This video demonstrates Laparoscopic Management of Posterior Intramural Fibroid performed by Dr. R K Mishra at World Laparoscopy Hospital. Uterine fibroids (also known as leiomyomas or myomas) are the most common form of benign uterine tumors. Clinical presentations include abnormal bleeding, pelvic masses, pelvic pain, infertility, bulk symptoms, and obstetric complications.

Almost a third of women with leiomyomas will request treatment due to symptoms. Current management strategies mainly involve surgical interventions, but the choice of treatment is guided by the patient's age and desire to preserve fertility or avoid ‘radical’ surgery such as hysterectomy. The management of uterine fibroids also depends on the number, size, and location of the fibroids. Other surgical and non-surgical approaches include myomectomy by hysteroscopy, myomectomy by laparotomy or laparoscopy, uterine artery embolization, and interventions performed under radiologic or ultrasound guidance to induce thermal ablation of the uterine fibroids.

Uterine fibroids, also known as leiomyomas, are the most common benign tumors of the female reproductive system. Among their various types, posterior intramural fibroids arise within the myometrium on the posterior uterine wall and often pose significant surgical challenges due to their proximity to the rectum, ureters, and uterine vessels. Laparoscopic management has emerged as a preferred minimally invasive approach, offering excellent clinical outcomes with reduced morbidity.

Clinical Presentation and Indications

Patients with posterior intramural fibroids may present with:

Menorrhagia or abnormal uterine bleeding

Dysmenorrhea and chronic pelvic pain

Infertility or recurrent pregnancy loss

Pressure symptoms such as constipation or dyspareunia

Laparoscopic myomectomy is indicated in women who desire uterine conservation, fertility preservation, or symptomatic relief while benefiting from a minimally invasive technique.

Preoperative Evaluation

Accurate preoperative assessment is essential for safe surgical planning. This includes:

Pelvic ultrasonography for initial diagnosis

MRI for detailed mapping of fibroid size, depth, and relation to adjacent structures

Hemoglobin optimization and correction of anemia

Counseling regarding risks, fertility outcomes, and possible conversion to open surgery

Surgical Challenges of Posterior Intramural Fibroids

Posterior intramural fibroids present unique challenges such as:

Limited access and visualization

Close proximity to the rectum and ureters

Increased risk of bleeding

Difficulty in uterine suturing

Advanced laparoscopic skills are required to overcome these challenges safely.

Laparoscopic Surgical Technique
Patient Positioning and Port Placement

The patient is placed in dorsal lithotomy with steep Trendelenburg position. A standard four-port technique is commonly used, with careful port placement to optimize posterior uterine access.

Vasopressin Injection

Diluted vasopressin is injected into the myometrium surrounding the fibroid to reduce intraoperative blood loss and improve the surgical plane.

Myometrial Incision and Enucleation

A vertical or transverse incision is made over the most prominent part of the fibroid using monopolar energy or harmonic scalpel. The fibroid is carefully enucleated using traction–countertraction while preserving surrounding myometrium.

Hemostasis and Uterine Reconstruction

Meticulous hemostasis is achieved, followed by multilayer laparoscopic suturing to restore uterine integrity. Barbed sutures are often used to facilitate secure closure and reduce operative time.

Specimen Retrieval

The fibroid is retrieved using contained morcellation or posterior colpotomy, adhering to current safety guidelines.

Postoperative Care and Outcomes

Patients typically experience:

Minimal postoperative pain

Short hospital stay (often same-day or 24 hours)

Early ambulation and faster return to daily activities

Fertility outcomes following laparoscopic myomectomy are favorable, with reduced adhesion formation compared to open surgery.

Advantages of Laparoscopic Approach

Reduced blood loss

Lower postoperative morbidity

Smaller incisions and better cosmetic results

Faster recovery

Lower risk of adhesions

Complications and Risk Management

Potential complications include hemorrhage, uterine perforation, and injury to surrounding organs. These risks are minimized through:

Proper patient selection

Detailed preoperative imaging

Surgeon expertise in advanced laparoscopy

Conclusion

Laparoscopic management of posterior intramural fibroids is a safe, effective, and fertility-preserving surgical option when performed by experienced laparoscopic surgeons. With appropriate patient selection and advanced surgical techniques, this minimally invasive approach offers superior outcomes and improved quality of life for women affected by symptomatic fibroids.

For more information:
https://www.laparoscopyhospital.com/

World Laparoscopy Hospital
Cyber City, Gurugram, NCR Delhi
INDIA: +919811416838

World Laparoscopy Training Institute
Bld.No: 27, DHCC, Dubai
UAE: +971525857874

World Laparoscopy Training Institute
8320 Inv Dr, Tallahassee, Florida
USA : +1 321 250 7653