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Lerner V, Stuart AE, Baekalandt J. Vaginal Natural Orifice Transluminal Endoscopic Surgery Hysterectomy Deconstructed: Expanding Minimally Invasive Gynecologic Surgeons' Toolbox. J Gynecol Surg 2024; 40:78-99. [PMID: 38690154 PMCID: PMC11057779 DOI: 10.1089/gyn.2023.0098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024] Open
Abstract
Background The introduction of vaginal natural orifice transluminal endoscopic surgery (vNOTES) to the toolbox of gynecologic surgeons has the potential to reverse the trend of vaginal hysterectomy declines. Methods This review discusses nuances of the vNOTES technique applied to hysterectomy; describes vNOTES hysterectomy, step-by-step (including tips and tricks for low- and high-complexity cases for surgeons who may want to incorporate vNOTES hysterectomy into their surgical repertoires); and examines evidence and research trends in this field. Results The descriptions in the text, figures, tables, and videos all contribute to giving readers a clear understanding of vNOTES, its advantages, limitations, and research potentials. Conclusions vNOTES hysterectomy is a unique blend of vaginal, laparoscopic, and laparoendoscopic single-site surgery (LESS) techniques and is not a new procedure, but rather another tool to use in minimally invasive gynecologic surgery. (J GYNECOL SURG 40:78).
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Affiliation(s)
- Veronica Lerner
- Department of Obstetrics & Gynecology, Lenox Hill Hospital, Zucker School of Medicine at Hofstra/Northwell Health, Hempstead, New York, USA
| | - Andrea E Stuart
- Department of Obstetrics and Gynaecology, Institution of Clinical Sciences, Lund University, Lund, Sweden
- Department of Obstetrics and Gynaecology, Helsingborg Hospital, Sweden
| | - Jan Baekalandt
- Department of Gynaecologic Oncology, Imelda Hospital, Bonheiden, Belgium
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Raimondo D, Raffone A, Franceschini C, Virgilio A, Palermo R, Borghese G, Maletta M, Borgia A, Neola D, Travaglino A, Lenzi J, Guida M, Seracchioli R. Comparison of perioperative surgical outcomes between contained and free manual vaginal morcellation of large uteruses following total laparoscopic hysterectomy. Int J Gynaecol Obstet 2024; 164:1167-1173. [PMID: 37937384 DOI: 10.1002/ijgo.15224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 10/10/2023] [Accepted: 10/17/2023] [Indexed: 11/09/2023]
Abstract
OBJECTIVE To compare contained and free manual vaginal morcellation of large uteruses after total laparoscopic hysterectomy (TLH) in women at low risk of uterine malignancy in terms of feasibility and safety. METHODS A single-center, observational, retrospective, cohort study was carried out including all patients undergoing TLH requiring manual vaginal morcellation for specimen extraction of large uteruses from January 2015 to August 2021 at the Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria of Bologna, Bologna, Italy. Patients were divided into two groups according to the type of manual vaginal morcellation (contained or free), and compared in terms of demographic, clinical, and perioperative data. RESULTS In all, 271 patients were included: 186 (68.6%) in the contained morcellation group and 85 (31.4%) in the free morcellation group. The mean operative time was significantly lower in the contained morcellation group compared with the free morcellation group (median [interquartile range] 130 [45] vs. 155 [60] min; P < 0.001). No significant difference was found in complications related to the morcellation step, overall, intraoperative and postoperative complications, estimated blood loss, length of hospital stays, uterine weight, and rate of occult malignancy between the two groups. CONCLUSION Contained vaginal manual morcellation of the uterus after total laparoscopic hysterectomy using a specimen retrieval bag appears to be a safe procedure with significantly lower operative time than free vaginal manual morcellation.
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Affiliation(s)
- Diego Raimondo
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Antonio Raffone
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
- Gynecology and Obstetrics Unit, Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Camilla Franceschini
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Agnese Virgilio
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Roberto Palermo
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Giulia Borghese
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Manuela Maletta
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Alessandra Borgia
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Daniele Neola
- Gynecology and Obstetrics Unit, Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Antonio Travaglino
- Unit of Pathology, Department of Medicine and Technological Innovation, University of Insubria, Varese, Italy
| | - Jacopo Lenzi
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Maurizio Guida
- Gynecology and Obstetrics Unit, Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Renato Seracchioli
- Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
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Prospective Evaluation of Laparoscopic Sacrocolpopexy with Concomitant Laparoscopic-Assisted Total Vaginal Hysterectomy. SURGERIES 2022. [DOI: 10.3390/surgeries3010002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
(1) Background: Sacrocolpopexy (SCP) with subtotal hysterectomy (SH) is a standard procedure for the treatment of utero-vaginal prolapse. Several disadvantages are associated with the remaining cervix; therefor, SCP with total hysterectomy (TH) may be preferred. According to some publications, SCP with concomitant TH is associated with higher rates of mesh extrusion. Our hypothesis is that mesh extrusion at the apex can be avoided through prevention of thermal injury and through vaginal cuff suturing when performing the laparoscopic sacrocolpopexy combined with a laparoscopic-assisted vaginal total hysterectomy (LAVH). (2) Methods: This prospective cohort study was performed from 2016 until January 2019 including women with a utero-vaginal prolapse undergoing laparoscopic SCP with LAVH. The SCP was performed utilizing a non-absorbable polypropylene macroporous mesh (EndoGYNious®). The primary outcome was the mesh extrusion rate after SCP with concomitant LAVH. The secondary outcome was the objective and functional outcome. (3) There were 50 women included in this prospective cohort. At follow up of 6–12 weeks postoperatively, no mesh extrusion was detected and objectified. Overall, all women showed excellent anatomical and functional outcome. The median time from surgery was 42 months. (4) Laparoscopic SCP with concomitant LAVH showed no increased risk of mesh extrusion and good objective and functional outcomes.
