Uterine fibroids, or leiomyomas, are benign smooth muscle tumors that vary in location, size, and clinical impact. Intramural fibroids are embedded within the myometrium and often distort the uterine contour, while submucosal fibroids protrude into the uterine cavity, affecting menstrual function and fertility. A unique challenge arises when an intramural myoma develops a submucosal extension, as the fibroid spans both the uterine wall and cavity. This dual involvement complicates management and requires a precise, fertility-preserving approach. Laparoscopic myomectomy has emerged as a highly effective technique to deal with such cases, combining minimally invasive access with the ability to reconstruct the uterus.

Clinical Presentation

Patients with intramural myomas with submucosal extension often present with:

Menorrhagia and metrorrhagia, due to distortion of the endometrial cavity.

Severe dysmenorrhea, as the fibroid contracts within the myometrium.

Infertility or recurrent miscarriage, resulting from implantation failure or early pregnancy loss.

Pelvic pain and pressure symptoms, depending on fibroid size.

On examination, the uterus is usually enlarged and irregular. Ultrasound with saline infusion sonography or MRI is highly valuable to delineate both intramural and submucosal components, helping to plan surgery.

Why Laparoscopic Myomectomy?

Traditionally, submucosal fibroids are removed by hysteroscopic resection, while intramural fibroids are managed laparoscopically or by laparotomy. However, in fibroids with combined intramural and submucosal extension, hysteroscopy alone may not be sufficient. Laparoscopic myomectomy offers distinct benefits in these scenarios:

Comprehensive removal of the fibroid in a single setting.

Better hemostasis, especially for vascular intramural components.

Preservation of uterine integrity, crucial for fertility.

Minimally invasive approach, with less pain, quicker recovery, and improved cosmesis compared to laparotomy.

Possibility of cavity repair, if the endometrium is breached during surgery.

Thus, laparoscopic myomectomy becomes the preferred choice for women desiring fertility preservation.

Preoperative Preparation

Correction of anemia, often required due to heavy bleeding.

MRI or 3D ultrasound, to evaluate the depth of intramural involvement and degree of cavity distortion.

GnRH analogs may be used to reduce fibroid vascularity and size, although their effect on surgical planes is debated.

Counseling, to explain the risks of cavity entry, adhesions, and the importance of postoperative fertility planning.

Surgical Technique

Patient Positioning and Anesthesia

The patient is placed in lithotomy with Trendelenburg position under general anesthesia.

Port Placement

A standard 10 mm umbilical port for the laparoscope and two or three 5 mm accessory ports are inserted.

Ports may be adjusted higher in case of a bulky uterus.

Uterine Exposure

The uterus is manipulated to visualize the site of the fibroid bulge.

Care is taken to avoid excessive trauma to the endometrium.

Vasopressin Injection

Diluted vasopressin is injected around the fibroid, reducing blood loss and defining surgical planes.

Myometrial Incision

A vertical or transverse incision is made over the fibroid.

The submucosal extension is carefully identified, ensuring that the endometrial cavity is preserved whenever possible.

Fibroid Enucleation

The intramural portion is dissected from the pseudocapsule using blunt and sharp dissection.

If the cavity is inadvertently opened, meticulous repair is performed to restore uterine integrity.

Uterine Reconstruction

Layered suturing of the myometrium is performed using absorbable sutures.

The cavity, if breached, is closed carefully to prevent intrauterine adhesions.

Specimen Retrieval

Fibroid tissue is extracted via contained morcellation or mini-laparotomy.

Intraoperative Challenges

High vascularity, leading to potential blood loss.

Risk of endometrial breach, which must be repaired carefully.

Technical difficulty in identifying the cleavage plane between intramural and submucosal components.

Specimen extraction, particularly when the fibroid is large.

Surgeons must have advanced laparoscopic suturing skills to manage these challenges effectively.

Postoperative Care

Patients are mobilized on the same day and discharged within 24–48 hours.

Oral analgesics are sufficient for pain control.

Antibiotic prophylaxis reduces infection risk.

If the uterine cavity was entered, measures such as intrauterine catheter placement or anti-adhesion barriers may be considered to reduce intrauterine adhesions.

Conception is usually advised after 6–9 months to allow complete uterine healing.

Outcomes

Laparoscopic myomectomy for intramural fibroids with submucosal extension has shown excellent outcomes:

Improved menstrual regularity and relief from menorrhagia.

High fertility restoration rates, with successful pregnancies reported in many cases.

Reduced recurrence compared to incomplete hysteroscopic resection.

High patient satisfaction, due to minimally invasive nature and uterine preservation.

Conclusion

Laparoscopic myomectomy for intramural myoma with submucosal extension is a technically advanced but rewarding procedure. It addresses both the intramural and submucosal components in one sitting, preserves fertility, and restores normal uterine anatomy. While hysteroscopic surgery has limitations in such cases, laparoscopy provides a comprehensive solution, with minimal morbidity and faster recovery. With proper patient selection, meticulous surgical technique, and careful uterine reconstruction, this procedure ensures excellent outcomes, making it the gold standard for women who wish to retain their fertility and improve quality of life.