(a) Preoperative optimisation and consent (4 marks)

One mark per point, maximum four.

• Correction of anaemia — IV iron (e.g. ferric carboxymaltose 1000 mg in a single infusion) targeting Hb above 120 g/L before elective surgery; oral iron if IV access difficult; consider erythropoietin where transfusion is refused (Jehovah's Witness). Tranexamic acid 1 g IV/PO during breakthrough bleeding.^[5]
• Endometrial and structural workup — endometrial sampling (pipelle) for women over 35 with AUB, or before any morcellation; saline infusion sonography or diagnostic hysteroscopy to define the submucous fibroid; MRI if multiple or large fibroids or sarcoma suspected.
• GnRH analogue or relugolix combination therapy for 3 months in selected cases (fibroids >5 cm, anaemia, fertility-sparing resection) — reduces uterine volume by 30-50%, decreases vascularity, improves Hb before surgery.
• Written informed consent — operation, alternatives (UAE, HIFU in trial settings, myomectomy by laparotomy, medical therapy, hysterectomy), complications (bleeding 1-4%, transfusion, visceral injury including bowel/bladder/ureter 0.5-2%, conversion 1-3%, recurrence 15-30% at 5 years, uterine rupture 0.5-1% in subsequent pregnancy if cavity breached), specimen extraction and the morcellation discussion (occult uterine sarcoma approximately 1 in 1,124 hysterectomies for benign indications per Kho 2016; in-bag contained morcellation as good practice per RANZCOG C-Gyn 33), histology on every specimen, mode of future delivery if cavity breached.^[5]
• Anaesthetic considerations — pre-induction large-bore IV access (two 14-16 G cannulae), crossmatch 2 units, antibiotic prophylaxis (cefazolin 2 g IV at induction), thromboprophylaxis plan per Caprini, anti-emetic prophylaxis (morphine patient-controlled analgesia is common for postoperative analgesia), cell salvage availability for complex cases; communicate to anaesthetist plan to use vasopressin (potential hypotension, bradycardia).^[3]

(b) Operative technique for laparoscopic myomectomy (5 marks)

One mark per step, maximum five. Sequence matters.

• Patient position and port placement — modified Lloyd-Davies or supine with arms tucked; uterine manipulator; primary port at umbilicus (or Palmer's point if prior midline laparotomy); two lower quadrant 5 mm laterals; suprapubic 5 mm for the myoma screw and the suturing instrument.^[1]
• Inspection — pelvis and upper abdomen for additional fibroids, endometriosis, ovarian pathology, adhesions; take an image of the dominant fibroid for the operative note.^[1]
• Haemostasis strategy — dilute vasopressin 20 IU in 60 to 100 mL normal saline injected into the serosa overlying the fibroid and around the capsule; tell the anaesthetist before injection. Optional Bonney tourniquet not possible at laparoscopy; consider temporary occlusion of the uterine artery with laparoscopic vascular clips or a dedicated uterine artery clamp at the cervico-isthmic junction if bleeding persists.^[3]
• Hysterotomy and enucleation — transverse incision over the most prominent part of the fibroid with monopolar hook or harmonic shears, down to the pseudocapsule; apply the myoma screw for traction; enucleate the fibroid along the avascular pseudocapsule with sharp and blunt dissection, controlling feeder vessels with bipolar; inspect for additional satellite fibroids and remove them through separate hysterotomies if accessible.^[1]
• Haemostasis and closure — irrigate and achieve haemostasis with selective bipolar coagulation; close the hysterotomy in multiple layers with barbed suture (e.g. 0 or 2-0 V-Loc) for the deep myometrium, intermediate myometrium, and serosa (the 2024 meta-analysis of 14,000+ patients showed barbed sutures reduced operative time by 12 minutes, suturing time by 6 minutes, blood loss by 47 mL versus conventional sutures).^[1]
• Barrier agent — apply an oxidised regenerated cellulose (e.g. Interceed) or hyaluronic acid-carboxymethylcellulose (e.g. Seprafilm) sheet over the closure to reduce de novo adhesion formation; document the application in the operative note.

(c) Specimen extraction strategy (3 marks)

One mark per element, maximum three.

• Containment — place the dominant fibroid (and any satellite fibroids) into a sterile isolation bag (e.g. Espiner EcoSac, More-Cell-Safe, or hand-sealed rip-stop nylon) inside the peritoneal cavity under direct vision; cinch the bag closed.^[2]
• Morcellation within the bag — exteriorise the opening of the bag through a 12 mm port site or minilaparotomy; introduce the electromechanical morcellator into the closed bag under laparoscopic vision; morcellate the specimen within the bag (no spillage to the peritoneal cavity); inspect the bag for tears at the end.^[2]
• Histology and rationale — send every specimen for histology (occult leiomyosarcoma risk approximately 1 in 1,124 per Kho 2016); RANZCOG C-Gyn 33 endorses in-bag contained morcellation as good practice and mandates credentialed operators, no morcellation when malignancy is suspected, and explicit consent on the occult sarcoma risk.^[2][5]

(d) Port-site recurrence at 6 weeks (3 marks)

One mark per element, maximum three.

• Recognition — a subcutaneous nodule at a port site 6 weeks after laparoscopic myomectomy with contained morcellation is a port-site myoma (parasitic leiomyoma) until proven otherwise; differential includes endometriosis, suture granuloma, wound infection, port-site metastasis (rare). Ultrasound confirms a soft-tissue nodule.
• Management plan — excise the nodule with wide margins (2 cm) and send for histology; if histology confirms parasitic leiomyoma, ensure the abdomen is examined at subsequent procedures for further nodules; document the case; declare a clinical incident if in-bag breach was suspected at the original surgery.^[4]
• Counsel — recurrence after myomectomy is 15-30% by ultrasound at 5 years; re-intervention 5-15% at 5 years; ultrasound follow-up at 6 months and as symptoms dictate; future pregnancy — counsel on uterine rupture risk (0.5-1% after laparoscopic with cavity breach) and elective caesarean section if the cavity was breached.