BASIC INFORMATION

Date & Time: March 14, 2026, 10:07 AM (Indian Standard Time)

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

SUMMARY

This lecture provides postgraduate surgeons and gynecologists with a comprehensive overview of the principles and techniques of laparoscopic myomectomy and related advanced procedures. The discussion covers the entire surgical workflow, from preoperative diagnosis and patient counseling to operative techniques and postoperative management. Key topics include the critical role of MRI in differentiating myoma from adenomyosis, the medicolegal complexities of postoperative recurrence, and specific surgical strategies for various myoma types (intramural, pedunculated). The lecture details essential techniques for hemostasis, including the use of vasopressin and temporary uterine artery ligation at its origin, emphasizing anatomical landmarks and safety protocols. Principles of ergonomic port placement, myoma enucleation, and meticulous multi-layer uterine reconstruction are explained. Furthermore, the session addresses specimen extraction methods, including alternatives to power morcellation such as in-situ splitting and posterior colpotomy. Finally, the lecture covers the management of related conditions, such as laparoscopic isthmocele repair, and delves into the laparoscopy-oriented understanding of pelvic fascial anatomy.

KEY KNOWLEDGE POINTS

• Preoperative Planning: The essential role of MRI for accurate diagnosis, differentiation from adenomyosis, and mitigating medicolegal issues. Contraindication of preoperative GnRH agonists in laparoscopy.

• Hemostatic Techniques: Detailed protocols for preventive hemostasis, including diluted vasopressin administration and temporary bilateral uterine artery ligation at its origin via retroperitoneal dissection.

• Surgical Strategy: The principle that myoma location and consistency are more critical than size. Port placement based on the "baseball diamond" concept and uterine incision choices (vertical, horizontal, oblique) based on myoma location.

• Myoma Enucleation: The "pull and push" technique, correct myoma screw application, and plane identification using the "white is right" principle.

• Uterine Reconstruction: Meticulous two-layer continuous suturing, including the "baseball stitch," to ensure uterine integrity and prevent future rupture.

• Specimen Extraction: Techniques for power morcellation, including safety principles, and alternatives such as in-situ splitting with an endo-knife and transvaginal removal via posterior colpotomy.

• Advanced Procedures: The technique for laparoscopic isthmocele (uterine niche) repair, including bladder dissection and multi-layer closure.

• Anatomical Principles: A modern, laparoscopy-based understanding of pelvic fascial planes ("predictive anatomy") to facilitate avascular, nerve-sparing dissection.

INTRODUCTION

Uterine myomas (leiomyomas) are the most common benign tumors of the female genital tract and a leading operable cause of infertility. With an increasing incidence in younger women, uterine-preserving surgery is of paramount importance. Laparoscopic myomectomy has become the preferred minimally invasive approach for most intramural and subserous myomas. However, the procedure demands advanced surgical skills, particularly for large or deep intramural fibroids, which present challenges in hemostasis, enucleation, and uterine reconstruction.

This lecture provides a structured, in-depth guide to modern laparoscopic myomectomy. It addresses the entire spectrum of the procedure, from accurate preoperative assessment using MRI to advanced hemostatic maneuvers like uterine artery ligation. Furthermore, it details techniques for uterine reconstruction essential for preserving future fertility and discusses alternatives to power morcellation, which have become critical given the safety concerns regarding tissue dissemination. The session also explores the management of related iatrogenic conditions, such as isthmocele, and the contemporary understanding of pelvic surgical anatomy, which is fundamental to safe and effective laparoscopic surgery.

LEARNING OBJECTIVES

• Evaluate the role of MRI in the preoperative assessment of myomas and its medicolegal implications.

• Describe the principles of preventive hemostasis, including the use of vasopressin and the technique for temporary laparoscopic uterine artery ligation.

• Apply ergonomic principles for optimal port placement and select appropriate uterine incision types based on myoma location.

• Outline the step-by-step procedure for myoma enucleation and robust multi-layer uterine reconstruction.

• Identify and manage potential complications and understand various specimen extraction techniques, including alternatives to power morcellation.

• Describe the surgical technique for laparoscopic repair of an isthmocele (uterine niche).

CORE CONTENT

1. Preoperative Considerations and Patient Counseling

1.1. Diagnosis and Imaging

Accurate preoperative diagnosis is paramount. While transvaginal ultrasound is a common initial imaging modality, it has limitations in differentiating myoma from adenomyosis.

