Watch this detailed video demonstrating the operative technique of laparoscopic myomectomy, a minimally invasive surgery for removing uterine fibroids. In this video, our expert surgeons guide you through the step-by-step procedure, including patient preparation, fibroid excision, and closure techniques.

This surgical video is ideal for medical professionals, students, and anyone interested in advanced laparoscopic gynecologic surgery. Learn the best practices, tips, and techniques directly from experienced laparoscopic surgeons.

Myomectomy, sometimes also fibroidectomy, refers to the surgical removal of uterine leiomyomas, also known as fibroids. In contrast to a hysterectomy, the uterus remains preserved and the woman retains her reproductive potential.

Laparoscopic myomectomy is a minimally invasive surgical procedure aimed at the removal of uterine fibroids (leiomyomas) while preserving the uterus. It is the preferred option for women who desire future fertility or want to avoid the morbidity associated with open surgery. Advances in laparoscopic technology, instrumentation, and surgical technique have made laparoscopic myomectomy a safe and effective procedure with faster recovery and minimal complications.

Preoperative Considerations

1. Patient Selection:

   • Symptomatic fibroids causing abnormal uterine bleeding, pelvic pain, infertility, or pressure symptoms.

   • Fibroids size typically <10–12 cm or fewer than 5–6 in number for optimal laparoscopic access.

   • Exclusion: Extensive adhesions, extremely large fibroids, or contraindications to laparoscopy.

2. Preoperative Imaging:

   • Transvaginal ultrasound or MRI to determine fibroid size, number, location, and depth.

   • Assessment of endometrial cavity involvement.

3. Medical Optimization:

   • Correction of anemia if present.

   • Preoperative use of GnRH analogues may be considered to reduce fibroid size and vascularity.

4. Informed Consent:

   • Discuss benefits, risks, potential for conversion to laparotomy, and impact on future fertility.

Operative Technique

1. Anesthesia and Patient Positioning

• General anesthesia with endotracheal intubation.

• Patient placed in dorsal lithotomy position with Trendelenburg tilt to allow bowel displacement.

• Insertion of a uterine manipulator is recommended for better uterine mobilization.

2. Port Placement

• Umbilical port (10–12 mm) for the laparoscope.

• Accessory ports (5 mm or 10 mm) in the lower quadrants depending on fibroid location.

• Placement should ensure triangulation for optimal instrument access and ergonomic handling.

3. Inspection and Assessment

• Initial laparoscopic survey of the uterus, adnexa, and peritoneal cavity.

• Identification of all fibroids, noting their size, location, and type (subserosal, intramural, submucosal).

4. Myometrial Incision

• Localize the fibroid by hysteroscopic guidance, palpation, or transillumination if necessary.

• Vasoconstrictive agents (e.g., dilute vasopressin) injected into the myometrium to reduce intraoperative bleeding.

• A transverse or longitudinal incision is made over the fibroid using monopolar/bipolar scissors or harmonic scalpel.

• The incision should be slightly longer than the fibroid diameter.

5. Enucleation of Fibroid

• Blunt and sharp dissection are used to separate the fibroid from the surrounding myometrium.

• Maintain careful hemostasis during dissection.

• Fibroid is removed from the myometrial bed.

6. Hemostasis and Myometrial Closure

• Meticulous closure of the myometrium is critical to reduce the risk of uterine rupture in future pregnancies.

• Layered closure using absorbable sutures (e.g., 1–0 or 2–0 barbed sutures).

• Bipolar coagulation can assist in controlling residual bleeding.

7. Morcellation and Specimen Retrieval

• Fibroid tissue is extracted using manual or power morcellation within a containment bag to prevent dissemination.

• Alternative: minilaparotomy or vaginal retrieval for large fibroids.

8. Final Inspection and Closure

• Ensure complete hemostasis and irrigation of the peritoneal cavity.

• Remove trocars under direct vision.

• Fascial closure of ports >10 mm and skin closure using subcuticular sutures or skin adhesive.

Postoperative Care

• Early ambulation to prevent thromboembolic events.

• Pain management and monitoring for bleeding or infection.

• Patients are usually discharged within 24–48 hours depending on recovery.

• Avoid strenuous activity for 4–6 weeks.

• Follow-up with imaging if indicated to check uterine integrity.

Advantages of Laparoscopic Myomectomy

• Minimal blood loss and postoperative pain.

• Short hospital stay and faster recovery.

• Reduced adhesion formation compared to open myomectomy.

• Preservation of fertility.

Challenges and Considerations

• Requires advanced laparoscopic skills and experience.

• Large or multiple fibroids increase operative complexity.

• Risk of uterine rupture in future pregnancy if myometrium is not properly closed.

• Morcellation requires caution due to risk of tissue dissemination.

Conclusion:
Laparoscopic myomectomy is a highly effective minimally invasive technique for the removal of symptomatic fibroids, offering significant benefits over traditional open surgery. Mastery of port placement, meticulous dissection, hemostasis, and layered closure are essential for optimal outcomes and fertility preservation. With careful patient selection and surgical expertise, laparoscopic myomectomy ensures minimal morbidity, rapid recovery, and high patient satisfaction.