Design: Case series

Setting: Tertiary referral center

Patients or Participants: Two patients with extreme fibroid burden experiencing heavy bleeding and bulk symptoms desiring fertility sparing surgery.

Interventions: Hybrid myomectomy via laparoscopy and small laparotomy

Measurements and Main Results: The first case was a 34 yo G1P1001 with innumerable fibroids on magnetic resonance imaging (MRI) and uterus extending 2 fingerbreadths below the costal margin. She underwent a combined laparoscopic myomectomy with 12cm pfannenstiel laparotomy for removal of 43 total fibroids weighing 1050g. The second case was a 33 yo G0 with uterus measuring 26cm on preoperative MRI, extending 2-3 fingerbreadths below the costal margin. Four fibroids were removed in a similar fashion weighing 2108g. Perioperative management included depo lupron, intraoperative tranexamic acid, rectal misoprostol, dilute vasopressin, and consideration of uterine isthmus tourniquet and cell salvage. Laparoscopic entry was performed in the left upper quadrant, and when adequate room between the uterus and costal margin was present, 3 additional ports were placed. The 30 degree laparoscope was used to aid visualization. The most prominent and/or fundal fibroids were addressed via laparoscopic myomectomy, utilizing cranial traction, and moving the scope and active instrument to alternate ports to optimize visualization and operating angle. When the uterus was debulked, a small laparotomy is made, such as pfannenstiel incision, to exteriorize the uterus and complete the myomectomy - including suturing of incisions made laparoscopically as needed. To maximize fibroid removal, intraoperative ultrasound can be used to identify additional fibroids not visually or manually detected.

Conclusion: Hybrid laparoscopic myomectomy with small laparotomy can be utilized in cases of extreme fibroid burden as an alternative to large vertical midline incision. This approach may offer less invasive surgery while maximizing recovery, fibroid removal, and cosmesis.