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Laparoscopic myomectomy and other laparoscopic treatments for uterine leiomyomas (fibroids)
Laparoscopic myomectomy and other laparoscopic treatments for uterine leiomyomas (fibroids)
Author:
William H Parker, MD
Section Editor:
 Tommaso Falcone, MD, FRCSC, FACOG
Deputy Editor:
Sandy J Falk, MD, FACOG

Contributor Disclosures

All topics are updated as new evidence becomes available and our peer review process is
complete.
Literature review current through: May 2018. | This topic last updated: Jan 14, 2018.

INTRODUCTION — Laparoscopic techniques provide minimally invasive options for many

gynecologic procedures. Myomectomy, the removal of uterine leiomyomas (myomas or
fibroids), can be performed laparoscopically in selected women. Other laparoscopic procedures
have been developed for leiomyoma treatment, including uterine artery occlusion and myolysis,
but these are not commonly used.

Uterine leiomyomas are the most common type of pelvic tumor in women, with an
approximately 70 to 80 percent lifetime risk [1-3]. There are a wide variety of treatments for
leiomyomas, both pharmacologic and surgical. The choice of treatments depends upon many
factors, including characteristics of the myomas, the patient, and surgical expertise.

Laparoscopic myomectomy and other laparoscopic procedures for uterine leiomyomas will be
reviewed here. Abdominal, hysteroscopic, and vaginal myomectomy, as well as other approaches
to the management of leiomyomas, are discussed separately. (See "Abdominal myomectomy"
and "Hysteroscopic myomectomy" and "Prolapsed uterine leiomyoma (fibroid)" and "Overview
of treatment of uterine leiomyomas (fibroids)".)

PATIENT SELECTION — Laparoscopic myomectomy is primarily used to remove intramural

or subserosal leiomyomas (figure 1). Intracavitary myomas (submucosal and some intramural
myomas that protrude into the endometrial cavity) (figure 2) are difficult to remove during
laparoscopic myomectomy. In addition, hysteroscopic myomectomy is the procedure of choice
when only intracavitary myomas are removed, since it offers the advantages of a short recovery
and minimal perioperative morbidity. Women with both submucosal and intramural/subserosal
myomas may be candidates for concomitant laparoscopic and hysteroscopic myomectomy. (See
"Hysteroscopic myomectomy", section on 'Patient selection'.)

Appropriate candidates for laparoscopic myomectomy are women with the following
characteristics:

●Symptomatic uterine leiomyoma(s)

●Leiomyomas are the appropriate size, number, and location for laparoscopic removal (See
'Candidates for laparoscopic myomectomy' below.)

●Hysteroscopic myomectomy is not feasible

●An abdominal approach is required to treat intraabdominal pathology other than leiomyomas

Indications — The most common indications for laparoscopic myomectomy are:

●Abnormal uterine bleeding

●Bulk-related symptoms – pelvic/abdominal pain or pressure; pressure on the urinary or

gastrointestinal tract resulting in urinary (eg, urinary frequency, urinary incontinence,
hydronephrosis) or bowel symptoms (eg, constipation)

Dysmenorrhea is an infrequent indication for myomectomy. Dysmenorrhea is more commonly

associated with conditions (eg, endometriosis) other than with myomas. Myomectomy or other
fibroid-specific treatment for the indication of dysmenorrhea should be performed only when
other therapies for dysmenorrhea have failed. (See "Treatment of primary dysmenorrhea in adult
women".)

Unproven indications — Myomectomy should be performed only for women in whom the
procedure is likely to ameliorate a specific symptom. Indications for which the benefit of
laparoscopic (or abdominal) myomectomy remains unproven include:

●Evaluation of ovarian or uterine malignancy

●Infertility (removal of fibroids with a submucous component is associated with increased

fertility)

●Prevention of obstetric complications

These indications are discussed in detail separately. (See "Abdominal myomectomy", section on
'Unproven indications'.)

Contraindications — Laparoscopic myomectomy is contraindicated in women in whom

laparoscopy or uterine conservation are contraindicated (eg, medical comorbidities, cervical or
uterine cancer). (See "Overview of the principles of medical consultation and perioperative
medicine".)

