Uterine fibroids, or leiomyomas, are benign smooth muscle tumors of the uterus and are among the most common gynecological problems in women of reproductive age. They vary in size, location, and number, and can cause symptoms such as heavy menstrual bleeding, pelvic pain, infertility, and recurrent pregnancy loss. Among the various types of fibroids, intramural myomas—those that develop within the muscular wall of the uterus—are the most frequent. While small asymptomatic fibroids may not require surgical intervention, symptomatic intramural myomas often necessitate treatment. Laparoscopic myomectomy has emerged as the procedure of choice for women seeking relief from symptoms while preserving fertility and uterine integrity.

Understanding Intramural Myomas

Intramural fibroids grow inside the uterine myometrium and can expand to distort the uterine cavity or surface. They are commonly associated with:

Menorrhagia and dysmenorrhea, due to increased endometrial surface area and impaired uterine contractility.

Pelvic pain and pressure symptoms, particularly when large.

Infertility, either through distortion of the endometrial cavity or impairment of implantation.

Pregnancy complications, such as miscarriage, preterm labor, or malpresentation.

The decision to surgically remove intramural fibroids depends on symptoms, size (often >5 cm), rapid growth, and the patient’s reproductive goals.

Why Laparoscopic Myomectomy?

Historically, abdominal myomectomy was the mainstay for intramural fibroid removal, especially for larger fibroids. However, advances in minimally invasive surgery have made laparoscopy the preferred approach. The benefits of laparoscopic myomectomy include:

Smaller incisions and improved cosmetic outcomes

Reduced blood loss due to magnified visualization and precise dissection

Lower postoperative pain

Shorter hospital stays and quicker return to daily activities

Reduced adhesion formation, which is critical for fertility preservation

These advantages make laparoscopy particularly suitable for reproductive-age women who desire uterine conservation.

Surgical Technique

Dr. R. K. Mishra and other leaders in laparoscopic surgery emphasize a systematic step-by-step approach:

Patient Preparation

Preoperative optimization includes correction of anemia and, in selected cases, administration of GnRH analogs to shrink the fibroid and reduce vascularity.

Imaging with ultrasound or MRI helps in mapping fibroid size, number, and location.

Anesthesia and Positioning

General anesthesia is administered.

The patient is placed in the lithotomy and Trendelenburg position for optimal pelvic exposure.

Port Placement

Typically three or four trocars are inserted.

For large fibroids, ports may be placed higher on the abdominal wall to improve access.

Vasopressin Injection

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

Uterine Incision and Enucleation

A transverse or vertical incision is made on the uterine surface above the fibroid.

Using sharp and blunt dissection, the fibroid is enucleated carefully from its pseudocapsule.

Uterine Repair

The defect is closed in multiple layers using laparoscopic suturing techniques.

This step is vital to restore uterine strength and prevent rupture in subsequent pregnancies.

Specimen Retrieval

The fibroid is removed via contained morcellation or a mini-laparotomy incision to ensure tissue safety.

Clinical Considerations

Fibroid Size: Intramural fibroids up to 12–15 cm can be managed laparoscopically by skilled surgeons.

Number of Fibroids: Multiple intramural fibroids increase surgical complexity but can still be removed laparoscopically.

Fertility Goals: Uterine wall repair is essential for women planning future pregnancies.

Surgeon’s Expertise: Advanced laparoscopic suturing and hemostatic skills are critical for safe outcomes.

Conversion to Open Surgery: In rare cases of uncontrollable bleeding or unclear anatomy, conversion ensures patient safety.

Outcomes and Recovery

Laparoscopic myomectomy has excellent success rates for symptom relief, fertility restoration, and patient satisfaction. Studies show that:

Women typically return to normal activities within 1–2 weeks, compared to 4–6 weeks after open surgery.

Proper uterine repair reduces the risk of rupture during pregnancy to extremely low levels.

Fertility outcomes are significantly improved once the fibroid burden is removed and uterine anatomy restored.

Recurrence can occur, but recurrence rates are lower when intramural fibroids are completely excised.

Conclusion

Laparoscopic myomectomy for intramural myomas is a safe, effective, and fertility-preserving procedure that offers substantial benefits over traditional open surgery. Despite the challenges of managing large or multiple intramural fibroids, advances in laparoscopic techniques and instrumentation have made this minimally invasive option widely applicable. With meticulous surgical planning, skillful enucleation, and proper uterine reconstruction, laparoscopic myomectomy not only relieves symptoms but also restores reproductive potential, making it the treatment of choice for women with symptomatic intramural fibroids who desire uterine conservation.