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Asgari Z, Enzevaei A, Hosseini R, Behnia-Willison F. Predictive factors of the need to morcellate in total laparoscopic hysterectomy. Aust N Z J Obstet Gynaecol 2021; 61:759-764. [PMID: 34060074 DOI: 10.1111/ajo.13378] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 04/19/2021] [Accepted: 04/25/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Specimen extraction is a major challenge in total laparoscopic hysterectomy (TLH) and tissue morcellation may be needed to extract a large uterus. AIMS The study aims to determine preoperative factors that could predict the need for uterine morcellation in TLH, and also find the best cut-off values of each measured parameter leading to optimum sensitivity and specificity. MATERIALS AND METHODS This was a cross-sectional study of women from August 2019 to May 2020 who underwent TLH, with or without salpingo-oophorectomy in our department. We performed bimanual exams preoperatively to estimate the uterine size and recorded the uterine ultrasonographic dimensions and myoma size in myomatous uteri. Receiver operating characteristic (ROC) were used to establish cut-offs that maximised the sensitivity and specificity of each factor in predicting the need for morcellation. Poisson regression was used to calculate the relative risks (RR) of each cut-off. RESULTS One hundred and sixty-two women were recruited in the study. ROC curves demonstrated maximum sensitivities and specificities with a cross-sectional area of 36.5 cm2 , the largest leiomyoma dimension of 40 mm, uterine length of 10 cm, and bimanual uterine size of 13 weeks. Multiple modified Poisson regression revealed that the strongest predictors of morcellation were the largest leiomyoma diameter of >40 mm (RR: 3.58), the uterine cross-sectional area of >36.5 cm2 (RR: 6.38), and uterine size in the bimanual exam of >13 weeks pregnancy (RR: 3.57). CONCLUSION The largest leiomyoma diameter, uterine cross-sectional area, and size on a bimanual exam can all be used to predict needing morcellation preoperatively in TLH.
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Affiliation(s)
- Zahra Asgari
- Department of Obstetrics and Gynaecology, Arash Women's Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Anahita Enzevaei
- Department of Obstetrics and Gynaecology, Arash Women's Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Reihaneh Hosseini
- Department of Obstetrics and Gynaecology, Arash Women's Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Fariba Behnia-Willison
- Senior endo-gynaecologist at Flinders Medical Centre and Senior lecturer at Flinders University, Adelaide, South Australia, Australia
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Pepin K, Cope A, Einarsson JI, Cellini J, Cohen SL. Safety of Minimally Invasive Tissue Extraction in Myoma Management: A Systematic Review. J Minim Invasive Gynecol 2020; 28:619-643. [PMID: 32977002 DOI: 10.1016/j.jmig.2020.09.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 08/28/2020] [Accepted: 09/08/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE This review seeks to establish the incidence of adverse outcomes associated with minimally invasive tissue extraction at the time of surgical procedures for myomas. DATA SOURCES Articles published in the following databases without date restrictions: PubMed, EMBASE, Web of Science, Cochrane Database of Systematic Reviews and Trials. Search was conducted on March 25, 2020. METHODS OF STUDY SELECTION Included studies evaluated minimally invasive surgical procedures for uterine myomas involving morcellation. This review did not consider studies of nonuterine tissue morcellation, studies involving uterine procedures other than hysterectomy or myomectomy, studies involving morcellation of known malignancies, nor studies concerning hysteroscopic myomectomy. A total of 695 studies were reviewed, with 185 studies included for analysis. TABULATION, INTEGRATION, AND RESULTS The following variables were extracted: patient demographics, study type, morcellation technique, and adverse outcome category. Adverse outcomes included prolonged operative time, morcellation time, blood loss, direct injury from a morcellator, dissemination of tissue (benign or malignant), and disruption of the pathologic specimen. CONCLUSION Complications related to morcellation are rare; however, there is a great need for higher quality studies to evaluate associated adverse outcomes.
