Dr. Usha M Kumar presents an extensive discussion on laparoscopic myomectomy at WALS 2025, examining how minimally invasive surgery has transformed the management of uterine fibroids and discussing the factors that must be considered when selecting this approach. The session addresses the balance between the potential benefits of laparoscopic surgery and its technical demands, with particular attention to uterus preservation, recovery, surgical precision, patient selection, fibroid characteristics, and postoperative considerations.

Uterine fibroids are among the commonly encountered benign gynecological conditions and can affect women differently depending on their size, number, location, and relationship to the uterine cavity. While some fibroids remain asymptomatic and may only require observation, symptomatic fibroids can cause heavy menstrual bleeding, pelvic pain or pressure, and reproductive problems. When surgical treatment is appropriate, the choice of procedure depends on the clinical presentation and the patient's individual objectives.

Laparoscopic myomectomy provides a uterus-preserving alternative to hysterectomy for appropriately selected patients. The fundamental objective is to remove the fibroid while maintaining the surrounding healthy myometrium and reconstructing the uterus. This makes the procedure particularly relevant when preservation of the uterus is an important treatment goal. However, the decision to perform myomectomy—and the choice of laparoscopic versus another surgical approach—requires detailed assessment of the individual case.

One of the most important benefits of laparoscopic myomectomy is the use of small abdominal incisions rather than the larger incision traditionally associated with open abdominal surgery. The smaller access points can reduce abdominal wall trauma and may contribute to less postoperative discomfort, reduced scarring, shorter hospitalization, and faster return to routine activities. These benefits have contributed to the widespread development of minimally invasive approaches in gynecological surgery.

The minimally invasive approach also provides the surgeon with magnified visualization of the pelvic anatomy. A laparoscope can provide a detailed view of the uterus and surrounding structures, allowing the surgeon to identify fibroids and perform precise dissection. Specialized laparoscopic instruments can then be used to separate the fibroid from the surrounding uterine muscle while attempting to preserve as much healthy tissue as possible.

However, laparoscopic myomectomy can be technically demanding. The difficulty increases when there are multiple fibroids, very large fibroids, deep intramural lesions, difficult anatomical locations, or associated pelvic pathology. The surgeon must determine whether the fibroids can be safely removed laparoscopically and whether adequate reconstruction of the uterine wall can be achieved. This is why surgeon experience and appropriate training are important components of patient safety.

The WALS 2025 discussion places significant emphasis on preoperative planning. Before surgery, clinicians can use imaging to map the fibroids and understand their relationship to the uterine cavity and outer uterine surface. Ultrasound is an important first-line imaging modality, while MRI can be particularly helpful when detailed mapping is required for complex disease. The information obtained from imaging can influence the number and location of uterine incisions, the anticipated difficulty of enucleation, and the overall surgical strategy.

The actual operation involves several important stages. After laparoscopic access has been established, the surgeon identifies the fibroid and creates an appropriate uterine incision. The fibroid is then carefully enucleated from the myometrium, often using a combination of traction, countertraction, and precise dissection. Once the fibroid is completely removed, attention turns to reconstruction of the uterine wall.

Uterine suturing is a critical stage of laparoscopic myomectomy. Appropriate closure helps restore the anatomy of the uterus and may be particularly important for women who plan future pregnancies. Depending on the depth and extent of the uterine defect, multilayer closure may be performed to reconstruct the myometrium. The quality of uterine repair is therefore an important consideration when evaluating the overall surgical technique.

The session also considers the issue of blood loss and hemostasis. Fibroids can have substantial vascularity, and bleeding during enucleation can complicate the procedure. Modern laparoscopic surgery incorporates different strategies for controlling bleeding and maintaining a clear operative field. The exact method depends on the patient's anatomy, the number and size of fibroids, and the surgeon's experience.

After removal, the fibroid must be extracted from the abdomen. This can be straightforward for small lesions but becomes more challenging as the fibroid size increases. Tissue extraction and morcellation therefore represent important components of minimally invasive myomectomy. Current surgical practice emphasizes appropriate patient assessment and safe extraction techniques, including contained morcellation when indicated, to reduce the risk of unintended tissue dissemination.

The WALS 2025 presentation also highlights the importance of understanding the limitations of minimally invasive surgery. Although laparoscopy offers many potential advantages, it is not appropriate for every patient or every fibroid. Very extensive disease may require an alternative approach, and conversion to open surgery may sometimes be necessary when safe minimally invasive completion is not possible. Such decisions are part of responsible surgical planning rather than a failure of minimally invasive surgery.

Another consideration is the possibility of postoperative adhesions and fibroid recurrence. Minimally invasive surgery may reduce surgical trauma, but adhesions can still occur following pelvic surgery. In addition, removing existing fibroids does not eliminate the possibility of developing new fibroids in the future. Patients should therefore receive appropriate counseling regarding recurrence and long-term follow-up.

Technological developments have further expanded the field. Robotic-assisted gynecological surgery can provide three-dimensional visualization and wristed instruments that may facilitate suturing and dissection in selected complex procedures. Dr. Usha M Kumar's professional work includes both laparoscopic and robotic gynecological surgery, and the WALS 2025 discussion reflects the broader movement toward increasingly sophisticated minimally invasive approaches.

At the same time, technology does not replace fundamental surgical principles. Accurate diagnosis, appropriate patient selection, knowledge of pelvic anatomy, careful hemostasis, preservation of healthy tissue, secure uterine closure, and postoperative monitoring remain essential regardless of whether conventional laparoscopy or robotic assistance is used.

The presentation is particularly relevant for gynecologists and laparoscopic surgeons who manage uterine fibroids, as well as trainees seeking to understand advanced gynecological endoscopy. It provides a framework for considering the advantages and disadvantages of laparoscopic myomectomy and emphasizes that treatment decisions should be based on the patient's symptoms, fibroid characteristics, reproductive objectives, and overall clinical circumstances.

Dr. Usha M Kumar's WALS 2025 presentation ultimately illustrates the continuing evolution of fertility-conscious and uterus-preserving gynecological surgery. Laparoscopic myomectomy can offer selected patients the combination of fibroid removal and uterine preservation while potentially providing the recovery advantages associated with minimally invasive surgery. At the same time, the procedure requires significant technical expertise and careful planning, and its potential risks and limitations must be discussed with each patient.

The session therefore provides a valuable educational overview of how to weigh the pros and cons of laparoscopic myomectomy. By combining detailed preoperative assessment, advanced laparoscopic skills, careful fibroid enucleation, meticulous uterine reconstruction, safe tissue extraction, and appropriate postoperative care, surgeons can approach fibroid surgery with a comprehensive and individualized strategy.