As midline incisions are associated with increase perioperative [18] and postoperative morbidity where possible a low transverse abdominal or Pfannensteil incision should be used. Where uterine size is greater than 20 weeks consideration should be given to preoperative shrinkage of fibroids using GnRH agonists or SPRMs which may shrink the fibroids sufficiently to safely complete the procedure using a Pfannensteil approach [16].

More recently some have advocated undertaking abdominal myomectomy via a mini-laparotomy [19] (wound incision approximately 5 cm) or even an ultra-mini laparotomy [20] (wound incision <4 cm) which has been associated with reduced inpatient stays, shorter recovery time and improve cosmetic appearances compared to the traditional abdominal approach. This is appropriate where fibroids are not numerous or large.

Since Bonney [13] first described use of the Bonney’s clamp to temporarily occlude the uterine arteries and reduce uterine blood supply many other techniques have been used to reduce uterine blood supply and therefore minimise operative blood loss. The aim of these measures is to maximally restrict blood supply whilst limiting mechanical damage. Application of a pericervical tourniquet as an alternative to a clamp has been assessed [21], and has been shown to be associated with significant reductions in operative blood loss, although only when used in conjunction with occlusion of the ovarian arteries. More recently pharmacological developments have meant that vasopressors such as vasopressin [22] (diluted with normal saline) injected intramyometrially, resulting in local vasoconstriction, are now used to reduce intraoperative blood loss, avoiding the need for mechanical clamps or tourniquets which may cause inadvertent trauma. The use of intrauterine vasopressin injection has been associated with intraoperative morbidity such as hypotension, bradycardia, hypertension and asystole. Deaths have also been reported; as such this should be used with great care. Preferably a more dilute solution of vasopressin in normal saline, and using only a little at a time ensuring avoidance of blood vessels. If using vasopressin, it is also advisable that an experienced anaesthetist is on hand to deal with complications should they arise.

The technique of enucleation of the fibroid from its capsule as first described by Bonney [13] is still used in modern practice [5]. Initially a serosal incision over the fibroid is made, the incision is then extended down through myometrium until the pseudocapsule is reached. Once the pseudocapsule is reached it is carefully incised to reach the surface of the fibroid. When reached the surface of the fibroid can be grasped or held with a myomectomy screw allowing gentle traction to be applied the fibroid whilst the plane of cleavage is opened up between the fibroid and the pseudocapsule by dividing fibres largely with blunt and sharp dissection to achieve enucleation or ‘shelling out’ of the fibroid from its capsule (Fig. 11.3).

The technique has to be adapted to deal with fibroids that have degenerated; nevertheless a capsule should still be evident. Where a capsule is not easily identified, the presence of adenomyosis should be suspected.

To optimize future reproductive potential the route of the Fallopian tube should be identified and measures taken to avoid cutting or suturing the tubes.

Adequate closure of the uterus is essential not only to restore integrity of the uterine wall but also to ensure obliteration of the dead space thus avoiding haematoma formation and reducing postoperative febrile morbidity. This is usually achieved using two to three layers of continuous locking sutures within the myometrium (deep and more superficial) using an absorbable suture material. There are several techniques that have been described to effect closure including the herringbone, however of importance are close apposition of tissues and secure haemostasis even if interrupted sutures are used. If the endometrial cavity is inadvertently entered, this must be closed as an additional continuous layer.

Where there are submucous or partial submucous fibroids it is preferable to know if the cavity has been breeched, to this end it is the author’s practice to keep a Foley catheter (2 ml inflated balloon) within the uterine cavity via which blue dye can be instilled.

Mechanical measures to reduce perioperative blood loss have already been discussed, however, other pharmacological agents in addition to vasoconstrictors have been employed to reduce operative blood loss.