Laparoscopic Myomectomy: Removing Fibroids, Preserving the Uterus

Laparoscopic myomectomy removes uterine fibroids through small cuts in the abdomen and leaves the uterus in place. It suits women who want to keep their uterus, whether for fertility or by choice, and whose fibroids are of a size, number and position that keyhole surgery can manage. This article explains who it is for, how it compares with other treatments, what the operation involves, and the main risks, including the question of morcellation.

What laparoscopic myomectomy is

Fibroids (leiomyomas) are non-cancerous growths in the muscle wall of the uterus. In a myomectomy the surgeon cuts into the uterine wall, shells out each fibroid and repairs the defect with stitches. In the laparoscopic approach this is done under general anaesthesia through a camera port at the navel and two or three further cuts of under 1 cm for instruments. A hospital information leaflet from St George's Hospital puts the average operating time at about 90 minutes.

The fibroids then have to leave the abdomen. They are usually cut into pieces and removed with a morcellator, or taken out through a slightly larger incision. This step carries its own risks and is covered below.

Where the fibroid sits matters

Fibroids are classified by the FIGO system according to how far they bulge into the uterine cavity or out of the uterus. The key distinction is whether a fibroid distorts the cavity: Type 0 is completely within the cavity, Types I and II are submucosal with more or less than half inside the cavity, and deeper intramural and subserosal fibroids lie further out. This position decides the route of surgery.

• Submucosal fibroids are usually considered for removal through the cervix with a hysteroscope. NICE advises that hysteroscopic removal be considered for women with submucosal fibroids.
• Intramural and subserosal fibroids are the usual targets for laparoscopic or open myomectomy.

The sources reviewed for this article give no firm size or number limits for laparoscopy, and surgeons set their own limits by experience. Ask your surgeon how many fibroids and what sizes they consider suitable for the keyhole route.

What the guidelines say

Source	Document	Relevant position
NICE	Heavy menstrual bleeding, NG88 (as summarised by Evidence-Based Interventions)	Fibroids of 3 cm or more: refer to specialist care and offer tranexamic acid and/or NSAIDs in the meantime. Options include medicines, myomectomy, uterine artery embolisation, hysterectomy and, where criteria are met, endometrial ablation. Treatment choice weighs size, location and number of fibroids and symptom severity. Assess with ultrasound before surgery, with MRI if more detail is needed. Consider a GnRH analogue before myomectomy or hysterectomy if fibroids are enlarging or distorting the uterus.
Cochrane	Minimally invasive versus open myomectomy	Nine trials with 808 premenopausal women. Laparoscopic myomectomy is associated with less postoperative pain, less postoperative fever and shorter hospital stay than open myomectomy, with no evidence of a difference in recurrence. Evidence certainty ranged from very low to moderate, and the review is current to July 2014.
RCOG	Consent Advice 13: Morcellation for myomectomy or hysterectomy (2019)	Sets out the benefits and risks of morcellation, what women must be told, alternatives, and the pre-operative checks for sarcoma.
BSGE	Statement on power morcellation (2014)	Power morcellation has a place in managing fibroids. Laparoscopic myomectomy is best supported by evidence, but the approach should be individualised. Morcellation of any type should not be performed if uterine malignancy is suspected or diagnosed. Surgeons should have formal training.

I did not find an RCOG or NICE document dedicated to laparoscopic myomectomy itself, so the table covers the guidance that applies to it. The Cochrane review is more than ten years old, and newer trials may exist.

Laparoscopic or open myomectomy?

In the Cochrane review, laparoscopic surgery had these differences from open myomectomy.

• Less pain: pain scores on a 0 to 10 scale were lower at 6 hours (mean difference −2.4) and at 48 hours (−1.9), with moderate certainty.
• Less fever: postoperative fever was about half as likely (odds ratio 0.44; 6 trials, 635 women).
• Shorter hospital stay, as concluded by the authors.
• No clear difference in conversion to open surgery (odds ratio 1.11), return to theatre or recurrence (odds ratio 1.12).
• Blood loss could not be combined across studies because the results varied too widely.

The review did not report on uterine rupture in later pregnancy, blood clots or later hysterectomy, and the authors called for more research on them. Open myomectomy may still be chosen when the surgeon judges keyhole surgery unsuitable for the fibroids in question.

