In this video we describe a patient with two 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.

Fibroids, also known as leiomyomas, are benign tumors of the uterus that affect a significant number of women of reproductive age. Among these, broad ligament fibroids are rare and pose unique challenges due to their location, size, and proximity to vital pelvic structures like the ureters, bladder, and blood vessels. Traditionally, large broad ligament fibroids were managed through open surgery, but with advances in minimally invasive surgery, laparoscopic myomectomy has become a safe and effective alternative.

Understanding Broad Ligament Fibroids

The broad ligament is a double-layered fold of the peritoneum that supports the uterus, fallopian tubes, and ovaries. Fibroids in this area grow laterally, often displacing surrounding structures, which can lead to symptoms such as:

Pelvic pain or pressure

Abdominal distension

Urinary frequency or difficulty

Infertility in some cases

Large fibroids, especially those over 10 cm, can make surgical removal more challenging due to limited working space and risk of injury to adjacent organs.

Why Laparoscopic Myomectomy?

Laparoscopic myomectomy is a minimally invasive procedure where fibroids are removed using small incisions, a camera (laparoscope), and specialized instruments. For large broad ligament fibroids, laparoscopy offers several advantages over open surgery:

Reduced blood loss due to advanced energy devices and precise dissection

Shorter recovery time and less postoperative pain

Better cosmetic results with small incisions

Preservation of fertility for women wishing to conceive

Surgical Approach and Technique

Managing a large broad ligament fibroid laparoscopically requires meticulous planning and surgical expertise. The key steps include:

Preoperative Assessment

Imaging: Ultrasound and MRI help determine the fibroid’s size, location, and relation to nearby organs.

Lab tests: Hemoglobin levels, coagulation profile, and renal function are assessed.

Patient Positioning and Port Placement

The patient is positioned in a dorsal lithotomy with Trendelenburg tilt.

Ports are strategically placed to provide maximum working space, often using a combination of umbilical and lateral abdominal ports.

Dissection and Identification of Structures

The fibroid is carefully dissected from surrounding structures, with special attention to ureters and major blood vessels.

Vasopressin may be injected to reduce intraoperative bleeding.

Fibroid Removal

Depending on size, fibroids may be morcellated (cut into smaller pieces) or removed intact through a mini-laparotomy incision.

Laparoscopic suturing is used to repair the defect in the broad ligament and uterus.

Postoperative Care

Early ambulation and pain management are emphasized.

Most patients are discharged within 24–48 hours.

Follow-up imaging ensures no residual fibroid tissue remains.

Challenges and Considerations

Large broad ligament fibroids present unique challenges:

Limited space in the pelvis for manipulation

Risk of injury to ureters and major vessels

Difficulty in achieving hemostasis

Need for advanced laparoscopic skills and experience

Hence, only surgeons trained in advanced laparoscopic techniques should attempt removal of very large broad ligament fibroids via laparoscopy.

Conclusion

Laparoscopic myomectomy for large broad ligament fibroids is a safe, effective, and fertility-preserving procedure when performed by an experienced laparoscopic surgeon. With careful preoperative planning, advanced surgical techniques, and modern energy devices, even very large fibroids can be removed minimally invasively, allowing patients faster recovery, reduced postoperative pain, and minimal scarring.