Uterine fibroids, also known as leiomyomas or myomas, are benign smooth muscle tumors of the uterus that commonly affect women of reproductive age. Although many fibroids are asymptomatic, some women experience symptoms such as heavy menstrual bleeding, pelvic pain, infertility, or recurrent pregnancy loss. In such cases, surgical removal of fibroids, known as myomectomy, becomes necessary.

With advancements in minimally invasive surgery, laparoscopic myomectomy has become the preferred technique for selected patients. It offers all the benefits of laparoscopy—smaller incisions, reduced postoperative pain, quicker recovery, and excellent cosmetic results—while preserving the uterus and fertility potential. The following is a detailed step-by-step description of laparoscopic myomectomy.

Patient Preparation and Positioning

The procedure begins with thorough preoperative evaluation, including ultrasound or MRI to assess the size, location, and number of fibroids. Patients are counseled about risks, benefits, and fertility outcomes. Under general anesthesia, the patient is positioned in the dorsal lithotomy position with legs supported. A Foley catheter is placed for bladder decompression, and the patient is tilted in Trendelenburg position to allow bowel loops to fall away from the pelvis.

Port Placement and Entry

Pneumoperitoneum is created using a Veress needle or open (Hasson) technique, usually through the umbilicus. A 10 mm trocar is inserted for the laparoscope. Additional 5 mm accessory ports are placed under vision in the lower quadrants, usually in a triangular configuration. This setup allows optimal visualization and instrument triangulation for dissection and suturing.

Inspection of the Pelvis

A systematic inspection of the uterus, adnexa, and pelvic cavity is performed to confirm the number, location, and characteristics of fibroids. Adhesions, endometriosis, or other pelvic pathology are also noted. The surgical plan is finalized based on intraoperative findings.

Injection of Vasoconstrictive Agent

To minimize blood loss, a diluted vasopressin solution is injected into the myometrium overlying the fibroid. This causes blanching of the tissue and provides a relatively bloodless field for enucleation. Care is taken to avoid intravascular injection.

Uterine Incision

A linear incision is made over the most prominent part of the fibroid using monopolar energy, harmonic scalpel, or cold scissors. The incision is made deep enough to reach the pseudocapsule of the fibroid, but excessive thermal energy is avoided to preserve surrounding myometrium.

Enucleation of Fibroid

The fibroid is grasped with a tenaculum or myoma screw, and gentle traction is applied. Using traction–counter-traction technique, the fibroid is carefully dissected from its bed, following the natural cleavage plane between the fibroid and surrounding myometrium. Meticulous dissection ensures preservation of healthy uterine tissue. Large fibroids may require piecemeal dissection for easier removal.

Hemostasis

Bleeding points in the myoma bed are coagulated using bipolar cautery or advanced energy devices. Maintaining hemostasis is crucial to prevent hematoma formation and reduce postoperative morbidity.

Uterine Reconstruction

This is one of the most critical steps of laparoscopic myomectomy. The myometrial defect is closed in layers using delayed absorbable sutures. Intracorporeal or extracorporeal knotting techniques may be used. Deep myometrial closure restores the integrity of the uterine wall, while superficial closure ensures serosal approximation to reduce adhesion formation. Barbed sutures have become popular for faster and more efficient closure.

Specimen Retrieval

Once the fibroid(s) are enucleated, they must be removed from the abdominal cavity. Options include:

Morcellation (mechanical or manual) through a 10–15 mm port.

Colpotomy (removal through a vaginal incision).

Mini-laparotomy for very large fibroids.

Contained morcellation within a retrieval bag is recommended to minimize the risk of tissue dissemination, especially in cases where malignancy cannot be entirely excluded preoperatively.

Final Inspection and Lavage

The pelvis is thoroughly inspected for hemostasis and integrity of uterine closure. Copious irrigation is performed to remove blood clots and debris. Adhesion prevention barriers (such as oxidized regenerated cellulose or hyaluronic acid gel) may be applied over the uterine surface. Ports are removed under direct vision, pneumoperitoneum is released, and incisions are closed.

Postoperative Care

Patients are monitored in the recovery unit and discharged within 24–48 hours in most cases. Oral analgesics control pain effectively. Early ambulation and resumption of diet are encouraged. Follow-up includes monitoring for wound healing, symptom relief, and future fertility planning. Patients are usually advised to avoid pregnancy for at least 3–6 months to allow adequate uterine healing.

Benefits of Laparoscopic Myomectomy

Preservation of uterus and fertility.

Less blood loss compared to open myomectomy.

Smaller scars and better cosmetic outcomes.

Shorter hospital stay and quicker return to daily activities.

Reduced risk of adhesion formation.

Conclusion

Laparoscopic myomectomy is a safe, effective, and fertility-preserving surgical option for women with symptomatic fibroids. The procedure demands advanced laparoscopic skills, particularly in intracorporeal suturing and hemostasis. Step-by-step execution—beginning with careful preparation, precise dissection, secure uterine closure, and safe specimen retrieval—ensures optimal outcomes. With growing expertise and technological advancements, laparoscopic myomectomy continues to be the gold standard for minimally invasive management of uterine fibroids.