Uterine fibroids, also known as leiomyomas, are the most common benign tumors affecting women of reproductive age. Submucous fibroids, which protrude into the uterine cavity, are particularly associated with abnormal uterine bleeding, infertility, and recurrent pregnancy loss. The standard treatment for small submucous fibroids has traditionally been hysteroscopic myomectomy, a minimally invasive procedure performed through the cervix. However, when submucous fibroids are large, deeply embedded, or have significant intramural components, hysteroscopic removal may become technically difficult, time-consuming, and associated with higher complication rates. In such scenarios, laparoscopic myomectomy provides a safer, more efficient, and fertility-preserving alternative.

Limitations of Hysteroscopic Myomectomy

Hysteroscopic myomectomy is highly effective for fibroids confined to the endometrial cavity (FIGO Type 0 and Type 1). However, in large submucous fibroids (typically >4–5 cm) or fibroids with substantial intramural extension (Type 2), hysteroscopic surgery may be limited due to:

Difficulty achieving complete enucleation of the fibroid.

Increased risk of intrauterine fluid overload.

Longer operative times, potentially requiring staged procedures.

Higher likelihood of uterine perforation.

Difficulty controlling bleeding from the myometrial base.

These limitations make hysteroscopic removal less effective for large or complex submucous fibroids, prompting consideration of laparoscopic approaches.

Why Laparoscopic Myomectomy is Preferable

Laparoscopic myomectomy allows complete excision of both the submucous and intramural portions of the fibroid while preserving the uterus. Its advantages include:

Single-stage complete removal of large fibroids.

Multilayer closure of the uterine wall to maintain structural integrity.

Reduced risk of uterine perforation compared to hysteroscopic surgery.

Better hemostasis, especially for fibroids with significant vascularity.

Preservation of fertility, as the uterus is repaired meticulously.

Faster recovery and shorter hospital stay compared to open surgery.

Laparoscopic myomectomy is particularly advantageous in patients with large or multiple submucous fibroids, or when previous hysteroscopic attempts have failed.

Preoperative Evaluation

Preoperative planning is essential for optimal outcomes. Imaging modalities such as transvaginal ultrasound and MRI are used to determine the size, location, and depth of fibroids, as well as the degree of intramural extension. Hemoglobin levels are assessed, particularly in patients with heavy menstrual bleeding. Patients are counseled regarding potential risks, the need for general anesthesia, postoperative recovery, and fertility planning. Preoperative use of GnRH analogs may be considered to reduce fibroid size and vascularity in select cases.

Surgical Technique

Patient Preparation and Positioning
The patient is placed under general anesthesia in the dorsal lithotomy position with Trendelenburg tilt. A Foley catheter is inserted for bladder decompression.

Laparoscopic Access and Port Placement
Pneumoperitoneum is established, usually via an umbilical port. Two or three accessory ports (5 mm) are placed in the lower abdomen to allow optimal instrument triangulation for dissection and suturing.

Fibroid Identification
The uterus is inspected, and the large submucous fibroid is localized. Diluted vasopressin may be injected into the overlying myometrium to minimize intraoperative bleeding.

Myometrial Incision and Enucleation
A linear incision is made over the fibroid. Using traction and counter-traction, the fibroid is carefully enucleated along its natural cleavage plane. Large fibroids may require piecemeal excision for safe removal.

Hemostasis and Uterine Repair
Bleeding points are controlled with bipolar cautery. The myometrium is closed in two layers to restore uterine integrity, prevent hematoma formation, and reduce the risk of uterine rupture in future pregnancies. Barbed sutures or delayed absorbable sutures may be used for efficiency.

Specimen Retrieval
The fibroid is removed using contained morcellation or a mini-laparotomy incision to prevent intra-abdominal tissue dissemination.

Final Inspection and Adhesion Prevention
The pelvis is irrigated, hemostasis is confirmed, and adhesion barriers may be applied over the uterine surface. Ports are removed, and incisions are closed.

Postoperative Care

Patients generally recover quickly, with most discharged within 24–48 hours. Pain is managed with oral analgesics, and early ambulation is encouraged. Patients are advised to avoid pregnancy for 3–6 months to allow complete uterine healing. Follow-up includes evaluation of symptom resolution, wound healing, and uterine integrity using ultrasound if needed.

Benefits of Laparoscopic Myomectomy Over Hysteroscopy

Complete removal of large and complex submucous fibroids.

Preservation of fertility with multilayer uterine repair.

Single-stage procedure avoiding repeated interventions.

Reduced risk of uterine perforation and fluid overload.

Minimally invasive with smaller scars and faster recovery.

Lower recurrence and better long-term outcomes for large fibroids.

Conclusion

For large submucous fibroids, laparoscopic myomectomy is often superior to hysteroscopic myomectomy. It allows complete excision of both submucous and intramural components, ensures multilayered uterine repair, and preserves fertility. With careful patient selection, meticulous surgical technique, and proper postoperative care, laparoscopic myomectomy provides a safe, effective, and minimally invasive solution for women with complex submucous fibroids, offering improved symptom relief and excellent reproductive outcomes.