Laparoscopic Myomectomy for a plethora of submucous myomas

Abstract Study Objective To present a laparoscopic myomectomy technique for the removal of multiple submucous myomas Design A step by step demonstration of the surgery Setting In cases of multiple submucous myomas, hysteroscopic resection of myomas may not be a viable option especially in cases where fertility preservation is needed. It may cause significant damage to the endometrial surface, leading to the formation of endometrial synechiae1 . It is technically challenging and requires prolonged operating time due to impaired visibility and the need for repeated specimen removal. This can lead to complications like fluid overload and rarely air embolism2 . Hence, laparoscopic myomectomy may be a better option in such cases1. Case Report A 30-year-old nulligravida presented with heavy menstrual bleeding and dysmenorrhea since 3 years. She had no symptomatic relief with hormonal medications and magnetic resonance-guided focussed ultrasound (MRgFUS). On examination, she was anemic, and uterus was enlarged to 16weeks gravid uterus. Ultrasonography showed one intramural fundal myoma of 6 x 4.2cm and numerous submucous myomas of size 1-3.2cm. During hysteroscopy, multiple submucous myomas of varying sizes ranging from Type 0 to 1 were seen. On laparoscopy, an incision was made on the uterine fundus with an ultrasonic device after injecting vasopressin (20units in 200ml dilution) and the fundal myoma was enucleated. The incision was then extended to open the endometrial cavity for the removal of submucous myomas. Most of the myomas were removed with mechanical force along with the minimal use of ultrasonic energy. A total of 46 myomas were removed, and the myometrium was closed in 2 layers. The duration of the surgery was 210 minutes with an estimated blood loss of 850 mL. She did not require blood transfusion but she was advised to take hematinics. The patient came for review after 6 months with significant improvement in her symptoms and repeat hysteroscopy was done in December 2016. It showed moderate synechiae in the midline and 2 small submucous myomas near the internal os. The synechiae were incised with hysteroscopic scissors, and the submucous myomas were resected with a bipolar resectoscope. She was advised to try for conception after 2 months. Conclusion Laparoscopic myomectomy is an alternative to hysteroscopic resection for multiple submucous myomas. A repeat hysteroscopy is useful to identify any residual myomas and synechiae.