Uterine fibroids, also called leiomyomas, are the most common benign tumors in women of reproductive age. These smooth muscle tumors can lead to heavy menstrual bleeding, pelvic pain, infertility, and recurrent pregnancy loss. For women wishing to preserve fertility, myomectomy—the surgical removal of fibroids while conserving the uterus—is the treatment of choice. With advancements in minimally invasive surgery, laparoscopic myomectomy has become a preferred approach due to reduced postoperative pain, smaller incisions, faster recovery, and excellent cosmetic outcomes.

One of the most critical steps in laparoscopic myomectomy, particularly for large or deep fibroids, is intra-corporeal double layer suturing of the uterine defect. Proper suturing ensures hemostasis, preserves uterine integrity, prevents adhesion formation, and minimizes the risk of uterine rupture in future pregnancies.

Preoperative Evaluation

Successful laparoscopic myomectomy with intra-corporeal suturing begins with careful preoperative assessment. Imaging modalities such as transvaginal ultrasound and MRI are used to evaluate the number, size, and location of fibroids, as well as the thickness of the myometrium. Patients are screened for anemia due to heavy menstrual bleeding, and medical optimization is undertaken if necessary. Preoperative counseling includes discussing surgical risks, expected outcomes, and fertility considerations.

Patient Preparation and Positioning

The procedure is performed under general anesthesia. The patient is placed in the dorsal lithotomy position with a Trendelenburg tilt to allow bowel loops to move away from the pelvis. A Foley catheter is inserted to decompress the bladder. Standard aseptic preparation and antibiotic prophylaxis are administered.

Port Placement and Laparoscopic Access

After establishing pneumoperitoneum, a 10 mm umbilical port is used for the laparoscope. Additional 5 mm accessory ports are placed in the lower abdomen, usually in a triangular configuration, to facilitate instrument triangulation for dissection, traction, and suturing.

Identification and Enucleation of Fibroid

The uterus is inspected, and the location of the fibroid is confirmed. A diluted vasopressin solution may be injected into the overlying myometrium to reduce bleeding. A linear incision is made over the fibroid using monopolar scissors or harmonic scalpel. The fibroid is enucleated carefully using traction-countertraction technique along the natural cleavage plane between the fibroid and surrounding myometrium. For large fibroids, piecemeal removal may be necessary. Meticulous dissection preserves the surrounding healthy myometrium.

Achieving Hemostasis

After fibroid removal, bleeding points in the myoma bed are controlled using bipolar cautery or advanced energy devices. Achieving complete hemostasis before suturing is crucial to reduce postoperative hematoma formation and adhesion development.

Intra-Corporeal Double Layer Suturing

This is the most important step of the procedure, ensuring the uterus heals effectively and maintains structural integrity:

First Layer (Deep Myometrial Closure):

The deep myometrium is approximated using delayed absorbable sutures.

Interrupted or continuous sutures are placed to obliterate the dead space created by fibroid enucleation.

Proper closure of this layer restores uterine strength and reduces the risk of hematoma formation.

Second Layer (Serosal Closure):

The serosal layer is closed to cover the myometrial repair.

Continuous or interrupted sutures are used, often with barbed sutures for efficiency.

Serosal approximation reduces exposed raw surfaces, minimizing adhesion formation and improving healing.

Intra-corporeal suturing requires advanced laparoscopic skill, including precision in needle handling, knot tying, and tissue approximation within the abdominal cavity.

Specimen Retrieval

Enucleated fibroids are removed via contained morcellation or mini-laparotomy. Contained morcellation is preferred to prevent tissue dissemination, especially in cases where preoperative evaluation cannot completely exclude malignancy.

Final Inspection and Adhesion Prevention

The pelvis is irrigated to remove blood clots and debris. Hemostasis is reconfirmed, and adhesion barriers may be applied over the uterine surface. Ports are removed under vision, pneumoperitoneum is released, and skin incisions are closed.

Postoperative Care

Patients are monitored postoperatively for vital signs, pain control, and urinary output. Most are discharged within 24–48 hours. Oral analgesics are sufficient in most cases. Early ambulation is encouraged to reduce the risk of venous thrombosis. Patients are advised to delay conception for 3–6 months to allow complete healing of the uterine wall. Follow-up includes evaluation of symptom resolution, wound healing, and imaging to assess uterine integrity if required.

Benefits of Laparoscopic Myomectomy with Double Layer Suturing

Maintains uterine integrity and fertility potential

Reduces postoperative blood loss

Minimizes adhesion formation

Faster recovery and shorter hospital stay

Superior cosmetic outcomes with smaller incisions

Safe and effective for large or multiple fibroids

Conclusion

Laparoscopic myomectomy with intra-corporeal double layer suturing is a highly effective and fertility-preserving procedure for women with symptomatic fibroids. Proper execution of this technique—beginning with careful preoperative evaluation, meticulous fibroid enucleation, and precise two-layer uterine closure—ensures optimal outcomes, minimal complications, and enhanced uterine function. With growing expertise and advances in minimally invasive surgery, this procedure continues to be the gold standard for treating fibroids in women seeking fertility preservation.