A subject of some discussion has been whether or not pretreatment with a GnRHa before laparoscopic myomectomy is beneficial. Some advocate the potential benefit of shrinkage in size of the fibroids with GnRHa pretreatment and on hemostasis [4], whereas others have been concerned with a blurring of the cleavage plane between the myoma and the myometrium [5]. A recent systematic review and meta-analysis [6] has clarified the issue that pretreatment with GnRHa does not increase the operative time associated with laparoscopic myomectomy, a finding consistent with the most recent similar Cochrane review [7] related to the topic. Operative time can be thought of as a surrogate for operative ease, which would incorporate several surgical factors including myoma size, hemostasis, and the cleavage plane between the myoma and the myometrium.

Systematic reviews [6, 7] of the three randomized trials on GnRHa pretreatment before laparoscopic myomectomy did demonstrate a statistically significant reduction in intraoperative blood loss (60 mL) and postoperative hemoglobin (1.15 g/dL). It is debatable whether these findings have clinical significance. It is also interesting to note that there is a discrepancy between the very minimal decrease in intraoperative blood loss and the decrease in postoperative hemoglobin. It is possible, too, that a potential benefit of pretreatment (for 3–6 months) with GnRHa of surgical bleeding is outweighed by the adverse effects of cost and the delay in receiving treatment. This discrepancy may be attributable to an inaccurate estimate of intraoperative blood loss but also may be because of continued postoperative bleeding or oozing. If the latter is true, pretreatment with GnRHa may have a benefit on reducing peritoneal inflammation and postoperative adhesion formation given less postoperative blood loss. Further multicenter and long-term trials are needed.

Consideration should be given to treating the most symptomatic fibroids first. In the patient with submucosal fibroids and heavy menstrual bleeding, a hysteroscopic resection should be performed first, followed by laparoscopic myomectomy. These procedures may be performed during the same operation.

Attempts should be made to remove all visible or palpable fibroids to prevent future growth and recurrence of symptoms.

Preoperative laboratory work should include a complete blood count, human chorionic gonadotropin type, and screening. For patients with significant anemia or large intramural fibroids, a type and cross of two units of blood should be available. For procedures for which significant blood loss is a risk, the patient may consider having autologous blood available, or the surgeon can arrange to have cell saver technology available.

Once pneumoperitoneum and port placement are obtained, the abdominopelvic cavity is explored. The uterus is carefully assessed and a comparison made with its appearance in preoperative imaging. The relationship of the myomas to the fallopian tubes and ovaries is assessed. In uteri with multiple fibroids, the most symptomatic myoma may be targeted first. There may be cases where the uterus must be debulked by removing smaller, less symptomatic fibroids to achieve better access to the primary fibroid. Generally, removing fundal fibroids first will afford greater access to lower uterine segment fibroids.

Formulating a plan for hemostasis is critical. Typically, bleeding from the myometrium adjacent to the myoma is anticipated until the entire defect is closed. The bleeding may be slow but constant. The nature of this slow, steady bleeding may be deceiving. Communication with the anesthesiologist is important to keep an accurate count of blood loss. A dilute vasopressin solution (20 U/100 mL normal saline) can help limit blood loss [9]. The site of injection depends on the type of myoma. For example, a pedunculated myoma should be injected at the myometrial base of the stalk of the myoma. An intramural fibroid can be injected through the uterine serosa, ideally in the plane just inside of the pseudocapsule, creating a “wheel” effect. This technique is more effective than deep myoma injection. With large intramural myomas, the deeper adjacent myometrium toward the base may be injected as it is exposed if excessive bleeding is encountered. Spot cautery with bipolar energy can be helpful for distinct vessels but its use is limited with bleeding from the raw surface of the myometrium. Excessive use of thermal energy for hemostasis is discouraged because this may increase destruction of healthy myometrial tissue and impair uterine healing and functionality [9].

For patients with extremely large intramural myomas (>10 cm) that would require multilayer closure, additional steps may be considered for preventing excessive blood loss. Some authors describe selective use of a laparoscopically placed tourniquet to compress the uterine arteries at the level of the cervix [10, 12]. This technique involves threading a red rubber catheter through bilateral windows created in the broad ligament encircling the cervix. The ends of the red rubber catheter are brought through the lateral trocar skin incisions on contralateral sides, outside of the trocar, and secured with Kelly clamps where they exit the port sites [10].

For women who have completed childbearing, permanent uterine artery occlusion, using clips, suture, or complete transection can be performed. Preliminary studies suggest that this technique can decrease intraoperative blood loss and may also help prevent fibroid recurrence [12].