Harmonic scalpel, monopolar diathermy attached to a hook or scissors, plasma energy or laser may be used to incise the overlying serosa and myometrium. A smoke extraction system is useful to maintain clear visibility. The incision should be deep enough to reach the fibroid so that the actual plane between the fibroid and the myometrium is easier to identify (Fig. 12.2). The incision is then enlarged to the required size and the plane between the fibroid and the myometrium is gradually developed by mechanical dissection as well as division of the myometrial and fibrous bands utilising the energy source. Mechanical traction and counter-traction using a combination of instruments such as myomectomy screws, claw forceps and tooth graspers, as well as the counter traction applied by a second assistant via a volsellum on the cervix, is used to enucleate the fibroids. Care should be taken to avoid pushing laparoscopic instruments into the uterine cavity if possible, and similarly, the second assistant should refrain from using excessive force on the uterine manipulator to prevent uterine perforation. With this approach, it may be possible to avoid breaching the cavity, even during removal of fibroids protruding into the cavity as long as there is intact endometrium overlying the entire fibroid surface (Figs. 12.3 and 12.4).

Removed fibroids should be placed in a safe location so that they can be easily found later on for morcellation. Larger fibroids may be placed in the right iliac fossa as they would be difficult to fit into the pouch of Douglas (POD) and would be easy to locate. Smaller fibroids would be better kept in the POD to avoid difficulty in locating them later in the upper abdomen among the loops of bowel and the omentum.

Haemostasis is usually achieved by suturing. If there are obvious bleeding vessels these could be coagulated using targeted diathermy. Indiscriminate and excessive diathermy should be avoided as this is probably one of the main factors contributing to uterine rupture in future pregnancies, along with inadequate suturing.

The repair of the myometrial defect is frequently carried out using ‘barbed sutures’ which do not require knot-tying. If the endometrial cavity is opened, a separate repair of the endometrium may be beneficial in preventing the rare future cases of myometrial pregnancy. Barbed sutures should be avoided for the repair of endometrium to reduce the risk of intrauterine adhesion formation. The myometrium should be repaired in multiple layers if necessary and the repair should be similar to the repair at open myomectomy (Fig. 12.5). Inadequate repair is probably a major contributor to the future risk of uterine rupture in pregnancy or labour. The needles should be large enough and curved to avoid leaving significant ‘dead-spaces’ within the defect to reduce the risk of myometrial haematoma formation. In the absence of ‘barbed sutures’ delayed absorbable suture material such as polyglactin could be used. The serosa could also be closed with similar material, however if barbed-sutures are used it is probably useful to cover the incision with an anti-adhesion method to reduce risk of bowel adherence which may result in postoperative mechanical ileus (Fig. 12.6).

The fibroids are usually removed using single-use or reusable electromechanical morcellators. It is important to keep the tip of the morcellator in view when it is activated, taking extreme care that its tip is free of the abdominal wall, bowel and any other adjacent structure. After removing the fibroids, complete inspection of the abdominopelvic cavity should be carried out to remove any fibroid fragments, as morcellated fragments of fibroid can cause disseminated peritoneal leiomyomatosis [15]. In addition, thorough irrigation of the peritoneal cavity is beneficial to aspirate smaller fragments which may not be visible to naked eye.

After thorough irrigation and confirmation of haemostasis, an anti-adhesion method may be applied onto the incision(s) [16] (Fig. 12.7). At the end of the procedure it is important to repair the rectus sheath defects of larger ports, particularly the one used for the morcellator to avoid later herniation.