Decisions about when and how to treat uterine fibroids depend on the patient’s symptoms, the size and location of the fibroids, and her future fertility plans. For women who want to preserve their fertility, myomectomy is indicated when submucosal fibroids result in distortion of the endometrial cavity or heavy menstrual bleeding, or in the presence of large (>4–5 cm diameter) intramural fibroids [1, 2]. Myomectomy can also be considered with large leiomyoma in any location for treatment of significant abdominal pain or discomfort, or urinary tract symptoms. In the case described above, the patient had both unexplained infertility and abdominal pain. Based on the normal uterine cavity and the subserosal location of the fibroid, her infertility was unlikely to be related to her fibroid. In contrast, her episodic pain and urinary frequency was most likely related to her fibroid.

Uterine fibroids can be treated by both nonsurgical and surgical methods. Nonsurgical treatment options for fibroid treatment are not recommended in women desiring fertility treatment. Medical treatment with GnRH agonists or progesterone receptor antagonist can temporarily reduce fibroid size, but these treatments do not improve fertility [3]. Fibroid size can be more permanently reduced by occluding their blood supply using vascular techniques (e.g., uterine artery embolization or uterine fibroid embolization). Unfortunately, reducing uterine blood supply appears to decrease fertility and dramatically increases the risk of subsequent pregnancy complications [4–8].

Additional minimally invasive techniques have been developed to destroy fibroids without surgically removing them. However, there is not enough data yet available to recommend their use in women desiring future fertility [9–11]. These methods include focused ultrasound guided by either magnetic resonance or ultrasound [12, 13] and laparoscopic ultrasound-guided radiofrequency thermal ablation [14]. Although the effects of these treatments on fertility remain unknown, preliminary data suggests that they dramatically increase the subsequent risk of miscarriage and preterm delivery [9].

Myomectomy remains the standard treatment for women with symptomatic fibroids who wish to retain their fertility. The route and method chosen for myomectomy is based on the location, size, and number of fibroids, as well as the experience and skill of the surgeon. Although many submucosal fibroids can be removed hysteroscopically, an abdominal approach is required for intramural and subserosal fibroids. Abdominal myomectomy can be performed laparoscopically (with or without robotic assistance) or via laparotomy. In addition to the need for different equipment and skill sets, these approaches have other relative advantages and disadvantages.

Laparoscopic myomectomy , using either a standard or robotically assisted technique is the preferred method when feasible. The primary advantages of laparoscopy compared to laparotomy are less postoperative pain and shorter recovery time [15, 16]. The disadvantages are that it requires specialized skill and equipment, closure of subsequent myometrial defect can be difficult using standard laparoscopy without advanced training, and the fibroids must be removed from the abdomen using some type of morcellation.

Standard laparoscopy is used most commonly for removing subserosal or pendunculated fibroids that will not result in large myometrial defects, since such defects can be difficult to close in multiple layers using this technique in the absence of advanced laparoscopic skills. Injection of dilute vasopressin can help minimize blood loss. Dissecting graspers, scissors and both unipolar and bipolar surgical devices or ultrasonic instruments are used to detach fibroids (Fig. 4.3).

Robotically assisted laparoscopy allows more surgeons to perform complex laparoscopic surgeries such as myomectomies [17]. The technical advantages of robotic surgery aid in the careful multilayer closures of myometrial defects after fibroid removal. Special training is required, and this approach is more costly than standard laparoscopy. However, robotically assisted laparoscopic myomectomy is less expensive than a laparotomy approach and is associated with comparatively lower complication rates, less blood loss, and shorter hospitalization periods [18–20] (Fig. 4.4).

Morcellation to remove fibroids from the abdominal cavity has become the most controversial part of laparoscopic myomectomy. In the recent past, “open morcellation ” was performed using a power morcellator to cut each fibroid into small pieces within the abdominal cavity as they were withdrawn through a 12 mm port. However, this technique is no longer recommended because of the risk of inadvertent dispersion of small fragments of fibroid tissue within the abdomen during the procedure, which can result in disseminated leiomyomatosis in up to 1% of cases [21, 22]. A much less common, but more serious complication of open morcellation is inadvertent dissemination of an unsuspected leiomyosarcoma. Since these malignant tumors are much less common before menopause, the risk of this occurrence during myomectomy in a reproductive age women is likely to be <0.1% (for detailed discussion of the literature, see Chap. 10). However, since dissemination is likely to worsen the prognosis of this usually fatal disease, open morcellation within the abdominal cavity is no longer recommended.

