Feasibility of Laparoscopic Removal of the Largest Documented Uterine Fibroid Without Morcellation

Abstract

Background and Clinical Significance: Uterine fibroids affect up to 25% of women of reproductive age and can lead to significant symptoms or impact fertility, often requiring surgical management. While hysteroscopic myomectomy is suitable for intracavitary fibroids, intramural and subserosal fibroids typically necessitate open or minimally invasive surgery (MIS). Laparoscopic approaches offer notable advantages, including reduced postoperative pain and faster recovery. However, MIS is frequently avoided in cases of very large fibroids due to technical difficulty and concerns about safe tissue extraction. Power morcellation, previously used for specimen removal, has fallen out of favor due to the risk of disseminating occult malignancies, especially in women over 35. Therefore, establishing the feasibility of MIS without morcellation in such cases is essential. Case Presentation: A woman of reproductive age presented with a symptomatic uterine fibroid measuring approximately 4 kg (1500 cm³). Laparoscopic myomectomy was performed using a modified trocar entry technique and contained tissue fragmentation, avoiding morcellation. The operation was completed successfully without complications. Postoperative recovery was uneventful, and the patient was discharged on postoperative day two. Histopathological examination confirmed a benign leiomyoma. Conclusions: This case highlights the feasibility of laparoscopic removal of an exceptionally large uterine fibroid without morcellation. Through careful patient selection, strategic trocar placement, and controlled tissue fragmentation, MIS can be safely performed in select high-volume cases. These findings support reconsidering the size limitations of laparoscopic myomectomy when conducted by experienced surgeons using appropriate techniques.

Keywords: DTE; LUQ; direct trocar entry; fibroid; fragmentation; laparoscopy; large fibroids; left upper quadrant entry; morcellation; myomectomy; subserosal fibroid; trocar placement; uterine preservation.

Figure 1

Trocar placement demonstrates alignment with the principle of a 60-degree angle between instruments.

Figure 2

Ex vivo reconstruction of the fibroid: All removed fragments were reassembled to approximate the original dimensions (18 cm × 14 cm × 12 cm; 1583 cm³) and total weight of 3980 g.