Feasibility and Outcomes of Laparoscopic Surgery in Complex Benign Gynecologic Conditions: A Retrospective Case Series

Minimally invasive surgery has fundamentally transformed the field of gynecology over the past three decades [1]. Since the first laparoscopic hysterectomy was reported by Reich et al., laparo- scopic techniques have increasingly replaced conventional open procedures for the management of benign gynecological diseases due to their well-documented advantages, including reduced in- traoperative blood loss, shorter hospital stay, faster recovery, decreased postoperative pain, and improved cosmetic outcomes [2]. Despite these advantages, the adoption of laparoscopic surgery for complex gynecological conditions—such as large uterine fibroids, severe endometriosis with dense adhesions, previous multiple abdominal surgeries, and adnexal masses—remains challenging [3]. Technical difficulty, distorted anatomy, limited access to advanced energy devices, and concerns regarding specimen 1*. Corresponding author: Department of Obstetrics and Gynaecology, MGM Medical College, Jamshedpur, Jharkhand, India; Kolhan University; Email: [email protected] 2. Department of Obstetrics and Gynaecology, SBMCH, Hazaribag, Jharkhand, India; Vinoba Bhave University; 3. Department of Obstetrics and Gynaecology, Sadar Hospital, Ranchi, Jharkhand, India. / Open Access. © 2026 the author(s), published by InfoPub. This work is licensed under the Creative Commons Attribution 4.0 International License. (Journal homepage: https://www.simmr.info) https://doi.org/10.66224/smmr.202602.11.01

Minimally invasive surgery has become the preferred approach for benign gynecological conditions due to its well -established benefits over open surgery. However, its application in complex cases such as large uteri, dense adhesions, and advanced adnexal pa thology remains challenging, particularly in re- source-limited settings. We present a retrospective case series of nine patients undergoing laparoscopic management for various complex benign gynecological conditions in a single surgical center. Cases in- cluded large fibroid uterus, adenomyosis, endometriosis with dense adhesions, dermoid and ovarian cysts, post-hysterectomy adnexal mass, umbilical port hernia, and ruptured ectopic pregnancy. Surgical outcomes including operative time, blood loss, hemoglobin c hange, hospital stay, and complications were analyzed descriptively. All procedures were successfully completed laparoscopically without con- version to open surgery. Operative time ranged from 35 to 90 minutes. Estimated blood loss was mini- mal with no major intraoperative complications such as bowel, bladder, or vascular injury. Postopera- tive recovery was uneventful in most cases, with hospital stay ranging from 1 to 3 days. One case of port- site infection and delayed wound healing was noted in a dermoid cys t case. Laparoscopic surgery is feasible and safe even in complex benign gynecological conditions when performed by experienced sur- geons. With appropriate technical modifications, minimally invasive approaches can be extended to cases traditionally managed by laparotomy, even in resource-limited settings.