CHOOSING A TREATMENT APPROACH

Myomectomy versus other treatments — The choice of treatment for women with uterine
leiomyomas is guided by the type of symptoms: abnormal bleeding or bulk-related (eg, pelvic
pain/pressure). There are a variety of treatment approaches, both pharmacologic and surgical.

The choice between myomectomy and other treatments is discussed in detail separately. (See
"Abdominal myomectomy", section on 'Myomectomy versus other treatment approaches' and
"Management of abnormal uterine bleeding".)
Choosing the surgical approach for myomectomy — Laparoscopic myomectomy offers several
advantages compared with abdominal myomectomy, including decreased morbidity and a shorter
recovery. However, the wide application of laparoscopic myomectomy is limited by the
characteristics of myomas that can be reasonably removed and the surgical expertise required
(eg, laparoscopic suturing) [4]. Robot-assisted myomectomy has similar outcomes to
laparoscopic myomectomy, with longer operating times and higher costs. Hysteroscopic
myomectomy is the procedure of choice for women with intracavitary myomas (submucosal and
some intramural myomas that protrude into the endometrial cavity).

Candidates for laparoscopic myomectomy — Determining whether a woman is a candidate for

laparoscopic myomectomy depends upon the location, size, and number of leiomyomas,
although parameters for these vary with surgical expertise. These criteria are used to ensure that
women undergoing the procedure avoid perioperative complications and/or conversion to
laparotomy. Preoperative imaging is important to assess the precise characteristics of the tumors.
(See 'Imaging' below.)

Important factors regarding the location of fibroids include the depth of penetration into the
myometrium and position relative to important structures (eg, uterine vessels, fallopian tubes).
Pedunculated subserosal fibroids are the easiest to remove, but myomas in other locations can
also be excised laparoscopically. In addition, many surgeons find anterior or fundal myomas
easier to remove than those that are posterior. Performing laparoscopic myomectomy in women
with large or numerous myomas is likely to be time consuming, particularly since morcellation is
usually required. In addition, removal of such fibroids may lead to increased blood loss, which is
better prevented and controlled during open myomectomy. (See "Techniques to reduce blood loss
during abdominal or laparoscopic myomectomy", section on 'Intraoperative measures'.)

Few data address the optimal criteria for a successful laparoscopic myomectomy, and the ability
to successfully perform a laparoscopic myomectomy also depends in large part on surgical
expertise. The largest study was a prospective multicenter study of 2050 women undergoing
laparoscopic myomectomy [5]. Leiomyoma characteristics that were significantly associated
with major complications (eg, bleeding requiring blood transfusion, visceral injury, procedural
failure) included: size of myoma >5 cm; >3 myomas removed; and intraligamentous location;
intramural myomas were significantly associated with an increase in minor, but not major,
complications (eg, fever, uterine manipulator injuries).

Laparoscopic versus open myomectomy — In appropriately selected patients, laparoscopic

myomectomy has lower overall morbidity and a shorter recovery time than open myomectomy.

A systematic review of six randomized trials including 576 women compared laparoscopic with
abdominal myomectomy [6]. Laparoscopic myomectomy had a statistically significant increase
in operative duration (13 min longer), but a decrease in blood loss (34 ml less). However, these
differences are small and unlikely to be clinically significant. The overall risk of complication
was significantly lower for laparoscopic myomectomy (OR 0.47; 95% CI 0.26-0.85), but there
was no statistically significant difference in the risk of major complications (eg, hemorrhage
requiring transfusion, visceral injury, thromboembolism) (OR 0.49; 95% CI 0.09-2.70); however,
the analysis lacked sufficient statistical power to detect this difference. Two of the trials reported
that significantly more patients in the laparoscopic group had fully recuperated by postoperative
day 15. Although the data were too heterogeneous for meta-analysis, the shorter recovery time
for laparoscopic surgery is well established.

Regarding long-term outcomes, follow-up ranged widely across studies in the meta-analysis
from 6 to 52 months [6]. There was no significant difference in the rate of recurrent myomas
laparoscopic and open myomectomy (20 versus 18 percent; OR 1.2, 95% CI 0.4-3.0), although
this analysis also lacked statistical power. Interestingly, some data suggest that a laparoscopic
approach results in less severe adhesive disease, particularly fewer adnexal adhesions, which
may impact fertility [7]. (See 'Adhesive disease' below.) Further randomized trials are needed to
compare between these two procedures.

