BASIC INFORMATION

Date & Time (Indian Standard Time): 14 February 2026, 12:19:02 IST
Lecture Handout Prepared from the Teaching Session by: Dr. R. K. Mishra

SUMMARY

This lecture integrated procedure selection and advanced operative strategy for laparoscopic myomectomy, emphasizing that outcomes depend on correct case selection, disciplined hemostasis, preservation of dissection planes, and high-quality uterine reconstruction. Procedure selection was guided by fibroid location, size, and intramural extension, with laparoscopy presented as the gold standard for subserosal fibroids and appropriate for intramural fibroids when laparoscopic suturing skills are strong. For submucous fibroids larger than 4 cm or with significant intramural components, laparoscopy was favored over hysteroscopy due to hysteroscopic limitations in working space and inability to address the intramural portion.

Operative planning focused on port placement targeted to the myoma base and adaptation of access for very large uteri, including higher port placement and Palmer’s point entry when standard access is unsafe. Core operative tasks were preventive hemostasis (vasopressin-induced transient ischemia and hydrodissection, or temporary uterine artery ligation when vasopressin is contraindicated), fixation, enucleation with strict endometrial cavity protection, dead-space obliteration, and safe specimen retrieval. Detailed technical instruction covered correct vasopressin technique (single optimal injection; avoid intramyoma injection), incision orientation by fibroid location, traction vectors to prevent major vascular injury, and avoidance of instrument failure. Reconstruction principles included disciplined two-layer closure (muscle-to-muscle followed by serosa-only), optional baseball serosal inversion, and safe use and termination of barbed sutures. Specimen extraction strategies included morcellation safety rules and an alternative morcellator-free approach using longitudinal splitting with an endo knife and colpotomy-assisted vaginal extraction with appropriate colpotomy closure. Counseling, documentation, and medicolegal prevention were emphasized, particularly regarding residual sub-centimeter myomas, postoperative ultrasound interpretation, and the need for postoperative GnRH therapy for uterine rest.

KEY KNOWLEDGE POINTS

• Classification of fibroids into subserosal, intramural, and submucous types, with procedure selection based on size and intramural extension.
• Laparoscopy favored for submucous fibroids larger than 4 cm and for grade 2 lesions with significant intramural components; hysteroscopy favored for smaller grade 0 lesions.
• Differentiation of myoma from adenomyosis before laparoscopic surgery.
• Limitations of laparoscopy due to lack of tactile feedback; optional use of 5 mm laparoscopic ultrasound for sub-centimeter lesions (with feasibility constraints).
• Core operative tasks: preventive hemostasis, fixation, enucleation, dead-space closure, and specimen retrieval.
• Hemostasis strategies: vasopressin (ischemia plus hydrodissection), and temporary uterine artery ligation (shoelace knot) when vasopressin is contraindicated.
• Vasopressin safety rules: single optimal injection, correct uterine-side plane placement, 30-degree needle angle, anesthetist notification, and monitoring for “marble white” blanching; never inject into the myoma.
• Incision orientation rules: anterior oblique, fundal horizontal, posterior vertical with uterine manipulator.
• Safe enucleation: screw placement at the base, adequate depth of insertion, anterior traction vector, avoidance of double-action jaw instruments, and strict endometrial cavity protection using visual-plane rules (“only white is right”).
• Pedunculated myoma control with extracorporeal slip knots (Melzer’s or Mishra’s), use of No. 1 suture, and preference for Teflon-tip knot pushers.
• Uterine reconstruction: disciplined two-layer closure (non-locking myometrial layer and serosa-only second layer), baseball serosal inversion (serosa only), needle selection (curved, preferably round-bodied), and avoidance of lateral needle movements due to iliac vessel risk.
• Morcellation safety: correct rotation direction (anti-clockwise when port is on the left), pull tissue into the morcellator, and maintain anterior cannula orientation.
• Morcellator-free extraction: longitudinal splitting with an endo knife, posterior colpotomy with vaginal sponge bulge, controlled vaginal traction, and closure of large colpotomy defects to reduce rectocele risk.
• Postoperative counseling and medicolegal prevention regarding residual small myomas, apparent persistence due to migration into dead space, and postoperative GnRH therapy for at least 6 months.