Gynecologic Laparoscopy; Uterine Fibroid; Endometriosis; Ovarian Cyst; Ectopic Pregnancy. Studies in Multidisciplinary Medical Research Published By InfoPub SMMR Journal ǁ (2026) NO 11; VOL 02: 01-10 ǁ ǁ https://doi.org/10.66224/smmr.202602.11.01 ǁ InfoPub https://doi.org/10.32592/smmr.202501.02.02 www.simmr.info retrieval in the absence of morcellation continue to restrict its widespread application, particu- larly in resource-constrained healthcare settings [4]. In high-resource environments, advanced laparoscopic techniques and energy devices have enabled surgeons to extend minimally invasive approaches even to large uteri and advanced pel- vic pathology [5]. However, in many developing and semi-urban settings, cost constraints, limited availability of morcellators, and lack of extensive preoperative imaging or oncologic workup ne- cessitate alternative surgical strategies while maintaining safety and outcomes [5, 6]. Specimen retrieval remains one of the most critical challenges in laparoscopic hysterectomy for large uteri. Various techniques such as vaginal morcellation, intracorporeal bisection, and piecemeal extraction have been described as safe alternatives when p ower morcellation is not available or not preferred due to concerns regarding occult malignancy dissemination [7, 8]. In this context, we present a retrospective case series of nine patients with complex benign gynecological conditions managed laparoscopically in a resource -limited setting. The aim of this study is to evaluate the feasibility, safety, and practical adaptability of minimally invasive surgical techniques in challenging cases that would traditionally require open laparotomy. Literature review Over the last two decades, the literature has progressively reframed laparoscopic surgery —par- ticularly total laparoscopic hysterectomy (TLH)—as a viable approach for benign gynecologic dis- ease even when operative complexity is increased by uterine enlargement, fibroid burden, adhe- sions, or challenging anatomy. Early landmark series established proof -of-feasibility for TLH in “very enlarged” uteri and helped shift the field away from uterine size as an absolute contraindi- cation to minimally invasive surgery [9, 10]. As experience increased, subsequent work broad- ened the size thresholds examined (for example, uteri exceeding 500 g and later those exceeding 1 kg), while refining the operative strategies used to maintain safety and efficiency in these diffi- cult cases [11, 12]. High-volume, technique-forward studies have been influential in describing how surgeons overcome the constraints imposed by large fibroid uteri. Sinha and colleagues reported a large retrospective experience of TLH for uteri weighing more than 500 g, emphasizing structured tech- nical modifications—such as early uterine artery control, selective intraoperative debulking (my- omectomy), and planned specimen morcellation—to preserve visualization and reduce bleeding risk across a wide range of uterine sizes [11]. In a later series focused on uteri larger than 16 weeks, the same group further characterized perioperative outcomes and highlighted that exten- sive adhesiolysis and debulking are frequently required in large -uterus laparoscopy, underscor- ing that “size” often represents a proxy for distorted anatomy rather than a stand-alone determi- nant of difficulty [7]. Complementing these experiences, Roman et al. described TLH for enlarged benign uteri using primary uterine artery coagulation at its origin, reinforcing the concept that early devascularization can facilitate safer dissection in enlarged uteri and may m itigate the ex- pected relationship between uterine size and operative difficulty in selected settings [13]. Several comparative and risk -focused studies have attempted to quantify how uterine en- largement affects conversion, operative time, and perioperative morbidity. Takamatsu et al. strat- ified TLH outcomes by uterine weight and found that cases exceeding 500 g were associated with longer operative times and increased blood loss relative to smaller uteri, alongside a higher rate of conversion to laparotomy in the larger group —illustrating that feasibility is maintained but with measurable increases in technical burden [11]. In contrast, Yakıştıran et al. compared TLH for clinically large fibroid uteri (>14 weeks) with TLH for smaller benign uteri and reported SMMR Journal ǁ (2026) NO 11; VOL 02: 01-10 ǁ ǁ https://doi.org/10.66224/smmr.202602.11.01 ǁ InfoPub https://doi.org/10.32592/smmr.202501.02.02 www.simmr.info broadly similar perioperative outcomes between groups, while still documenting that conver- sions occurred and were typically driven by bleeding, impaired uterine mobilization, or bowel injury—mechanisms that resonate with the practical challenges of large fibroid surgery [14]. Im- portantly, Cianci et al. examined conversion risk in an enlarged -fibroid cohort and reported that conversion was more strongly associated with the diameter of the largest fibroid and the sur- geon’s experience than with uterine weight alone, supporting the contemporary view that uterine configuration and operator factors may outperform weight-based thresholds as predictors of dif- ficulty [15]. A parallel body of evidence has focused specifically