In summary, laparoscopic myomectomy is a minimally invasive procedure with a shorter

recovery and a lower overall risk of complications than abdominal myomectomy. More data are
needed about the comparative risks of major complications and fibroid persistence or recurrence.
Patient eligibility and access to trained surgeons limit the availability of this procedure. Given
the available data, we suggest laparoscopic rather than open myomectomy for women with
leiomyomas when technically feasible (depending upon size, number, and location) and who
have easy access to a surgeon with advanced laparoscopic skills.

Alternative laparoscopic techniques

Robot-assisted laparoscopy — Robot-assisted laparoscopic myomectomy may decrease technical

difficulty by making laparoscopic suturing easier than during conventional laparoscopic
procedures. However, use of robot-assisted laparoscopy is expensive, and, currently, there are
fewer surgeons with expertise in robot-assisted than in conventional laparoscopy [8].

Robot-assisted laparoscopic myomectomy is associated with decreased blood loss and recovery
time compared with open myomectomy, but appears to increase operative duration, based upon
observational data [8-13]. As an example, in one case-control study (n = 125), robotic-assisted
compared with open procedures had a significant decrease in blood loss (226 versus 459 ml),
change in postoperative hematocrit (5.1 versus 7.1 percent), length of hospital stay (0.5 versus
3.3 days), number of days to regular diet (0.9 versus 2.3 days), and febrile morbidity (1.3 percent
versus 38 percent), despite significantly longer robotic surgical times (3.2 versus 2.3 hours) [10].

There are few data comparing robot-assisted with conventional laparoscopic myomectomy
[9,14]. In the largest study to-date, a retrospective case series of 575 myomectomies (68.3
percent open, 16.2 percent conventional laparoscopic, and 5.5 percent robot-assisted) reported
that robotic-assisted myomectomy was associated with blood loss (robot-assisted: 150mL and
conventional laparoscopic: 100mL) and operative duration (181 and 155 minutes) that were
comparable to conventional laparoscopic procedures [9]. Case selection bias is likely in
retrospective studies, however, which makes these low-quality data.

Some data suggest that obesity is not associated with poor surgical outcomes in patients
undergoing robotic myomectomy [15].
It is not known whether robotic technology results in a more secure myometrial closure, and
thus, in a lower risk of subsequent uterine rupture; there is only one report of pregnancy after a
robot-assisted myomectomy [12]. Although robotic technology facilitates laparoscopic suturing,
the lack of haptic (tactile) feedback may limit the ability to hold tension on a suture. However,
the third operative arm instrument enables the surgeon to hold tension on the suture while he or
she sutures with the other arms. Additionally, recently introduced barbed sutures (eg, Quill Self-
Retaining System, V-Loc Absorbable Wound Closure Device) facilitate suture fixation in
myometrial tissue during both robotic and laparoscopic myomectomy, also decreasing the need
to hold tension on sutures [16]. (See "Principles of abdominal wall closure", section on 'Skin'.)

Single port laparoscopy — Single port laparoscopy, or laparoendoscopic single-site surgery

(LESS), is the most recent laparoscopic innovation. Successful LESS myomectomy has been
reported, but the data are limited to small case series and small fibroids [17-19]. Further study is
needed to evaluate this procedure. (See "Abdominal access techniques used in laparoscopic
surgery", section on 'Single-incision surgery (SIS)'.)

The technique for LESS myomectomy was described by one surgeon [20]. The technique
involved the placement of three 5 mm trocars through a common umbilical incision, but through
separate fascial perforations. A harmonic scalpel and blunt dissection were used to remove a 4
cm transmural posterior fundal myoma and the uterine defect was repaired in layers using
bidirectional barbed suture. After removal of the trocars, a fascial incision connecting the
perforations was made to facilitate removal of the myoma.

PREOPERATIVE EVALUATION AND PREPARATION — Preoperative evaluation and

preparation are similar for laparoscopic and abdominal myomectomy. Information specific to
laparoscopic myomectomy is discussed in this section. The remainder of the information can be
found separately. (See "Abdominal myomectomy", section on 'Preoperative evaluation' and
"Abdominal myomectomy", section on 'Preoperative preparation'.)

