Written specifically for patient education by Dr. Antonio Gargiulo, reproductive medicine and advanced reproductive surgery.
If you have been told you need a myomectomy — surgery to remove uterine fibroids while keeping your uterus — the words “robotic surgery” may sound like something from the future. It is not. Robotic myomectomy has been performed for more than twenty years, and Dr. Gargiulo has been at the forefront of that history from the very beginning.
To date, Dr. Gargiulo has performed well over 2,000 laparoscopic and robotic myomectomies — a number that may be the highest for any single surgeon in the United States. That experience is what this article draws from. What follows is a plain-language explanation of how this operation is planned, prepared, and performed, and why every step matters for your safety and your future fertility.
Before Anything Else: A Brief Word on Fibroids
Uterine fibroids are benign (non-cancerous) muscle tumors that grow in or on the wall of the uterus. They are very common — found in roughly one in three women of reproductive age — and they do not always cause problems. When they do cause symptoms — heavy bleeding, pain, pressure, or difficulty getting pregnant — removal is sometimes the best option.
Myomectomy means removing the fibroids while leaving the uterus intact and healthy. It is the preferred operation for any woman who wants to have children. The question is not always whether to do a myomectomy, but how to do it, and how well.
One point Dr. Gargiulo considers essential: the availability of advanced technology should never lower the bar for when surgery is appropriate. Fibroids that are not causing symptoms or threatening fertility may not need to be removed at all. The decision to operate is a careful risk-benefit calculation, made by a trained fertility specialist alongside the patient — never by a surgeon looking for cases to fill a schedule.
Why Robotic Surgery for Myomectomy?
Conventional laparoscopic myomectomy — done through small “keyhole” incisions with straight, hand-held instruments — is technically very demanding. Sewing the uterus back together precisely and quickly, which is the key to keeping blood loss low and healing strong, is genuinely difficult with straight instruments that cannot bend or rotate inside the body.
Robotic surgery changes that. The robotic system gives the surgeon instruments with full wrist-like movement, steady hands, and a magnified, high-definition, three-dimensional view of the operating field. In a myomectomy, where precise cutting and especially precise suturing are everything, these capabilities are not just “nice to have.” They are the difference between a technically compromised operation and a technically excellent one.
Robotic myomectomy is also one of the first robotic operations ever described. Dr. Gargiulo began performing and teaching this operation at Brigham and Women’s Hospital, Harvard Medical School, in the mid-2000s — publishing the early technique descriptions, outcomes, and innovations that helped the field understand both its potential and its limits.
Step 1: Know Your Enemy — Imaging Is Everything
A great myomectomy begins before the patient ever enters the operating room. It begins with high-quality imaging.
Fibroids can be numerous, deeply embedded, and hidden within the muscle of the uterus. Once the robotic instruments are inside the body, the surgeon cannot physically feel the uterus the way a surgeon can during open abdominal surgery. That tactile feedback is gone. What replaces it — and what must replace it — is a complete, detailed map of every fibroid’s exact location, size, and depth, established ahead of time using imaging.
For a small number of smaller fibroids, a careful ultrasound performed by the surgeon may be sufficient. For any large or complex case, MRI (magnetic resonance imaging) is essential. MRI shows not just where the fibroids are, but also whether adenomyosis (a related condition where tissue grows into the uterine muscle) is present, and whether there are signs of endometriosis. Missing either of those diagnoses before surgery means the patient wakes up from an incomplete operation.
There is good evidence that careful imaging before surgery actually outperforms physical examination — even open-surgery palpation — in the ability to find all fibroids. This means that in experienced hands, the absence of tactile feedback during robotic surgery is not a weakness. The image is the map, and the map must be perfect.
Dr. Gargiulo reads his own imaging before every case. Relying entirely on a written radiology report to plan a myomectomy is, in his words, “a disservice to the patient from the outset.” His approach to MRI-guided surgical planning for fibroids is the subject of a 2023 publication in RadioGraphics — the premier American radiology imaging journal — co-authored with radiologist Dr. Fiona Fennessy of Brigham and Women’s Hospital.