• Magnetic Resonance Imaging (MRI): MRI is the gold standard for accurately mapping myoma number, size, and location. Its superiority in distinguishing myomas from adenomyosis is crucial for surgical planning. MRI can also detect sub-centimeter myomas often missed on ultrasound, allowing for thorough patient counseling.

1.2. Medicolegal Issues and Patient Education

A common medicolegal issue arises when a patient is found to have a "recurrent" myoma on postoperative ultrasound. This is typically due to the growth of a pre-existing, non-palpable sub-centimeter myoma that was undetectable during surgery and migrated into the dead space.

• Mitigation Strategy: Preoperatively, it is essential to counsel the patient about this phenomenon using MRI findings. Postoperative administration of a GnRH agonist for six months can be considered to suppress the growth of any residual sub-centimeter myomas and allow for uterine rest during healing.

1.3. Role of GnRH Agonists

• Preoperative Use: Preoperative GnRH agonists are contraindicated in laparoscopic myomectomy. They render the myoma soft and friable, akin to a "boiled potato," obliterating the clear dissection plane between the myoma and its pseudocapsule. This significantly increases surgical difficulty. Surgery should be postponed for three months after cessation of GnRH agonist therapy.

• Postoperative Use: May be recommended to suppress residual small myomas and manage abnormal uterine bleeding.

2. Anesthetic and Physiological Considerations

2.1. Vasopressin Administration

Vasopressin is a potent vasoconstrictor used for hemostasis. However, its use is off-label in many regions and requires strict precautions.

• Precautions:

  1. Anesthetist Communication: The anesthetist must be informed before administration.

  2. Hemodynamic Monitoring: The patient's pulse and blood pressure must be continuously monitored.

  3. Avoid Intravascular Injection: Always aspirate before injecting to ensure the needle is not in a vessel.

  4. Avoid Extraperitoneal Leakage: The needle tip must be well within the myometrium to prevent leakage into the peritoneal cavity, where rapid absorption can cause hemodynamic collapse.

  5. Patient Comorbidities: Use with extreme caution or avoid in patients with cardiac disease, respiratory conditions, uncontrolled hypertension, or hypothyroidism.

• Adrenaline Contraindication: Adrenaline must never be used for hemostasis in myomectomy due to the risk of rebound vasodilation and delayed postoperative bleeding.

3. Surgical Principles and Technique

3.1. General Principles

• Location vs. Size: Surgical difficulty is determined more by myoma location and consistency than by size. A 4 cm deep intramural myoma can be more challenging than a 20 cm subserous one.

• Uterine Manipulator: A manipulator should be used with caution, especially with deep intramural myomas, and is generally avoided for anterior wall myomas due to the risk of perforation.

• Surgical Steps: The procedure is broadly divided into five steps: (1) Preventive Hemostasis, (2) Fixation, (3) Enucleation, (4) Obliteration of Dead Space (Suturing), and (5) Retrieval.

3.2. Port Placement: The Baseball Diamond Concept

Ergonomic port placement is essential. The "baseball diamond" concept is applied with the base of the myoma as the surgical target.

• Telescope Port: Positioned to allow the laparoscope to be approximately 24 cm from the myoma base for a panoramic view. For very large uteri, this port may be placed in the epigastric region or at Palmer's point.

• Instrument Ports: Placed so instruments are approximately 18 cm from the target.

3.3. Preventive Hemostasis

• Method 1: Vasopressin Injection: Dilute 5 IU of vasopressin in 100-200 mL of normal saline. The large volume aids in hydrodissection. Inject into the myometrium surrounding the myoma capsule at a single entry point.

• Method 2: Temporary Uterine Artery Ligation: An alternative when vasopressin is contraindicated. This can be performed near the uterus or, more definitively, at the vessel's origin from the internal iliac artery.

3.4. Laparoscopic Uterine Artery Ligation at Origin

This technique requires a thorough understanding of retroperitoneal anatomy.

1. Peritoneal Incision: The peritoneum is incised in the "gray area" between the round ligament and the infundibulopelvic (IP) ligament.

2. Ureter Identification: The ureter is identified by its vermiculating peristalsis as it crosses the iliac vessels.

3. Ureter Medialization: The ureter must always be medialized. This protects its medial blood supply and the underlying hypogastric nerve plexus.

4. Dissection of Spaces: Medializing the ureter develops the Okabayashi space (medial). The Latzko space (lateral) is then entered.

5. Uterine Artery Identification: The uterine artery is the first anterior branch of the internal iliac artery and the only structure crossing the Latzko space at a right angle. It is straight and isolated from veins at its origin.