Informed consent — Women with symptomatic fibroids should be counseled about other
medical, interventional radiology, and surgical options for treatment. (See "Overview of
treatment of uterine leiomyomas (fibroids)" and "Management of abnormal uterine bleeding".)

Potential complications of the procedure, including conversion to laparotomy and the likelihood
of recurrence of fibroid-associated symptoms should also be reviewed. (See "Abdominal
myomectomy", section on 'Complications' and "Abdominal myomectomy", section on 'Persistent
or new myomas'.) This discussion should be documented on the surgical consent form and in the
medical record.

Imaging — Women who are planning myomectomy should undergo imaging to confirm the
presence of uterine leiomyomas rather than other pelvic pathology. In addition, incidental
findings of other lesions (eg, ovarian cyst) may impact surgical planning.

Pelvic sonography is typically the initial imaging study. Ultrasound can confirm the presence of
leiomyomas and their approximate number and location [21]. Magnetic resonance imaging
(MRI) provides more accurate information regarding myoma size, number, and location than
other imaging modalities [21]. For women who are being evaluated for possible laparoscopic
myomectomy, this information may help the surgeon determine whether laparoscopic surgery is
feasible and may help avoid missing myomas not palpable during laparoscopic surgery. MRI is
also the best modality to diagnose adenomyosis, which can mimic leiomyomas and/or make
myomectomy more difficult. MRI is also indicated if uterine sarcoma is suspected. (See "Uterine
adenomyosis", section on 'Diagnosis' and "Differentiating uterine leiomyomas (fibroids) from
uterine sarcomas", section on 'Choice of imaging modality'.)

Imaging of uterine leiomyomas is discussed in detail separately. (See "Uterine leiomyomas

(fibroids): Epidemiology, clinical features, diagnosis, and natural history", section on 'Imaging
and endoscopy' and "Differentiating uterine leiomyomas (fibroids) from uterine sarcomas",
section on 'Imaging'.)

GnRH agonists — Preoperative use of gonadotropin releasing hormone agonists reduces the size
of myomas, and may theoretically allow a laparoscopic rather than abdominal approach in some
women. No studies have evaluated this approach. Disadvantages of these agents are that they
may make removal of myomas more difficult and may increase the risk of persistent myomas. In
our practice, we do not pretreat with these agents prior to laparoscopic myomectomy.

The use of gonadotropin releasing hormone agonists prior to myomectomy is discussed in detail
separately. (See "Abdominal myomectomy", section on 'Reducing uterine size with GnRH
agonists' and "Techniques to reduce blood loss during abdominal or laparoscopic myomectomy",
section on 'GnRH agonists'.)

Thromboprophylaxis — Patients undergoing laparoscopic myomectomy (major surgery, defined

as >30 minutes duration) are at low to moderate risk for venous thromboembolism and require
appropriate thromboprophylaxis, whether mechanical or pharmacologic. (See "Prevention of
venous thromboembolic disease in adult nonorthopedic surgical patients" and "Overview of
preoperative evaluation and preparation for gynecologic surgery", section on
'Thromboprophylaxis'.)

Prophylactic antibiotics — Antibiotic prophylaxis is typically not administered for laparoscopic

procedures [22]. The risk of surgical site infection is low in laparoscopic procedures in which the
vagina or bowel are not entered [23]. (See "Overview of preoperative evaluation and preparation
for gynecologic surgery", section on 'Antibiotic prophylaxis'.)

Anesthesia — Laparoscopic myomectomy requires general anesthesia, since pneumoperitoneum

and potential upper abdominal manipulation make it preferable to have full abdominal anesthesia
[24].

PROCEDURE — The basic steps of laparoscopic myomectomy are:

●Insert laparoscopic ports

●Apply measures to reduce blood loss

●Make uterine incision(s)

●Remove myomas

●Close uterine defects

Laparoscopic port placement — Port placement is based upon the position and size of the
myomas to be removed, usually higher than the uterine fundus to allow access to the myomas. A
left upper quadrant approach may be used for initial access if uterine size is near or above the
umbilicus [25]. (See "Overview of gynecologic laparoscopic surgery and non-umbilical entry
sites".)

Once the initial port has been placed, the camera is inserted and the pelvis and abdomen
surveyed. The feasibility of the procedure is assessed. If there are unexpected findings (eg,
extensive adhesive disease) that preclude laparoscopic myomectomy, the procedure should be
converted to laparotomy. (See "Abdominal myomectomy", section on 'Procedure'.)

