Laparoscopic Myomectomy INTRODUCTION Fibroids or leiomyomas are a very commonly occurring uterine tumor affecting up to 20–25% of women. Fibroid develops from benign transformation of a single smooth muscle cell. The growth of myoma is dependent on many factors. Increased estrogen stimulation alone or together with growth hormone or human placental lactogen appears to be the major growth regulator of fibroid. The severities of symptoms depend on the number of tumors, size, and location. Many a time, they can cause abdominal pressure leading to urinary frequency, abdominal pain, or constipation. One of the common occurrences is dysfunctional uterine bleeding (DUB) due to altered blood flow through the uterus. The fibroids many a time do not affect pregnancy. Fibroids are clinically diagnosed in 25% of women, although their actual incidence is probably much higher since they are frequently found on routine ultrasound. In women with menorrhagia, the hematocrit is used to assess the degree of anemia. Patients with large broad ligament fibroid may require an intravenous pyelogram to rule out any ureteral obstruction. For anemic patients, preoperative treatment with gonadotropin-releasing hormone (GnRH) may enable restoration of a normal hematocrit and decrease the size of myoma and, thus, reduce the risk of transfusion. Fibroid types are defined by where they grow in relation to the uterine wall (Fig. 1) . There are four types of uterine fibroids: 1. Submucosal fibroids: Grow in the submucosa, which means just below the thin layer of tissue found in the uterus. These fibroids can protrude into the uterine cavity. These are the rarest type of fibroid. 2. Intramural fibroids: Grown in and are contained within the uterine wall. These are the most common type of fibroid. 3. Subserosal fibroids: Grown on the outside of the uterine wall. 4. Pedunculated fibroids: Types of fibroids that grow on stalks or stems. These stems are attached to the uterine wall and can grow either outside the uterus or inside the uterine cavity. Fig. 1: Different types of fibroid uterus. Uterine leiomyomas are the most frequent indication for hysterectomy all over the world. Many patients with symptomatic leiomyomas desire to retain the option of future childbearing or simply want to preserve their uterus. For these women, myomectomy, the removal of the myomas with reconstruction and preservation of the uterus, is an important option. Over the past 10 years, several studies have demonstrated that laparoscopic myomectomy has several advantages over laparotomic and minilaparotomic approaches, including lower operative hemoglobin drop, shorter hospital stays, less postoperative pain, and faster recovery times. On the other hand, laparoscopy itself is a surgical technique that may present significant challenge to the surgeons. The suture of the uterine wall defect is probably the most difficult and time-consuming task for surgeons performing laparoscopic myomectomy. INDICATIONS The decision to perform surgery for uterine leiomyoma is complex and varies from patient to patient based on their medical conditions, surgical history, clinical picture, and patient preference. In general, consideration for a hysterectomy is given in patient with: ■ Excessive uterine bleeding: z Profuse bleeding causing lifestyle derangements that is refractory to medical management z Uterine bleeding that results in anemia Prof. Dr. R. K. Mishra