Uterine fibroids, also called leiomyomas, are the most common benign tumors affecting women of reproductive age. Among them, intramural fibroids are located within the muscular wall of the uterus. Large intramural myomas can cause a range of symptoms, including heavy menstrual bleeding, pelvic pain, pressure on adjacent organs, and infertility. In symptomatic women who wish to preserve fertility, myomectomy—the surgical removal of fibroids while conserving the uterus—is the treatment of choice.

Over the past two decades, laparoscopic myomectomy has emerged as a preferred minimally invasive technique for large intramural fibroids. It offers numerous advantages, including smaller incisions, reduced postoperative pain, faster recovery, and better cosmetic outcomes compared to traditional open myomectomy. However, the procedure is technically demanding, especially for large intramural myomas, requiring advanced laparoscopic skills for enucleation, hemostasis, and uterine reconstruction.

Preoperative Evaluation

Proper preoperative planning is critical for successful laparoscopic myomectomy. Imaging studies such as transvaginal ultrasound or MRI are essential to determine the size, location, and number of fibroids, as well as the thickness of the myometrium. Blood tests are conducted to assess hemoglobin levels and overall fitness for anesthesia. In some cases, preoperative administration of GnRH analogs may be considered to reduce fibroid size and vascularity, facilitating easier removal and reducing intraoperative bleeding. Patients are also counseled regarding the procedure, potential complications, recovery, and implications for future fertility.

Patient Preparation and Positioning

The procedure is performed under general anesthesia. The patient is positioned in the dorsal lithotomy position with Trendelenburg tilt to allow the intestines to fall away from the pelvis. A Foley catheter is inserted to decompress the bladder. Standard aseptic preparation and prophylactic antibiotics are administered before surgery.

Laparoscopic Access and Port Placement

Pneumoperitoneum is created using a Veress needle or open (Hasson) technique. A 10 mm umbilical port is used for the laparoscope, and two or three 5 mm accessory ports are placed in the lower abdomen to allow optimal instrument triangulation for enucleation, suturing, and tissue retrieval.

Identification and Enucleation of the Fibroid

The uterus is inspected carefully, and the large intramural fibroid is identified. To minimize intraoperative bleeding, a diluted vasopressin solution is injected into the overlying myometrium. A linear incision is made over the most prominent part of the fibroid using monopolar scissors or harmonic scalpel.

The fibroid is then enucleated using traction-countertraction technique, carefully separating it from the surrounding healthy myometrium. For very large fibroids, piecemeal excision may be necessary. Preserving the surrounding myometrium is essential for maintaining uterine integrity and fertility potential.

Hemostasis

Bleeding from the myoma bed is controlled using bipolar cautery or advanced energy devices. Achieving complete hemostasis before closure is critical to prevent hematoma formation and reduce the risk of postoperative adhesion development.

Uterine Reconstruction

Repairing the myometrial defect is a crucial step, particularly for large intramural fibroids. The defect is closed in two layers:

Deep myometrial layer: Closed with delayed absorbable sutures to obliterate the dead space and restore uterine strength.

Serosal layer: Approximated with continuous or interrupted sutures, often using barbed sutures, to cover raw surfaces and minimize adhesion formation.

Proper multilayer closure is essential for uterine healing and reduces the risk of rupture in future pregnancies.

Specimen Retrieval

The excised fibroid is removed via contained morcellation or a mini-laparotomy incision, depending on size. Contained morcellation is preferred to prevent intra-abdominal tissue dissemination and minimize the risk of parasitic fibroids.

Final Inspection and Adhesion Prevention

The pelvis is irrigated with warm saline to remove blood clots and debris. Hemostasis is confirmed, and adhesion prevention barriers such as oxidized regenerated cellulose or hyaluronic acid gels may be applied over the uterine repair site. Ports are then removed, and incisions are closed.

Postoperative Care

Patients typically recover quickly, with most discharged within 24–48 hours. Pain is managed with oral analgesics, and early ambulation is encouraged to reduce the risk of venous thrombosis. Patients are advised to avoid pregnancy for 3–6 months to allow adequate uterine healing. Follow-up includes monitoring wound healing, symptom resolution, and imaging if necessary to assess uterine integrity.

Advantages of Laparoscopic Myomectomy

Minimally invasive with smaller incisions and faster recovery.

Preservation of fertility and uterine function.

Precise enucleation of large fibroids.

Reduced intraoperative blood loss.

Shorter hospital stay and quicker return to daily activities.

Reduced risk of adhesion formation compared to open surgery.

Conclusion

Laparoscopic myomectomy for large intramural myomas is a safe, effective, and fertility-preserving surgical option. With careful preoperative planning, meticulous fibroid enucleation, effective hemostasis, and multilayer uterine repair, excellent outcomes can be achieved. The procedure combines the benefits of minimally invasive surgery with the ability to manage large, complex fibroids, making it the gold standard for women seeking definitive treatment while preserving reproductive potential.