BASIC INFORMATION

Date & Time:

12 April 2026, 16:13 IST

Lecture Handout Prepared from the Teaching Session by: Dr. R. K. Mishra

SUMMARY

This lecture provides a comprehensive guide to laparoscopic myomectomy for postgraduate surgeons and gynecologists, covering fundamental principles and advanced techniques. The session establishes laparoscopy as the gold standard for subserous myomas and a preferred approach for intramural and large submucous fibroids, contingent on advanced surgical skills. Key procedural steps are detailed, including patient selection, the critical role of preoperative MRI for surgical planning, strategic port placement, and the core stages of surgery: hemostasis, enucleation, multi-layer uterine reconstruction, and specimen retrieval. Significant emphasis is placed on techniques for achieving hemostasis, such as vasopressin hydrodissection and temporary uterine artery ligation. Various uterine suturing methods (continuous, baseball, barbed) are compared, and different specimen retrieval options, including power morcellation and colpotomy, are explained. The lecture also addresses the management of complex cases, such as multiple myomas and exceptionally large fibroids, and discusses potential complications and important medicolegal considerations.

KEY KNOWLEDGE POINTS

Laparoscopy is the standard of care for subserous myomas and is increasingly used for intramural and large (>4 cm) submucous myomas, provided the surgeon possesses advanced suturing skills.
Preoperative MRI is the ideal imaging modality for differentiating myomas from adenomyosis, mapping fibroids for surgical planning, and counseling patients on the inability to remove sub-centimeter fibroids.
Hemostasis is a critical component, achievable through vasopressin hydrodissection, temporary uterine artery ligation using a "shoelace knot," or a combination of methods.
Systematic enucleation involves the "push and pull" technique, with the myoma screw placed at the base of the fibroid for effective traction.
Meticulous, multi-layered uterine wall reconstruction is essential to prevent hematoma and uterine rupture in subsequent pregnancies. Suturing techniques include continuous, baseball, and barbed sutures.
Specimen retrieval can be performed via power morcellation (ideally in an endobag for older patients) or, if a morcellator is unavailable, via posterior colpotomy.
Management of large pedunculated myomas involves extracorporeal ligation of the pedicle, while multiple intramural myomas require a staged approach of separate incisions and closures.

INTRODUCTION

The incidence of uterine myomas (fibroids) is increasing, partly due to factors such as delayed childbirth, making myomectomy a frequent and essential procedure in gynecological practice. While open myomectomy was historically the standard, advancements in laparoscopic techniques have established laparoscopic myomectomy as the primary surgical modality for symptomatic fibroids in women desiring uterine preservation. This approach is now considered the gold standard for subserous myomas and a superior alternative to open surgery for many intramural and large submucous myomas. However, the procedure, particularly for large or deep intramural fibroids, demands advanced skills in dissection, hemostasis, and intracorporeal suturing. This lecture will delineate the principles and techniques required to perform both simple and complex laparoscopic myomectomies safely and effectively.

LEARNING OBJECTIVES

To understand the indications for laparoscopic myomectomy based on myoma type, size, and location.
To learn the principles of preoperative assessment, surgical planning, and port placement strategies for various myoma sizes.
To master the step-by-step surgical technique, including hemostasis (vasopressin, uterine artery ligation), systematic enucleation, multi-layer uterine reconstruction, and specimen retrieval.
To compare and contrast different suturing techniques (continuous, baseball, barbed) and specimen retrieval methods (morcellation, colpotomy).
To recognize and manage potential intraoperative and postoperative complications associated with the procedure.

CORE CONTENT

1. Classification of Myomas and Surgical Approach

Myomas are classified by their location, which dictates the surgical strategy.

Subserous Myomas: Located on the outer uterine surface. Laparoscopy is the gold standard. Pedunculated subserous myomas are the simplest to remove, often requiring only ligation of the pedicle.
Intramural Myomas: Embedded within the myometrium. Laparoscopic removal requires a deep uterine incision and meticulous multi-layer closure, demanding a high level of suturing proficiency.
Submucous Myomas: Project into the uterine cavity. Hysteroscopic resection is preferred for fibroids <4 cm. For those >4 cm, laparoscopic myomectomy is increasingly favored.

2. Preoperative Evaluation and Patient Counseling

2.1. Diagnostic Imaging

Magnetic Resonance Imaging (MRI) is the ideal modality for definitive diagnosis, accurately mapping the number, size, and location of all fibroids, and differentiating myomas from adenomyosis, which can have an ambiguous appearance on ultrasound.