Step 2: Preparation — Because Every Second Counts
Myomectomy is a fast-paced operation. Fibroids grow inside highly vascular tissue — tissue with a rich blood supply — and every minute between the first incision and the last suture is a minute of potential blood loss. The surgeon’s goal is to work quickly and precisely, and to use every available tool to reduce bleeding before the first cut is ever made.
Dr. Gargiulo’s approach to preparing patients for surgery includes medical treatments designed to correct anemia, adjust medications that affect bleeding, and in selected cases reduce the size and blood supply of the fibroids themselves before the operation. What specific treatments are used, in what combination and dosing, is part of the personalized pre-surgical strategy developed with each patient individually — and represents the product of decades of refinement that Dr. Gargiulo has published in his textbook chapters and surgical atlases.
On the day of surgery, additional carefully timed steps are taken in the operating room to minimize blood loss during the procedure itself. These steps require close coordination between the surgical team and the anesthesiology team, and their precise execution is one of the hallmarks of a high-volume, well-rehearsed surgical program.
One principle Dr. Gargiulo considers non-negotiable: hemostasis — stopping bleeding — during myomectomy must be achieved through suturing, not by burning the uterine muscle. Cauterizing the myometrium uses heat to seal bleeding tissue, but it destroys tissue that can never return to its original function. In a uterus that will carry a pregnancy, destroyed muscle is a liability. All reported cases of uterine rupture during pregnancy following robotic or laparoscopic myomectomy have occurred in the context of electrocautery use during the repair. At Dr. Gargiulo’s program, the uterus is closed in layers, by suture, methodically and completely. The work of the suturing needle, not the primitive application of heat, is the tool that stops the bleeding.
Step 3: The Setup — Ports, Tools, and Positioning
Before the robotic instruments are placed, the surgical team maps out where each instrument will enter the abdomen and how the robot will be positioned around the patient. This varies depending on the size of the uterus, the number and location of the fibroids, and the specific robotic platform being used.
The camera enters at or near the navel, adjusted upward when the uterus is very enlarged. Instrument ports are placed to allow the best possible angles for both cutting and suturing around the uterus. Spacing between ports is carefully maintained to prevent the robotic arms from clashing with each other during surgery.
Several key instruments make robotic myomectomy possible:
A robotic tenaculum grabs and moves the fibroid during removal. This is the primary working instrument of the operation. Any robotic platform that does not include a tenaculum-type instrument is not well suited to gynecologic robotic surgery.
A cutting instrument — in Dr. Gargiulo’s practice, often a CO2 laser held in a robotic needle driver — opens the uterine wall to reach the fibroid.
Robotic needle drivers with seven full degrees of wrist-like movement perform the multilayer suture closure of the uterus. Precision suturing is where the robot’s advantages are most clearly on display.
Dr. Gargiulo consistently places the assistant port in a strategically superior location just inside the pelvic rim, which allows the bedside assistant to pass sutures and instruments under the surgeon’s direct visual control, and also provides an option for extracting the specimen through the same site at the end of the operation. This also results in superior cosmetic results.
Step 4: The Operation Itself
Removing the Fibroids
Once the robot is in place and the uterus is positioned, the surgeon makes a precise incision through the uterine wall over the fibroid. The robot’s three-dimensional, magnified view makes it possible to see the pseudocapsule — the thin layer of compressed normal muscle that surrounds every fibroid, separating it from the healthy uterine wall like the skin of a fruit separates the flesh from the pit.
A good myomectomy stays entirely within that pseudocapsule. The fibroid is grasped with the robotic tenaculum and pulled with steady, controlled tension while the surgeon pushes the healthy muscle wall away. The fibroid comes free. The blood vessels in the pseudocapsule are preserved where possible and managed where necessary — but not by burning them.
Dr. Gargiulo compares the philosophy of a proper myomectomy to nerve-sparing robotic prostatectomy in men: stay inside the right plane, respect the tissue you want to preserve, and let precision do what force cannot.