INTRODUCTION

Laparoscopic myomectomy is a major reconstructive gynecologic operation requiring accurate case selection, precise operative planning, and advanced laparoscopic suturing. The procedure is limited by absent tactile feedback and depends heavily on visual assessment of tissue planes, controlled traction, and disciplined uterine reconstruction to prevent hemorrhage, cavity injury, hematoma, and late uterine rupture. The lecture emphasized that surgical success includes not only removal of symptomatic myomas but also safe hemostasis, preservation of fertility-relevant anatomy, careful specimen handling, and structured patient counseling to prevent postoperative misunderstanding and medicolegal conflict.

LEARNING OBJECTIVES

• Describe procedure selection for fibroid surgery based on location, size, and intramural extension, including situations favoring laparoscopy over hysteroscopy.
• Apply standardized operative strategies for hemostasis, incision planning, safe enucleation, and endometrial cavity protection during laparoscopic myomectomy.
• Perform disciplined uterine reconstruction and safe specimen extraction using techniques discussed, including two-layer closure, barbed sutures, morcellation safety, and morcellator-free vaginal extraction strategies.

CORE CONTENT

1. Procedure Selection and Preoperative Decision-Making

1.1 Classification of Fibroids

Fibroids were categorized by location as subserosal, intramural, and submucous. Case selection was described as primarily driven by fibroid type, size, and depth of intramural extension.

1.2 Laparoscopy Versus Hysteroscopy for Submucous Fibroids

For submucous fibroids larger than 4 cm, laparoscopy was presented as preferable due to limited hysteroscopic working space. For submucous fibroids with significant intramural components (including grade 2 lesions as referenced), hysteroscopy was described as limited because it can remove only the projected portion and cannot adequately address the intramural part.

1.3 Differentiation from Adenomyosis

Before planning laparoscopic myomectomy, myoma should be differentiated from adenomyosis. Adenomyosis was described as too soft for effective laparoscopic removal and unfavorable because deroofing does not remove the major part, limiting benefit.

2. Counseling and Expectations

2.1 Residual Sub-Centimeter Myomas and Imaging Interpretation

Laparoscopy was described as unable to reliably identify and remove sub-centimeter myomas without additional technology. Patients should be counseled that surgery may not render them completely myoma-free and that future myomas may develop.

2.2 Laparoscopic Ultrasound for Small Lesions

A 5 mm laparoscopic ultrasound probe connected to an ultrasound machine was discussed as a method to localize sub-centimeter myomas, with limitations related to cost and feasibility.

2.3 Postoperative Ultrasound Disputes Due to Migration into Dead Space

After dominant myoma removal, a postoperative dead space may remain. A residual small myoma may migrate into this space and later appear on ultrasound as if the original lesion persists. This scenario was emphasized as a cause of patient dissatisfaction and allegations of incomplete surgery if not preemptively addressed through counseling and documentation.

3. Medical Therapy Considerations

3.1 Postoperative GnRH Therapy

Postoperative GnRH therapy was recommended for at least 6 months to provide uterine rest, discourage pregnancy during early healing, and promote shrinkage of residual small myomas prior to follow-up imaging.

3.2 Preoperative GnRH Therapy: Avoidance in Laparoscopic Myomectomy

Preoperative GnRH was discouraged for laparoscopic myomectomy because myoma softening reduces traction, increasing the risk of tearing by the myoma screw during fixation and enucleation. In contrast, preoperative GnRH was described as useful for open surgery due to the advantage of palpation and finger dissection.

4. Operative Planning and Access

4.1 Port Placement Principles

Port placement was individualized based on the myoma base as the operative target, not the myoma tip. The telescope was described as commonly placed suprapubically, with ports moved higher for very large uteri or fibroids.

