This video demonstrate Laparoscopic Removal of Intramural and Broad Ligament Myoma by Dr R K Mishra at World Laparoscopy Hospital. We describe a patient with three fibroids; the largest was a broad ligament fibroid, which was managed successfully with laparoscopic myomectomy. It is well known that myomectomy of a large broad ligament fibroid presents a challenge to the surgeon with intraoperative complications such as excessive bleeding and ureteric injury or later complications such as pelvic hematoma and infection. The aim of presenting this case was to demonstrate that in patients with a large broad ligament fibroid, who want to preserve their reproductive potential, laparoscopic myomectomy is feasible and safe. Trans-vaginal US plays an important role in determining the degree of attachment, location and vascularity between the uterus and the broad ligament fibroid, which in turn helps in the choice of surgical procedure and technique.

Uterine fibroids, also known as myomas, are benign smooth muscle tumors of the uterus, commonly affecting women of reproductive age. Among the various types, intramural fibroids (located within the uterine wall) and broad ligament fibroids (arising from the connective tissue supporting the uterus) present unique challenges in management due to their location, size, and potential impact on fertility. Laparoscopic surgery has emerged as a minimally invasive and effective approach for their removal, offering faster recovery, reduced blood loss, and better cosmetic outcomes compared to open surgery.

Understanding Intramural and Broad Ligament Myomas

Intramural Myomas:
These fibroids develop within the muscular layer (myometrium) of the uterus. They can cause symptoms such as heavy menstrual bleeding, pelvic pain, infertility, or pressure symptoms on the bladder or bowel depending on their size.

Broad Ligament Myomas:
These are rare fibroids that grow in the broad ligament, the peritoneal fold that connects the sides of the uterus to the pelvis. They are often large and may displace the uterus, ureters, or other pelvic structures, making surgical removal challenging.

Indications for Laparoscopic Myomectomy

Laparoscopic myomectomy is indicated for women who:

• Have symptomatic fibroids causing pain, heavy bleeding, or pressure effects.

• Desire fertility preservation.

• Have fibroids that are accessible and suitable for laparoscopic removal.

Note: Very large broad ligament fibroids or those with complex vascular supply may sometimes require advanced laparoscopic expertise or a combined approach.

Preoperative Evaluation

1. Imaging Studies:

   • Ultrasound: First-line for diagnosis and localization.

   • MRI: Useful for detailed mapping, especially for large intramural or broad ligament myomas.

2. Laboratory Tests:

   • Complete blood count (to check for anemia).

   • Blood grouping and crossmatch if significant blood loss is anticipated.

3. Medical Optimization:

   • Anemia correction with iron supplementation.

   • Preoperative use of GnRH analogs may reduce fibroid size and vascularity.

Laparoscopic Surgical Technique

Step 1: Patient Positioning and Port Placement

• The patient is placed in the lithotomy or supine position with a Trendelenburg tilt.

• A pneumoperitoneum is created using a Veress needle or open technique.

• Standard laparoscopic ports are placed for optimal access.

Step 2: Identification of Fibroids

• The uterus and adnexa are inspected.

• Intramural fibroids are located within the uterine wall; broad ligament fibroids are carefully distinguished from surrounding structures like the ureters and vessels.

Step 3: Myoma Enucleation

• Intramural Myomas: A small incision is made over the myometrium, and the fibroid is carefully dissected and enucleated.

• Broad Ligament Myomas: Dissection is done meticulously to avoid injury to the ureters and uterine vessels. The broad ligament is opened, and the fibroid is separated from surrounding tissues.

Step 4: Hemostasis and Suturing

• Bleeding is controlled using electrocautery or hemostatic agents.

• The uterine wall is closed with laparoscopic sutures to restore integrity and prevent postoperative complications like adhesions or uterine rupture.

Step 5: Specimen Removal

• Fibroids are removed through morcellation (if allowed) or via mini-laparotomy for larger specimens.

Advantages of Laparoscopic Approach

• Minimal postoperative pain.

• Reduced hospital stay and faster recovery.

• Less blood loss compared to open surgery.

• Preservation of fertility and uterine function.

• Better cosmetic results due to small incisions.

Postoperative Care

• Early ambulation and pain management.

• Monitoring for bleeding or infection.

• Follow-up imaging if needed to assess uterine healing.

• Fertility advice if planning pregnancy in the future.

Conclusion

Laparoscopic removal of intramural and broad ligament myomas is a safe and effective minimally invasive option in experienced hands. Proper preoperative planning, careful surgical technique, and knowledge of pelvic anatomy are crucial to prevent complications. This approach not only provides symptomatic relief but also preserves fertility, making it the preferred choice for women desiring future pregnancies.