Uterine fibroids, also known as leiomyomas or myomas, are the most common benign tumors of the uterus. They affect up to 30–40% of women of reproductive age and can lead to a variety of symptoms such as heavy menstrual bleeding, pelvic pain, pressure symptoms, infertility, and recurrent pregnancy loss. While medical management can provide temporary relief, surgical removal remains the gold standard in symptomatic cases. Myomectomy, the excision of fibroids while preserving the uterus, is the procedure of choice for women who wish to retain their fertility or avoid hysterectomy.

In this lecture, Dr. R. K. Mishra, Director of the World Laparoscopy Hospital and a leading figure in minimally invasive surgery, provides a comprehensive overview of laparoscopic myomectomy, its principles, techniques, and outcomes. His expertise and structured approach have made him one of the most respected global trainers in advanced gynecological endoscopy.

Indications of Laparoscopic Myomectomy

According to Dr. Mishra, laparoscopic myomectomy is indicated in:

Symptomatic fibroids causing menorrhagia, dysmenorrhea, or pelvic pain

Infertility associated with submucous or intramural fibroids distorting the endometrial cavity

Rapidly growing fibroids where malignancy is excluded

Fibroids causing pressure symptoms on bladder or bowel

Recurrent pregnancy loss linked to fibroid distortion of uterine anatomy

Preoperative Considerations

Dr. Mishra emphasizes that careful patient selection is essential. Preoperative imaging with ultrasound or MRI helps determine the number, size, and location of fibroids. Hemoglobin levels should be optimized, and preoperative GnRH analogs may be used in select cases to reduce fibroid volume and vascularity.

Informed consent should include discussion of the possibility of conversion to open surgery, risks of excessive bleeding, and need for suturing expertise.

Surgical Technique

Dr. Mishra outlines the laparoscopic myomectomy procedure in a systematic manner:

Anesthesia and Positioning
The patient is placed under general anesthesia in lithotomy position with Trendelenburg tilt for optimal pelvic access.

Port Placement
Typically, a 10-mm umbilical camera port and two to three 5-mm accessory ports are placed. In cases of large fibroids, supraumbilical entry may be preferred.

Uterine Manipulation
A uterine manipulator helps mobilize the uterus and expose different surfaces for fibroid enucleation.

Vasopressin Infiltration
Diluted vasopressin is injected into the myometrium overlying the fibroid to reduce bleeding by causing vasoconstriction.

Uterine Incision
Using monopolar scissors, harmonic scalpel, or other energy devices, a serosal incision is made directly over the fibroid.

Enucleation of Fibroid
Traction–countertraction technique is applied. The fibroid is grasped and dissected out from the surrounding myometrium using blunt and sharp dissection. Dr. Mishra stresses minimal use of electrocautery to preserve uterine tissue integrity.

Uterine Reconstruction
This is the most critical step. The uterine defect is closed meticulously in multiple layers with delayed absorbable sutures. Dr. Mishra highlights the importance of laparoscopic intracorporeal suturing skills, ensuring hemostasis and restoration of uterine contour.

Specimen Retrieval
Fibroids are usually extracted using power morcellation or contained tissue retrieval systems to avoid spillage. For smaller fibroids, colpotomy may be used.

Peritoneal Toilet
Thorough irrigation is performed to remove blood clots and prevent adhesion formation. Anti-adhesion barriers may be applied in selected cases.

Advantages of Laparoscopic Myomectomy

Dr. Mishra stresses that compared to open myomectomy, laparoscopy offers:

Smaller incisions and superior cosmetic outcomes

Less blood loss due to vasopressin and precise dissection

Faster recovery and shorter hospital stay

Reduced postoperative adhesions

Preservation of uterine integrity and fertility potential

Better visualization due to magnification of pelvic anatomy

Challenges and Limitations

Despite its benefits, laparoscopic myomectomy is technically demanding. Dr. Mishra points out potential challenges:

Excessive intraoperative bleeding if vasopressin or hemostasis is inadequate

Difficulty in suturing deep myometrial defects

Retrieval of large fibroids without spillage

Risk of uterine rupture in future pregnancy if closure is not meticulous

Longer operative times in cases with multiple or giant fibroids

Thus, he emphasizes that only surgeons with advanced laparoscopic training and strong suturing skills should undertake complex cases.

Postoperative Care and Outcomes

Most patients recover rapidly and can resume normal activities within 1–2 weeks. Analgesic requirements are minimal. Regular follow-up includes monitoring of menstrual cycles, fertility, and uterine healing.

Studies have shown excellent reproductive outcomes after laparoscopic myomectomy, with high rates of spontaneous conception and live births in previously infertile women. The recurrence rate of fibroids remains, but laparoscopic management allows repeated interventions if needed.

Conclusion

In this lecture, Dr. R. K. Mishra underscores the importance of laparoscopic myomectomy as a safe, effective, and fertility-preserving surgical option for women with symptomatic uterine fibroids. With his structured step-by-step approach, emphasis on meticulous suturing, and vast teaching experience, he has trained thousands of surgeons globally in this advanced technique.

Laparoscopic myomectomy not only restores uterine anatomy and function but also enhances patient quality of life with minimal invasiveness. Under the guidance of experts like Dr. Mishra, this procedure stands as a benchmark in modern gynecological surgery.