4.2 Entry Strategy for Very Large Masses

When standard entry is unsafe due to mass size, Palmer’s point entry was described, with camera introduction under vision before transferring the telescope. A caution was given that direct entry is unsafe if the camera is positioned high above the operative target, due to risk of visceral injury.

5. Defined Intraoperative Tasks

The lecture defined five major tasks in laparoscopic myomectomy:

• Preventive hemostasis
• Fixation of the myoma
• Enucleation
• Obliteration of dead space
• Retrieval of the myoma

6. Hemostasis: Vasopressin and Temporary Uterine Artery Control

6.1 Vasopressin: Combined Ischemia and Hydrodissection

Vasopressin was described as required in many cases to create transient ischemia and facilitate hydrodissection. A dilution of 1 mL vasopressin in 100 mL saline was described.

6.2 Vasopressin: Critical Safety Rules

Vasopressin should be injected only once at the optimal site to reduce leakage from multiple punctures. The solution should not be injected into the myoma, as this destroys the dissection plane and softens tissue in a non-beneficial manner. Technique points included a 30-degree needle angle, immediate anesthetist notification for vital monitoring, and visual confirmation by “marble white” blanching.

6.3 Temporary Uterine Artery Ligation When Vasopressin Cannot Be Used

When vasopressin is contraindicated or disallowed by anesthesia (severe hypertension, severe hypothyroidism, significant cardiac history or post-cardiac surgery, or cardiac medications as stated), temporary uterine artery ligation was described as an alternative. Stepwise pelvic sidewall dissection principles were emphasized, including identification of the ureter as the only structure crossing iliac vessels at a right angle and the requirement to medialize (not lateralize) the ureter to reduce risks of ureteral devascularization, hypogastric nerve injury, and iliac vein injury.

6.4 Shoelace Knot Technique for Temporary Ligation

Temporary occlusion using a “shoelace knot” was described, emphasizing that the preformed knotted end should not be pulled during loop construction to avoid unintended tightening. The non-knotted end is used to encircle the artery and form a loop, followed by a half-knot analogous to tying a shoelace. Temporary occlusion for 2–3 hours was described as safe due to multiple uterine blood supplies. For infertility cases, ligation should be released at the end by pulling the non-knotted end; in selected patients not desiring pregnancy, the uterine artery may be left ligated to reduce abnormal uterine bleeding and reduce recurrence likelihood, as stated.

7. Incision Strategy by Fibroid Location

7.1 Anterior Wall Fibroid

An oblique incision was advised. Horizontal incision was cautioned against due to risk to the intramural tube component, and vertical incision was described as making suturing difficult due to ipsilateral instrument alignment.

7.2 Fundal Fibroid

A horizontal incision was advised to facilitate suturing with ipsilateral instrumentation.

7.3 Posterior Fibroid

A vertical incision was advised, especially for lower posterior or cervical fibroids, with use of a uterine manipulator to achieve anteversion. In anterior wall and fundal fibroids, uterine manipulator use was discouraged due to perforation risk and lack of need.

8. Fixation and Safe Enucleation

8.1 Fixation Instruments and Base Targeting

Fixation was described using a myoma screw or tenaculum, with the myoma screw preferred in laparoscopy for lever action. The screw should be applied at the base, not the apex, to maintain traction and safety.

8.2 Myoma Screw Depth and Port Safety

Adequate insertion depth was emphasized to prevent bending, inability to withdraw through the port, port removal with wound laceration, or breakage.

8.3 Traction Vector and Major Vascular Safety

Traction was advised anteriorly. Posterior or lateral overshoot was cautioned as potentially injuring iliac vessels with catastrophic consequence.

8.4 Plane Development and Visual-Plane Rule

After seromuscular entry, repetitive deep cutting was discouraged; mechanical splitting of muscle was emphasized to allow the capsule to appear and enlarge the incision. Dissection should remain near the capsule to protect the endometrial cavity. Because tactile feedback is absent, the lecture emphasized visual judgment: blunt dissection is appropriate in white areolar tissue planes, while colored planes suggest the need for energy to prevent bleeding (“only white is right”).