on very large (“giant”) uteri, commonly defined as ≥1 kg or even ≥1.5 kg, and has expanded feasibility claims into more extreme size ranges while introducing more robust comparisons with open hysterectom y. Kondo and col- leagues directly addressed whether laparoscopic hysterectomy is feasible for uteri larger than 1,000 g, helping anchor the “giant uterus” category in the minimally invasive literature [12]. Uc- cella and collaborators subsequently reported dedicated experience with laparoscopic hysterec- tomy for uteri ≥1 kg and later extended this work to comparative analyses in uteri >1 kg, position- ing laparoscopy as a reasonable alternative to laparotomy in appropriately selected benign dis- ease even at very high uterine weights [16, 17]. Ito et al. similarly evaluated minimally invasive hysterectomy in uteri >1 kg and documented that conversions still occur in a minority of cases, commonly due to hemorrhage or adhesions, thereby reinforcing that technical feasibility at ex- treme size remains contingent on intraoperative conditions rather than size alone [18]. More re- cently, Fitzgerald et al. compared laparoscopic versus open hysterectomy for benign indications in a large cohort of patients with uteri >1 kg and reported broadly comparable adjusted composite perioperative outcomes between routes, contributing contemporary support that laparoscopy is not necessarily associated with higher overall perioperative risk even in very large uteri when performed in experienced systems [19]. Collectively, these studies indicate that while uterine en- largement increases operative complexity and may lengthen operating time, minimally invasive approaches can maintain acceptable safety profiles in expert hands, with conversion risk shaped by hemorrhage, adhesions, and anatomic distortion as much as by uterine weight [14, 15, 18]. Beyond hysterectomy itself, the literature also emphasizes that operative success in complex benign gynecology depends on technical adaptations for specimen handling and extraction, par- ticularly when tissue bulk or cyst content spillage introduces contamination risk. Wang et al. com- pared different approaches to removing large uteri in TLH (transvaginal extraction versus mor- cellation-based strategies), illustrating that extraction strategy can influence operative efficiency and intraoperative event profiles even when global outcomes such as blood loss and hospital stay remain similar [20]. Similarly, Oh et al. evaluated transumbilical versus transvaginal morcellation in single-port TLH for uteri ≥500 g, highlighting that multiple extraction routes may be feasible when matched to anatomy and surgeon preference [21]. In anatomically demanding subgroups, Taniguchi et al. focused on large cervical fibroids (≥10 cm) and demonstrated completion of TLH using planned debulking strategies when standard progression was limited, reflecting a broader theme across the literature: complexity is frequently overcome by stepwise modifications rather than by abandoning laparoscopy [22]. Study Design and Methodology This study is a retrospective case series evaluating the feasibility, technical challenges, and peri- operative outcomes of laparoscopic management in complex benign gynecological conditions. SMMR Journal ǁ (2026) NO 11; VOL 02: 01-10 ǁ ǁ https://doi.org/10.66224/smmr.202602.11.01 ǁ InfoPub https://doi.org/10.32592/smmr.202501.02.02 www.simmr.info Setting and Surgeon All procedures were performed by a single experienced laparoscopic gynecologist in a re- source-limited surgical setting. Patient Selection Nine consecutive patients with various benign gynecological pathologies requiring surgical intervention were included. Indications included large uterine fibroids, adenomyosis, endometri- osis with dense adhesions, adnexal masses, post-hysterectomy ovarian cyst, umbilical port hernia, and ruptured ectopic pregnancy. Surgical Technique All surgeries were performed under general anesthesia with endotracheal intubation. Pneu- moperitoneum was established using a Veress needle. A standard three - or four-port technique was used. A 10 mm umbilical primary port was inserted at or above the umbilical level depending on uterine size. Two 5 mm accessory ports were placed in the right and left iliac fossae for opera- tive instruments including harmonic scalpel, graspers, and suction devic es. A suprapubic 5 mm port was used for uterine manipulation when required. A systematic abdominal survey was performed prior to procedure -specific intervention. Pa- tients were placed in Trendelenburg position to facilitate bowel displacement and pelvic expo- sure. Adhesiolysis, cystectomy, salpingo-oophorectomy, hysterectomy, or ectopic pregnancy man- agement was performed depending on pathology. Specimen retrieval was performed via the vag- inal route or through enlarged port sites. Morcellation devices were not used in any case. Alterna- tive techniques such as vaginal myomectomy, uterine bisection, or piecemeal extraction were adopted when required. Hemostasis was ensured at the end of each procedure. A drain was placed through a 5 mm port in selected cases. Postoperative management included early ambulation, oral intake after bowel activity, and prophylactic antibiotics for three days in selected patients.

