Uterine fibroids, also known as leiomyomas, are the most common benign tumors in women of reproductive age. While a single fibroid can cause symptoms, multiple myomas present unique challenges due to their variable size, location, and number. Women with multiple fibroids often experience heavy menstrual bleeding, pelvic pain, pressure on adjacent organs, infertility, or recurrent pregnancy loss. For those seeking fertility preservation or minimally invasive treatment, laparoscopic myomectomy is considered the gold standard, offering complete fibroid removal while maintaining uterine integrity.

Challenges of Multiple Myomas

Surgical management of multiple myomas is more complex than single fibroids because of several factors:

Difficulty in identifying and accessing all fibroids within the uterus.

Increased risk of intraoperative bleeding due to multiple myoma beds.

Longer operative time and potential for increased technical complexity.

Need for meticulous uterine reconstruction to maintain uterine strength and fertility.

Despite these challenges, laparoscopic myomectomy provides an effective, minimally invasive solution for women with multiple fibroids, reducing postoperative pain and ensuring faster recovery.

Preoperative Evaluation

Successful laparoscopic myomectomy for multiple myomas begins with a detailed preoperative assessment. Imaging techniques such as transvaginal ultrasound and MRI are crucial for mapping all fibroids, determining their size, number, and precise locations, and planning the surgical approach. Laboratory tests, including hemoglobin and coagulation profiles, are essential to identify anemia or bleeding risks. In selected cases, preoperative treatment with GnRH analogs may shrink fibroids and reduce vascularity, facilitating easier removal and minimizing blood loss. Comprehensive counseling regarding surgery, potential risks, and fertility considerations is essential for patient preparedness.

Patient Preparation and Positioning

The procedure is performed under general anesthesia. The patient is positioned in the dorsal lithotomy position with Trendelenburg tilt, allowing intestines to move away from the pelvic field. A Foley catheter is inserted to decompress the bladder. Standard aseptic preparation and prophylactic antibiotics are administered prior to surgery.

Laparoscopic Access and Port Placement

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

Identification and Enucleation of Multiple Fibroids

The uterus is carefully inspected, and all fibroids are localized. To minimize bleeding, diluted vasopressin is injected into the myometrium overlying each fibroid.

For each fibroid:

A linear or curvilinear incision is made over the most prominent area.

The fibroid is gently enucleated using traction-countertraction technique along the natural cleavage plane.

Large or deep fibroids may be excised in pieces for safe removal.

All fibroids are addressed in a sequential and systematic manner, ensuring complete removal while preserving healthy myometrium.

Hemostasis

After enucleation, bleeding from each myoma bed is controlled using bipolar cautery or advanced energy devices. Meticulous hemostasis is essential to prevent hematoma formation and postoperative adhesions.

Uterine Reconstruction

Repairing multiple myoma sites is a critical step for uterine integrity and fertility preservation. Each defect is closed in two layers:

Deep myometrial layer: Delayed absorbable sutures are placed to obliterate dead space and restore uterine strength.

Serosal layer: Continuous or interrupted sutures cover the serosa to minimize adhesion formation.

Proper multilayer closure is particularly important when multiple fibroid beds are involved to prevent weakening of the uterine wall.

Specimen Retrieval

Excised fibroids are removed via contained morcellation or a mini-laparotomy incision, depending on size and number. Contained morcellation prevents intra-abdominal tissue dissemination and reduces the risk of parasitic fibroids.

Final Inspection and Adhesion Prevention

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

Postoperative Care

Recovery after laparoscopic myomectomy for multiple myomas is usually rapid. Most patients are discharged within 24–48 hours. Oral analgesics manage pain, and early ambulation is encouraged. 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 needed to evaluate uterine integrity.

Advantages of Laparoscopic Myomectomy for Multiple Fibroids

Minimally invasive with smaller incisions and faster recovery.

Preservation of fertility and uterine function.

Precise removal of multiple fibroids while preserving healthy myometrium.

Reduced intraoperative blood loss with vasopressin use and careful hemostasis.

Lower risk of adhesions compared to open surgery.

Shorter hospital stay and quicker return to daily activities.

Conclusion

Laparoscopic myomectomy for multiple myomas is a safe, effective, and fertility-preserving procedure when performed by experienced surgeons. Careful preoperative planning, systematic enucleation of all fibroids, meticulous hemostasis, and multilayer uterine repair ensure excellent outcomes. This minimally invasive approach allows women to achieve symptom relief, maintain reproductive potential, and enjoy faster postoperative recovery, making it the preferred choice for managing multiple uterine fibroids.