8.5 Incision Length for Laparoscopic Enucleation

The incision was described as needing to be larger in laparoscopy than in open surgery, approximately two-thirds of the myoma size.

8.6 Instrument Selection and Avoidance of Breakage

Single-action instruments or a myoma rod were recommended for enucleation maneuvers. Double-action jaw instruments were cautioned against due to risk of joint breakage and potential retention of fragments, creating major difficulty and possible need for laparotomy.

9. Pedunculated Myoma: Slip Knot Pedicle Control

9.1 Indication for Slip Knot

A slip knot was described as appropriate for thick pedicular structures and major vascular bundles, and explicitly not appropriate for delicate fistula repairs such as vesicovaginal fistula closure.

9.2 Suture and Knot Pusher Selection

No. 1 suture was specified for extracorporeal slip knotting. Smaller sizes (including “2030” as stated) were cautioned as nonfunctional in this context. Teflon-tip knot pushers were preferred to avoid cutting suture; metal-tip knot pushers were discouraged.

9.3 Technique Points

The knot should be tightened to a secure “dumbbell” configuration. A long suture limb of approximately 6–8 cm was retained to act as a retractor and to exploit progressive tightening of the slip knot with traction. Pedicle division should be slow and under direct vision; if bleeding is seen, it may arise from the myoma side rather than the uterine side when pedicle control is adequate.

10. Uterine Reconstruction After Myomectomy

10.1 Principles of Two-Layer Closure

Two-layer closure was emphasized. The uterine cavity should ideally remain intact; if a small opening is encountered, it should be approximated immediately with a surgeon’s knot and not misinterpreted as tissue requiring excision.

10.2 First Layer: Continuous Non-Locking Myometrial Closure

The first layer was described as continuous, non-locking muscle-to-muscle closure with deep bites at least 1 cm from the incision edge and deliberate exclusion of serosa. Locking was discouraged to allow final retightening at the end of the suture line.

10.3 Second Layer: Serosa-Only Continuous Closure

The second layer was described as continuous closure taking serosa only, excluding muscle, to allow automatic inversion. Bites should be taken approximately 1 cm from the serosal edge and spaced to prevent cut-through.

10.4 Needle Choice and Tightening Safety

A curved needle was described as mandatory, and a round-bodied needle was preferred over a cutting needle to reduce bleeding. During tightening while holding the needle, lateral movements were cautioned against due to iliac vessel injury risk; tightening was advised anteriorly and superiorly with appropriate needle orientation.

10.5 Baseball Serosal Suturing

A baseball technique was demonstrated as a serosal-only method to invert the margin, compress dead space, and reduce exposed uterine edges. This method was explicitly restricted to serosa and not used for muscle closure.

10.6 Barbed Sutures

Barbed sutures (including V-Loc and Stratafix as mentioned) were described as unidirectionally locking and useful in muscular tissue. The starter-loop locking step (for looped designs) was performed by passing the needle through the loop. Termination was described by exiting through healthy tissue, taking an extra bite in healthy tissue, and cutting close to the tissue to avoid bowel or omental entrapment; Aberdeen termination was described as unnecessary for the demonstrated barbed technique.

11. Specimen Retrieval: Morcellation Safety and Alternatives

11.1 Morcellation Safety Rules

Morcellation was taught with strict safety rules: rotate anti-clockwise when the port is on the left to keep sigmoid colon and omentum away; pull tissue into the morcellator and do not slide the morcellator over tissue; maintain the conical cannula tip oriented anteriorly and proceed slowly.

11.2 Extraction Without Morcellation

When a morcellator is unavailable, longitudinal splitting of a fibroid using an endo knife with retractable, replaceable blade was described to reduce extraction diameter by changing specimen geometry. A posterior colpotomy technique was demonstrated using a vaginal sponge to create a bulge, followed by controlled vaginal extraction with directional traction.

