This video demonstrates Laparoscopic myomectomy instead of hysteroscopic myomectomy for large submucous fibroids. Laparotomy, laparoscopy, and hysteroscopy are the three main procedures employed by gynecologists to remove uterine fibroids. The abdominal approach (laparotomy and laparoscopy) is used to treat subserosal and intramural lesions, and the vaginal approach (hysteroscopy) is used for submucous fibroids. With the advent of hysteroscopic surgery, operative hysteroscopies can manage most intrauterine surgical problems with fast recovery. However, hysteroscopic myomectomy for large deeply intramural extension submucous fibroid has still been deemed a challenge for hysteroscopies.

It involves issues of longer operating time, fluid overload, uterine perforation, and incomplete resection in one surgery. In conclusion, even hysteroscopic myomectomy offers several benefits to the patient. We must bear in mind that hysteroscopic removal of large deeply intramural invasion submucous fibroids is still a technically challenging procedure and might be associated with higher surgical morbidity and incidence of additional surgery. To avoid these tough situations, the vaginal approach should be shifted to the abdominal approach with laparoscopy, which can remove fibroids and still meet the principle of minimally invasive surgery; however, this particular approach should be performed only by those surgeons who are skilled in laparoscopic suturing.

Laparoscopic myomectomy has emerged as an advanced minimally invasive option for the management of large submucous fibroids, especially when hysteroscopic removal becomes technically difficult or incomplete. At World Laparoscopy Hospital, emphasis is placed on selecting the most appropriate minimally invasive technique based on fibroid size, location, and depth of myometrial invasion. For large submucous fibroids with significant intramural extension, laparoscopic myomectomy is often preferred over hysteroscopic myomectomy because it allows complete removal with better uterine reconstruction and reduced need for repeat procedures.

Submucous fibroids represent around 5–10% of uterine fibroids and are strongly associated with abnormal uterine bleeding, infertility, and recurrent pregnancy loss. The traditional treatment for submucous fibroids is hysteroscopic myomectomy, which is effective for smaller lesions confined mainly to the uterine cavity. However, when fibroids are large (generally more than 4–5 cm) or extend deeply into the myometrium (>50%), hysteroscopic removal becomes technically challenging and may require multiple procedures. Studies have shown that hysteroscopic resection success decreases significantly when type II fibroids are ≥6 cm or have deep intramural extension.

Laparoscopic myomectomy offers several advantages in such cases. Clinical studies demonstrate that laparoscopic removal of large submucous fibroids can achieve complete excision in a single procedure with minimal blood loss, short hospital stay, and low complication rates. One study reported median operating time of about 60 minutes, average blood loss around 50 mL, and hospital stay of approximately 2 days with no major complications. Additionally, laparoscopy reduces the risk of incomplete removal and allows simultaneous removal of other fibroids present in different uterine layers.

Comparative research between hysteroscopic and laparoscopic myomectomy in large submucous fibroids suggests that although hysteroscopy may have faster recovery and less postoperative pain in small fibroids, laparoscopy shows higher single-stage success rates and fewer repeat surgeries in larger fibroids. Complications like uterine perforation and intrauterine adhesions are more commonly reported with hysteroscopic procedures in large lesions. Moreover, evidence suggests hysteroscopy is more advantageous for fibroids smaller than 4 cm, whereas laparoscopy is more beneficial for fibroids equal to or greater than 4 cm in terms of operative efficiency and bleeding control.

From a surgical perspective, laparoscopic myomectomy provides superior visualization of uterine anatomy and allows multilayer suturing of the myometrium, which is crucial for future fertility and prevention of uterine rupture during pregnancy. Proper suturing and minimal use of excessive thermal energy are essential to maintain uterine strength and vascularity. At World Laparoscopy Hospital, advanced laparoscopic suturing techniques and energy control principles are emphasized during training to ensure safe and effective outcomes.

Another key advantage of laparoscopic myomectomy is preservation of uterine integrity. When performed by skilled laparoscopic surgeons, the risk of uterine rupture in subsequent pregnancy is minimal, provided the myometrium is adequately repaired. Modern laparoscopic techniques also help reduce postoperative adhesions and improve reproductive outcomes.

In conclusion, laparoscopic myomectomy is an excellent alternative to hysteroscopic myomectomy for large submucous fibroids, particularly those with deep intramural extension. It offers the benefits of complete fibroid removal, better uterine reconstruction, and reduced need for repeat surgery. At World Laparoscopy Hospital, laparoscopic myomectomy is considered a safe, effective, and fertility-preserving technique when performed by trained minimally invasive surgeons. With advances in laparoscopic instrumentation and surgical expertise, this approach continues to improve outcomes for women suffering from large submucous fibroids.

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