Placement of two ports on either the patient's right side for right-handed surgeons or left side for
left-handed surgeons makes laparoscopic suturing more ergonomic. These include a 12 mm port
at approximately 2 cm medial to the iliac crest to allow access for adequately sized curved
needles and an ipsilateral 5 mm port medial and slightly cephalad to the larger port [26]. A
contralateral 5 mm port is also placed.

Measures to reduce blood loss — Myomectomy may involve significant blood loss. Bleeding can
be prevented or decreased with mechanical or pharmacologic methods. Allogeneic blood
transfusion can be avoided by using methods of autologous blood transfusion (autologous blood
donation, intraoperative and postoperative blood salvage, or acute normovolemic [isovolemic]
hemodilution).

Techniques to reduce blood loss during myomectomy are discussed separately. (See "Techniques
to reduce blood loss during abdominal or laparoscopic myomectomy", section on 'Intraoperative
measures'.)

To control bleeding from large vessels within a myometrial defect, we desiccate briefly with
bipolar electrosurgical paddles. Excessive desiccation devascularizes the myometrium and
should be avoided, since it may increase the risk of uterine rupture in subsequent pregnancy. (See
'Uterine rupture during pregnancy following myomectomy' below.)

Uterine incision — A transverse myometrial incision, rather than a vertical incision, allows more
ergonomic laparoscopic suturing of the uterine defect. The incision is made directly over the
myoma and carried deeply until definite myoma tissue and the avascular plane just deep to the
capsule of the myoma are noted.

Removal and morcellation of myomas — Techniques for removing myomas vary [27,28]. In our
practice, we grasp each myoma with a tenaculum for traction and use blunt and sharp dissection
to separate the plane between the myometrium and myoma.
For myomas that cannot be removed through the existing ports, morcellation of the myoma with
an electromechanical device is one option.

Concerns have been raised about uterine morcellation and the risk of dissemination of malignant
tissue if an unsuspected uterine malignancy is present. The US Food and Drug Administration
has provided guidance that limits use of power morcellation of uterine tissue. This is discussed in
detail separately.

In our practice, we review these issues and as part of the consent process for women who
consider laparoscopic myomectomy with morcellation. We think each woman should consider
the issues pertinent to her situation and have the freedom to undertake shared decision-making
with her surgeon and to select the procedure that is most appropriate for her.

Closure of uterine defects — Delayed absorbable sutures are placed in one, two or three layers,
depending upon the depth of the myometrial defect. In our practice, we use size 0 polydioxanone
(eg, PDS). Other sutures, including polyglactin (Vicryl) or barbed suture, may be used, although
no studies have compared the use of different sutures with regard to strength of the uterine
wound. Entrance into the uterine cavity can usually be detected due to the different texture and
color of the endometrium. Some surgeons place methylene blue into the cavity via a transcervical
catheter so that the dye can be seen if the cavity is entered. We close all defects, including the
serosa following removal of a pedunculated fibroid.

We adhere as closely as possible to the surgical technique for abdominal myomectomy. It is

controversial whether reapproximation of the myometrium via laparoscopic suturing gives the
uterine wall the same strength as multilayer closure at laparotomy [29-31]. The security of the
closure may impact the risk of uterine rupture in subsequent pregnancy. (See "Abdominal
myomectomy", section on 'Closure of uterine defects' and 'Uterine rupture during pregnancy
following myomectomy' below.)

At the close of the procedure, the pelvis and abdomen are irrigated, the fluid suctioned, and
measures to prevent adhesion formation are applied, if desired. (See "Postoperative peritoneal
adhesions in adults and their prevention".)

COMPLICATIONS — Complications are similar for laparoscopic and abdominal myomectomy.

Information specific to laparoscopic myomectomy is discussed in this section. The remainder of
the information can be found separately. (See "Abdominal myomectomy", section on
'Complications'.)

Hemorrhage — In series of 500 or more laparoscopic myomectomies, the rate of hemorrhage or

blood transfusion varied widely from 0.1 to 6 percent [5,32,33]. The average blood loss reported
was 80 to 248 ml (range 20 to 1000 mL) [32,33].