2.2. Patient Counseling and Informed Consent

It is imperative to review MRI findings with the patient. The surgeon must clarify that laparoscopy does not allow for the tactile feedback necessary to identify and remove very small, sub-centimeter myomas. Patients must be counseled that these may grow, leading to potential recurrence of symptoms. This manages expectations and mitigates medicolegal issues.

3. Surgical Principles and Technique

3.1. Patient and Port Positioning

The patient is placed in a steep Trendelenburg position. Port placement is planned after initial visualization.

Telescope Port: A supraumbilical port is standard. For very large uteri (>12-14 weeks size) that distort the anatomy, primary entry at Palmer’s point (mid-clavicular line, 2-3 cm below the left costal margin) is recommended to avoid injury. An epigastric port can then be placed for the camera.
Instrument Ports: Two main working ports are placed to form an ergonomic "baseball diamond" configuration. The telescope is positioned approximately 24 cm from the myoma base, and instruments are about 18 cm away.

3.2. Hemostasis Techniques

Minimizing blood loss is paramount.

Vasopressin Hydrodissection: A dilute solution of vasopressin (25 IU in 100 mL normal saline) is injected into the myometrium at the junction with the myoma capsule. This creates hydrodissection, defines the surgical plane, and provides approximately 20-40 minutes of vasoconstriction, indicated by a "marble white appearance." Adrenaline is contraindicated due to rebound vasodilation.
Temporary Bilateral Uterine Artery Ligation: A highly effective method for controlling blood supply. After identifying the ureter and internal iliac artery, the uterine artery is isolated. A "shoelace knot" (a single half-knot) using a non-locking suture (e.g., No. 1 Vicryl) is placed around the artery. This temporarily occludes flow and is reversed by pulling one suture tail after the myomectomy is complete.

3.3. Enucleation of Intramural Myomas

The procedure follows a structured sequence:

Uterine Incision: An oblique incision over the myoma is often preferred for easier suturing. The incision is made down to the pseudocapsule using an energy device.
Myoma Screw and Traction: The myoma screw must be attached to the base of the myoma, not the apex, to provide effective traction without tearing the tissue.
"Push and Pull" Technique: The surgeon applies firm traction on the myoma screw (pull) while using a dissecting instrument to develop the plane between the myoma and its pseudocapsule (push).
Dissection at the Base: Caution is required at the base, which contains the main feeding vessels. Dissection should be slow, using an energy source to coagulate vessels before cutting.

3.4. Uterine Wall Reconstruction

Meticulous multi-layer closure is critical.

First Layer (Deep Myometrium): A continuous running stitch using a size 1 absorbable suture closes the deep muscular layer, eliminating dead space. The serosa and endometrial cavity should be excluded.
Second Layer (Seromuscular Closure):
- Continuous Suturing: A conventional over-and-over closure of the superficial myometrium and serosa.
- Baseball Suturing: This technique uses "in-to-out" bites on both sides of the incision, resulting in excellent serosal eversion and potentially reducing adhesion risk. It is particularly useful for managing redundant serosa.
- Barbed Sutures: These self-anchoring sutures facilitate a faster, tension-free closure and can be combined with the baseball technique. They are more expensive than traditional sutures.

3.5. Specimen Retrieval

Power Morcellation: The standard method. In patients over 50 years of age, morcellation must be performed inside a contained extraction bag (endobag) to prevent the potential dissemination of an occult leiomyosarcoma.
Colpotomy: An alternative when a morcellator is unavailable. The myoma is bisected, and a transverse incision is made in the posterior vaginal fornix. The specimen is then extracted vaginally. The colpotomy is closed laparoscopically.

4. Management of Special Cases

Large Pedunculated Subserous Myomas: These are managed by identifying the pedicle and securing it with an extracorporeal knot before transection. A second reinforcing knot is recommended on the stump.
Multiple Intramural Myomas: This is an advanced procedure. The recommended strategy is to make separate incisions, enucleate one myoma, and completely suture the defect before proceeding to the next.

