This video demonstrate laparoscopic myomectomy for large intramural myoma. Laparoscopic myomectomy using pneumoperitoneum for large intramural myomas is considered a difficult and time-consuming procedure, requiring great skill to move a large uterus; to locate, grasp, enucleate, and remove a bulky myoma from the abdominal cavity; to achieve adequate hemostasis; and to repair the muscle layer. Laparoscopic myomectomy allows your surgeon to remove your fibroids through several small incisions. This may be done robotically. It's less invasive and recovery is faster than with abdominal myomectomy. Laparoscopic myomectomy (LM) currently brings more attention because of increased demands on uterine conservation and less invasive management of myomas. The advantages of Laparoscopic Myomectomy are shorter hospitalization, faster recovery, fewer adhesions, and less blood loss. In spite of the increasing improvements in laparoscopic instruments and techniques, advanced laparoscopic technical skills are required to perform Laparoscopic Myomectomy with success. Technical problems inherent to the removal of large uterine myomas include hemostasis, uterine closure, and removal of the uterine tissue.

Uterine fibroids, medically termed leiomyomas, are common benign tumors affecting women of reproductive age. Among them, intramural myomas—fibroids embedded within the muscular wall of the uterus—can grow large, causing heavy menstrual bleeding, pelvic pain, and fertility issues. Traditionally, large intramural fibroids required open surgery, but advances in minimally invasive surgery now allow safe removal through laparoscopic myomectomy, offering patients quicker recovery and fewer complications.

What is Laparoscopic Myomectomy?

Laparoscopic myomectomy is a minimally invasive procedure performed through small abdominal incisions using a camera and specialized instruments. The surgeon carefully removes fibroids while preserving the uterus, which is especially important for women desiring future fertility.

Challenges with Large Intramural Myomas
Large intramural myomas (typically >10 cm) present unique challenges in laparoscopic surgery:

• Limited working space inside the abdomen.

• Risk of bleeding, as large fibroids have abundant blood supply.

• Technical difficulty in enucleating the fibroid without damaging the surrounding uterine tissue.

• Safe extraction of the fibroid from the abdominal cavity.

Preoperative Considerations
Before surgery, a thorough evaluation is necessary:

• Imaging: Ultrasound or MRI helps assess size, location, and number of fibroids.

• Medical optimization: Preoperative medications, such as gonadotropin-releasing hormone (GnRH) analogs, may be used to shrink fibroids and reduce blood loss.

• Fertility assessment: For women planning pregnancy, uterine cavity integrity and myometrial thickness are considered.

Surgical Technique

1. Anesthesia and Positioning: The patient is placed under general anesthesia in a lithotomy or supine position.

2. Port Placement: Typically, 3–4 small incisions (5–12 mm) are made for laparoscope and instruments.

3. Uterine Incision: A careful incision is made over the fibroid.

4. Fibroid Enucleation: The myoma is dissected from surrounding uterine tissue. Hemostasis is maintained with energy devices or sutures.

5. Uterine Reconstruction: The uterine wall is meticulously sutured to restore structural integrity and prevent future complications.

6. Specimen Retrieval: Large fibroids are removed via mini-laparotomy, morcellation (with safety protocols), or contained extraction systems.

7. Closure: All ports are closed, and the patient is monitored postoperatively.

Advantages of Laparoscopic Myomectomy

• Smaller incisions and minimal scarring.

• Less postoperative pain and faster recovery.

• Reduced blood loss compared to open surgery.

• Shorter hospital stay.

• Preservation of fertility.

Potential Risks

• Bleeding and need for transfusion.

• Uterine rupture in future pregnancies if uterine wall healing is inadequate.

• Injury to surrounding organs (rare).

• Recurrence of fibroids.

Postoperative Care

• Early mobilization to reduce the risk of blood clots.

• Pain management with oral medications.

• Gradual resumption of daily activities.

• Follow-up imaging to monitor uterine healing.

Conclusion
Laparoscopic myomectomy for large intramural myomas is a safe and effective procedure in skilled hands. With modern surgical techniques, women can enjoy the benefits of minimally invasive surgery—rapid recovery, reduced pain, and preservation of fertility—without compromising surgical outcomes. Patients should consult experienced laparoscopic surgeons to discuss individualized treatment plans, especially when dealing with large or multiple fibroids.