Morcellation: what you should know

Breaking a fibroid into pieces inside the abdomen brings a small but serious risk. A rare cancer of the uterine muscle, leiomyosarcoma, can look like a fibroid, and morcellating it may spread it. RCOG Consent Advice 13 quotes estimates of about 1 in 1,250 to 1 in 769 for women under 50 and higher figures at older ages, and notes that morcellation can worsen the outlook of an unrecognised sarcoma. It also quotes a chance of benign fibroid fragments seeding in the abdomen of between 1 in 120 and 1 in 1,200. The older BSGE statement estimated the sarcoma risk as under 1 in 500, and under 1 in 1,000 under age 40. Estimates differ between studies.

The RCOG consent advice recommends:

• a review of red flags before surgery, such as abnormal bleeding, suspicious imaging, a fibroid that grows rapidly after the menopause or does not shrink on GnRH treatment, a family history of certain cancers, tamoxifen use or earlier pelvic radiotherapy;
• an up-to-date cervical smear, with an endometrial biopsy if indicated, and MRI or ultrasound before morcellation. Neither scan can definitely exclude sarcoma;
• team discussion if sarcoma is suspected. In that case, morcellation should not be done and removal of the whole uterus in one piece is advised;
• explaining the alternatives, including open surgery and contained retrieval in a bag. The advice notes that no current evidence shows bags reduce spread, and that open surgery has its own risks of clots, wound infection, transfusion and hernia.

What to expect

1. Before. You have scans to map the fibroids and may be offered a GnRH analogue first if the fibroids are enlarging or distorting the uterus. You discuss morcellation and the chance of conversion to open surgery.
2. The operation. Under general anaesthesia, the surgeon opens the uterine wall over each fibroid, removes it and closes the wall in layers. The fibroids are then removed from the abdomen.
3. After. Discharge is usually the same or the next day. Expect cramping, shoulder-tip pain, bruising around the cuts and mild vaginal bleeding. Stitches are dissolvable.
4. Recovery. The St George's leaflet advises light activities within two weeks and work within four to six weeks, and avoiding vigorous sport, sex and heavy lifting for six weeks. Follow your own team's advice, which may differ.

Risks

The St George's leaflet lists the following.

• Infection, in the wound or inside the abdomen.
• Bleeding, which can need a blood transfusion.
• Injury to the bowel, bladder, ureters or large blood vessels, which may need repair and, rarely, a stoma.
• Failure to complete the operation by keyhole, so that it is converted to open surgery.
• Hernia at a port site (under 1 in 100) and, very rarely, blood clots.
• Risks of morcellation as above.

Fibroids can also come back or new ones can grow, and the Cochrane review found no evidence that keyhole surgery changes that risk compared with open surgery. Seek urgent care for severe abdominal pain, fever or heavy bleeding after discharge. This is general advice.

Fertility and future pregnancy

Myomectomy is chosen when the uterus is to be kept, but the surgery leaves a scar in the uterine wall. The effect on pregnancy depends on the size, number and depth of the fibroids removed. Tell your obstetric team that you have had a myomectomy as soon as you are pregnant, so a plan for the birth can be made. I did not find a guideline source to quote on the interval before trying to conceive or the mode of delivery, so ask your surgeon for advice that suits your operation.

Frequently asked questions

Does everyone with fibroids need surgery?

No. Fibroids that cause no symptoms need no treatment. NICE advises looking at medicines first for heavy bleeding, and weighs fibroid size, position and number and symptom severity when choosing between treatments.

Can fibroids grow back after myomectomy?

Yes, new fibroids can form. The Cochrane review found no clear difference in recurrence between laparoscopic and open myomectomy.

Is hysterectomy an alternative?

For women who have finished having children or do not want to keep the uterus, hysterectomy removes the fibroids for good along with the uterus. Myomectomy is for women who want to keep it.

Will I have to be morcellated?

Not necessarily. Alternatives include a slightly larger incision. Discuss this and your pre-operative checks with your surgeon before agreeing to surgery.

Sources

This article is educational and does not replace individual medical advice. Details were taken from the pages below; some points rely on summaries, so confirm exact recommendations against the originals before clinical use.

• Cochrane: Minimally invasive surgical techniques versus open myomectomy for uterine fibroids (CD004638)
• RCOG Consent Advice No. 13: Morcellation for myomectomy or hysterectomy
• BSGE statement on power morcellation
• NICE NG88: Heavy menstrual bleeding
• Evidence-Based Interventions: Hysterectomy for heavy menstrual bleeding
• St George's Hospital: Laparoscopic myomectomy patient leaflet
• Contemporary OB/GYN: Optimal approaches to fibroid management (FIGO classification)