Uterine fibroids, also called leiomyomas, are the most common benign tumors of the female reproductive system. They are composed of smooth muscle cells and fibrous connective tissue. Depending on their location, they are classified as submucosal, subserosal, cervical, broad ligament, and intramural fibroids. Among these, intramural fibroids, which arise within the muscular wall of the uterus, are the most frequent and often the most symptomatic. They can enlarge the uterus, distort the uterine cavity, and interfere with fertility. For women who wish to retain their uterus, particularly for future childbearing, laparoscopic myomectomy has become the treatment of choice.

Understanding Intramural Fibroids

Intramural fibroids grow within the thickness of the uterine wall. Depending on size and direction of growth, they may protrude toward the endometrial cavity (causing heavy bleeding and infertility) or bulge outward toward the serosal surface (leading to pressure symptoms).

Symptoms commonly include:

Heavy or prolonged menstrual bleeding

Pelvic pain or pressure

Backache and urinary frequency

Difficulty conceiving or recurrent miscarriage

Enlarged uterus detected on examination

While small intramural fibroids can often be managed conservatively, large or symptomatic ones typically require surgical removal.

Why Choose Laparoscopic Myomectomy?

Historically, abdominal myomectomy through laparotomy was the standard approach, particularly for large intramural fibroids. However, advances in minimally invasive surgery have established laparoscopy as the gold standard due to several advantages:

Minimal blood loss: magnified view allows precise dissection and vessel control.

Smaller incisions and improved cosmetic results.

Less pain and reduced need for postoperative analgesia.

Shorter hospital stay and quicker return to normal activities.

Lower adhesion formation, which is important for preserving fertility.

These benefits make laparoscopic myomectomy particularly suitable for young women with reproductive goals.

Preoperative Preparation

Imaging: Ultrasound and MRI help define the number, size, and location of intramural fibroids.

Anemia correction: Many women with heavy bleeding are anemic and may need iron therapy or transfusion.

GnRH analogs: In selected cases, these medications may shrink the fibroid and reduce intraoperative bleeding.

Counseling: Patients should be informed about the possibility of conversion to laparotomy in rare cases of excessive bleeding or technical difficulty.

Surgical Technique

Anesthesia and Positioning

General anesthesia is administered.

Patient placed in lithotomy position with Trendelenburg tilt for pelvic exposure.

Port Placement

Usually three to four ports are used.

A 10 mm umbilical port for the laparoscope, and 5 mm accessory ports in the lower quadrants for instruments.

Uterine Incision

The site overlying the fibroid is infiltrated with diluted vasopressin to minimize bleeding.

A transverse or vertical incision is made on the myometrium using monopolar scissors or harmonic scalpel.

Enucleation

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

Hemostasis is maintained with bipolar energy.

Uterine Closure

The myometrial defect is repaired in multiple layers with laparoscopic suturing to restore uterine strength.

Proper closure is vital to prevent uterine rupture in future pregnancies.

Specimen Retrieval

Fibroid tissue is extracted using contained morcellation or via a mini-laparotomy, depending on size and safety considerations.

Clinical Considerations

Size: Laparoscopic myomectomy is feasible even for large intramural fibroids (10–15 cm) in skilled hands.

Number: Multiple fibroids can be removed in one sitting, though operative time increases.

Future Pregnancy: Women are advised to wait at least 6 months before attempting conception, allowing adequate uterine healing.

Conversion to Open Surgery: Required in less than 5% of cases due to uncontrolled bleeding or difficult anatomy.

Postoperative Care and Outcomes

Patients recover faster after laparoscopy compared to open surgery. Most are mobilized within hours, resume oral intake on the same day, and are discharged within 24–48 hours. Pain is minimal and usually managed with oral analgesics.

Long-term outcomes include:

Relief from heavy bleeding and pressure symptoms.

High patient satisfaction due to rapid recovery and minimal scars.

Improved fertility and pregnancy outcomes once the uterine cavity is restored.

Low recurrence rate if complete excision of fibroids is achieved, though new fibroids may develop over time.

Conclusion

Laparoscopic myomectomy for intramural fibroids is a safe, effective, and fertility-preserving procedure that has become the standard of care for symptomatic women desiring uterine conservation. With its advantages of minimal invasiveness, rapid recovery, and excellent surgical outcomes, laparoscopy has surpassed open myomectomy in most scenarios. The key to success lies in meticulous surgical planning, skillful enucleation, and secure uterine repair. For women suffering from symptomatic intramural fibroids, laparoscopic myomectomy not only restores health and fertility but also ensures faster return to a normal lifestyle with minimal surgical morbidity.