This video demonstrates Laparoscopic Hysterectomy for Multiple Fibroid and Endometrioma performed by Dr. R.K. Mishra at World Laparoscopy Hospital.  Total Laparoscopic hysterectomy (TLH) has been the traditional procedure. It is an invasive procedure that is best suited for women with large fibroids, when the ovaries also need to be removed, or when cancer or pelvic disease is present. 

Fibroids range in size from seedlings, undetectable by the human eye, to bulky masses that can distort and enlarge the uterus. You can have a single fibroid or multiple ones. In extreme cases, multiple fibroids can expand the uterus so much that it reaches the rib cage and can add weight. A laparoscopic Myomectomy is a good option for fibroid removal but if the family is complete and there is abnormal uterine bleeding and the age of the patient is more than 40 years TLH is also an option. 

This patient has left side endometrioma also. Endometrioma is the presence of endometrial tissue in and sometimes on the ovary. It is the most common form of endometriosis. Endometrioma is found in 17–44% of patients with endometriosis. More broadly, endometriosis is the presence of endometrial tissue located outside the uterus.
 

At World Laparoscopy Hospital (WLH), the management of a "double pathology"—multiple uterine fibroids (myomas) combined with ovarian endometrioma—represents one of the most challenging yet rewarding applications of minimal access surgery. This procedure requires a surgeon to navigate distorted anatomy while adhering to the meticulous surgical principles taught by Dr. R.K. Mishra.

1. The Clinical Challenge: Distorted Anatomy

When multiple fibroids and endometriomas coexist, the pelvic environment is often referred to as a "frozen pelvis."

• Fibroids: These can enlarge the uterus significantly, crowding the workspace and displacing the ureters and major blood vessels.

• Endometriomas: Often called "chocolate cysts," these cause dense, inflammatory adhesions that tether the ovaries to the pelvic sidewall or the back of the uterus (the Pouch of Douglas).

2. The Systematic Surgical Approach at WLH

Phase I: Access and Visualization

Given the enlarged uterus, port placement is key. The umbilical port is often shifted higher (the "Palmer’s Point" or a supra-umbilical entry) to gain a panoramic view over the fibroids.

Phase II: Managing the Endometrioma

Before the hysterectomy begins, the surgeon must mobilize the ovaries.

• Cystectomy/Aspiration: The endometrioma is carefully dissected from the pelvic sidewall.

• Adhesiolysis: Using the "cold scissors" technique or ultrasonic shears, the surgeon separates the ovaries and rectum from the posterior uterus, restoring identifiable anatomy.

Phase III: The Hysterectomy (TLH)

Once the anatomy is clear, the hysterectomy proceeds following Dr. Mishra’s standardized steps:

1. Ligation of the Round Ligaments: This opens the broad ligament and allows the surgeon to identify the ureters.

2. Bladder Flap Creation: The bladder is gently pushed down away from the cervix, which is often difficult if fibroids are located in the lower uterine segment.

3. Uterine Artery Ligation: This is the critical step. At WLH, the "Mishra Technique" emphasizes identifying the uterine artery at its origin to minimize blood loss.

4. Vault Closure: After the uterus is removed through the vagina, the vaginal vault is sutured laparoscopically, often using extracorporeal or intracorporeal knotting for a robust, leak-proof seal.

3. Special Considerations: Specimen Retrieval

Removing a large, fibroid-filled uterus through a small laparoscopic incision requires Morcellation.

• In-Bag Morcellation: To ensure safety, WLH utilizes a specialized containment bag. The uterus is placed inside the bag and then cut into smaller strips using a power morceller. This prevents any potentially undiagnosed tissue (or endometriotic fluid) from spreading within the abdominal cavity.

4. Recovery and Outcomes

Patients undergoing this combined procedure at WLH typically experience:

• Hospital Stay: 24–48 hours.

• Pain Levels: Significantly lower than open surgery due to the lack of a large abdominal incision.

• Return to Normalcy: Full activity usually resumes within 2 weeks, compared to 6–8 weeks for traditional "open" hysterectomy.

Conclusion

A Total Laparoscopic Hysterectomy for multiple fibroids and endometrioma is a "masterclass" procedure. By systematically addressing the adhesions of endometriosis first and then tackling the fibroids with precise vascular control, surgeons at World Laparoscopy Hospital ensure a safe, effective, and scar-minimizing solution for complex gynecological issues.

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