Low Lying Obstacles: Approaches to Cervical Fibroid During Hysterectomy.

OBJECTIVE: To demonstrate techniques for safe dissection, optimizing visualization, and reducing blood loss when approaching cervical fibroids during hysterectomy. SETTING: Tertiary care academic medical center. PARTICIPANTS: Two patients with symptomatic uterine fibroids involving the cervix who underwent total laparoscopic hysterectomy. Case 1 is a 51 year old patient with a multifibroid uterus and a 5.6cm cervical fibroid filling the anterior lip of the cervix. Case 2 is a 44 year old with a 11.1cm posterior uterine body, lower uterine segment subserosal fibroid. (The patient(s) included in this video gave consent for publication of the video and posting of the video online including social media, journal website, scientific literature websites (such as PubMed, ScienceDirect, Scopus, etc.) and other applicable sites.) INTERVENTION: Total laparoscopic hysterectomy was safely completed in both cases. Techniques that are reviewed are identification of the ureter and ureterolysis if possible, use of the fibroid pseudocapsule to help mobilize the bladder, identification and isolation of uterine artery at its origin, use of vasopressin for improved hemostasis, single tooth tenaculum for fibroid manipulation, use of vaginal retractors to delineate the cervicovaginal junction, and use of the cervical fibroid for the colpotomy border. These techniques are discussed in the context of altered anatomy and increased surgical complexity posed by cervical fibroids, especially those distorting the lower uterine segment and vaginal cuff border. CONCLUSION: Cervical fibroids can significantly distort pelvic anatomy and increase surgical complexity during hysterectomy. A deliberate stepwise approach including early vascular control, ureter identification, strategic retraction, and thoughtful colpotomy planning, can reduce complications and optimize outcomes. This video provides a practical framework for approaching these challenging cases with safety and confidence.