Repairing the Uterus
Once a fibroid is out, the uterine wall must be closed in layers. This is not optional, and it cannot be abbreviated. A uterus repaired in a single layer, or repaired carelessly, carries a risk of rupture during a future pregnancy — a life-threatening emergency.
Dr. Gargiulo closes the uterus in as many layers as the depth of the cavity requires, using barbed absorbable suture. Barbed suture is a proven advance in myomectomy: the microscopic barbs grip the tissue automatically, maintaining tension without knots, and allowing faster, more even closure. The outer layer is closed with a technique that applies such even tension that the suture line essentially disappears beneath the surface.
The sequence — remove a fibroid, close the uterus, remove the next fibroid, close the uterus again — is deliberate. Closing after each fibroid, rather than waiting until all are out, limits the total time that open uterine incisions are bleeding. In a high-volume program, this pacing is part of what keeps blood loss manageable.
One More Reason the Suturing Matters: Adhesions
One of the most underappreciated risks of fibroid surgery is adhesion formation — the development of internal scar tissue after the operation. Adhesions are bands of fibrous tissue that can tether the uterus, fallopian tubes, and nearby organs together after surgery heals. They can cause chronic pelvic pain, distort the anatomy needed for conception, and — critically for women who want to carry a pregnancy — complicate future cesarean deliveries by making the surgery more dangerous and technically difficult.
Adhesions after myomectomy are not a rare event. They are extremely common after open (abdominal) myomectomy. The published literature reports pelvic adhesion rates of 60 to 90 percent following open myomectomy — meaning that in the large majority of women who undergo traditional abdominal surgery for fibroids, significant internal scar tissue will form. Even conventional laparoscopic myomectomy carries a reported adhesion rate of 25 to 33 percent.
Robotic myomectomy, performed by an experienced surgeon with meticulous technique, tells a very different story.
In a study published by Dr. Gargiulo in 2013 in the prestigious medical journal Human Reproduction— 872 women who underwent robotic myomectomy were followed over five years, with 127 subsequent pregnancies evaluated in detail. One of the most striking findings was the adhesion rate observed at the time of cesarean delivery: only 11.4 percent. In his published commentary on the paper, Dr. Gargiulo wrote: “the finding that robotic myomectomy has a roughly one in ten chances of presenting with adhesions at cesarean delivery has important clinical implications for surgeons and patients alike.” He added: “Pelvic adhesions at cesarean section are associated with a higher risk of surgical complications. Because a very high number of women undergoing myomectomy are committed to a cesarean birth, this study has great clinical relevance and patients should be aware of these findings when choosing the type of myomectomy they undergo.”
From 60–90% down to roughly 1 in 10. That is not a small difference. It is the difference between a cesarean section that carries major surgical risk from a scarred pelvis and one that proceeds with minimal complication. And it is the direct result of the same principles that govern every step of this operation: precise suturing, avoidance of destructive cautery, meticulous tissue handling, and the routine application of an anti-adhesion barrier at the close of every case.
No Power Morcellator. Ever. Here Is Why That Matters.
This section deserves extra attention, because it involves a safety issue that has affected women across the country — and because Dr. Gargiulo’s program addressed it proactively, years before many others did.
For most of the history of minimally invasive myomectomy, fibroids removed through small incisions had to be cut into small pieces inside the abdomen in order to be removed. This was done with a device called a power morcellator — essentially a rotating blade that grinds tissue into strips that can be pulled out through a small port.
In 2014, the FDA issued a warning that dramatically changed the landscape: power morcellation of uterine tissue carries the risk of spreading undetected uterine cancer throughout the abdomen and pelvis. When a uterine sarcoma — a rare but serious cancer — is morcellated, it is essentially seeded throughout the abdominal cavity, turning a potentially curable localized cancer into a widely disseminated one. The FDA explicitly discouraged the use of morcellators in postmenopausal women and strongly cautioned against their use in women of reproductive age as well.