6. Temporary Ligation: A "shoelace knot" using a non-absorbable suture can be applied for temporary occlusion. A knot is placed at one end; this end is never pulled. The free end is used to tighten and later release the ligature. The procedure is repeated bilaterally.

3.5. Uterine Incision

The incision type is dictated by myoma location to preserve fertility.

• Fundal Myoma: Horizontal incision.

• Anterior Wall Myoma: Oblique incision to avoid the intramural portion of the fallopian tubes.

• Deep Posterior/Cervical Myoma: Vertical incision to avoid injury to the uterosacral ligaments and uterine vessels.

3.6. Myoma Enucleation

1. Plane Identification: After incising the seromuscular layer, use two graspers to mechanically split the remaining fibers. The white pseudocapsule will "pop up," defining the avascular plane.

2. Myoma Screw Application: The screw must be inserted deep into the base of the myoma, with at least 5 mm of its solid rod embedded to prevent bending.

3. "Pull and Push" Technique: The surgeon controls the myoma screw for traction with the non-dominant hand while pushing the myometrium away with a dissector in the dominant hand.

4. "White is Right": Blunt dissection is safe in the white, avascular plane. Energy devices should be used for vascular pedicles (often bluish), especially near the myoma base.

5. Cavity Preservation: If dissection approaches the uterine cavity, care must be taken to preserve the basal endometrial layer to prevent Asherman's syndrome.

3.7. Uterine Reconstruction (Two-Layer Closure)

A meticulous, tension-free closure is essential to prevent uterine rupture. Suture length should be approximately four times the incision length.

• First Layer (Myometrial):

  • A continuous running suture (e.g., 0 Vicryl) is used to approximate the deep myometrium and obliterate dead space.

  • Bites are deep and full-thickness, taken 1 cm from the edge, but excluding the serosa.

  • Suture bites must be at the same horizontal level to ensure symmetrical apposition.

• Second Layer (Seromuscular):

  • This layer inverts the wound margins to prevent adhesions.

  • Bites are superficial, incorporating only the serosa and minimal superficial myometrium. Deep bites must be avoided to prevent eversion.

  • "Baseball" Suture Technique: An alternative for the second layer, using an "in-to-out" bite on both sides to achieve excellent inversion.

• Knot Tying: After returning to the start, the initial suture tail is pulled to retroactively tighten the deep layer before a single final knot is tied.

4. Specimen Extraction

4.1. Power Morcellation

• Principle: Pull the tissue into the morcellator; do not push the morcellator toward the tissue.

• Safety: Must be performed under a panoramic view. Directional rotation (anticlockwise from left port, clockwise from right port) pushes adjacent viscera away.

• Risks: Uncontained morcellation carries a risk of creating parasitic myomas (1%) and, more catastrophically, disseminating an unsuspected leiomyosarcoma (0.1%). In-bag morcellation is the standard of care.

4.2. Colpotomy and In-Situ Splitting

An alternative when a morcellator is unavailable or contraindicated.

1. In-Situ Splitting: The enucleated myoma is split in situ using an endo-knife, leaving a small hinge of tissue intact. This does not create the small fragments associated with power morcellation.

2. Posterior Colpotomy: A bulge is created in the posterior fornix using a sponge-on-a-stick (a standard colpotomizer is ineffective). An incision is made with a "cold" instrument (e.g., scissors) about 3 cm below the uterosacral arch.

3. Extraction: A claw forceps is introduced transvaginally to grasp and extract the split myoma.

4. Closure: The colpotomy incision must be closed laparoscopically in full thickness to prevent future rectocele. Extracorporeal knotting is advantageous in the deep pelvis.

5. Laparoscopic Isthmocele Repair

An isthmocele (uterine niche) is a myometrial defect from a previous Cesarean section scar.

• Indications for Repair: Symptomatic patients (e.g., postmenstrual spotting) or those desiring fertility. Laparoscopic repair is indicated when the residual myometrial thickness (RMT) is < 2.5 mm.

• Technique:

  1. Bladder Dissection: The bladder is often densely adherent. The "lateral window technique" (dissecting from lateral to medial) is used for safe, sharp mobilization.

  2. Niche Excision: The fibrotic scar tissue is completely excised with cold scissors until healthy, bleeding myometrial edges are visible.

  3. Suturing: A two-layer closure is performed. A bone-cutting needle is essential to penetrate the dense tissue. The first layer is full-thickness, including the endometrium, followed by a second seromuscular layer.