Prevention and management of blood loss during myomectomy are discussed in detail separately.
(See "Techniques to reduce blood loss during abdominal or laparoscopic myomectomy" and
"Management of hemorrhage in gynecologic surgery".)
Fever and infection — Fever occurs in many women following myomectomy, but a localized
source is often not identified. (See "Abdominal myomectomy", section on 'Fever and infection'.)

Evaluation and management of postoperative fever are discussed separately. (See "Postoperative
fever".)

Bowel or bladder injury — Visceral injury during laparoscopic myomectomy is rare. In series of
500 or more laparoscopic myomectomies, the rate of bowel injury was 0 to 0.04 and of bladder
injury was 0 to 0.3 percent [5,32].

Conversion to laparotomy — Conversion to laparotomy occurs in 1 to 2 percent of laparoscopic

myomectomy procedures [34-36]. A laparoscopic myomectomy may be converted to a
laparotomy if initial evaluation reveals pathology that precludes a laparoscopic approach or to
aid management of an intraoperative complication (eg, hemorrhage).

Adhesive disease — Adhesion formation after myomectomy has been well documented. Studies
in which second look laparoscopy has been performed following laparoscopic myomectomy
have reported intraabdominal adhesions in 36 to 66 percent of women [37-39].

As noted above, laparoscopic myomectomy may result in fewer adhesions than abdominal
myomectomy. This was suggested by a prospective cohort study (n = 28) in which second look
laparoscopy following laparoscopic compared with abdominal myomectomy revealed adhesions
in fewer women (4 of 14 versus 9 of 14 women) and less dense adhesions [7]. Further study is
needed to validate these findings. (See 'Choosing the surgical approach for myomectomy' above.)

A detailed discussion of methods of adhesion prevention can be found separately. (See

"Postoperative peritoneal adhesions in adults and their prevention".)

Other complications — The evaluation and management of other complications, such as ileus or
wound infection, are discussed separately. (See "Urinary tract injury in gynecologic surgery:
Identification and management" and "Postoperative ileus" and "Complications of abdominal
surgical incisions" and "Overview of management of mechanical small bowel obstruction in
adults".)

OUTCOME

Relief of symptoms — There are no data regarding the rate of relief of symptoms following
laparoscopic myomectomy. It is uncertain whether success rates can be extrapolated from
abdominal myomectomy, which has been reported to relieve symptoms in approximately 80
percent of women [2,40].

Persistent or new myomas — In a multicenter retrospective cohort study of 512 women who
underwent laparoscopic myomectomy, the rates of post-myomectomy myomas at five and eight
years were 53 and 84 percent; however, the rates of reoperation were much lower, 7 and 16
percent [41]. Risk factors for the presence of leiomyomas were similar to those for open
myomectomy, including: multiple myomas at time of surgery, uterine size ≥13 weeks, and age
<36 years. In this study, pregnancy after myomectomy was associated with an increased risk of
subsequent myomas, but this was contrary to findings of other studies of laparoscopic and open
myomectomy [42]. (See "Abdominal myomectomy", section on 'Persistent or new myomas'.)

A systematic review of six randomized trials including 576 women that compared laparoscopic
with open myomectomy found no significant difference in the rate of recurrent myomas between
the two surgical approaches [6].

INPATIENT POSTOPERATIVE CARE — Laparoscopic myomectomy is typically performed as

an outpatient procedure or with a one day hospital stay.

Routine postoperative care following myomectomy is reviewed separately. (See "Abdominal

myomectomy", section on 'Inpatient postoperative care'.)

FOLLOW-UP — A woman is encouraged to resume her normal daily activities as quickly as is

comfortable. Decisions regarding resumption of vaginal intercourse are made by the patient;
there are no medical restrictions on sexual activity [43]. Patients may return to work as soon as
they have regained sufficient stamina and mobility.

Routine postoperative instructions for patients can be found separately. (See "Patient education:
Care after gynecologic surgery (Beyond the Basics)".)

We see patients for a follow-up visit at two weeks postoperatively. The follow-up visit includes
an evaluation for potential complications and an examination of the abdomen and wounds. We
review the details of the surgery and pathology results with the patient.

CONCEPTION AND PREGNANCY AFTER MYOMECTOMY

Interval to conception — Women who undergo myomectomy with significant uterine disruption
should wait several months before attempting to conceive; recommendations for the interval to
conception range from three to six months [44].