11.3 Colpotomy Closure

A colpotomy created for specimen removal was described as requiring closure when sufficiently large to reduce rectocele risk. Closure was performed with full-thickness bites including epithelium and extracorporeal square knots advanced with a knot pusher. A precaution was given to avoid inadvertent suturing of glove material used for packing.

12. Difficult Fibroids and Advanced Strategies

12.1 Cervical Fibroid

A vertical incision after vasopressin injection was described, with careful lateral dissection due to ureteral proximity. Closure methods described included a Dundee jamming knot for initiation, continuous suturing, and Aberdeen termination.

12.2 Broad Ligament Fibroid

In broad ligament fibroids, vasopressin injection was emphasized at the uterus–fibroid junction in uterine tissue rather than into the fibroid. Oblique serosal incision and careful attention to surrounding structures were emphasized. Round ligament plication was described to close dead space and centralize the uterus. In difficult cases, a ureteric catheter (not a DJ stent) was described as removable at the end to reduce ureteric injury risk.

SURGICAL PEARLS

• Select the operative route based on fibroid size and intramural extension; hysteroscopy is limited for large or deeply embedded submucous fibroids as described.
• Target the base of the myoma for port planning, incision planning, and fixation; do not plan based on the myoma tip.
• Perform vasopressin injection once at the best uterine-side location; avoid intramyoma injection to preserve the capsule plane.
• Confirm vasopressin effect visually by “marble white” blanching and coordinate injection with anesthesia monitoring.
• Use incision orientation rules to reduce suturing difficulty and risk: anterior oblique, fundal horizontal, posterior vertical with manipulator.
• Maintain anterior traction during enucleation to reduce risk of iliac vessel injury from overshoot.
• Avoid double-action jaw instruments during enucleation due to breakage risk; prefer myoma rod or single-action instruments.
• Protect the endometrial cavity by staying near the capsule and using the visual-plane rule for blunt versus energy dissection (“only white is right”).
• Use slip knots only for thick pedicles; choose No. 1 suture and a Teflon-tip knot pusher to reduce suture damage.
• Close the uterus with strict layer discipline: muscle-to-muscle first layer (non-locking), serosa-only second layer; use baseball suturing only for serosa.
• During tightening, avoid lateral needle movements because of iliac vessel risk.
• For morcellation, rotate anti-clockwise when the port is on the left, pull tissue into the device, and keep the cannula tip anterior.
• When morcellation is unavailable, longitudinal splitting with an endo knife and colpotomy-assisted extraction can be used; close large colpotomies to reduce rectocele risk.
• Counsel and document the likelihood of residual sub-centimeter myomas and postoperative ultrasound misinterpretation due to migration into dead space.

ANESTHETIC AND PHYSIOLOGICAL CONSIDERATIONS

Vasopressin injection requires immediate communication with the anesthetist for vital sign monitoring. Vasopressin was described as potentially disallowed in patients with severe hypertension, severe hypothyroidism, significant cardiac history, current cardiac medications, or prior cardiac surgery due to marked blood pressure fluctuations; temporary uterine artery ligation was described as an alternative strategy. Temporary uterine artery occlusion for 2–3 hours was described as tolerated due to multiple uterine blood supplies.

COMPLICATIONS AND THEIR MANAGEMENT

Intraoperative

• Bleeding (most common and most serious complication as emphasized): Prevention and control using vasopressin with correct technique, careful base dissection, appropriate energy use in colored planes, slip-knot pedicle control where indicated, and temporary uterine artery ligation when needed; ensure blood grouping/matching and availability.
• Loss of dissection plane after intramyoma vasopressin injection: Prevention by injecting into uterine tissue around the capsule plane only.
• Endometrial cavity entry and loss of lining: Prevention by maintaining dissection near the capsule and avoiding soft, fluctuating, pink-appearing tissue planes; if a small opening occurs, immediate approximation with a surgeon’s knot was advised.
• Major vascular injury risk (iliac vessels): Prevention by maintaining anterior traction and avoiding lateral needle movement during tightening.
• Instrument-related complications (myoma screw bending/breakage; double-action jaw breakage): Prevention by adequate screw insertion depth and avoiding double-action jaw instruments during enucleation.
• Bowel or omental injury during morcellation: Prevention by correct rotation direction, pulling tissue into the morcellator, and maintaining anterior cannula orientation.
• Ureteral injury risk during cervical/broad ligament fibroids and pelvic sidewall dissection: Prevention by careful lateral dissection, ureter identification, and medialization during pelvic sidewall work; ureteric catheter use was described for difficult cases.

