Uterine fibroids, or leiomyomas, are the most common benign tumors of the female reproductive system. They originate from the smooth muscle cells of the uterus and can vary greatly in size, number, and location. Among the different types, intramural myomas are located within the muscular wall of the uterus and often cause significant symptoms such as heavy menstrual bleeding, pelvic pain, pressure symptoms, and infertility. When these fibroids are large and deeply embedded, surgical removal becomes technically demanding. However, with advances in minimally invasive surgery, laparoscopic myomectomy has become a safe and effective option, even for large deep intramural myomas, provided it is performed by skilled surgeons.

Challenges of Large Deep Intramural Myomas

Unlike subserosal or pedunculated fibroids, which are easily accessible, deep intramural myomas are surrounded by healthy myometrium. Their removal requires careful dissection to prevent excessive blood loss, preserve uterine integrity, and maintain fertility potential. The challenges include:

Difficulty in identifying the correct plane between fibroid and myometrium.

Increased risk of intraoperative bleeding.

Longer operative time due to complex dissection.

Need for meticulous uterine repair to avoid weakening of the uterine wall.

Despite these challenges, laparoscopic myomectomy offers excellent outcomes when performed with a systematic, step-by-step approach.

Preoperative Evaluation

Thorough preoperative assessment is crucial for successful outcomes. Imaging techniques such as transvaginal ultrasound or MRI help determine the exact size, number, and location of fibroids. MRI is particularly useful for mapping large and multiple intramural fibroids. Patients are evaluated for hemoglobin levels, as anemia is common due to heavy bleeding. Medical therapy with gonadotropin-releasing hormone (GnRH) analogs may be considered to shrink fibroid size and reduce vascularity before surgery, especially in very large cases.

Patient Preparation and Positioning

The procedure is performed under general anesthesia. The patient is positioned in dorsal lithotomy with Trendelenburg tilt, allowing the intestines to move out of the pelvic field. A Foley catheter is inserted to keep the bladder decompressed. Standard aseptic preparation and prophylactic antibiotics are administered.

Laparoscopic Access and Port Placement

After establishing pneumoperitoneum, a 10 mm laparoscope is introduced through the umbilical port. Two or three accessory 5 mm ports are placed in the lower abdomen under direct vision, ensuring ergonomic instrument placement for suturing.

Uterine Mapping and Vasopressin Injection

The uterus is inspected carefully, and the location of the deep intramural myoma is confirmed. To minimize bleeding, a diluted vasopressin solution is injected into the overlying myometrium, producing blanching and reduced vascularity.

Uterine Incision

A strategically placed linear incision is made over the most prominent part of the myoma using monopolar energy or scissors. The incision must be deep enough to reach the fibroid’s capsule without excessive use of cautery, which could damage surrounding healthy tissue.

Enucleation of the Myoma

Once the pseudocapsule is identified, the fibroid is grasped with a myoma screw or tenaculum, and traction is applied. Using the traction–counter-traction technique, the surgeon gently dissects along the cleavage plane to separate the myoma from the surrounding myometrium. In large, deep fibroids, this process can be time-consuming and requires patience. Piecemeal excision may be necessary if the fibroid is extremely bulky.

Hemostasis

After removal of the myoma, bleeding points are coagulated with bipolar energy. Adequate hemostasis is essential to avoid hematoma formation, which can compromise uterine healing and increase adhesion formation.

Uterine Reconstruction

Reconstruction of the uterine wall is one of the most critical steps in laparoscopic myomectomy for large deep intramural myomas. The myometrial defect is closed in multiple layers using delayed absorbable sutures or barbed sutures. This layered closure restores the strength of the uterine wall, reduces the risk of rupture in future pregnancies, and ensures proper healing. The serosal layer is approximated to minimize raw surfaces and reduce adhesion formation.

Specimen Retrieval

The excised fibroid is removed through a contained morcellation system or mini-laparotomy incision, depending on its size. Contained morcellation reduces the risk of tissue dissemination within the peritoneal cavity.

Final Inspection and Adhesion Prevention

The pelvis is irrigated with warm saline to clear blood clots and debris. Hemostasis is reconfirmed, and adhesion barriers such as oxidized regenerated cellulose or hyaluronic acid gel may be applied over the uterine incision to minimize postoperative adhesions.

Postoperative Care

Patients usually recover quickly after laparoscopic myomectomy. Pain is managed with oral analgesics, and ambulation is encouraged within hours. A liquid diet is initiated the same day, advancing to solids as tolerated. Most patients are discharged within 24–48 hours. Follow-up includes monitoring hemoglobin levels, wound healing, and ultrasound assessment of uterine integrity. Women are generally advised to delay conception for at least 3–6 months to allow proper uterine healing.

Benefits of Laparoscopic Approach

Reduced blood loss compared to open surgery.

Smaller incisions and superior cosmetic results.

Faster recovery and shorter hospital stay.

Lower risk of adhesion formation.

Preservation of fertility and uterine function.

Conclusion

Laparoscopic myomectomy for large deep intramural myomas is a technically demanding but highly rewarding procedure. With careful preoperative planning, meticulous surgical technique, and secure multilayer uterine repair, excellent outcomes can be achieved. Patients benefit from faster recovery, less pain, and preserved fertility, making this approach the gold standard for women seeking a minimally invasive yet definitive solution for symptomatic deep intramural fibroids.