  4. Peritoneal Closure: The vesicouterine peritoneum is left open to reduce the risk of bladder re-adherence to the uterine scar.

SURGICAL PEARLS

• Never use preoperative GnRH agonists for laparoscopic myomectomy; a firm myoma is easier to enucleate.

• The surgeon should control both the myoma screw (traction) and the dissecting instrument (counter-traction) for optimal coordination.

• During uterine artery ligation, always medialze the ureter to protect its blood supply and the hypogastric nerve plexus.

• When suturing the myometrial defect, ensure bites are horizontally aligned to prevent puckering and dehiscence.

• A bone-cutting needle is mandatory for suturing dense, fibrotic tissue as seen in isthmocele repair.

• During morcellation, remember the principle: "The tissue comes to be morcellated; the morcellator does not go to morcellate." Use directional rotation for safety.

• When performing a posterior colpotomy, a sponge-on-a-stick is superior to a colpotomizer for creating a bulge.

COMPLICATIONS AND THEIR MANAGEMENT

• Intraoperative:

  • Hemorrhage: The most common complication. Managed with meticulous hemostasis, uterine artery ligation, and ensuring blood is cross-matched and available.

  • Bladder/Ureteric Injury: A risk during bladder dissection for isthmocele or retroperitoneal dissection for artery ligation. Requires immediate recognition and repair.

  • Bowel Injury: A risk during morcellation or colpotomy. Avoided with panoramic visualization and using cold instruments for colpotomy incision.

• Late Postoperative:

  • Uterine Rupture: The most feared long-term complication. Prevented by meticulous multi-layer uterine reconstruction.

  • Adhesion Formation: Minimized by inverting serosal edges and using adhesion barriers.

  • Parasitic Myomas: A consequence of uncontained power morcellation.

  • Rectocele: Can result from an unsutured posterior colpotomy incision.

MEDICOLEGAL AND PATIENT SELECTION CONSIDERATIONS

• Informed Consent: Must explicitly cover the possibility of "recurrence" from pre-existing small myomas, the risks of morcellation (including sarcoma dissemination), and the risk of uterine rupture in future pregnancies.

• Surgical Skill: Laparoscopic myomectomy, especially for large intramural fibroids or isthmocele repair, is an advanced procedure. Surgeons must be proficient in laparoscopic suturing.

• Uterine Artery Embolization (UAE): Generally a poor choice for young women desiring fertility due to the risk of compromised uterine perfusion.

• Ethical Conduct: The pursuit of surgical "world records" is ethically unacceptable and has been formally discouraged by regulatory bodies. Patient safety must always be the sole focus.

SUMMARY AND TAKE-HOME MESSAGES

• Laparoscopic myomectomy requires advanced surgical skills, with thorough preoperative planning using MRI being essential for success and medicolegal safety.

• Surgical difficulty depends on myoma location and consistency, not just size. Mastery of hemostatic techniques, including vasopressin and uterine artery ligation, is critical.

• A robust, multi-layer uterine reconstruction with proficient suturing is non-negotiable to ensure uterine integrity for future pregnancies.

• Surgeons must be proficient in alternatives to power morcellation, such as colpotomy, and understand the associated risks and benefits of each extraction method.

• A deep, practical understanding of pelvic anatomy, particularly fascial planes and retroperitoneal structures, is the foundation of safe and effective advanced laparoscopic gynecological surgery.

MULTIPLE CHOICE QUESTIONS (MCQs)

1. According to the lecture, what is the primary reason for contraindicating preoperative GnRH agonists in laparoscopic myomectomy?

   a) They increase the risk of intraoperative bleeding.

   b) They soften the myoma, making enucleation difficult.

   c) They increase the size of the myoma.

   d) They interfere with vasopressin's vasoconstrictive effect.

2. In the "baseball diamond" concept for port placement, what is considered the primary surgical target?

   a) The apex of the myoma

   b) The uterine fundus

   c) The base of the myoma

   d) The tip of the uterine manipulator

3. What is a major risk associated with inadequate suturing of the myometrial defect after myomectomy?

   a) Postoperative infection

   b) Development of adenomyosis

   c) Uterine rupture in a future pregnancy

   d) Formation of parasitic myomas

4. When performing temporary laparoscopic uterine artery ligation at its origin, what is the most critical initial step after incising the peritoneum?