Overall Outcomes All nine procedures were completed laparoscopically without conversion to open surgery. No major intraoperative complications such as bowel, bladder, or vascular injury were observed. Op- erative outcomes are summarized in Table 1 and Table 2. Table 1. Patient age, symptoms, past surgical history, duration of hospitalization and postoperative analysis Cases Age Symptoms Past Surgical History Days of hospitalization Use of post- operative analgesia 1 48 Metrorrhagia Previous 2 LSCS 3 2 days, NSAIDS 2 38 Severe dysmenorrhoea - 3 2 days, NSAIDS 3 42 Chronic pelvic pain & severe dysmenorrhoea - 3 2 days, NSAIDS 4 48 Menorrhagia - 3 2 days, NSAIDS 5 48 Right sided lower abdominal pain Total abdominal hysterectomy 2 1 day, NSAIDS 6 52 left sided iliolumbar mass(para umbilical) LAVH 3 2 days, NSAIDS 7 28 Right sided pain abdomen - 1 1 day, NSAIDS 8 24 Right sided pain abdomen Previous 1 LSCS 1 1 day, NSAIDS 9 26 Dizziness,acute pain abdomen Previous appendicectomy 2 2 days, NSAIDS SMMR Journal ǁ (2026) NO 11; VOL 02: 01-10 ǁ ǁ https://doi.org/10.66224/smmr.202602.11.01 ǁ InfoPub https://doi.org/10.32592/smmr.202501.02.02 www.simmr.info Table 2. Description of pathology, method of retrieval of specimen, duration of Surgery, Blood Loss, Histopathological Diagnosis Cases Pathology

of retrieval of specimen Duration of surgery Blood loss Histopathological diagnosis Preop Hb(gm) Postop Hb(gm) 1 14 weeks size uterus multiple fibroids– largest 5x6cm Vaginally after vaginal myomectomy 1hr 30 mts 9 8.2 Fibroid 2 20 weeks size adenomyotic uterus Vaginally 1 hr 45 mts 10 9.2 Adenomyosis 3 Chronic PID + chocolate cyst Vaginally 1 hr 38 mts 10.2 9.2 Endometriosis 4 20 weeks uterus + adnexal lump Vaginally after ovarian cyst suctioning 1 hr 34 mts 9.8 9.0 Cystadenoma 5 Post hysterectomy ovarian cyst Through right sided port incision 45 mts 10.4 10.0 Simple ovarian cyst 6 Umbilical port hernia - 1 hr 30 mts 10.8 10.0 7 Dermoid cyst 6.8 x6cm Through right sided port 35 mts 11.2 10.4 Mature cystic teratoma 8 Dermoid cyst 6 x7cm Through right sided port 45 mts 12 11.2 Mature cystic teratoma 9 Ruptured left sided tubal ectopic with gross haemoperitoneum Through left sided port 56 mts 8 11(after 2 packed cell transfusion Tubal ectopic Case Series Description Uterine Pathology Cases The first group included patients undergoing laparoscopic hysterectomy for large fibroid uterus and adenomyosis. In a 48 -year-old multiparous woman with a 14 -week-sized fibroid uterus and previous two cesarean sections, dense bladder adhesions were encountered intraoper- atively. Adhesiolysis was performed using harmonic scalpel. Due to the absence of morcellation, uterine volume reduction was achieved via vaginal myomectomy prior to extraction (Table 2, Case 1). A second case involved a 38 -year-old nulliparous woman with a 20 -week-sized adenomyotic uterus. Vaginal extraction was not feasible due to narrow introitus; therefore, uterine bisection and piecemeal retrieval were performed (Table 2, Case 2, Figure 1). Figure 1. Large adenomyotic uterus (20-week size) before piecemeal extraction. SMMR Journal ǁ (2026) NO 11; VOL 02: 01-10 ǁ ǁ https://doi.org/10.66224/smmr.202602.11.01 ǁ InfoPub https://doi.org/10.32592/smmr.202501.02.02 www.simmr.info A third case demonstrated severe endometriosis with bilateral ovarian endometriomas and dense pelvic adhesions. Intraoperative rupture of endometriotic cyst occurred during adhesioly- sis, releasing thick chocolate fluid. Extensive adhesiolysis was required before completion of hys- terectomy (Figure 2 A&B). Figure 2. A with dense omental and gut adhesions. B. with adenomyosis and endometriotic tissue. Adnexal and Ovarian Pathology A 48-year-old patient with a large uterine enlargement and right adnexal cyst underwent lap- aroscopic hysterectomy with ovarian cyst aspiration prior to specimen retrieval (Table 2, Case 4, Figure 3). Figure 3. 