Uterine fibroids, or leiomyomas, are benign smooth muscle tumors of the uterus that can cause a range of symptoms including heavy menstrual bleeding, pelvic pain, pressure effects, and infertility. When fibroids are located in the posterior wall of the uterus, they may compress the rectum, cause deep pelvic pain, or interfere with fertility. The presence of endometriosis, a condition in which endometrial tissue grows outside the uterus, adds an additional layer of complexity to surgical management due to adhesions, distorted pelvic anatomy, and increased risk of bleeding.

Laparoscopic myomectomy is the preferred minimally invasive approach for women with symptomatic fibroids who wish to preserve fertility, particularly when posterior wall fibroids coexist with endometriosis. This procedure allows precise excision of fibroids, careful management of adhesions, and restoration of normal pelvic anatomy, all while minimizing postoperative pain and promoting rapid recovery.

Preoperative Evaluation

Comprehensive preoperative assessment is crucial in patients with posterior wall fibroids and endometriosis. Imaging with transvaginal ultrasound and MRI is used to determine the size, location, and number of fibroids, as well as the extent of endometriotic lesions. Patients with infertility or chronic pelvic pain may also undergo hysterosalpingography or laparoscopic diagnostic evaluation. Laboratory investigations include hemoglobin levels to assess for anemia due to heavy menstrual bleeding. Preoperative counseling should address potential complications such as bleeding, adhesion formation, and future fertility outcomes.

Patient Preparation and Positioning

The procedure is performed under general anesthesia. The patient is placed in the dorsal lithotomy position with Trendelenburg tilt to allow bowel loops to fall away from the pelvis. A Foley catheter is inserted to decompress the bladder. Antibiotic prophylaxis is administered, and the abdomen is prepped and draped in a sterile manner.

Laparoscopic Access and Port Placement

Pneumoperitoneum is established using a Veress needle or open (Hasson) technique. A 10 mm umbilical port is used for the laparoscope, with two or three 5 mm accessory ports placed in the lower abdomen to facilitate triangulation for dissection, suturing, and tissue retrieval.

Pelvic Inspection and Adhesiolysis

Upon entry, the pelvis is carefully inspected. Endometriotic lesions, ovarian cysts (endometriomas), and adhesions are identified. Adhesiolysis is performed meticulously using sharp dissection, blunt dissection, or energy devices, restoring normal anatomy while minimizing injury to surrounding organs such as bowel, ureters, and bladder. The posterior uterine wall is then visualized, and the fibroid is localized.

Myoma Enucleation

To minimize blood loss, a diluted vasopressin solution is injected into the overlying myometrium. A linear incision is made over the posterior wall fibroid using monopolar scissors or harmonic scalpel. The fibroid is then enucleated carefully using traction-countertraction technique, following the natural cleavage plane between the fibroid and surrounding myometrium. Large fibroids may require piecemeal excision. Maintaining integrity of surrounding myometrium is essential to preserve uterine function.

Hemostasis

Bipolar cautery or advanced energy devices are used to achieve hemostasis in the myoma bed. Hemostasis is particularly important in posterior wall fibroids due to their proximity to the uterine vessels and presacral venous plexus, which can cause significant bleeding if injured.

Uterine Reconstruction

Reconstruction of the posterior uterine wall is critical for uterine integrity, future fertility, and prevention of adhesions. The myometrial defect is closed in layers using delayed absorbable or barbed sutures. The serosal layer is approximated to minimize raw surfaces and adhesion formation. Proper closure also reduces the risk of uterine rupture during future pregnancy.

Management of Endometriosis

Concurrently, visible endometriotic lesions are excised or ablated using energy devices. Ovarian endometriomas are drained and cyst walls excised if present. Careful removal of endometriotic tissue, along with adhesiolysis, restores pelvic anatomy and improves fertility and symptom relief.

Specimen Retrieval

Excised fibroids and endometriotic tissue are removed through contained morcellation or mini-laparotomy depending on size. Contained morcellation minimizes the risk of tissue dissemination within the abdominal cavity.

Final Inspection and Adhesion Prevention

The pelvis is irrigated with warm saline to remove blood clots and debris. Hemostasis is reconfirmed. Adhesion barriers such as oxidized regenerated cellulose or hyaluronic acid gels may be applied over the posterior uterine wall and other raw surfaces to minimize postoperative adhesions.

Postoperative Care

Patients are monitored postoperatively and discharged within 24–48 hours in most cases. Pain is managed with oral analgesics. Early ambulation is encouraged to prevent venous thromboembolism. Patients are advised to resume a normal diet as tolerated. Follow-up includes assessment of wound healing, symptom resolution, and imaging to ensure uterine integrity. Fertility counseling is recommended, and pregnancy is generally deferred for 3–6 months to allow adequate uterine healing.

Benefits of Laparoscopic Approach

Minimally invasive with smaller incisions and reduced pain

Faster recovery and shorter hospital stay

Fertility preservation

Precise excision of fibroids and endometriotic lesions

Reduced adhesion formation compared to open surgery

Improved symptom relief and quality of life

Conclusion

Laparoscopic myomectomy for posterior wall fibroids with endometriosis is a technically demanding but highly effective surgical intervention. It addresses both fibroid-related symptoms and endometriosis-related pelvic pain and infertility in a single minimally invasive procedure. Careful preoperative planning, meticulous surgical technique, and multilayered uterine reconstruction ensure excellent outcomes, preserving fertility and enhancing overall quality of life for women with complex gynecological pathology.