   a) Identifying and ligating the uterine artery

   b) Identifying and medially retracting the ureter

   c) Dissecting the pararectal space

   d) Identifying the internal iliac artery

5. What type of uterine incision is mandatory for a deep posterior wall cervical myoma?

   a) Horizontal

   b) Oblique

   c) Vertical

   d) Transverse

6. To prevent the myoma screw from bending, where and how should it be inserted?

   a) Superficially into the apex of the myoma

   b) Deep into the base, ensuring the solid rod part is embedded

   c) Parallel to the uterine surface

   d) Only after the myoma is 50% enucleated

7. What is the recommended dilution for vasopressin to achieve both hemostasis and hydrodissection?

   a) 5 IU in 20 mL saline

   b) 20 IU in 50 mL saline

   c) 5 IU in 100-200 mL saline

   d) 20 IU in 10 mL saline

8. In the first layer of myometrial closure, which tissue layer should be explicitly excluded from the suture bite?

   a) The deep myometrium

   b) The uterine serosa

   c) The endometrial layer

   d) The pseudocapsule remnants

9. What is the primary safety principle of laparoscopic morcellation?

   a) Push the morcellator firmly against the tissue for a faster cut.

   b) Pull the tissue into the morcellator under a panoramic view.

   c) Use the highest possible rotation speed.

   d) Operate without pneumoperitoneum to avoid tissue scatter.

10. A potential late complication of failing to suture a posterior colpotomy incision is:

    a) Vesicovaginal fistula

    b) Uterine prolapse

    c) Rectocele

    d) Dyspareunia

11. What is the primary indication for choosing a laparoscopic repair of an isthmocele over a hysteroscopic approach?

    a) The patient is asymptomatic.

    b) Residual myometrial thickness is > 3 mm.

    c) Residual myometrial thickness is < 2.5 mm.

    d) The patient has completed her family.

12. What type of needle is described as essential for suturing an isthmocele?

    a) Taper-cut needle

    b) Round-body needle

    c) Blunt-tip needle

    d) Bone-cutting needle

13. According to the principle of "predictive anatomy," veins are consistently located:

    a) Superior to their associated fascial layer

    b) Within the fascial layer

    c) Underneath (deep to) their associated fascial layer

    d) Lateral to their corresponding artery

14. The surgical dictum "fat belongs to the rectum" is a guide for safely developing which space?

    a) Pararectal space

    b) Rectovaginal space

    c) Paravesical space

    d) Cave of Retzius

15. What is the approximate incidence of unsuspected leiomyosarcoma in presumed benign myomas?

    a) 1 in 100 (1%)

    b) 1 in 1,000 (0.1%)

    c) 1 in 5,000 (0.02%)

    d) 1 in 10,000 (0.01%)

16. What is the recommended technique for creating a bulge in the posterior fornix for colpotomy?

    a) Using a standard uterine colpotomizer

    b) Pushing with a uterine manipulator

    c) Using a sponge-on-a-stick

    d) Asking the patient to perform a Valsalva maneuver

17. When should the Trendelenburg position be initiated during laparoscopic entry for a large uterine mass?

    a) Before establishing pneumoperitoneum

    b) Immediately after establishing pneumoperitoneum

    c) After the primary optical trocar and telescope are safely inserted

    d) Only after the myoma is enucleated

18. What is the main advantage of the "baseball" suturing technique for the serosal layer?

    a) It is faster than a running suture.

    b) It provides excellent inversion of the serosal edges.

    c) It uses less suture material.

    d) It is a hemostatic stitch for the deep myometrium.

19. A patient has a "recurrent" myoma six months after surgery. What is the most likely explanation?

    a) The surgeon failed to remove the original myoma.

    b) A pre-existing, sub-centimeter myoma grew into the surgical dead space.

    c) The myoma completely regrew from a microscopic remnant.

    d) It is an artifact from postoperative scarring.

20. What is the correct management of the vesicouterine peritoneum after an isthmocele repair?

    a) Close it meticulously with a running suture.

    b) Leave it open.

    c) Place an omental patch over it.

    d) Close it with interrupted, non-absorbable sutures.

MCQ Answers:

1-b, 2-c, 3-c, 4-b, 5-c, 6-b, 7-c, 8-b, 9-b, 10-c, 11-c, 12-d, 13-c, 14-b, 15-b, 16-c, 17-c, 18-b, 19-b, 20-b

MOTIVATIONAL MESSAGE FROM DR. R. K. MISHRA

The mark of a master surgeon is not the absence of difficulty, but the presence of a mind so disciplined in its knowledge of anatomy and principle that it navigates adversity with calm precision.

My best wishes to all of you as you pursue this noble craft with dedication and an unwavering commitment to your patients.