20 weeks size uterus. A post-hysterectomy ovarian cyst case was managed laparoscopically with adhesiolysis and adnexal excision through a port site (Table 2, Case 5, Figure 4). Figure 4. Ovarian cyst. SMMR Journal ǁ (2026) NO 11; VOL 02: 01-10 ǁ ǁ https://doi.org/10.66224/smmr.202602.11.01 ǁ InfoPub https://doi.org/10.32592/smmr.202501.02.02 www.simmr.info Dermoid cyst cases (Cases 7 and 8) were managed laparoscopically. In one case, spillage of sebaceous material occurred leading to delayed port -site wound healing (Figure 5). In a subse- quent similar case, use of an endobag prevented contamination and no pos toperative infection occurred. Figure 5. Depicting right sided dermoid in patient. Emergency and Special Cases A ruptured tubal ectopic pregnancy with hemoperitoneum was successfully managed via lap- aroscopic salpingectomy. Blood was evacuated and patient stabilized postoperatively (Table 2, Case 9, Figure 6). Umbilical port hernia repair was also performed laparoscopically (Case 6). Figure 6. Rupture ectopic.

In this case series of nine complex benign gynecologic conditions, laparoscopic management was feasible across a heterogeneous spectrum including large fibroid and adenomyotic uteri, severe endometriosis with dense adhesions, adnexal pathology (including d ermoid cyst), port-site her- nia, and ruptured ectopic pregnancy. All procedures were completed laparoscopically without conversion to laparotomy, operative time ranged from approximately 35 to 105 minutes, and no major intraoperative complications such as bowel, bladder, or major vascular injury were encoun- tered. Postoperative outcomes were generally favorable with short hospitalization (1–3 days) and uncomplicated recovery in most patients. SMMR Journal ǁ (2026) NO 11; VOL 02: 01-10 ǁ ǁ https://doi.org/10.66224/smmr.202602.11.01 ǁ InfoPub https://doi.org/10.32592/smmr.202501.02.02 www.simmr.info Our findings are consistent with the broader minimally invasive gynecology literature demon- strating that procedural difficulty is influenced not only by uterine size but also by case configu- ration, adhesions, and surgeon experience. Large-uterus hysterectomy series have shown that to- tal laparoscopic hysterectomy can be performed even at high uterine weights when enabling strategies such as early devascularization, debulking, and tailored specimen extraction are used [7, 11]. However, conversion to open surgery is not uniformly eliminated in larger cohorts, with conversions commonly attributed to hemorrhage, extensive adhesions, or inability to progress [14, 18]. Predictive analyses further emphasize that the diameter and location of dominant fi- broids and surgeon experience may be more informative than uterine weight alone for anticipat- ing conversion risk [15]. In this context, our zero-conversion rate likely reflects careful intraoper- ative strategy and operator proficiency, while the small sample size limits inference about ex- pected conversion rates in broader practice. A notable event in our series was postoperative port -site infection following dermoid cyst spillage. In a subsequent case, the use of an endobag prevented contamination and was associated with uneventful recovery. Although most comparative studies focus on large uterus extraction techniques rather than dermoid cysts specifically, multiple reports underscore the importance of specimen extraction strategy as a modifiable technical element in complex laparoscopy [20, 21]. Our experience supports routine consideration of containment techniques when managing cystic lesions at risk for intraperitoneal spillage. This study has limitations typical of small case series, including limited power to estimate complication rates, heterogeneity in diagnoses and procedures, and lack of a comparator group. Future work would benefit from standardized reporting of complexity drivers (e.g., adhesions, dominant lesion size, prior surgery), intraoperative blood loss, and longer follow -up, ideally through prospective registries. Nonetheless, our results add pragmatic evidence that complex be- nign gynecologic conditions can be managed laparoscopically with acceptable perioperative out- comes when performed by experienced surgeons using appropriate technical modifications, in- cluding specimen containment strategies.

