Establishing an accurate diagnosis can be challenging given the factors mentioned, and because of this reason, it is crucial to proceed with a thorough work-up. When the patient presents for a consultation, a meticulous history must first be obtained. As stated, due to the location of the fibroid, these patients may not necessarily present with menorrhagia or be anemic; it is not uncommon for these patients to present with what may sound like orthopedic complaints. Patients may experience lower back pain or “tail bone” pain, as well as encounter dull achy discomfort when getting into and out of a car, or getting in or out of bed, affecting potentially what appear to be weight-bearing joints such as the hip.

For all patients with uterine fibroids presenting for a potentially minimally invasive surgical approach for removal, a systematic method is utilized. Since the authors perform almost exclusively laparoscopic and robot-assisted procedures, some type of morcellation will be required to extract these large specimens. Therefore, we have established an algorithm that we follow to screen for appropriate cases where morcellation (whether manual or using power morcellators ) can safely be performed. The authors’ institutions and hospitals also refer to this algorithm to assist and guide their OB/GYN departments in determining which cases would be applicable for power morcellators to be used. Our patients are also informed that, unfortunately, there are no preoperative assessments that are available that would allow us to confidently rule out an unidentified malignant process, and a consent form stating this understanding is signed by all patients prior to proceeding with surgery.

Given that the authors see a vast number of patients for second and third opinions, as part of our work-up for very large or what appears to be a rapidly growing fibroid (primarily in postmenopausal women), in addition to performing our own pelvic ultrasounds, we obtain a pelvic MRI with contrast to rule out any suspicious features for a possible sarcoma [27, 28]. We also order a lactate dehydrogenase isoenzyme panel  (LDH isoenzymes) to complete our work-up [29, 30]. Any abnormalities involving the MRI or LDH isoenzyme levels may potentially heighten our suspicion for a possible sarcoma, and a gynecologic oncology consultation may be requested.

Following the pelvic ultrasound, pelvic MRI with contrast, and LDH isoenzyme assessment, all patients undergo endometrial sampling (endometrial biopsy or dilatation and curettage if biopsy is inconclusive) prior to the myomectomy. Depending on the presence of potential risk factors for a possible sarcoma such as Black women over the age of 40 years [31, 32], history of previous pelvic radiation [33, 34], Tamoxifen usage exceeding 5 years [35–37], childhood retinoblastoma, renal cell carcinoma, certain hereditary cancer syndromes (e.g., Lynch Syndrome) [38–40], and tumor growth after menopause regardless of hormone replacement therapy [41–44], the algorithm the authors developed is used to help delineate which patients would be applicable to undergo morcellation in a safe manner (Table 11.1).

When working with massive broad ligament fibroids laparoscopically, one must keep in mind several key factors. The retroperitoneal space can serve as a reservoir, which can house a very large specimen. The surgeon should therefore be aware that the specimen can be much larger than its initial appearance. This space can also hold significant amount of blood, and hence, meticulous hemostasis early in the case is vital [45]. Since the location is peculiar due to the complex anatomy in this region (i.e., ureters, internal iliac and obturator vessels and nerves), the surgeon must pay close attention during dissection. Mass effect due to size can compress the vessels and nerves in this region and can cause weakness and numbness of the affected side as was the case in this patient.

After the mentioned work-up has been completed and all appropriate consents have been obtained, the patient is scheduled for surgery under general anesthesia. The patient is examined and is prepped and draped in the normal sterile fashion. A Foley catheter is then inserted. All patients undergo our modified open laparoscopy technique [46], and the abdominal and pelvic anatomy is carefully assessed. The presence of potential adhesions and/or the size of the pathology will determine where our ancillary trocars will be placed. For large specimens as in this case, the trocars should be placed cephalad to the large fibroid to facilitate surgical maneuvers. This may mean placing the camera port several centimeters above the umbilicus if need be (Fig. 11.3). After this step has been completed, three ancillary 5 mm trocars are placed. If adhesiolysis is required, this step is executed next.

Based on the authors’ experience, careful dissection and location of the ureter of the affected side would be helpful for small tumors. However, in cases such as this where the broad ligament fibroid is extremely large, the surgeon will not know exactly how the ureter has been displaced (laterally, superiorly, inferiorly, etc.), and therefore, attempts for locating and dissecting out the ureter may be futile and dangerous since the anatomy can be significantly distorted. We therefore recommend that the surgeon should “hug” the fibroid and stay close while dissecting and enucleating the tumor (Fig. 11.4). This way, as the peripheral structures are falling away from the specimen, visualization of the surrounding anatomy may become more familiar.

