Myomectomy — Steps by Approach

1. Abdominal (Open) Myomectomy

1. Incision — Low transverse (Pfannenstiel) or vertical midline laparotomy incision
2. Exposure — Retract bowel superiorly; identify and assess fibroid locations
3. Vasopressin injection — Dilute vasopressin injected into the myometrium overlying the fibroid to reduce bleeding
4. Uterine incision — A transverse or vertical incision is made over the fibroid through the serosa and myometrium
5. Enucleation — The fibroid is dissected bluntly and sharply from the pseudocapsule using traction-countertraction
6. Hemostasis — Bleeding vessels in the myometrial bed are cauterized or suture-ligated
7. Closure of the uterine defect — The myometrium is closed in multiple layers with delayed-absorbable sutures to eliminate dead space; the serosa is then closed
8. Morcellation (if needed) — Large fibroids may be cut into pieces (morcellated) for removal through the incision
9. Anti-adhesion measures — Oxidized regenerated cellulose or other adhesion barriers may be placed
10. Abdominal closure — Fascia, subcutaneous tissue, and skin are closed in layers

2. Laparoscopic Myomectomy

1. Port placement — Based on fibroid size/position; typically a periumbilical camera port + 2–3 accessory ports. For right-handed surgeons, two ports on the patient's right side (a 12-mm port medial to the iliac crest for suture access; a 5-mm lateral port near the umbilicus)
2. Survey — Laparoscopic inspection of the pelvis to identify all fibroids
3. Vasopressin injection — Injected via laparoscopic needle into the overlying myometrium
4. Uterine incision — Ultrasonic blade or monopolar electrosurgery used to make a transverse incision over the fibroid
5. Enucleation — Fibroid dissected out from the myometrium laparoscopically with traction using a tenaculum or corkscrew device
6. Closure of myometrial defect — Multiple layers of running laparoscopic suture (the most technically demanding step; robotic assistance may facilitate this)
7. Morcellation and extraction — Fibroid removed through ports using electromechanical or hand-held morcellator, or via a contained bag morcellation system; tissue sent to pathology
8. Peritoneal closure and desufflation

3. Vaginal Myomectomy

1. Lateral cervical sutures — Placed at 3 and 9 o'clock in the proximal cervix to occlude the lower uterine artery branches
2. Vasopressin injection — Into the stalk to reduce bleeding
3. Stalk ligation — One or two Endoloop sutures passed around the stalk and secured proximally
4. Transection — Stalk cut distal to the ligation (sharply or with electrosurgery)
5. Hemostasis — If bleeding persists after removal, hysteroscopic bipolar cautery or uterine packing with a Foley balloon is used

4. Hysteroscopic Myomectomy

1. Operative hysteroscope introduced with distension media
2. Small resecting loop (monopolar or bipolar) shaves the fibroid down to its base
3. Polyp forceps retrieves shaved tissue fragments from the cavity
4. Tissue sent to pathology

1. Hysteroscope with mechanical/electrosurgical morcellator introduced
2. Suction draws fibroid to the cutting end
3. Fibroid cut and removed in small segments via suction

• Isotonic fluids (normal saline, LR): deficit limit ≤ 2,500 mL
• Hypotonic fluids (mannitol, used with monopolar): stricter limits due to risk of hyponatremia
• Excess fluid absorption → fluid overload, pulmonary edema, electrolyte imbalance

Hysterectomy — Steps by Approach

Total Abdominal Hysterectomy (TAH)

Vaginal Hysterectomy (VH)

Laparoscopic / Robotic Hysterectomy

1. Port placement (periumbilical camera; accessory ports based on uterine size)
2. Uterine manipulator placed vaginally for traction
3. Round ligament sealed and divided (electrosurgical vessel sealing device)
4. Broad ligament windows developed
5. IP ligament or utero-ovarian vessels sealed and divided (based on oophorectomy decision)
6. Bladder dissected off lower segment
7. Uterine vessels sealed and divided at the isthmus
8. Cardinal and uterosacral ligaments divided
9. Circumferential colpotomy (using an illuminated vaginal manipulator/colpotomizer cup)
10. Specimen removed vaginally or via morcellation if too large
11. Vaginal cuff closed laparoscopically with running suture
12. Port site closure

Subtotal (Supracervical) Hysterectomy

• Uterine corpus amputated at the level of the internal os
• Cervical stump oversewn
• Cervix and upper vagina are not entered; vaginal cuff closure not required

Key Differences: Myomectomy vs. Hysterectomy