Early Postoperative

• Hematoma risk with overly airtight closure: The lecture advised balancing closure to avoid excessive airtightness while preventing raw defects that invite adnexal entrapment and adhesions.
• Rectocele risk after inadequately closed large colpotomy: Prevention by closing sufficiently large extraction colpotomies with full-thickness bites and secure knots.

Late Postoperative

• Adhesions and fibrosis: Addressed through proper tissue handling, appropriate closure, and adhesion-prevention measures discussed, including correct Interceed handling and full serosal inversion with baseball suturing.
• Uterine rupture (linked to inadequate suturing quality): Prevention by high-quality reconstructive suturing and adequate closure of the myometrial defect.
• Patient dispute regarding “persistent” fibroid on ultrasound: Prevention through preoperative counseling regarding residual small myomas and postoperative dead-space migration, and the described use of postoperative GnRH therapy before follow-up imaging.
• Rare hysterectomy in extreme neglected cases: Mentioned as a potential endpoint in very difficult disease involving critical adjacent structures.

MEDICOLEGAL AND PATIENT SELECTION CONSIDERATIONS

• Document counseling that laparoscopy may not remove all sub-centimeter myomas without laparoscopic ultrasound and that new myomas may develop in the future.
• Document counseling regarding postoperative ultrasound interpretation, including the described possibility of residual myoma migration into dead space mimicking incomplete surgery.
• Clearly document fertility intent because it determines whether temporary uterine artery ligation is released at the end of the procedure or may be left ligated in selected non-fertility cases, as described.
• Document anesthesia-related contraindication or refusal of vasopressin and the rationale for selecting temporary uterine artery ligation as an alternative.
• Ensure strict morcellation safety rules and document adherence, given the risk of bowel or omental injury.
• In difficult fibroids (cervical, broad ligament), document ureteral risk mitigation strategies, including meticulous dissection and ureteric catheter use when chosen.
• Ensure blood grouping/matching and availability for high-risk cases, as emphasized.

SUMMARY AND TAKE-HOME MESSAGES

• Procedure selection should be guided by fibroid location, size, and intramural extension; large or deeply embedded submucous fibroids were described as better managed laparoscopically than hysteroscopically.
• Hemostasis and plane preservation are central to safety; perform vasopressin injection correctly or use temporary uterine artery ligation when vasopressin cannot be used.
• Uterine reconstruction is reconstructive surgery requiring disciplined two-layer closure and safe needle handling; inadequate suturing was linked to serious late complications.
• Specimen retrieval must follow strict safety rules for morcellation, and morcellator-free extraction requires controlled splitting, colpotomy technique, and appropriate closure.
• Counseling and documentation regarding residual small myomas and postoperative imaging expectations are essential to prevent dissatisfaction and medicolegal conflict.

MULTIPLE CHOICE QUESTIONS (MCQs)

1. Laparoscopy was described as the gold standard approach for which fibroid type?
A. Submucous fibroid
B. Subserosal fibroid
C. Adenomyosis
D. Vesicovaginal fistula
Correct answer: B

2. For submucous fibroids larger than 4 cm, the lecture favored which approach over hysteroscopy?
A. Laparoscopy
B. No treatment
C. Vesicovaginal fistula repair
D. Slip-knot closure of the cavity
Correct answer: A

3. The primary limitation of hysteroscopy for certain grade 2 submucous myomas described was that hysteroscopy:
A. Cannot visualize the uterine cavity
B. Removes only the projected portion and not the intramural component
C. Requires vasopressin injection into the myoma
D. Always causes iliac vessel injury
Correct answer: B

