Laparoscopic Myomectomy: A Minimally Invasive Approach for Uterine Fibroids
Introduction
Laparoscopic myomectomy has emerged as a gold standard for the surgical removal of uterine fibroids (leiomyomas) while preserving the uterus. This minimally invasive technique offers reduced postoperative pain, faster recovery, and improved reproductive outcomes, making it the preferred choice for women seeking fertility preservation or symptomatic relief.
Indications for Laparoscopic Myomectomy
Laparoscopic myomectomy is indicated in patients with:
Symptomatic uterine fibroids causing heavy menstrual bleeding, pelvic pain, or pressure symptoms.
Infertility or recurrent pregnancy loss attributed to submucosal or intramural fibroids.
Rapidly enlarging fibroids or suspicion of degeneration.
Compression symptoms affecting the bladder or rectum.
Surgical Technique
The procedure is performed under general anesthesia and involves the following key steps:
1. Patient Positioning and Trocar Placement
The patient is placed in a lithotomy position with Trendelenburg tilt.
Pneumoperitoneum (CO₂ insufflation) is established for adequate visualization.
Trocar placement typically includes a 10mm umbilical port for the laparoscope and two to three 5mm accessory ports for surgical instruments.
2. Uterine Incision and Fibroid Enucleation
The serosal layer of the uterus is incised, and the fibroid is carefully dissected.
Blunt and sharp dissection techniques are used to minimize tissue trauma.
Vasopressin or dilute epinephrine is often injected to reduce intraoperative bleeding.
3. Myometrial Reconstruction
The uterine defect is repaired using multilayer suturing with absorbable sutures to restore uterine integrity.
Hemostatic agents and energy devices (e.g., bipolar electrocautery, harmonic scalpel) help minimize blood loss.
4. Fibroid Removal and Specimen Extraction
Morcellation is used for fibroid extraction via the trocar site, but contained morcellation is recommended to prevent tissue dissemination.
Alternative techniques include mini-laparotomy or colpotomy-assisted removal.
Advantages of Laparoscopic Myomectomy
Compared to open (abdominal) myomectomy, laparoscopic myomectomy offers several benefits:
Smaller incisions leading to minimal scarring and improved cosmetic outcomes.
Reduced postoperative pain and shorter hospital stay (often performed as a day-care procedure).
Faster recovery, with return to normal activities within 7-14 days.
Lower risk of adhesions and infections compared to open surgery.
Better fertility outcomes, preserving the uterus for future pregnancies.
Potential Complications and Risk Factors
While laparoscopic myomectomy is a safe procedure, potential risks include:
Intraoperative bleeding, which may necessitate conversion to open surgery.
Uterine rupture in subsequent pregnancies, particularly if myometrial repair is inadequate.
Fibroid recurrence, as myomectomy does not prevent new fibroid growth.
Adhesion formation, though significantly lower than with open surgery.
Recent Advancements in Laparoscopic Myomectomy
Robotic-Assisted Myomectomy: Enhances precision with improved dexterity and visualization.
Fluorescence-Guided Imaging: Improves tissue differentiation and bleeding control.
Contained Power Morcellation: Reduces the risk of tissue dissemination in cases of undiagnosed malignancy.
Hysteroscopic Myomectomy: An alternative approach for submucosal fibroids, avoiding abdominal incisions.
Postoperative Care and Recovery
Patients are usually discharged within 24 hours.
Early ambulation is encouraged to prevent deep vein thrombosis (DVT).
A light diet is recommended initially, with a gradual return to normal food intake.
Pelvic rest for 4-6 weeks is advised to allow proper uterine healing.
Women planning pregnancy should wait 3-6 months before conception.
Conclusion
Laparoscopic myomectomy is a minimally invasive, safe, and effective surgical option for symptomatic uterine fibroids. With continuous advancements in robotic technology, energy-based devices, and tissue extraction techniques, the procedure continues to evolve, offering better outcomes and faster recovery. For women desiring fertility preservation and uterine conservation, laparoscopic myomectomy remains the preferred surgical approach.
For the latest updates in laparoscopic surgery and minimally invasive gynecologic techniques, stay connected with the World Association of Laparoscopic Surgeons (WALS).
