This video demonstrates Laparoscopic Myomectomy for Large Deep Intramural Myoma which was intending the cavity. Laparoscopic myomectomy using pneumoperitoneum for large myomas like 12 cm or more is now very popular altho it is difficult by several factors, such as the increased operative time, the risk of perioperative bleeding, and the risk of conversion to laparotomy. With the introduction of skilled surgeons in laparoscopy using good suturing skills, this procedure can be performed using laparoscopic surgical instruments introduced through small abdominal incisions. The aim of this video is to evaluate the feasibility, reproducibility, and safety of laparoscopic myomectomy for very large myomas ≥10 cm using three-port.

Laparoscopic myomectomy for large deep intramural myoma is one of the most technically demanding procedures in minimally invasive gynecologic surgery. At World Laparoscopy Hospital, advanced laparoscopic techniques, standardized surgical protocols, and structured training help surgeons safely manage complex fibroid cases while preserving uterine integrity and fertility potential.

Large deep intramural myomas are fibroids located within the myometrium and deeply embedded in uterine muscle fibers. These fibroids often cause menorrhagia, pelvic pain, infertility, and recurrent pregnancy loss. Traditionally, large intramural fibroids were treated by open myomectomy due to concerns regarding excessive bleeding, difficulty in enucleation, and uterine reconstruction. However, with the evolution of energy devices, advanced suturing techniques, and improved visualization systems, laparoscopic myomectomy has become feasible even for large and deeply seated fibroids.

Preoperative evaluation is critical. Detailed transvaginal ultrasound and MRI help assess fibroid size, depth, number, and relation to endometrial cavity. Preoperative optimization may include correction of anemia and, in selected cases, GnRH analogues to reduce vascularity and size. Proper patient selection and surgical planning significantly reduce intraoperative complications.

The surgical technique begins with proper port placement to allow ergonomic suturing and dissection. After diagnostic laparoscopy, vasopressin is injected into the myometrium to reduce blood loss. A transverse or vertical uterine incision is made over the fibroid using monopolar or harmonic energy. Deep intramural myomas require careful layer-by-layer dissection, maintaining the pseudocapsule to minimize bleeding and preserve myometrial strength. Gentle traction and counter-traction facilitate safe enucleation.

Hemostasis is a crucial step. Bipolar coagulation is used judiciously to avoid excessive thermal damage. Uterine reconstruction is performed in multiple layers using delayed absorbable sutures. Proper closure restores uterine anatomy, reduces hematoma formation, and decreases the risk of uterine rupture in future pregnancy. Specimen retrieval is usually done through power morcellation or contained manual morcellation depending on safety protocols.

The advantages of laparoscopic myomectomy include reduced postoperative pain, shorter hospital stay, faster recovery, minimal adhesions, and better cosmetic outcome. Additionally, magnified visualization allows precise dissection and preservation of normal myometrium. However, the procedure requires advanced laparoscopic suturing skills, excellent anatomical knowledge, and experience in managing intraoperative bleeding.

Challenges include prolonged operative time, risk of conversion to open surgery, and difficulty in handling multiple or very large fibroids. With proper training and experience, these challenges can be minimized. Simulation-based training and mentorship programs play a vital role in developing surgeon confidence and competence.

In conclusion, laparoscopic myomectomy for large deep intramural myoma is a safe and effective fertility-preserving surgery when performed by skilled laparoscopic surgeons. With structured training, modern instrumentation, and adherence to surgical principles, complex fibroid cases can be managed successfully through minimally invasive approaches, improving patient outcomes and quality of life.

https://www.laparoscopyhospital.com