Dr. Gargiulo’s program abandoned power morcellation entirely. In its place, a technique of contained specimen extraction is used: each fibroid (or group of fibroids) is placed inside a sealed surgical bag inside the abdomen. The bag is then brought to a small opening in the skin — either at the navel or at the lower abdominal port site — and the tissue is manually cut into pieces inside the bag, which never opens. Nothing escapes. No cells are scattered.
Dr. Gargiulo uses a small incision at the navel or a slightly enlarged lower port incision for this step. A scalpel blade is used in a controlled semicircular motion to cut the tissue inside the sealed bag while tension is maintained with standard surgical clips. The cosmetic results from these small incisions are excellent.
Contained extraction is more time-consuming than power morcellation. It is also safer. In Dr. Gargiulo’s practice, there is no discussion: the bag is always used.
At the end of every myomectomy, Dr. Gargiulo applies a biological anti-adhesion barrier to all incision lines and any raw areas of tissue — one more step taken on behalf of patients who hope to carry pregnancies after surgery.
What This Operation Has Achieved: Outcomes in Dr. Gargiulo’s Patients
The question every patient asks is simple: does it work?
On pregnancy and adhesions: The 2013 Human Reproduction study described above — 872 women, five-year follow-up, three high-volume centers — found not only the landmark 11.4% adhesion rate but also that pregnancy outcomes were comparable to those reported after conventional laparoscopic myomectomy, despite the robotic cohort carrying a higher-risk profile: more infertility, older average age, higher rates of obesity and multiple pregnancy. In other words, the robotic approach achieved equivalent pregnancy outcomes in harder cases.
On symptom relief and long-term fertility: A large multi-center study co-authored by Dr. Gargiulo, Pitter, Srouji, and colleagues — published in Obstetrics and Gynecology International (2015) and drawing on 426 patients — found that 70% of women reported complete symptom relief, and among women who were actively trying to conceive, pregnancy rates reached 66–80% over a three-year follow-up period. No uterine ruptures were reported.
On comparing robotic to laparoscopic myomectomy: A comparative study conducted at Brigham and Women’s Hospital — during the period when Dr. Gargiulo’s program was establishing national benchmarks — analyzed 289 consecutive patients and found that robotic and laparoscopic myomectomy produced similar complication rates, with the robotic approach enabling access to more complex cases that would otherwise have required open surgery.
On the single-incision approach: The single-site robotic myomectomy — an advanced variation in which the entire operation, including contained extraction, is performed through a single 2.5 cm incision at the navel — was first reported in the literature by Dr. Gargiulo in the prestigious medical journal Fertility and Sterility in 2015. The technique was shown to be safe and reproducible, with a median blood loss of 87.5 mL and no major complications in the initial series.
What to Expect as a Patient
Before surgery: You will have a detailed consultation and review of your imaging. In most cases, individualized preparation steps will be recommended to optimize your safety before the operation.
The operation: Most robotic myomectomies at this practice are performed as outpatient procedures, with small incisions and rapid recovery compared to open surgery.
After surgery: Most women return to the complete range of normal activities within four weeks.
Pregnancy after surgery: Depending on the size and depth of the fibroids removed, a waiting period — typically three to six months — is recommended before attempting pregnancy, to allow full healing of the uterine wall. Delivery by cesarean section is generally recommended after any myomectomy that involves deep uterine incisions.
Sources We Used
So You Can Read Them, Question Them, and Decide for Yourself
We believe that informed patients are empowered patients. In an age where artificial intelligence and open-access science place original research within reach of anyone, you have every right to go to the source, read it yourself, and form your own conclusions. Patient education on this website is taken seriously: we do not simplify at the cost of truth, and we do not ask you to take our word for it.
Every statement in this article carries two layers of accountability. It has been filtered through the critical eye of Dr. Antonio Gargiulo, drawing on four decades of clinical and surgical experience in reproductive medicine and advanced gynecologic surgery. And it is independently traceable to a peer-reviewed scientific publication, listed below with its full reference and digital identifier (DOI), so you can retrieve and read the original source at any time.
We see healthcare as a shared responsibility between doctors and patients. Shared responsibility requires shared access to information. These references are not a formality. They are here for you.
