This video demonstrates the Laparoscopic Removal of Large Grade II Submucous Myoma at World Laparoscopy Hospital. This technique decreases the complications of removing the submucous myoma hysteroscopically. Laparoscopic myomectomy for large submucous myomas is a technically feasible procedure. It can be performed by experienced surgeons irrespective of the size or depth of the myoma. It prevents the complications of hysteroscopic removal of the myoma.

Submucous myomas are a type of uterine fibroid that arise just beneath the endometrial lining and often protrude into the uterine cavity. According to the FIGO classification, Grade II submucous myomas have more than 50% intramural extension, making their management technically challenging. Traditionally, large Grade II submucous myomas were treated by open surgery or staged hysteroscopic procedures. However, advances in minimally invasive surgery have made laparoscopic removal a safe and effective option in selected cases.

Clinical Presentation

Patients with large Grade II submucous myomas commonly present with:

Heavy or prolonged menstrual bleeding (menorrhagia)

Dysmenorrhea

Pelvic pain or pressure symptoms

Infertility or recurrent pregnancy loss

Anemia due to chronic blood loss

The size and intramural component of these myomas often contribute to significant distortion of the uterine cavity.

Preoperative Evaluation

Accurate preoperative assessment is essential for successful laparoscopic management. This includes:

Transvaginal ultrasonography to assess size, location, and depth of myoma

MRI pelvis for large or complex myomas to define intramural extension

Diagnostic hysteroscopy, when indicated, to confirm cavity involvement

Correction of anemia and optimization of patient’s general condition

Proper patient selection plays a key role in achieving good outcomes.

Surgical Technique

Laparoscopic removal of a large Grade II submucous myoma requires advanced surgical expertise.

Key steps include:

Patient positioning and port placement ensuring adequate uterine manipulation

Vasopressin injection into the myometrium to reduce intraoperative bleeding

Serosal incision over the most prominent bulge of the myoma

Careful enucleation of the myoma using traction and counter-traction techniques

Endometrial cavity management, taking care to minimize damage

Meticulous multilayer uterine suturing to restore uterine integrity

Morcellation and specimen retrieval under safe conditions

Hemostasis and preservation of uterine architecture are critical, especially in women desiring future fertility.

Advantages of Laparoscopic Approach

Compared to open surgery, laparoscopy offers several benefits:

Minimal blood loss

Reduced postoperative pain

Faster recovery and shorter hospital stay

Better cosmetic results

Lower risk of postoperative adhesions

In experienced hands, laparoscopy allows precise removal while maintaining uterine function.

Postoperative Care and Outcomes

Most patients experience rapid recovery and significant improvement in symptoms. Menstrual bleeding normalizes, anemia improves, and fertility outcomes are favorable in appropriately selected cases. Follow-up imaging may be performed to assess uterine healing, particularly in women planning pregnancy.

Conclusion

Laparoscopic removal of large Grade II submucous myoma is a feasible and effective minimally invasive option when performed by skilled laparoscopic surgeons. With proper patient selection, meticulous surgical technique, and advanced suturing skills, this approach provides excellent clinical outcomes while preserving uterine anatomy and function.