Discover the advanced surgical technique of laparoscopic myomectomy for multiple large intramural fibroids in this educational video from World Laparoscopy Hospital. This procedure demonstrates the principles of minimally invasive uterine surgery, focusing on the removal of multiple fibroids while aiming to preserve the uterus and reconstruct the uterine wall.

Large and multiple uterine fibroids can present a significant surgical challenge. Their number, size, and location may distort the normal uterine anatomy and make dissection more demanding. Removing several intramural fibroids requires a systematic approach to localization, controlled enucleation, bleeding management, and careful suturing.

Laparoscopic myomectomy is an important uterus-preserving surgical option for appropriately selected patients. It combines the benefits of laparoscopic visualization with advanced dissection and intracorporeal suturing skills.

Multiple Intramural Fibroids: Why Surgical Management Can Be Challenging

Intramural fibroids grow within the muscular wall of the uterus. When multiple large fibroids develop, they can enlarge the uterus, distort its shape, and affect the surrounding pelvic anatomy.

The clinical presentation varies from patient to patient. Some women experience heavy menstrual bleeding, pelvic pressure, pain, or urinary symptoms, while others may have no significant symptoms.

For patients considering pregnancy, the location of the fibroids and their relationship to the uterine cavity may be important. A detailed evaluation helps determine whether surgery is appropriate and which treatment option offers the most suitable balance of benefits and risks.

Laparoscopic Myomectomy: A Uterus-Preserving Approach

The main objective of laparoscopic myomectomy is to remove selected uterine fibroids without removing the uterus. Small abdominal incisions provide access for the laparoscope and operating instruments, allowing the surgeon to perform dissection and uterine reconstruction under magnified visualization.

The procedure requires expertise in:

• Laparoscopic pelvic anatomy.

• Identification of multiple fibroids.

• Controlled incision and tissue-plane dissection.

• Fibroid enucleation.

• Hemostasis and bleeding management.

• Intracorporeal suturing and uterine reconstruction.

• Safe specimen retrieval.

When several large intramural fibroids are present, the surgeon must carefully plan each step to preserve uterine tissue and restore the integrity of the uterine wall.

Detailed Surgical Workflow

1. Preoperative Imaging and Assessment

The surgeon evaluates the number, size, and location of the fibroids through appropriate imaging. Ultrasound is commonly used, while MRI may provide additional information in selected complex cases.

The assessment includes the relationship of the fibroids to the endometrial cavity and uterine serosa, the patient's symptoms, reproductive plans, and overall medical condition.

2. Laparoscopic Access

Under general anesthesia, pneumoperitoneum is established and laparoscopic ports are placed. The camera provides magnified visualization of the pelvis, allowing the surgeon to inspect the uterus and surrounding structures.

3. Mapping the Fibroids

Each fibroid is assessed according to its location and depth within the uterine wall. The surgeon plans the sequence of removal and selects appropriate incision sites. This planning is important because multiple incisions may be required for several large fibroids.

4. Creating the Uterine Incision

An incision is made over the selected fibroid using an appropriate laparoscopic instrument. The surgeon aims to reach the fibroid while minimizing injury to the surrounding healthy myometrium.

5. Enucleation of the Fibroid

The fibroid is separated from the surrounding uterine muscle. Controlled traction and countertraction help expose the dissection plane. Large fibroids may require careful progressive mobilization to facilitate complete removal without unnecessary tissue trauma.

6. Repeating the Process for Additional Fibroids

The surgeon identifies and removes the remaining fibroids according to the operative plan. The sequence may be modified depending on the location, accessibility, and relationship of each fibroid to the others.

7. Controlling Bleeding

After each fibroid is removed, the surgeon assesses the surgical bed and manages bleeding using appropriate techniques. Careful hemostasis is essential because excessive bleeding can affect visualization and increase operative complexity.

8. Reconstructing the Uterus

The uterine incisions are closed with appropriate laparoscopic suturing. Multilayer repair may be necessary for deep defects to restore the muscular wall, minimize dead space, and achieve adequate hemostasis.

This reconstruction is particularly important in patients who may wish to become pregnant in the future.

9. Specimen Removal and Final Inspection

The fibroids are retrieved using an appropriate extraction technique. The surgeon performs a final inspection of the uterus and pelvis, checking the repair sites and ensuring that bleeding is controlled.

Why Uterine Reconstruction Is a Critical Part of Myomectomy

Removing the fibroids is only one part of the operation. Reconstructing the uterus is equally important, especially when several large intramural fibroids have been removed.

A well-planned repair aims to:

• Restore the continuity of the uterine muscular wall.

• Close deep defects and reduce dead space.

• Achieve adequate hemostasis.

• Minimize unnecessary tissue tension.

• Support appropriate uterine healing.

The surgeon selects the closure technique according to the depth and number of incisions and the condition of the remaining myometrium.

Important Risks and Postoperative Considerations

Like every major operation, laparoscopic myomectomy has potential risks. These may include bleeding, infection, injury to surrounding organs, adhesions, conversion to open surgery, and complications related to anesthesia. Fibroids may recur after myomectomy, and additional treatment may be needed in the future.

Patients should also understand that removal of fibroids does not guarantee pregnancy or resolve every fertility-related problem. The benefits of surgery must be considered alongside ovarian function, age, other reproductive factors, and the condition of the uterine cavity.

Following surgery, recovery instructions, activity restrictions, follow-up appointments, and advice about future pregnancy should be provided by the treating gynecologist.

The Role of Advanced Laparoscopic Skills

Laparoscopic removal of multiple large intramural fibroids is an advanced procedure requiring coordinated instrument movements and strong suturing skills. The surgeon must maintain visualization while performing dissection, controlling bleeding, and reconstructing the uterine wall.

For trainees, this operation provides valuable learning in operative planning, anatomical orientation, tissue preservation, and intracorporeal suturing. It also demonstrates why a uterus-preserving procedure must be planned around the patient's long-term health and reproductive goals.

World Laparoscopy Hospital: Advancing Minimally Invasive Gynecological Surgery

World Laparoscopy Hospital is committed to professional education in laparoscopic and robotic surgery. Through surgical demonstrations and structured training, medical professionals can study advanced techniques and develop a deeper understanding of minimally invasive procedures.

This video offers an educational opportunity to observe the surgical principles of laparoscopic myomectomy for multiple large intramural fibroids, including fibroid localization, enucleation, hemostasis, and uterine reconstruction.

Watch the complete procedure to understand how advanced laparoscopic techniques can be applied to complex fibroid cases while aiming to preserve the uterus.

Educational disclaimer: This content is intended for medical education and professional learning. The appropriate treatment and surgical technique must be determined by qualified clinicians after individual assessment of the patient.