4. Before planning laparoscopic myomectomy, the surgeon should differentiate myoma from:
A. Appendicitis
B. Adenomyosis
C. Renal stone
D. Rectocele
Correct answer: B

5. A key limitation of laparoscopy compared with open surgery emphasized in the lecture is absence of:
A. Magnification
B. Pneumoperitoneum
C. Tactile feedback
D. Working ports
Correct answer: C

6. The laparoscopic ultrasound probe size described for detecting sub-centimeter myomas was approximately:
A. 2 mm
B. 5 mm
C. 12 mm
D. 20 mm
Correct answer: B

7. Postoperative GnRH therapy was recommended for at least:
A. 2 weeks
B. 1 month
C. 3 months
D. 6 months
Correct answer: D

8. Preoperative GnRH therapy was discouraged for laparoscopic myomectomy because it:
A. Calcifies the fibroid
B. Softens the myoma and increases tearing with a myoma screw
C. Eliminates the need for suturing
D. Prevents hydrodissection
Correct answer: B

9. The lecture emphasized that laparoscopic port placement should target the:
A. Umbilicus only
B. Myoma tip
C. Myoma base
D. Endometrial cavity
Correct answer: C

10. The five defined intraoperative tasks included all of the following EXCEPT:
A. Preventive hemostasis
B. Fixation of myoma
C. Enucleation of myoma
D. Routine permanent metal clip uterine repair
Correct answer: D

11. The dilution of vasopressin described was:
A. 10 mL in 10 mL saline
B. 1 mL in 100 mL saline
C. 5 mL in 5 mL saline
D. 0.1 mL in 1 mL saline
Correct answer: B

12. A critical vasopressin safety rule emphasized was:
A. Inject repeatedly at multiple sites
B. Inject into the myoma to improve the plane
C. Avoid injection into the myoma to preserve the capsule plane
D. Inject perpendicular at 90 degrees
Correct answer: C

13. The needle angle recommended for vasopressin injection was approximately:
A. 90 degrees
B. 60 degrees
C. 30 degrees
D. 10 degrees
Correct answer: C

14. The “marble white” appearance after injection indicates:
A. Effective ischemic blanching has started
B. Endometrial cavity entry
C. Iliac vessel injury
D. Bowel entrapment in morcellator
Correct answer: A

15. Incision direction recommended for an anterior wall fibroid was:
A. Vertical
B. Horizontal
C. Oblique
D. Circular
Correct answer: C

16. The lecture’s rule for blunt dissection was:
A. Blunt dissection is best in red planes
B. Blunt dissection is best in blue planes
C. Blunt dissection is best in white areolar planes (“only white is right”)
D. Blunt dissection is unnecessary in laparoscopy
Correct answer: C

17. Slip knots were described as appropriate primarily for:
A. Vesicovaginal fistula closure
B. Thick pedicular vascular structures
C. Tubal recanalization
D. Endometrial cavity approximation
Correct answer: B

18. For extracorporeal slip-knot pedicle control, the preferred suture size specified was:
A. 4-0
B. 3-0 (“2030”)
C. 2-0
D. No. 1
Correct answer: D

19. In two-layer uterine closure after myomectomy, the first layer was described as:
A. Serosa-only continuous suturing
B. Locked continuous full-thickness suturing
C. Continuous non-locking muscle-to-muscle suturing excluding serosa
D. Interrupted serosal baseball suturing only
Correct answer: C

20. When morcellating with the port on the left side, the recommended direction of rotation was: A. Clockwise
B. Anti-clockwise
C. Direction is irrelevant
D. Alternating every 2 seconds
Correct answer: B

MOTIVATIONAL MESSAGE FROM DR. R. K. MISHRA

“Skill is proven when technique remains precise under pressure, and safety is protected by the stitch you refuse to rush.”
Wishing you disciplined practice, sound judgment, and consistently safe outcomes for every patient.
Dr. R. K. Mishra