SURGICAL PEARLS

Always obtain a preoperative MRI to plan surgery and counsel the patient about residual sub-centimeter fibroids.
Attach the myoma screw to the base of the myoma for effective traction; applying it at the apex will cause tearing.
When using vasopressin, inject at a shallow 30-degree angle to achieve hydrodissection and look for the "marble white" sign.
For the serosal layer, baseball suturing provides excellent apposition and inversion, which may reduce adhesions.
When using barbed sutures, always bury the terminal end within the myometrium to prevent the exposed barb from entrapping the bowel.
During morcellation, adopt the principle: "Bring the tissue to the morcellator, not the morcellator to the tissue" to prevent injury.
Fascial closure of all ports 10 mm and larger is mandatory to prevent incisional hernias.

ANESTHETIC AND PHYSIOLOGICAL CONSIDERATIONS

Vasopressin Use: The anesthetist must be informed before vasopressin injection due to the risk of systemic effects (hypertension, tachycardia). It should only be used in hemodynamically stable patients with no cardiovascular comorbidities. Stop the injection immediately if the heart rate rises sharply.
GnRH Agonists: Preoperative use of GnRH agonists can soften the myoma, making it difficult to grasp with a myoma screw and prone to tearing during enucleation.
Uterine Blood Supply: The uterus has a rich collateral blood supply from the ovarian and vaginal arteries, which allows it to tolerate temporary bilateral uterine artery ligation for several hours without ischemic injury.

COMPLICATIONS AND THEIR MANAGEMENT

Intraoperative
- Hemorrhage: The most feared complication. Can be managed with efficient suturing, additional hemostatic agents, uterine artery ligation, or, if uncontrollable, conversion to open surgery.
- Systemic Effects of Vasopressin: Tachycardia and hypertension require immediate communication with the anesthesia team for management.
- Inadvertent Entry into Endometrial Cavity: A small tear should be closed with sutures as part of the first-layer repair.
Early Postoperative
- Adhesion Formation: Minimized by meticulous hemostasis, serosal inversion, and the use of adhesion barriers on raw surfaces like pedicle stumps.
Late Postoperative
- Uterine Rupture: A catastrophic complication during a subsequent pregnancy or labor, directly related to inadequate myometrial defect closure.
- Port-Site Hernia: Prevented by proper fascial closure of larger port sites.
- Myoma Recurrence: An inherent risk due to the growth of pre-existing, non-removable sub-centimeter fibroids.

MEDICOLEGAL AND PATIENT SELECTION CONSIDERATIONS

Informed Consent: A critical discussion must be had with the patient regarding the inability to remove all sub-centimeter myomas, the potential for recurrence, and the risks of hemorrhage, conversion to laparotomy, and uterine rupture in future pregnancies.
Surgical Skill: Surgeons should not attempt laparoscopic intramural myomectomy without having first mastered advanced laparoscopic suturing. Inadequate closure is a major cause of uterine rupture.
Fibroid Size and Number: While laparoscopy is feasible for large myomas, those exceeding an 18-week gravid size or multiple intramural myomas require significant expertise and should be undertaken by experienced surgeons.

SUMMARY AND TAKE-HOME MESSAGES

Laparoscopic myomectomy is the standard of care for subserous myomas and a viable option for large submucous and intramural myomas, contingent on surgeon skill.
Successful outcomes depend on meticulous preoperative planning with MRI, precise surgical technique incorporating effective hemostasis, and proficient multi-layer uterine reconstruction.
Surgeons must be adept at various techniques, including different suturing methods and specimen retrieval options, to adapt to intraoperative findings.
Thorough patient counseling regarding the limitations of the procedure, specifically the inability to remove all small fibroids and the potential for recurrence, is essential for patient satisfaction and medicolegal protection.

MULTIPLE CHOICE QUESTIONS (MCQs)

What is the gold standard surgical approach for a 6 cm subserous myoma?

a) Hysteroscopy

b) Laparoscopic myomectomy

c) Open myomectomy

d) Medical management with GnRH agonists
For a patient with a 30 cm fibroid reaching the epigastrium, what is the recommended primary port entry site?

a) Supraumbilical

b) Subumbilical

c) Palmer’s point

d) Left lower quadrant
What is the recommended imaging modality for surgical planning and differentiating myomas from adenomyosis?

a) Transvaginal ultrasound

b) Abdominal ultrasound

c) MRI

d) CT scan
Where is the correct placement for a myoma screw to ensure effective traction during enucleation?

a) At the apex of the myoma

b) On the uterine serosa adjacent to the myoma

c) At the base of the myoma

d) In the center of the myoma after incision
The "baseball suturing" technique is primarily used for the seromuscular layer to achieve what outcome?

a) Faster closure time

b) Inversion of the serosal edges

c) Increased suture tension

d) Deeper myometrial approximation
During vasopressin injection, what visual sign on the uterine surface indicates correct placement and effect?

