Uterine fibroids, or leiomyomas, are benign tumors of the uterine smooth muscle that frequently affect women of reproductive age. Among the different types of fibroids, intramural myomas are the most common. They develop within the muscular wall of the uterus and can enlarge the uterus, distort its shape, and contribute to heavy menstrual bleeding, pelvic pain, infertility, or recurrent miscarriage. The surgical management of intramural myomas depends largely on their size, location, and the patient’s reproductive goals. While smaller fibroids can be managed with conservative or minimally invasive approaches, large intramural myomas pose significant challenges. Laparoscopic myomectomy has emerged as a safe and effective method for removing even large intramural fibroids while preserving the uterus and improving fertility outcomes.

Challenges of Large Intramural Myomas

Large intramural fibroids, particularly those greater than 8–10 cm, present unique difficulties in surgical management. Their size often distorts uterine anatomy, making enucleation and uterine reconstruction more complex. They are usually associated with increased vascularity, which raises the risk of intraoperative blood loss. In addition, intramural myomas are deeply embedded within the myometrium, requiring meticulous surgical dissection to prevent damage to surrounding tissue. These factors previously led many surgeons to prefer open abdominal myomectomy for large fibroids. However, with advances in laparoscopic instruments, energy devices, and suturing techniques, laparoscopic myomectomy has become feasible even for very large intramural fibroids.

The Laparoscopic Approach

Laparoscopic myomectomy is performed through small abdominal incisions, using a laparoscope for visualization and specialized instruments for dissection and suturing. The surgical steps typically include:

Patient Preparation: Preoperative optimization may involve correction of anemia and, in selected cases, short-term use of GnRH analogs to reduce fibroid size and vascularity.

Port Placement: Usually three to four ports are inserted for adequate access.

Uterine Incision: A precise incision is made over the fibroid, often guided by intraoperative ultrasound if the fibroid margins are unclear.

Fibroid Enucleation: The myoma is carefully dissected from the surrounding myometrium. Advanced energy devices and vasoconstrictive agents such as diluted vasopressin are used to minimize bleeding.

Uterine Reconstruction: Multilayer closure of the myometrial defect with laparoscopic suturing restores uterine integrity, crucial for women desiring future pregnancy.

Specimen Retrieval: The fibroid is typically removed using contained morcellation or through a mini-laparotomy, ensuring tissue safety and minimizing the risk of dissemination.

Advantages of Laparoscopic Myomectomy for Large Intramural Myomas

Minimally Invasive Benefits
Compared with open myomectomy, laparoscopic surgery offers smaller incisions, less postoperative pain, shorter hospital stay, and faster return to normal activities.

Reduced Adhesion Formation
The magnified view in laparoscopy allows meticulous hemostasis and minimal tissue handling, which reduces postoperative adhesions—a significant factor in fertility preservation.

Improved Uterine Healing
Advanced laparoscopic suturing ensures secure closure of the myometrial defect. This decreases the risk of uterine rupture during future pregnancies and maintains uterine functionality.

Cosmetic Advantage
Small incisions leave minimal scars, which is often a preference among younger women seeking uterus-preserving surgery.

Fertility Preservation
By removing the fibroid and restoring normal uterine anatomy, laparoscopic myomectomy improves reproductive outcomes, making it the surgery of choice for women planning conception.

Clinical Considerations

Fibroid Size and Location: While laparoscopy is increasingly used for fibroids larger than 10–12 cm, surgical expertise is key to safe outcomes.

Surgeon’s Skill: Advanced laparoscopic suturing and hemostatic techniques are critical in large intramural myoma cases. Surgeons with limited experience may prefer open surgery to avoid complications.

Patient Selection: Ideal candidates are women with symptomatic fibroids, fertility desires, and no contraindications for laparoscopy such as severe cardiopulmonary disease.

Safety Measures: Use of vasopressin, careful dissection planes, and contained morcellation techniques are essential to minimize blood loss and avoid tissue spillage.

Outcomes and Recovery

Studies have demonstrated that laparoscopic myomectomy for large intramural myomas is associated with favorable outcomes comparable to open myomectomy, but with significantly reduced morbidity. Patients generally resume daily activities within 1–2 weeks, as opposed to 4–6 weeks after open surgery. Blood loss is minimized with advanced energy sources and hemostatic agents, and fertility outcomes after laparoscopic removal of large intramural fibroids are encouraging. Women achieve high rates of symptom relief, improved quality of life, and successful pregnancies.

Conclusion

Large intramural myomas were once considered a relative contraindication for laparoscopic management due to technical difficulties and concerns about intraoperative complications. However, with the evolution of laparoscopic technology, surgical expertise, and safe tissue retrieval techniques, laparoscopic myomectomy has become a gold standard for managing even large intramural fibroids. It combines the advantages of minimal invasiveness with effective fibroid removal, uterine preservation, and enhanced fertility outcomes. For women desiring uterine conservation and rapid recovery, laparoscopic myomectomy offers a superior alternative to open surgery in the treatment of large intramural myomas.