Laparoscopic myomectomy has emerged as a cornerstone in minimally invasive gynecologic surgery, offering women with uterine fibroids an effective alternative to open surgery with reduced morbidity, faster recovery, and improved cosmetic outcomes. Among the various types of fibroids, large posterior wall intramural fibroids pose a unique surgical challenge due to their location, size, and proximity to critical structures such as the ureters and uterine vessels. Mastering the stepwise approach to these complex cases is essential for gynecologic surgeons aiming to achieve optimal outcomes.

The first step in managing large posterior wall intramural fibroids is thorough preoperative assessment. Imaging modalities, particularly transvaginal ultrasonography and magnetic resonance imaging (MRI), help delineate the size, number, and exact location of the fibroids. Understanding the fibroid’s relationship with the endometrium and serosal surface aids in planning the surgical approach and minimizing intraoperative complications. Preoperative optimization, including correction of anemia and consideration of pre-surgical medical therapy, may further facilitate a safer procedure.

Patient positioning and port placement are critical to achieving adequate visualization and instrument mobility. A steep Trendelenburg position combined with strategic placement of laparoscopic ports allows optimal access to the posterior uterine wall. Once the peritoneal cavity is entered, the surgeon performs careful inspection and mapping of the uterus and surrounding structures. Identification of ureters and major vessels reduces the risk of inadvertent injury during fibroid enucleation.

The key step in laparoscopic myomectomy is precise incision and enucleation. For posterior wall intramural fibroids, a transverse or longitudinal uterine incision over the bulge is commonly employed. Electrosurgical or advanced energy devices can be used judiciously to minimize blood loss while preserving myometrial integrity. Enucleation is performed using blunt and sharp dissection, maintaining hemostasis and protecting surrounding tissue. The surgeon must frequently reassess the depth and direction of dissection to prevent uterine perforation or excessive bleeding.

Hemostasis and meticulous myometrial closure are essential to ensure structural and functional integrity of the uterus, especially for women desiring future fertility. Multi-layer closure with absorbable sutures prevents hematoma formation and promotes optimal healing. In cases of large fibroids, careful tissue approximation and, if needed, morcellation of the fibroid for removal may be performed, following current safety guidelines.

Postoperative care includes monitoring for bleeding, infection, and signs of adhesion formation. Early mobilization, pain management, and follow-up imaging are recommended to assess uterine healing. Long-term outcomes depend on complete fibroid removal, preservation of myometrial function, and prevention of recurrence.

In conclusion, mastering laparoscopic myomectomy for large posterior wall intramural fibroids requires a systematic, stepwise approach. Preoperative planning, precise surgical technique, and meticulous postoperative care collectively ensure safety, efficacy, and preservation of fertility. With growing experience and adherence to these principles, gynecologic surgeons can confidently offer minimally invasive solutions to patients with complex fibroid presentations, improving both surgical outcomes and quality of life.