Minimally invasive surgery for benign gynecologic disease offers improved outcomes compared to laparotomy [1]. In 1979, Kurt Semm performed the first laparoscopic myomectomy [2]. Studies have since demonstrated that minimally invasive myomectomies are associated with shorter hospital stays, reduced estimated blood loss (EBL), and fewer complications—without an increase in major complications [3, 4]. Despite these advantages, many myomectomies are still performed via laparotomy, with 93% of myomectomies registered with the 2021 United States National Inpatient Sample database using this approach [5].

Minimally invasive myomectomy, whether traditional laparoscopy or robotic-assisted, should be considered for myomas not amenable to medical therapy or hysteroscopic resection [6, 7]. Despite strong evidence supporting its safety and efficacy, minimally invasive myomectomy remains underutilized due to perceived challenges with dissection and laparoscopic suturing [7]. Conventional laparoscopic myomectomy involves enucleating myomas, closing myometrial defects, and tissue extraction through three or more 5-mm (or larger) ports using at least two laparoscopic instruments and a camera [6, 7]. Variations of this technique may incorporate additional abdominal incisions or robotic assistance. Numerous studies comparing abdominal, robotic, and laparoscopic myomectomies show lower EBL, fewer blood transfusions, and shorter hospital stays with minimally invasive approaches, though robotic surgery may increase operative time [8, 9].

Single-port myomectomy has been described but presents challenges with surgeon ergonomics, visualization, triangulation, and suturing [10]. Several studies have highlighted the advantages of single-port laparoscopic surgery, including improved cosmetic outcomes, reduced postoperative pain, and comparable intraoperative and postoperative complication rates [11, 12, 13, 14, 15]. However, systemic limitations—such as restricted instrument mobility and collisions—require a higher level of skill and postural constraints for the surgical team [10,16]. A learning curve of approximately 45 cases is necessary to achieve proficiency [17]. A 2014 study found no significant differences in operative time, EBL, or hospital stay between single-site and conventional myomectomy after a learning period of 100 cases [12].

Historically, laparoscopic myomectomy commonly used power morcellation for specimen extraction through existing port sites without having to extend the length of incisions [18, 19]. The 2014 FDA warning regarding power morcellators and the potential risk of leiomyosarcoma dissemination led to a decline in minimally invasive gynecologic procedures [19, 20, 21]. However, it also spurred innovation and many gynecologic surgeons adopted alternative tissue extraction methods such as mini-laparotomy, culdotomy for transvaginal specimen extraction, and techniques like the ExCITE method [18,22,23]. Options of extending a port site or creating a mini-laparotomy for specimen extraction must be balanced against cosmetic concerns and potential risk of hernia. Patients value cosmetic outcomes, provided there is no increase in complication rates [17]. Therefore, any surgical approach that prioritizes both safety and cosmesis should be considered for optimal patient satisfaction.

The two-port myomectomy approach combines benefits of traditional triangulation with improved cosmesis of single-site surgery. A 2–3 cm umbilical incision accommodates a multi-port system, with an additional right lower quadrant port aiding traction-countertraction for fibroid enucleation and laparoscopic suturing. This reduces the number of incisions while providing a dedicated specimen extraction site. Candidates for two-port myomectomy include all patients eligible for a conventional laparoscopic approach, though challenges may arise with intramural fibroids >10 cm, multiple fibroids (≥4), and fibroid locations requiring multiple hysterotomy incisions—criteria that has been accepted in the literature as more technically challenging for minimally invasive myomectomy [6, 7].

This study aims to present our novel two-port laparoscopic myomectomy technique and outcomes from 87 cases, including patient characteristics and perioperative outcomes. As minimally invasive gynecologic surgery continues to evolve, innovation is essential to ensure safety, surgical efficacy, and patient satisfaction. We propose this technique as a safe alternative to the conventional four-port myomectomy and encourage surgeons to consider incorporating it into their practice.