Fertility — If a woman is having difficulty conceiving following a myomectomy, early

assessment of the uterine cavity and fallopian tubes with a hysterosalpingogram is advisable
[45].

Issues of fertility and leiomyomas are discussed separately. (See "Abdominal myomectomy",
section on 'Infertility' and "Reproductive issues in women with uterine leiomyomas (fibroids)".)

Uterine rupture during pregnancy following myomectomy — Myomectomy is associated with an

increased risk of uterine rupture during subsequent pregnancy. Operative techniques, instruments
and energy sources used during laparoscopic myomectomy often differ from those employed
during laparotomy. Failure to adequately suture myometrial defects, lack of hemostasis within
uterine defects with subsequent hematoma formation, or the excessive use electrosurgery with
devascularization of the myometrium have all been postulated to interfere with myometrial
wound healing and increase the potential for rupture [26].
In the largest study of laparoscopic myomectomy, 2050 women followed for an average of 42
months, there were 386 pregnancies and one uterine rupture (spontaneous rupture at 33 weeks)
[5]. A review of published and unpublished cases yielded 19 instances of uterine rupture during
pregnancy following laparoscopic myomectomy [46]. Almost all of the cases contained a
deviation from standard technique, as described for abdominal myomectomy. In seven cases, the
uterine defect was not repaired; in three cases, it was repaired with a single suture; in four cases,
it was repaired in only one layer; and, in one case, only the serosa was closed. A multi-layered
closure employed in only three cases. In 16 of the 19 cases, primarily monopolar or bipolar
energy was used for hemostasis.

Presently, it appears prudent for surgeons who perform laparoscopic myomectomy to adhere to
time-tested techniques developed for abdominal myomectomy, including limited use of
electrosurgery and use of multi-layered closure of myometrium. Yet, even with ideal surgical
technique, individual wound healing characteristics may predispose to uterine rupture [47].

Many experts advise cesarean delivery as a conservative approach.

Uterine rupture during pregnancy following myomectomy is discussed in detail separately. (See
"Pregnancy in women with uterine leiomyomas (fibroids)", section on 'Management of patients
with prior myomectomy'.)

ALTERNATIVE LAPAROSCOPIC TECHNIQUES — There are ongoing efforts to develop

minimally invasive treatments for fibroids. Methods that are performed laparoscopically are
discussed in this section.

Uterine artery occlusion — Laparoscopic uterine artery occlusion procedures have been
investigated [48-52]. However, such techniques have distinct disadvantages compared with other
minimally invasive approaches, such as laparoscopic myomectomy or uterine artery
embolization.

Myomas may shrink after uterine artery occlusion, but uterine volume is not reduced to the same
extent as myomectomy. This, combined with the exposure of women to general anesthesia and
abdominal incisions for both procedures, makes myomectomy the preferred procedure. No
studies have compared these two procedures.

Uterine artery embolization has been compared with laparoscopic uterine artery occlusion, since
both treat fibroids with occlusion of the uterine blood supply. Laparoscopic occlusion has some
advantages compared with uterine artery embolization, including: (1) avoids introduction of
foreign bodies (eg, polyvinyl alcohol particles, coils); (2) provides laparoscopic assessment of
the pelvis and abdomen; and (3) was associated with less postoperative pain in a prospective
cohort study of 46 women [48]. However, these advantages are superseded by several
disadvantages, including that laparoscopic occlusion requires general anesthesia, is invasive, and
requires a skilled laparoscopic surgeon. Also, uterine artery embolization performed better in a
small randomized trial (n = 58) comparing the two methods, as measured by the mean uterine
volume reduction (51 versus 33 percent) and rate of recurrent symptoms (17 verus 48 percent)
[53]. Thus, women who are planning treatment of leiomyomas with blockage of the uterine
blood supply are better treated with uterine artery embolization than laparoscopic uterine artery
occlusion.

Thus, we suggest either laparoscopic myomectomy or uterine artery embolization rather than
laparoscopic uterine artery occlusion. Choosing between myomectomy and uterine artery
embolization is discussed separately. Use of concurrent laparoscopic myomectomy and uterine
artery ligation has been reported [54]. (See "Abdominal myomectomy", section on
'Interventional radiology procedures'.)

