Uterine fibroids, also known as leiomyomas, are the most common benign tumors in women of reproductive age. Among them, intramural fibroids, which are located within the muscular wall of the uterus, are particularly significant because of their impact on menstrual health, pelvic function, and fertility. Large intramural fibroids can lead to heavy menstrual bleeding, pelvic pain, pressure on the bladder or bowel, and infertility. For women wishing to preserve fertility or maintain uterine integrity, myomectomy—the surgical removal of fibroids—is the procedure of choice.

With the advancements in minimally invasive surgery, laparoscopic myomectomy has emerged as a safe and effective alternative to open surgery, even for large intramural fibroids. It offers the advantages of reduced postoperative pain, smaller scars, faster recovery, and excellent visualization, which is crucial when dealing with large or multiple fibroids.

Preoperative Evaluation

Comprehensive preoperative assessment is critical to ensure a safe and successful laparoscopic myomectomy. Imaging studies such as transvaginal ultrasound or MRI are utilized to assess the size, location, and number of fibroids and the thickness of the myometrium. Blood tests are conducted to evaluate hemoglobin and overall fitness for surgery. In select cases, preoperative medical therapy using GnRH analogs may be employed to reduce the size and vascularity of the fibroid, facilitating easier enucleation and minimizing blood loss. Patients are counseled about the surgical procedure, potential risks, postoperative recovery, and implications for future fertility.

Patient Preparation and Positioning

The procedure is performed under general anesthesia. The patient is placed in the dorsal lithotomy position with a Trendelenburg tilt, which allows the intestines to move away from the pelvis. A Foley catheter is inserted to decompress the bladder. Standard aseptic preparation is undertaken, and prophylactic antibiotics are administered.

Laparoscopic Access and Port Placement

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

Fibroid Identification and Enucleation

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

The fibroid is then carefully enucleated using traction-countertraction techniques along the natural cleavage plane between the fibroid and the surrounding myometrium. For very large fibroids, piecemeal excision may be necessary. Preservation of healthy myometrium is essential to maintain 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 crucial to prevent hematoma formation and reduce the risk of postoperative adhesion development.

Uterine Reconstruction

Repairing the uterine defect is a critical step, particularly for large intramural fibroids. The myometrium is typically closed in two layers:

Deep myometrial layer: Closed with delayed absorbable sutures to obliterate dead space and restore structural 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 minimize the risk of intra-abdominal tissue dissemination and formation of parasitic fibroids.

Final Inspection and Adhesion Prevention

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

Postoperative Care

Recovery is typically rapid, with most patients discharged within 24–48 hours. Pain is managed with oral analgesics, and early ambulation is encouraged to reduce the risk of venous thromboembolism. Patients are advised to avoid pregnancy for 3–6 months to allow complete uterine healing. Follow-up includes assessment of symptom resolution, wound healing, and imaging if necessary to evaluate uterine integrity.

Advantages of Laparoscopic Myomectomy

Minimally invasive with smaller incisions and faster recovery.

Preservation of fertility and uterine function.

Precise enucleation of large intramural fibroids.

Reduced intraoperative blood loss compared to open surgery.

Shorter hospital stay and quicker return to daily activities.

Lower risk of adhesion formation due to careful uterine reconstruction.

Conclusion

Laparoscopic myomectomy for large intramural fibroid uterus is a safe, effective, and fertility-preserving procedure. With careful preoperative planning, meticulous fibroid enucleation, adequate hemostasis, and multilayer uterine closure, excellent outcomes can be achieved. This minimally invasive approach combines the benefits of modern laparoscopy with definitive treatment of large fibroids, providing patients with symptom relief, preservation of reproductive potential, and faster postoperative recovery.