This video demonstrates Laparoscopic Myomectomy with Palmer's Point and Extraction by Colpotomy. This patient has a previous laparoscopy scar and intestinal adhesion. We performed laparoscopic myomectomy left side salpingo-oophorectomy for left side dermoid cyst and tubectomy for family planning. Extraction of tissue by colpotomy has the advantage that morcellator is not required and endobag is also not required. Palmer's point is the most attractive site of access is when a previous laparostomy is there. Laparoscopic Myomectomy, sometimes also called fibroidectomy, refers to the minimal access to 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. Here Salpingo-oophorectomy was performed for a dermoid cyst. Although ovarian cystectomy was possible patient opted for oophorectomy. She also wanted family planning so we did a tubectomy of the right side also.

Combined Laparoscopic Myomectomy and Salpingo-oophorectomy is a sophisticated gynecological intervention that requires a high degree of spatial awareness and surgical precision. At World Laparoscopy Hospital (WLH), this procedure is often performed using Palmer’s Point for safe entry and Colpotomy for specimen extraction, ensuring a minimally invasive experience with superior cosmetic results.

1. The Strategy: Why Palmer’s Point?

In cases involving large uterine fibroids (myomas) or prior pelvic surgeries, the standard umbilical entry (Veress needle or Trocar) can be dangerous due to the risk of bowel adhesions or the high fundus of the uterus.

• Location: Palmer’s Point is located 3 cm below the left costal margin in the mid-clavicular line.

• Safety: It is a "clear zone" where the risk of hitting the bladder or the enlarged uterus is significantly reduced.

• WLH Protocol: Surgeons at WLH use this entry to establish pneumoperitoneum safely, providing a panoramic view of the pelvic pathology before placing secondary ports.

2. Phase I: Laparoscopic Salpingo-oophorectomy

The removal of the fallopian tube and ovary (usually due to a cyst, risk of cancer, or endometriosis) is the first step.

• Ligation: The infundibulopelvic (IP) ligament, which contains the ovarian vessels, is desiccated and divided.

• Precision: Dr. Mishra’s technique emphasizes identifying the ureter as it crosses the pelvic brim before any "firing" of energy, ensuring zero collateral damage.

3. Phase II: Laparoscopic Myomectomy

The removal of "middle-sized" myomas (fibroids) requires a careful three-step process:

1. Incision: A dilute solution of Vasopressin is injected into the myometrium to minimize bleeding. A longitudinal incision is made over the most prominent part of the fibroid.

2. Enucleation: Using a myoma screw and a dissector, the fibroid is "shelled out" from its capsule.

3. Suturing: The "dead space" left by the fibroid must be closed in layers to ensure uterine strength for future pregnancies. WLH focuses on intracorporeal multi-layer suturing using barbed sutures (like V-Loc) for tension-free closure.

4. Phase III: Extraction by Colpotomy (Natural Orifice)

Rather than enlarging a skin incision or using a power morcellator (which carries risks of tissue seeding), WLH often utilizes Posterior Colpotomy for specimen retrieval.

• The Procedure: A small incision is made in the posterior vaginal fornix (the Pouch of Douglas).

• Retrieval: An Endobag is passed through the vagina into the pelvic cavity. The fibroid and the adnexa (ovary/tube) are placed in the bag and pulled out through the vaginal canal.

• Benefits:

  • Cosmetic: No "mini-laparotomy" scar on the abdomen.

  • Pain: Significantly less post-operative pain compared to abdominal extraction.

  • Safety: The vaginal wall heals rapidly with minimal risk of incisional hernia.

5. Recovery and Clinical Outcomes

At World Laparoscopy Hospital, the integration of these techniques results in:

• Surgical Time: Approximately 90–120 minutes for a combined middle-sized case.

• Hospital Stay: 24 to 48 hours.

• Return to Activity: Patients are usually back to light work within 10–14 days.

Conclusion

By combining Palmer’s Point entry for safety, meticulous Myomectomy for uterine preservation, and Colpotomy for "scarless" extraction, World Laparoscopy Hospital provides a comprehensive solution for complex gynecological pathologies. This approach balances the necessity of radical tissue removal with the desire for aesthetic and functional preservation.

For more information:
World Laparoscopy Hospital
Cyber City, Gurugram, NCR Delhi
INDIA : +919811416838

World Laparoscopy Training Institute
Bld.No: 27, DHCC, Dubai
UAE : +971525857874

World Laparoscopy Training Institute
8320 Inv Dr, Tallahassee, Florida
USA : +1 321 250 7653