertility, or recurrent pregnancy loss. Submucous fibroids, which develop beneath the uterine lining and protrude into the cavity, are particularly notorious for causing excessive menstrual bleeding and fertility issues. The management of these fibroids largely depends on their size, number, and the extent to which they distort the endometrial cavity. While hysteroscopic myomectomy is the standard approach for submucous fibroids, large fibroids often present technical challenges that make laparoscopic myomectomy a more suitable alternative.

Understanding the Limitation of Hysteroscopic Myomectomy

Hysteroscopic myomectomy is considered the gold standard for treating small to medium-sized submucous fibroids. This procedure involves the introduction of a hysteroscope through the cervix into the uterine cavity, followed by resection of the fibroid using an electrosurgical loop or morcellator. It is minimally invasive, requires no abdominal incisions, and allows same-day discharge in most cases. However, its effectiveness is largely limited to fibroids less than 4–5 cm in size and those classified as type 0 or type I according to the FIGO classification, meaning they are either entirely within the cavity or have less than 50% intramural extension.

For large submucous fibroids with deep intramural components, hysteroscopic removal becomes technically difficult. Prolonged surgery increases the risks of uterine perforation, fluid overload, incomplete removal, and thermal damage to the endometrium. Moreover, large fibroids often require multiple staged procedures to achieve complete resection, thereby increasing patient discomfort, costs, and surgical risks. These limitations highlight the need for alternative surgical techniques, such as laparoscopic myomectomy, when dealing with large submucous fibroids.

Role of Laparoscopic Myomectomy

Laparoscopic myomectomy is a minimally invasive surgical technique in which fibroids are removed through small abdominal incisions using advanced laparoscopic instruments. Unlike hysteroscopy, which is confined to the uterine cavity, laparoscopy provides direct access to both the serosal and intramural aspects of the uterus. This approach is particularly advantageous in large submucous fibroids with significant intramural extension.

During laparoscopic myomectomy, the surgeon makes a small incision on the uterus, enucleates the fibroid, and meticulously repairs the uterine wall with sutures to maintain structural integrity. Modern laparoscopic suturing techniques and energy devices have made this procedure safer, with reduced blood loss and faster recovery compared to open surgery.

Advantages Over Hysteroscopic Myomectomy

Complete Removal in a Single Sitting
Large submucous fibroids often cannot be fully removed hysteroscopically in one procedure. Laparoscopic myomectomy, on the other hand, allows complete enucleation in a single sitting, minimizing the need for repeat interventions.

Better Access to Intramural Components
Many submucous fibroids extend deep into the myometrium. Laparoscopy enables surgeons to reach and remove these intramural extensions effectively, ensuring complete excision and reducing recurrence.

Preservation of Uterine Integrity
Suturing the uterine defect laparoscopically helps in restoring the myometrial wall and reducing the risk of uterine rupture in future pregnancies, which is difficult to achieve with hysteroscopy.

Reduced Risk of Complications
Risks of hysteroscopic surgery, such as excessive fluid absorption (TURP syndrome), thermal injury, and uterine perforation, are avoided with laparoscopy.

Simultaneous Management of Multiple Fibroids
Women with submucous fibroids often have additional intramural or subserosal fibroids. Laparoscopy provides the flexibility to treat multiple fibroids in the same session, which is not possible with hysteroscopy.

Clinical Considerations

The decision to choose laparoscopic myomectomy over hysteroscopic myomectomy depends on several factors:

Size of Fibroid: Fibroids larger than 5 cm with significant intramural extension are best managed laparoscopically.

Number of Fibroids: Multiple fibroids involving different layers of the uterus make laparoscopy more appropriate.

Patient’s Fertility Goals: Women desiring future pregnancy benefit from laparoscopic myomectomy, as it allows proper closure of the uterine wall.

Surgeon’s Expertise: Successful laparoscopic myomectomy requires advanced skills in suturing and hemostasis, underscoring the importance of surgical experience.

Recovery and Outcomes

Recovery after laparoscopic myomectomy is typically rapid, with most patients discharged within 24–48 hours. Return to normal activities usually occurs within one to two weeks, significantly shorter than open myomectomy. Patients experience reduced pain, minimal scarring, and improved fertility outcomes. Importantly, studies have shown that laparoscopic myomectomy achieves lower recurrence rates compared to incomplete hysteroscopic resections of large fibroids.

Conclusion

While hysteroscopic myomectomy remains the first-line treatment for small submucous fibroids, it is not always ideal for large fibroids with deep intramural involvement. In such cases, laparoscopic myomectomy offers a safe, effective, and fertility-preserving alternative. It ensures complete removal in a single sitting, preserves uterine strength through proper suturing, and allows simultaneous treatment of other fibroids. With advancements in laparoscopic technology and surgical expertise, laparoscopic myomectomy has rightfully emerged as the preferred approach over hysteroscopic myomectomy for large submucous fibroids.