Uterine fibroids, or leiomyomas, are benign tumors of the uterus that occur in nearly 20–40% of women of reproductive age. They vary in size, number, and location, and can lead to symptoms such as heavy menstrual bleeding, pelvic pain, pressure symptoms, infertility, and recurrent miscarriage. While a single fibroid can cause significant symptoms, many women present with multiple myomas, which create additional challenges for surgical management. For years, open abdominal myomectomy was the standard treatment for multiple fibroids, particularly when they were large or numerous. However, with advancements in minimally invasive surgery, laparoscopic myomectomy has become a safe and effective alternative, even for patients with multiple myomas.

Challenges of Multiple Myomas

Multiple fibroids present technical difficulties compared to a single lesion. These include:

Varied Location: Myomas may be intramural, subserosal, or submucous, sometimes requiring multiple uterine incisions.

Increased Surgical Time: Each fibroid must be carefully identified, enucleated, and the defect sutured, which prolongs operative duration.

Higher Blood Loss: Multiple incisions and dissections increase vascular exposure.

Uterine Reconstruction: Repairing several myometrial defects is complex and critical for restoring uterine integrity.

Risk of Adhesions: More tissue handling and suturing raise the risk of postoperative adhesions, which can affect fertility.

Despite these challenges, laparoscopic myomectomy, when performed by an experienced surgeon, achieves excellent results with minimal morbidity.

Surgical Technique

Preoperative Preparation

Correction of anemia is essential due to frequent heavy bleeding in women with multiple fibroids.

Imaging studies like ultrasound or MRI help map the number, size, and location of fibroids to guide surgical planning.

Anesthesia and Port Placement

General anesthesia is used, and three to four ports are placed. In cases with a very enlarged uterus, ports may need to be positioned higher.

Vasopressin Injection

Dilute vasopressin injected into the myometrium significantly reduces bleeding and enhances surgical visibility.

Enucleation of Fibroids

The largest or most symptomatic fibroids are usually removed first.

A precise uterine incision is made over each fibroid bulge, and the myoma is dissected using blunt and sharp techniques.

Uterine Reconstruction

After each fibroid is removed, the myometrial defect is sutured in multiple layers to restore uterine strength.

Laparoscopic suturing techniques such as barbed sutures reduce operative time.

Specimen Retrieval

All fibroids are removed through contained morcellation or a small laparotomy incision, ensuring tissue safety.

Advantages of Laparoscopic Myomectomy for Multiple Myomas

Minimally Invasive Recovery
Patients experience less postoperative pain, shorter hospital stays, and quicker return to normal activities compared to open surgery.

Fertility Preservation
By carefully reconstructing the uterus, laparoscopic myomectomy restores uterine anatomy, thereby improving fertility outcomes in women with multiple fibroids.

Reduced Adhesion Formation
The magnified laparoscopic view allows meticulous hemostasis and minimal tissue trauma, lowering the risk of adhesions that can impact fertility.

Cosmetic Benefit
Small incisions leave minimal scarring, an important consideration for many women.

Simultaneous Management
Multiple fibroids of different types—subserosal, intramural, and even some submucous—can be treated in the same session.

Clinical Considerations

Number and Size of Fibroids: Laparoscopy is feasible for multiple fibroids, even when more than five are present, provided the surgeon has advanced expertise.

Operative Time: Surgery may take longer compared to single myoma removal, but outcomes remain favorable.

Blood Loss: Use of vasoconstrictors, energy devices, and effective suturing techniques is crucial for minimizing bleeding.

Surgeon Expertise: Laparoscopic myomectomy for multiple fibroids is technically demanding and should be performed in specialized centers by experienced surgeons.

Patient Counseling: Patients should be informed about the possibility of conversion to open surgery if fibroids are extremely numerous or technically difficult to remove laparoscopically.

Outcomes and Recovery

Clinical evidence supports the safety and efficacy of laparoscopic myomectomy for multiple fibroids. Patients typically recover within 1–2 weeks, compared to 4–6 weeks after open myomectomy. Most report significant symptom relief, including reduction in heavy bleeding and pelvic pressure. Fertility outcomes are encouraging, as removal of multiple fibroids restores the normal architecture of the uterus. Recurrence can occur, as fibroids tend to regrow in predisposed women, but complete removal of visible myomas during laparoscopy reduces this risk.

Conclusion

Multiple fibroids were once considered a limitation for minimally invasive surgery, but laparoscopic myomectomy has revolutionized their management. It allows safe removal of numerous myomas with excellent outcomes, provided surgical expertise and appropriate patient selection. The advantages of reduced morbidity, rapid recovery, and preservation of fertility make laparoscopic myomectomy the gold standard for treating multiple fibroids in women who wish to retain their uterus. With advancing technology and growing surgeon experience, even complex cases of multiple myomas can now be managed effectively through laparoscopy, offering patients a safer and more patient-friendly alternative to open surgery.