This retrospective case series demonstrates that laparoscopic management of complex benign gy- necological conditions is feasible and can be performed with favorable perioperative outcomes in appropriately selected patients. All nine procedures were successfully completed laparoscopically without conversion to laparotomy, with no major intraoperative complications and a short post- operative hospital stay of 1 –3 days. The study highlights the importance of surgeon experience, careful patient selection, individualized surgical planning, appropriate adhesiolysis and debulking techniques, and safe specimen retrieval strategies. However, given the small sample size, hetero- geneous pathology, retrospective design, and absence of a comparator group, these findings should be interpreted cautiously. Larger prospective studies are required to further establish the safety, reproducibility, and generalizability of laparoscopic approaches in complex benign gyne- cological surgery. Abbreviations TLH: Total Laparoscopic Hysterectomy; LAVH: Laparoscopic -Assisted Vaginal Hysterectomy; PID: Pelvic Inflammatory Disease; LSCS: Lower Segment Caesarean Section; NSAIDs: Non-Steroi- dal Anti-Inflammatory Drugs; Hb: Hemoglobin. SMMR Journal ǁ (2026) NO 11; VOL 02: 01-10 ǁ ǁ https://doi.org/10.66224/smmr.202602.11.01 ǁ InfoPub https://doi.org/10.32592/smmr.202501.02.02 www.simmr.info Ethical Approval Ethical approval was not required for this study, as it was a retrospective case series involving the review of existing clinical data and did not involve any prospective intervention or alteration in patient management. The authors confirm that the study was conducted in accordance with the ethical principles of the Declaration of Helsinki and all applicable institutional ethical standards. The Institutional/University authorities at MGM Medical College, Jamshedpur, Jharkhand, India (Kolhan University), the institution affiliated with the first author, confirmed that formal ethical committee approval and an ethics approval number were not required for this retrospective case series. Clinical Trial Number Not applicable. This study was a retrospective case series and did not involve prospective clinical trial registration. Availability of Data and Materials The data supporting the findings of this study are available from the corresponding author upon reasonable request, subject to institutional policies and protection of patient confidentiality. Funding No specific funding was received for this study. Authors’Contribution SK: Conceptualization, study design, data collection, surgical management, and manuscript prep- aration. SL: Data interpretation, literature review, and manuscript revision. ST: Data collection, clinical input, and manuscript revision. SR: Supervision, clinical oversight, and critical revision of the manuscript. All authors reviewed and approved the final manuscript. Acknowledgment The authors would like to acknowledge the surgical, nursing, anesthesia, and supporting staff in- volved in the care and management of the patients included in this study. Consent for Publication Written informed consent for publication of anonymized clinical information was obtained from the patients included in the study, where applicable. Competing Interests The authors declare that they have no competing interests.

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JSLS : Journal of the Society of Laparoendoscopic Surgeons. 2021;25(4). https://doi.org/10.4293/jsls.2021.00031 Publisher’s Note © 2026 The Author(s). Published by InfoPub Press. Publisher Homepage: https://www.infopubpress.com/ Disclaimer: The views, opinions, and data presented in this article are solely those of the author(s) and do not necessarily reflect the official policy or position of Infopub Press.