• The patient was a 45-year-old G0 with large uterine fibroids.
• A Maylard incision is planned, which increases exposure.
• The uterus was exteriorized from the abdominal cavity, along with the fibroid.
• Starting on one side, the round ligament is clamped, transected and suture ligated.
• The right fallopian tube is excised.
• Within the retroperitoneum space, the right uteter and external/internal iliac vessels are identified.
• The utero-ovarian pedicle is clamped, transected and suture ligated.
• The same steps are repeated on the left side.
• The vesicouterine space is developed, and the bladder is mobilized away from the uterus and cervix.
• The uterine arteries are clamped 90 degrees to the uterus, and suture ligated bilaterally.
• Cardinal ligament pedicles are clamped parallel to the cervix, also suture ligated bilaterally.
• Subsequent cardinal ligament clamps are placed medial to the divided pedicles, before transection and suture ligation.
• The vaginal angles are clamped, and the vagina is divided.
• The specimen is removed, making sure the cervix is intact.
• The vaginal angles are suture ligated, followed by vaginal cuff closure.
• The peritoneum is closed, along with the fascia and skin. The rectus muscles will heal spontaneously without sutures.

• Patients with with significant peripheral vascular disease, as the inferior epigastrics are important as collateral circulation to lower limbs in this population.

FIGO type 1-7 fibroid classifications

Hapugoda S, Uterine leiomyoma (fibroid) classification system (illustration). Case study, Radiopaedia.org