Description

Uterine fibroids, or leiomyomas, are benign tumors that develop from the muscle tissue of the uterus. While many fibroids are asymptomatic, others can cause significant symptoms such as heavy menstrual bleeding, pelvic pain, pressure symptoms, or infertility. For women desiring uterine preservation, myomectomy—the surgical removal of fibroids—is often the treatment of choice. With the evolution of minimally invasive surgery, laparoscopic myomectomy has become the gold standard for selected patients. A refined technique within this approach involves specimen extraction via colpotomy, offering a safe, effective, and cosmetically favorable solution. What is Laparoscopic Myomectomy? Laparoscopic myomectomy involves removing uterine fibroids through small abdominal incisions using a laparoscope—a thin instrument with a camera. The benefits of this minimally invasive approach include: Reduced postoperative pain Minimal blood loss Shorter hospital stay Faster recovery time Improved cosmetic outcomes However, one technical challenge in laparoscopic myomectomy is the removal of large or multiple fibroids from the abdominal cavity. Traditionally, fibroids are removed using a morcellator. Due to concerns about the spread of undiagnosed uterine sarcoma, alternative specimen retrieval methods, such as colpotomy, have gained attention. What is Colpotomy? A colpotomy is a surgical incision made in the posterior vaginal fornix (the upper portion of the vagina) to access the peritoneal cavity. In laparoscopic procedures, colpotomy can be used as a natural orifice for specimen extraction, eliminating the need for enlarging abdominal incisions or using a power morcellator. Procedure Overview 1. Preoperative Assessment Patients are evaluated using imaging (ultrasound or MRI) to assess fibroid size, number, and location. Suitable candidates are those with benign fibroids and a desire for uterine preservation. 2. Laparoscopic Myomectomy The fibroid(s) are carefully dissected from the uterine wall using electrosurgical instruments. Hemostasis is achieved, and the uterine wall is sutured in layers to ensure integrity. 3. Specimen Containment The fibroid specimen is placed into a sterile endoscopic retrieval bag within the peritoneal cavity to avoid tissue spillage. 4. Colpotomy Creation A posterior colpotomy is created under laparoscopic guidance. The vaginal cuff is incised, and the bagged fibroid is gently extracted through the vaginal canal. 5. Closure The colpotomy incision is closed vaginally or laparoscopically. The abdomen is inspected for hemostasis, and the procedure is concluded. --- Advantages of Specimen Extraction via Colpotomy No need for morcellation, reducing the risk of spreading occult malignancy Preservation of abdominal wall integrity, with no additional incisions Reduced postoperative pain due to avoidance of enlarging abdominal ports Shorter operative time compared to time-consuming manual morcellation Better cosmetic outcomes as there are no visible incisions for specimen removal Limitations and Considerations While this technique offers numerous benefits, it may not be suitable for all patients. Limitations include: Size limitations: Very large fibroids may be difficult to extract via colpotomy without morcellation. Pelvic anatomy variations: In patients with a narrow vaginal canal or history of pelvic surgery, access may be restricted. Surgeon expertise: Requires familiarity with laparoscopic and vaginal surgical techniques. Conclusion Laparoscopic myomectomy with specimen extraction via colpotomy exemplifies the advancement of gynecologic minimally invasive surgery. It combines the benefits of laparoscopic precision with the natural orifice approach to enhance patient safety, reduce recovery time, and optimize surgical outcomes. For appropriately selected patients, this technique provides an excellent alternative to conventional morcellation, aligning with modern surgical principles of minimal access, maximum safety, and uterine preservation.