Large uterine fibroids can make minimally invasive surgery technically demanding, and the challenge may be different when the myoma becomes unusually soft following Gonadotropin-Releasing Hormone (GnRH) therapy. This surgical video presents the laparoscopic approach to myomectomy for a large soft myoma, emphasizing operative planning, safe dissection, enucleation, bleeding control, and restoration of the uterine wall.

Laparoscopic myomectomy is a uterus-preserving surgical procedure used for appropriately selected patients with symptomatic or clinically significant uterine leiomyomas. When the fibroid is large, the surgeon must carefully evaluate its location, depth, relationship with the uterine cavity, surrounding myometrium, and vascular supply before beginning the procedure.

Preoperative GnRH therapy can alter the size and characteristics of fibroids. A softer myoma may not provide the same firm surface for grasping and traction that surgeons commonly encounter with untreated fibroids. Consequently, identification of the capsule and maintenance of the correct dissection plane require careful technique. The surgeon must balance adequate traction with preservation of surrounding myometrial tissue.

This procedure demonstrates important principles of advanced laparoscopic myomectomy, including strategic incision, identification of the fibroid capsule, gradual enucleation, appropriate use of traction and counter-traction, management of bleeding, and careful assessment of the uterine defect after fibroid removal. The reconstruction of the myometrium is a critical component of the procedure, particularly when removing a large intramural lesion.

The case also highlights how surgeons may need to modify their operative technique according to the consistency of the myoma. Soft tissue can require different handling compared with a dense or well-circumscribed fibroid. Maintaining visualization, avoiding excessive thermal injury, achieving effective hemostasis, and performing secure multilayer suturing when indicated are important considerations in uterine reconstruction.

This video is intended as an educational resource for gynecologists, laparoscopic surgeons, residents, fellows, and medical professionals seeking to expand their knowledge of advanced minimally invasive gynecologic procedures. It offers valuable insight into the practical challenges of laparoscopic myomectomy for large and soft uterine fibroids following medical pretreatment.

Watch this detailed surgical demonstration to understand the operative principles, technical considerations, and laparoscopic skills involved in managing a large soft myoma while aiming to preserve uterine anatomy.