As the fibroid is being dissected and pulled out of the broad ligament, one can try to “walk the specimen” as the surgeon can cross over with laparoscopic grasper with teeth or tenaculum, to enhance grip providing traction, which will enhance visualization beyond the edge and horizon of the tumor (Fig. 11.5). It can become challenging at times to see clearly when dealing with large tumors, and the authors find this tip to be helpful.

After the fibroid is resected, careful dissection would lead to minimal bleeding. If moderate oozing is observed, hemostatic agents can be used to facilitate hemostasis. Bipolar cautery can also be used as long as the surgeon is mindful of the anatomy in this region. Zero absorbable polyglactin suture on a straight needle is used to close the peritoneum (Fig. 11.6).

In order to remove the specimen, we utilize our simplified laparoscopic abdominal morcellation (“SLAM”) technique . It is a technique that Carlos Rotman has developed in the early 1990s to remove large specimen in a safe and efficient manner [47]. The large fibroid is held under tension by using either two laparoscopic tenaculums or graspers with teeth, inserted from the left and right side. Grasping the large specimen initially with tenaculums may facilitate the handling of the large pathology especially when beginning the SLAM . The suprapubic trocar is removed and an 11-blade is inserted (Fig. 11.7). With forward motion, and with the blade always facing away from pelvic organs, the large fibroid is cut into longitudinal strips, which are carefully counted as they are being cut and stored for later extraction. This would prevent creating crumbs or debris of tissue unlike the automated morcellators, which can lead to unwanted seeding, and large specimens can be expeditiously removed. Abdominal wall tissues are generally forgiving, and thus, the small skin incision can be extended just slightly and the specimen can be removed as it is pulled out using a Kocher clamp (Figs. 11.8 and 11.9), making sure that all pieces are accounted for. Long strips of tissue can be removed quite rapidly in this fashion.

After all the counted specimen pieces are removed, the incision is copiously irrigated from the inside with the laparoscopic irrigator and again with the bulb-tip syringe from outside prior to the closure of the skin. This practice should be consistently observed to avoid potential inoculation of the incision, which can in rare circumstances lead to incisional implantation of pathology [48]. After confirming hemostasis and complete removal of the specimen, the fascial incision is re-approximated with a figure-of-eight stitch with 1-0 absorbable polyglactin suture, and the skin incision can be re-approximated with 4-0 absorbable suture. Various modifications of the SLAM technique exists around the world today, but the concept is still the same; large specimens can be removed quickly in a controlled and refined manner, without unwanted dissemination of tissue through a very cost-effective usage of a blade or two. The isthmic occlusion was repaired by performing a tubal anastomosis per patient’s request [49].

Cases involving a large broad ligament fibroid such as this cannot be successfully managed in a conservative fashion. Given its large size, there is a significant mass effect that cannot be relieved by medical treatment. Uterine artery embolization will have little or no effect on the broad ligament leiomyoma due to the fact that this type of fibroid does not necessarily rely on the uterus for its blood supply, which is why it can exist outside the confines of the uterus. Although there have been numerous studies that have demonstrated decreased tumor volume with pretreatment with gonadotropin-releasing hormone agonists (GnRH agonists) prior to a myomectomy [50–53], most studies involve fibroids that are under 10 cm in size. In the authors’ experience, GnRH agonists will soften the tumor and can at times impair the enucleation process since the capsule becomes compromised. Given the higher tendency of some degree of degeneration involving larger fibroids, presurgical treatment with GnRH agonists can increase risk of tearing and/or removing the fibroid specimen piece-meal due to its soft and weakened texture. Diluted vasopressin will work best to decrease blood loss during surgery compared to other medications or options, and establishing a clear plane with meticulous dissection and enucleation will further enhance the chances of a successful outcome.

Whether a robot-assisted laparoscopic myomectomy (RALM) or traditional laparoscopic myomectomy (LM) is performed is up to the preference of the surgeon. Based on the authors’ experience, for difficult cases or for cases involving a large specimen, traditional LM is preferable for several reasons. Just as a blind-folded individual can sense the difference in cutting loose leaf paper vs. cardboard paper with scissors, tactile feedback allows the surgeon to “feel” what he/she is cutting, which is an invaluable asset to have in performing complex cases. Traditional LM also allows more flexibility due to the fact that nothing is fixated or docked and different angles and views can be assessed easily since the scope (and various different degrees of scopes) can be placed through different ports. This flexibility exists with the latest version of the robot (da Vinci Surgical System Xi), but the majority of hospitals may not possess the latest model. Limited range of motion where the robotic arms can come in contact with each other is also high when maneuvering large pathology in a confined space such as the pelvis. However, one noticeable advantage that RALM will offer is limited fatigue for the surgeon, since the robot is strong and allows comfort and ergonomically correct posturing for the surgeon. The approach is ultimately a matter of personal choice, a choice that comes with its associated advantages and disadvantages. RALM was discussed in detail in Chap. 5.