Transvaginal occlusion of the uterine arteries is also under investigation. (See "Overview of
treatment of uterine leiomyomas (fibroids)", section on 'Uterine artery occlusion'.)

Myolysis — Myolysis refers to laparoscopic thermal coagulation or cryoablation (cryomyolysis)

of leiomyoma tissue to reduce myoma size (by approximately 50 percent) by means of myoma
destruction and interference with local vascular supply [55-57]. Laparoscopic myolysis has been
performed using a number of energy sources, including bipolar electrosurgery, Nd:YAG laser,
radiofrequency, and cryogenic probes [58,59].

Radiofrequency myolysis is easier to master than laparoscopic myomectomy, since it does not
require laparoscopic suturing. A multicenter study found that radiofrequency myoma ablation
was well tolerated and had a rapid recovery, high patient satisfaction, improved quality of life,
and good symptom relief [60].

In women with menorrhagia, myolysis combined with endometrial ablation may be more
effective therapy than either procedure alone, but this is investigational. An observational study
comparing ablation alone versus with the combined procedure found that the risks of a second
surgery were 38 and 13 percent, respectively [61].

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patient might have about a given condition. These articles are best for patients who want a
general overview and who prefer short, easy-to-read materials. Beyond the Basics patient
education pieces are longer, more sophisticated, and more detailed. These articles are written at
the 10th to 12th grade reading level and are best for patients who want in-depth information and
are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or
e-mail these topics to your patients. (You can also locate patient education articles on a variety of
subjects by searching on “patient info” and the keyword(s) of interest.)

●Beyond the Basics topics (see "Patient education: Uterine fibroids (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Laparoscopic myomectomy is the laparoscopic removal of leiomyomas from the uterus, leaving
the uterus in place. (See 'Introduction' above.)

●The most common indications for laparoscopic myomectomy are abnormal uterine bleeding or
bulk-related symptoms (eg, pelvic/abdominal pain or pressure). Indications for which the benefit
of laparoscopic (or abdominal) myomectomy is unproven or not likely to be helpful include
evaluation of pelvic malignancy (eg, ovarian or uterine cancer), infertility, and prevention of
obstetric complications. (See 'Indications' above and 'Unproven indications' above.)

●Determining whether a woman is a candidate for laparoscopic myomectomy depends upon the
location, size, and number of leiomyomas. Pedunculated subserosal fibroids are the easiest to
remove, but myomas in other locations can also be excised laparoscopically. Performing
laparoscopic myomectomy in women with large or numerous myomas is likely to be time
consuming, particularly since morcellation is usually required. (See 'Candidates for laparoscopic
myomectomy' above.)

●We suggest laparoscopic rather than abdominal myomectomy for women with leiomyomas for
whom laparoscopic removal is technically feasible (by size, number, and location) and who have
access to a surgeon with advanced laparoscopic skills (Grade 2B). (See 'Laparoscopic versus
open myomectomy' above.)

●The risk of uterine rupture in a pregnancy subsequent to laparoscopic myomectomy is not well
established. To optimize myometrial wound repair, we limit the use of electrosurgical desiccation
of bleeding vessels and use a multi-layered closure of myometrium. (See 'Measures to reduce
blood loss' above and 'Closure of uterine defects' above and 'Uterine rupture during pregnancy
following myomectomy' above.)

●Alternative laparoscopic techniques for treatment of leiomyomas have been investigated. For
women with symptomatic leiomyomas:

•We suggest laparoscopic myomectomy rather than laparoscopic uterine artery occlusion or
myolysis (Grade 2C).

•We suggest uterine artery embolization rather than laparoscopic uterine artery occlusion (Grade
2B). (See 'Alternative laparoscopic techniques' above.)

●The most common complications of laparoscopic myomectomy are hemorrhage, fever, and
conversion to laparotomy. Visceral injury and other complications occur rarely. (See
'Complications' above.)

●Following laparoscopic myomectomy, the five-year rate of persistent or new myomas is

approximately 53 percent, but the rate of women undergoing reoperation is approximately 7
percent. (See 'Persistent or new myomas' above.)
●Robotic myomectomy may benefit some surgeons who have difficulty with laparoscopic
suturing, but there are no data to show meaningful benefit to women over the outcomes achieved
with laparoscopic myomectomy.

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