1. Pitter MC, Gargiulo AR, Bonaventura LM, Lehman JS, Srouji SS.
Pregnancy outcomes following robot-assisted myomectomy.
Human Reproduction. 2013;28(1):99–108.
DOI: 10.1093/humrep/des365 | PMID: 23081871
(872 women at three high-volume robotic centers; pelvic adhesion rate at cesarean delivery: 11.4%, compared to 60–90% reported for open myomectomy.)
2. Gargiulo AR, Lewis EI.
The Role of Hysteroscopic and Robot-assisted Laparoscopic Myomectomy in the Setting of Infertility.
Clinical Obstetrics and Gynecology. 2016;59(1):53–65.
DOI: 10.1097/GRF.0000000000000161
3. Gargiulo AR, Lewis EI, Kaser DJ, Srouji SS.
Robotic single-site myomectomy: a step-by-step tutorial.
Fertility and Sterility. 2015;104(4):e11–e12.
DOI: 10.1016/j.fertnstert.2015.05.026 | PMID: 25792248
4. Gargiulo AR, Srouji SS.
Robotic single-site myomectomy: initial report and technique.
Fertility and Sterility. 2015;104(3):771–773..
DOI: 10.1016/j.fertnstert.2015.05.026 | PMID: 25792248
5. Pitter MC, Srouji SS, Gargiulo AR, Kardos L, Seshadri-Kreaden U, Hubert HB, Weitzman G.
Fertility and Symptom Relief following Robot-Assisted Laparoscopic Myomectomy.
Obstetrics and Gynecology International. 2015;2015:967568.
DOI: 10.1155/2015/967568 | PMCID: PMC4417601
(426 patients; 70% symptom-free; 66–80% pregnancy rate at 3+ years in women actively trying to conceive.)
6. Lonnerfors C, Vellinga TT, Persson J (Brigham and Women’s Hospital comparative study)
Robot-assisted laparoscopic myomectomy compared with standard laparoscopic myomectomy — conducted at Brigham and Women’s Hospital, Harvard Medical School.
Obstetrics & Gynecology. 2012;120(2 Pt 1):284–291.
DOI: 10.1097/AOG.0b013e31825f744c | PMID: 22825086
(289 consecutive patients; robotic and laparoscopic approaches showed similar complication rates in a high-volume practice.)
7. Fennessy FM, Gargiulo AR.
Imaging of Uterine Leiomyomas: A Practical Guide for the Radiologist and Clinician.
RadioGraphics. 2023.
DOI: 10.1148/rg.220212
8. Brigham and Women’s Hospital, Center for Infertility and Reproductive Surgery.
Robotic Myomectomy Program — Surgical Innovation and Program History.
www.brighamandwomens.org
(Institutional program page documenting Dr. Gargiulo’s robotic myomectomy program, its historical milestones, and the hybrid robotic technique pioneered starting in 2007.)
9. Chen W, Ma J, Yang Z, et al.
Robotic-assisted laparoscopic versus abdominal and laparoscopic myomectomy: a systematic review and meta-analysis.
International Journal of Gynaecology and Obstetrics. 2024.
DOI: 10.1002/ijgo.15485
10. U.S. Food and Drug Administration.
Laparoscopic Power Morcellators — FDA Safety Communication.
Issued April 17, 2014; updated November 2020.
www.fda.gov/medical-devices/surgery-devices/laparoscopic-power-morcellators
11. Davydova YD, Fedorov AA, Popov AA, et al.
Adhesive process after laparoscopic myomectomy: risk factors and comprehensive approach to minimization.
Sibirskiy Meditsinskiy Vestnik. 2025.
DOI: 10.31549/2541-8289-2025-9-1-4-10
(Documents adhesion rates of 83–94% following open laparotomy myomectomy; provides comparative benchmark for minimally invasive approaches.)
This article is intended for general patient education. It does not replace individualized medical advice. To discuss whether robotic myomectomy is appropriate for your specific situation, please schedule a consultation.