Introduction

Uterine fibroids, also known as leiomyomas, are benign smooth muscle tumors of the uterus that affect up to 70–80% of women by the age of 50. While many fibroids are asymptomatic, some can lead to symptoms such as heavy menstrual bleeding, pelvic pain, pressure symptoms, infertility, or recurrent pregnancy loss. Myomectomy, the surgical removal of fibroids, is often the preferred treatment for women who wish to preserve their uterus and fertility.

Over the years, surgical advancements have led to the development of minimally invasive approaches to myomectomy. Among these, laparoscopic myomectomy stands out for its advantages such as reduced postoperative pain, shorter hospital stay, quicker recovery, and minimal scarring. One of the critical considerations during laparoscopic myomectomy is the safe and efficient extraction of the fibroid specimen. Colpotomy-assisted specimen extraction has emerged as an effective alternative to power morcellation, providing a safe, minimally invasive method for fibroid removal. This article explores the technique, benefits, challenges, and clinical outcomes associated with laparoscopic myomectomy with specimen extraction via colpotomy.

What is Laparoscopic Myomectomy?

Laparoscopic myomectomy is a surgical procedure performed through small incisions using a laparoscope (a thin tube with a camera) and specialized instruments to remove fibroids from the uterus. It is indicated for women with symptomatic fibroids who wish to retain their uterus. The surgery involves:

Mapping and identifying fibroids using preoperative imaging and intraoperative assessment.
Making a precise incision on the uterine surface.
Enucleating (removing) the fibroids.
Suturing the uterine defect to restore the anatomical and functional integrity of the uterus.

This technique requires advanced laparoscopic skills, especially for suturing and hemostasis, but offers superior cosmetic and recovery outcomes compared to open surgery.

Specimen Extraction Challenge in Minimally Invasive Surgery

A significant challenge in laparoscopic myomectomy is the removal of large fibroid specimens from the abdominal cavity through small trocar incisions. Traditionally, power morcellators were used to fragment fibroids into smaller pieces, allowing removal through laparoscopic ports. However, safety concerns arose following reports of inadvertent dissemination of undiagnosed uterine malignancies, particularly leiomyosarcomas, during morcellation. This led the U.S. FDA and other global regulatory bodies to issue warnings and restrict the use of uncontained power morcellation.

In response, contained morcellation and alternative specimen retrieval methods were explored. One such approach that gained popularity is colpotomy-assisted extraction, which eliminates the need for power morcellation while maintaining the minimally invasive nature of the surgery.

What is Colpotomy-Assisted Specimen Extraction?

Colpotomy refers to a surgical incision made in the vaginal wall to access the pelvic cavity. In laparoscopic myomectomy, once the fibroid(s) are enucleated, they are placed in a specimen retrieval bag and extracted through the vagina via a posterior colpotomy incision.

Steps Involved:

1. Laparoscopic Myomectomy: Standard laparoscopic removal of fibroids with careful dissection and repair of the uterine wall.
2. Specimen Bag Placement: The fibroid specimen is placed in an endoscopic retrieval bag inside the abdomen.
3. Colpotomy Creation: A posterior vaginal colpotomy is performed under laparoscopic guidance.
4. Specimen Delivery: The bag containing the fibroid is guided to the posterior vaginal fornix and carefully extracted through the colpotomy incision.
5. Colpotomy Closure: The vaginal incision is sutured either laparoscopically or vaginally to ensure complete closure and prevent complications.

Advantages of Colpotomy-Based Extraction

1. Avoids Power Morcellation: Eliminates the risk of tissue dissemination and associated oncological concerns.
2. Maintains Minimally Invasive Approach: No need for enlarging abdominal incisions or converting to open surgery.
3. Reduces Operative Time: Compared to contained morcellation, colpotomy-assisted extraction is often faster and simpler.
4. Better Cosmesis: Vaginal incision avoids additional scars on the abdomen.
5. Cost-Effective: Does not require expensive morcellation devices or containment systems.

Patient Selection and Preoperative Considerations

Not all patients are suitable for colpotomy-based extraction. Proper patient selection is essential. Ideal candidates include:

Women with moderate to large fibroids that are difficult to remove laparoscopically through standard ports.

Patients with favorable pelvic anatomy allowing easy vaginal access.

Women who are not at high risk of malignancy based on clinical and imaging criteria.

Preoperative imaging, such as ultrasound or MRI, helps assess fibroid size, number, and location. Informed consent should include a discussion on the risks, benefits, and potential need for colpotomy.
Potential Challenges and Limitations

While colpotomy-assisted extraction is advantageous, it is not without limitations:

Vaginal Access Issues: Obesity, nulliparity, or narrow vaginal canal can complicate specimen retrieval.

Risk of Infection: Though low, any vaginal incision carries a risk of postoperative infection.

Increased Vaginal Discomfort: Some patients may report temporary postoperative vaginal pain or discharge.

Technical Expertise Required: The surgeon must be adept in both laparoscopic and vaginal surgical techniques.

Proper training and familiarity with pelvic anatomy are essential to avoid complications like injury to the rectum, bladder, or ureters.
Outcomes and Clinical Evidence

Multiple studies have demonstrated the safety and efficacy of laparoscopic myomectomy with colpotomy-assisted specimen extraction. Reported outcomes include:

Low complication rates: Comparable to or lower than traditional laparoscopic myomectomy with morcellation.

Short hospital stay: Most patients are discharged within 24 hours.

Fast recovery: Return to daily activities within 1–2 weeks.

Minimal postoperative pain: Due to avoidance of large abdominal incisions.

Low infection rates: With appropriate aseptic precautions.

Moreover, long-term outcomes in terms of fertility, uterine integrity, and recurrence rates are favorable, particularly when proper surgical technique is followed.

Conclusion

Laparoscopic myomectomy with specimen extraction via colpotomy is a safe, effective, and minimally invasive approach for the surgical management of uterine fibroids. It preserves the benefits of laparoscopy while avoiding the risks associated with power morcellation. With proper patient selection and surgical expertise, this technique can offer optimal outcomes for women seeking fertility-preserving surgery for fibroids.

As the field of gynecologic surgery continues to evolve, such innovative techniques will play a crucial role in enhancing patient safety, surgical efficiency, and recovery experiences. Continuing research and training in minimal access surgery are vital to ensure widespread adoption and mastery of such advanced procedures.