a) A blue discoloration

b) A "marble white appearance"

c) Rapid swelling of the myoma itself

d) Formation of a hematoma
What is a critical safety precaution when concluding a suture line with a barbed suture?

a) Tie at least three surgical knots

b) Leave a long tail for easy identification

c) Bury the tip of the suture into healthy tissue

d) Apply a surgical clip to the end of the suture
Why must morcellation be performed in an endobag for patients over 50 years of age?

a) To prevent blood loss

b) To make morcellation faster

c) To prevent peritoneal dissemination of a potential leiomyosarcoma

d) To prevent injury to the bowel
What is the key feature of the "shoelace knot" for temporary uterine artery ligation?

a) It is a permanent ligature.

b) It consists of a single half-knot and is easily reversible.

c) It requires a special type of suture material.

d) It can only be tied extracorporeally.
What is a common disadvantage of pre-operative GnRH agonist treatment for laparoscopic myomectomy?

a) It increases the size of the myoma.

b) It makes the myoma very hard and difficult to cut.

c) It makes the myoma soft, leading to a poor grip with the myoma screw.

d) It increases intraoperative bleeding.
What is the recommended strategy for the laparoscopic removal of multiple, separate intramural myomas?

a) Make one large incision to access all myomas simultaneously.

b) Remove all myomas, then suture all defects at the end.

c) Use a morcellator to remove them without formal incisions.

d) Make separate incisions, and suture each defect completely before proceeding to the next.
What is a viable alternative for specimen retrieval if a morcellator is unavailable?

a) Leaving the specimen in the abdomen

b) Making a large abdominal incision

c) Bisection of the myoma and removal via a posterior colpotomy

d) Using a harmonic scalpel to disintegrate the myoma
The most severe long-term complication of an inadequately sutured myomectomy defect is:

a) Adhesion formation

b) Recurrence of myoma

c) Chronic pelvic pain

d) Uterine rupture during pregnancy
The "push and pull" enucleation technique involves:

a) Pushing the uterus and pulling the bowel away.

b) Pushing with a dissector while pulling the myoma with a screw.

c) Pushing the morcellator and pulling the tissue.

d) Pushing and pulling the same instrument for blunt dissection.
What physiological principle allows the uterus to tolerate temporary uterine artery ligation for several hours?

a) Low metabolic demand of the myometrium.

b) Presence of significant collateral blood supply from ovarian and vaginal arteries.

c) The ability of myometrial cells to survive in anaerobic conditions.

d) Arterio-venous shunts that bypass the capillary bed.
Why is an oblique incision on the uterus often preferred over a vertical one?

a) It bleeds less.

b) It heals faster.

c) It is ergonomically easier to suture with ipsilateral ports.

d) It allows for a larger myoma to be removed.
When should the temporary uterine artery ligatures (shoelace knots) be removed?

a) Immediately after the myoma is enucleated.

b) After all suturing is complete and hemostasis is confirmed.

c) Before starting the suturing of the myometrium.

d) After exactly 40 minutes.
What must a patient be counseled about regarding small, sub-centimeter myomas?

a) They can be easily removed with a harmonic scalpel.

b) They are best removed hysteroscopically.

c) They cannot be reliably identified and removed laparoscopically due to a lack of tactile feedback.

d) They always disappear after menopause.
After removing a large pedunculated myoma via pedicle ligation, what is the recommended next step for the uterine stump?

a) Leave it as is.

b) Apply a second, reinforcing knot.

c) Extensively cauterize it.

d) Suture it to the round ligament.
Before injecting vasopressin, the surgeon must inform which member of the surgical team due to the risk of systemic effects?

a) The scrub nurse

b) The circulating nurse

c) The anesthetist

d) The assistant surgeon

Answer Key:

B, 2. C, 3. C, 4. C, 5. B, 6. B, 7. C, 8. C, 9. B, 10. C, 11. D, 12. C, 13. D, 14. B, 15. B, 16. C, 17. B, 18. C, 19. B, 20. C

MOTIVATIONAL MESSAGE FROM DR. R. K. MISHRA

Surgical excellence is the quiet product of a thousand moments of practice, a million questions asked, and the unwavering discipline to do what is right, even when no one is watching.

May your hands be guided by a clear mind, and may your dedication to learning be the ultimate safeguard for every patient you treat. My best wishes are with you in all your future endeavors.