Several methods have been developed for enclosed morcellation Perhaps, the simplest method is to place the fibroids into a laparoscopic bag, pull the opening of the bag through a 4 cm mini-laparotomy incision, and use scalpel to morcellate the fibroids within the bag [23]. This technique has been termed “laparoscopically assisted myomectomy ” by some authors [24, 25]. The disadvantage is that the larger abdominal incision reduces some of the minimally invasive advantages of the laparoscopic approach.

Other surgeons have recommended power morcellation of fibroids within a bag while still inside the abdomen, termed “enclosed intracorporeal morcellation ” [21, 23, 26]. However, since the US Food and Drug Administration strong warnings against intracorporeal morcellation issued in April 2014 [27], some power morcellators have been withdrawn from the market, many surgeons have elected to stop using them, and many hospitals have banned their use. Regardless of whether morcellation is done via mini-laparotomy, using manual morcellation with a scalpel or using a power morcellator, bag-enclosure is recommended to avoid inadvertent dissemination of benign, or in rare cases, malignant tissue.

Myomectomy via laparotomy remains an acceptable method, particularly for removing very large or multiple fibroids for women wishing to retain their fertility. This approach is most advantageous for large transmural fibroids and in the presence of a large number of fibroids where an open technique improves the chances of avoiding the uterine cavity and aids in careful closure of the complex myometrial defects compared to a laparoscopic approach, with or without robotic assistance [28, 29].

The advantages of myomectomy via laparotomy are twofold: morcellation is not required and myometrial defects can be carefully closed in multiple layers. The disadvantages of laparotomy compared to a laparoscopic approach are increased pain, hospital stay, recovery time, and wound infection risk. Blood loss also appears to be increased using the laparotomy approach. However, this is in part related to the differences in types of fibroids relegated to laparotomy compared to laparoscopic treatment is retrospective studies. The use of vasopressin and/or tourniquets with vascular clamps can minimize blood lost during laparotomy myomectomy [30–32].

For the case described above, we utilized laparoscopic myomectomy with enclosed morcellation via a 4 cm minilaparotomy. The surgery was performed with the patient in a lithotomy position and under general anesthesia. A 5 mm open laparoscopic entry approach was used to place the initial umbilical port [33]. Three additional 5 mm ports were placed under direct visualization, one in the suprapubic area, a second at McBurney’s point on the right, and a third at the corresponding point on the left. Vasopressin (10 U in 100 mL normal saline) was injected into the uterine fundus at the base of the subserous fibroid. The serosa was incised 1 cm above the attachment of the fibroid to the uterus with monopolar electrosurgery. The fibroid was circumferentially detached from the underlying myometrium using a combination of bluntly dissection with grasping forceps and sharp dissection with scissors (Fig. 4.5). The fibroid was temporarily placed in the rectouterine pouch beneath the uterus.

After operative site Hemostasis was obtained, the myometrial defect was closed using absorbable barbed suture (v-Loc; Covidien, New Haven, CT) (Fig. 4.6).

To minimize post-myomectomy adhesions and bowel irritation related to barbed suture, the serosal defect was covered with an absorbable adhesions barrier (Interceed; Ethicon, Somerville, NJ) (Fig. 4.7).

The fibroid was subsequently placed in a 50 × 50-cm isolation bag (3M Steri-Drape Isolation Bag 1003; 3M Corp., St. Paul, MN). The neck of the bag was removed through a 4 cm Pfannenstiel incision made 3 cm cephalad to the symphysis pubis in the midline. The fibroid was carefully morcellated with a scalpel by serially grasping the protruding edge with a towel clip and removing wedge-shaped sections.

The peritoneum beneath the Pfannenstiel incision was closed with 3–0 absorbable monofilament running suture (Biosyn, United States Surgical Corp, Norwalk, CT) to minimized adhesions [34]. The fascia was closed with 0 absorbable braided running suture (Polysorb, United States Surgical Corp).

After hemostasis was verified at the operative and port sites under decreased intra-abdominal pressure, the operative ports and laparoscope were removed from the abdomen. Local anesthetic (20 mL of 0.25% bupivacaine) was injected at each port site and into the Pfannenstiel incision beneath the fascia and intradermally. Skin incisions were closed with 4–0 absorbable monofilament running subcuticular suture (Biosyn, United States Surgical Corp) followed by tissue adhesive (Dermabond, Ethicon; Somerville, NJ). The patient was awakened and sent home after a 2 h recovery period.