Uterine fibroids, also known as leiomyomas, are the most common benign tumors in women of reproductive age. These tumors arise from the smooth muscle cells of the uterus and can vary in size, number, and location. Intramural fibroids, which are located within the muscular wall of the uterus, are the most frequent type. While some intramural myomas may remain asymptomatic, larger or multiple fibroids can cause significant symptoms including heavy menstrual bleeding, pelvic pain, pressure on adjacent organs, infertility, and recurrent pregnancy loss.

For women who wish to preserve fertility or maintain uterine integrity, myomectomy is the surgical procedure of choice. Among the surgical options, laparoscopic myomectomy has gained prominence due to its minimally invasive nature, providing benefits such as smaller incisions, reduced postoperative pain, faster recovery, and excellent cosmetic outcomes.

Preoperative Evaluation

Proper preoperative assessment is crucial for a successful laparoscopic myomectomy, especially for intramural fibroids. Imaging studies, including transvaginal ultrasound and MRI, help determine the size, number, and location of the fibroids as well as the thickness of the myometrium. Blood tests, including hemoglobin levels, renal and liver function, and coagulation profile, are performed to ensure patient safety.

In selected cases, preoperative administration of GnRH analogs may be considered to reduce fibroid size and vascularity, making surgical dissection easier and minimizing intraoperative blood loss. Comprehensive patient counseling is also essential, covering surgical risks, recovery, and implications for fertility and future pregnancies.

Patient Preparation and Positioning

The procedure is performed under general anesthesia. The patient is placed in the dorsal lithotomy position with a slight Trendelenburg tilt to allow bowel loops to move away from the pelvis. A Foley catheter is inserted to decompress the bladder. Standard aseptic precautions are followed, and prophylactic antibiotics are administered prior to the procedure.

Laparoscopic Access and Port Placement

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

Identification and Enucleation of Intramural Fibroid

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

The fibroid is carefully enucleated using a traction-countertraction technique along the natural cleavage plane between the fibroid and surrounding myometrium. In the case of large fibroids, piecemeal excision may be necessary. Care is taken to preserve healthy myometrial tissue to maintain uterine integrity and reproductive potential.

Hemostasis

Bleeding from the myoma bed is controlled meticulously using bipolar cautery or advanced energy devices. Achieving complete hemostasis before closure is essential to prevent hematoma formation, reduce adhesion development, and ensure a safe postoperative recovery.

Uterine Reconstruction

Reconstruction of the uterine wall is a critical step, especially for intramural fibroids, to restore structural integrity and prevent complications in future pregnancies. The myometrium is typically closed in two layers:

Deep myometrial layer: Closed using delayed absorbable sutures to obliterate the dead space and strengthen the uterine wall.

Serosal layer: Approximated with continuous or interrupted sutures, often using barbed sutures to reduce operative time and minimize adhesion formation.

Proper multilayer closure significantly reduces the risk of uterine rupture during subsequent pregnancies.

Specimen Retrieval

The excised fibroid is removed via contained morcellation or a mini-laparotomy incision, depending on the size. Contained morcellation prevents tissue dissemination and reduces the risk of parasitic fibroid formation.

Final Inspection and Adhesion Prevention

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

Postoperative Care

Patients typically recover rapidly after laparoscopic myomectomy. Most are 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 delay conception for 3–6 months to allow complete healing of the uterine wall. Follow-up includes monitoring for symptom resolution, wound healing, and imaging if necessary to assess uterine integrity.

Advantages of Laparoscopic Myomectomy

Minimally invasive approach with smaller incisions and faster recovery

Preservation of fertility and uterine function

Precise enucleation of intramural fibroids with minimal damage to surrounding myometrium

Reduced intraoperative blood loss compared to open surgery

Lower risk of adhesion formation due to careful uterine reconstruction

Shorter hospital stay and faster return to normal activities

Conclusion

Laparoscopic myomectomy for intramural fibroids is a safe, effective, and fertility-preserving surgical option. With meticulous preoperative planning, careful fibroid enucleation, thorough hemostasis, and multilayered uterine repair, excellent surgical and reproductive outcomes can be achieved. This minimally invasive technique provides women with significant symptom relief, maintains uterine function, and ensures a faster recovery, making it the preferred choice for managing intramural fibroids.