Uterine fibroids, also called leiomyomas, are the most common benign tumors of the female reproductive system. They arise from the smooth muscle cells of the uterus and vary in size, number, and location. Among the different types, intramural fibroids, which develop within the muscular wall of the uterus, are the most frequent. When intramural fibroids grow to a large size, they can cause severe menstrual bleeding, pelvic pain, pressure symptoms on the bladder or bowel, and significant enlargement of the uterus. In addition, they can interfere with fertility and complicate pregnancy outcomes. Surgical removal remains the most effective treatment for large symptomatic fibroids, especially in women wishing to preserve their uterus. Laparoscopic myomectomy has emerged as a preferred minimally invasive approach, even for a large intramural fibroid uterus, owing to advances in surgical skills and technology.

Clinical Challenges of Large Intramural Fibroids

Large intramural fibroids, often measuring more than 8–10 cm, can distort the uterine cavity and complicate surgical excision. They are deeply embedded in the myometrium, making enucleation technically demanding. Increased vascularity associated with large fibroids also raises the risk of intraoperative bleeding. The enlarged uterus further limits maneuverability in the pelvic cavity, which was once considered a contraindication for laparoscopic surgery. Traditionally, such cases were managed through open abdominal myomectomy. However, with improvements in laparoscopic instruments, hemostatic techniques, and uterine suturing, laparoscopy is now feasible and effective even for large intramural fibroid uteri.

Surgical Technique

The steps of laparoscopic myomectomy for large intramural fibroid uterus are carefully structured to ensure safety and complete fibroid removal:

Preoperative Preparation

Correction of anemia is crucial, as heavy menstrual bleeding is common in these patients.

In select cases, GnRH analogs or selective progesterone receptor modulators may be given preoperatively to reduce fibroid size and vascularity.

Port Placement and Access

Usually three or four laparoscopic ports are placed. In very large uteri, ports may need to be positioned higher than usual to allow adequate access.

Uterine Incision and Enucleation

Dilute vasopressin is injected into the myometrium to minimize blood loss.

A strategic incision is made over the bulge of the fibroid.

The fibroid is carefully dissected and enucleated from its capsule using blunt and sharp dissection.

Myometrial Closure

The defect is meticulously closed in multiple layers using laparoscopic sutures.

This step is critical for restoring uterine strength and preventing rupture during future pregnancies.

Specimen Retrieval

The fibroid is removed by contained morcellation or through a mini-laparotomy incision, ensuring safety and preventing tissue dissemination.

Advantages of Laparoscopic Myomectomy for Large Intramural Fibroids

Minimally Invasive Recovery
Compared to open myomectomy, laparoscopy provides smaller incisions, less postoperative pain, reduced blood loss, and faster recovery. Patients are usually discharged within 24–48 hours.

Uterine Preservation
Laparoscopic suturing allows effective closure of the uterine wall, making the procedure safe for women desiring future pregnancies.

Reduced Adhesions
The magnified view of laparoscopy enables precise dissection with minimal tissue trauma, thereby lowering adhesion formation, which is important for fertility.

Cosmetic and Psychological Benefits
Small incisions and quick recovery are particularly appreciated by younger women who value cosmesis and the ability to return to normal life early.

Clinical Considerations

Fibroid Size and Uterine Volume: While large fibroids once necessitated open surgery, laparoscopy is now routinely performed for fibroids measuring up to 12–15 cm in selected patients.

Surgeon’s Expertise: Advanced skills in laparoscopic suturing and blood loss control are essential to handle large intramural fibroids safely.

Patient Selection: Candidates include women with symptomatic large intramural fibroids, those with infertility, and women who strongly desire uterine conservation.

Safety Protocols: The use of vasoconstrictive agents, energy devices, and careful morcellation techniques are key to minimizing intraoperative and postoperative risks.

Outcomes and Recovery

Clinical studies have shown that laparoscopic myomectomy for large intramural fibroids provides outcomes comparable to open surgery in terms of symptom relief and fertility results, but with far fewer complications and faster recovery. Patients often resume routine activities within one to two weeks. Importantly, when uterine closure is performed correctly, the risk of uterine rupture during pregnancy is extremely low. Fertility outcomes are promising, as the removal of fibroids restores normal uterine anatomy and function.

Conclusion

Managing a large intramural fibroid uterus is a surgical challenge that requires precision, skill, and advanced laparoscopic expertise. Despite the technical difficulties, laparoscopic myomectomy has become the gold standard for many such cases, offering women the benefits of minimal invasiveness, rapid recovery, and uterine preservation. With careful patient selection, meticulous surgical technique, and safe specimen retrieval methods, laparoscopic myomectomy stands as the most effective and patient-friendly option for treating large intramural fibroid uteri.