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Affiliation(s)
- Kristen Pepin
- Department of Obstetrics & Gynecology, Weill Cornell Medical Center, New York, New York (Dr. Pepin).
| | - Adela Cope
- Department of Obstetrics & Gynecology, The Mayo Clinic, Rochester, Minnesota (Drs. Cope and Cohen)
| | - Jon I Einarsson
- Department of Obstetrics & Gynecology, Brigham and Women's Hospital (Dr. Einarsson)
| | - Jacqueline Cellini
- Department of Research & Instruction, Harvard TH Chan School of Public Health (Ms. Cellini), Boston, Massachusetts
| | - Sarah L Cohen
- Department of Obstetrics & Gynecology, The Mayo Clinic, Rochester, Minnesota (Drs. Cope and Cohen)
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Abstract
PURPOSE OF REVIEW This review was written in an effort to describe the evolution of power morcellation equipment from their creation to their current state. In addition, this review addresses the continuously evolving equipment involved with power morcellation and looks to describe where the field is headed in the future. In addition, recent professional and federal recommendations have changed the way power morcellation is being approached and has led to the development of contained morcellation systems, which, although in their infancy, are also being proven to be well tolerated options. RECENT FINDINGS This article will review the most current research on electronic power morcellation and the multiple attempts to prove superiority from the many different types of equipment, and also the many different approaches to morcellation. In addition, with the adaptation to contained morcellation, this review will cover research focused on optimizing a containment system and the techniques involved. SUMMARY In summary, this review is aimed at describing many of the currently available power morcellation products and contained morcellation systems in an effort to allow physicians to understand the different options available, and to discuss well tolerated, effective, and clinically proven techniques that can lead to improved surgical outcomes in the future.
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In-Bag Morcellation as a Routine for Laparoscopic Hysterectomy. BIOMED RESEARCH INTERNATIONAL 2017; 2017:6701916. [PMID: 29318153 PMCID: PMC5727682 DOI: 10.1155/2017/6701916] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 08/08/2017] [Indexed: 02/06/2023]
Abstract
Tissue morcellation during laparoscopic hysterectomy carries the risk of spreading cells from unsuspected malignancy. Contained morcellation inside a bag is supposed to minimize this risk. The present study evaluated routine use of in-bag morcellation during laparoscopic hysterectomy in a consecutive patient cohort (n = 49). The system used was More-Cell-Safe (A.M.I. Austria). Median age was 47 (35 to 76) years and BMI 25.1 (18.8 to 39.8). Indications for hysterectomy were fibroids (71.4%), adenomyosis (16.3%), prolapse (8.2%), and bleeding disorders (4.1%). 48 (98%) patients underwent supracervical hysterectomy and 1 (2%) underwent total hysterectomy. No unsuspected malignancy occurred. Median weight of extirpated tissue was 195 g (18 to 1110). Residual tissue and/or fluid in the bag amounted to 29 g (0 to 291). Median overall duration of surgeries was 100.5 min, and median time associated with the use of the bag was 10 min (5 to 28), significantly correlated with uterine volume (p = 0.0094) and specimen weight (p = 0.0002), but not with patient's BMI (p = 0.6970). Technical success rate for contained morcellation was 93.9%. Peritoneal washings after contained morcellation were all negative for malignant or smooth muscle cells.
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Wong M, De Wilde RL, Isaacson K. Reducing the spread of occult uterine sarcoma at the time of minimally invasive gynecologic surgery. Arch Gynecol Obstet 2017; 297:285-293. [PMID: 29128980 DOI: 10.1007/s00404-017-4575-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 10/19/2017] [Indexed: 12/18/2022]
Abstract
PURPOSE This review covers the most recent evidence to discuss the incidence of occult uterine sarcoma, whether morcellation increases tumor dissemination or mortality, and whether there is a difference between different types of morcellation. We will also discuss techniques to reduce the spread of an undiagnosed uterine sarcoma. METHOD A comprehensive literature search was made in Pubmed, Medline, the Cochrane Library, and Google Scholar for articles related to the incidence of occult uterine sarcoma after morcellation. RESULTS Fibroids are benign uterine tumors and are a common indication for gynecologic surgery. Increasingly, gynecologists are approaching these surgeries with minimally invasive techniques. Uterine sarcomas are rare malignant mesenchymal tumors that are difficult to distinguish preoperatively from uterine fibroids. CONCLUSION During a minimally invasive surgery, there is a risk of disseminating an occult sarcoma during tissue extraction. Minimally invasive gynecologists are tasked with balancing taking a minimally invasive approach, which is shown to result in better patient outcomes, with minimizing the risk of spreading an occult sarcoma.
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Affiliation(s)
- Marron Wong
- Newton-Wellesley Hospital, Center for Minimally Invasive Gynecologic Surgery, Harvard Medical School, Newton, MA, USA
| | - Rudy Leon De Wilde
- Department of Gynecology, Obstetrics and Gynecological Oncology at Pius Hospital, University Hospital for Gynecology-Carl von Ossietzky University, Oldenburg, Germany.
| | - Keith Isaacson
- Newton-Wellesley Hospital, Center for Minimally Invasive Gynecologic Surgery, Harvard Medical School, Newton, MA, USA
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Change in Surgical Practice for Women With Leiomyomas After the U.S. Food and Drug Administration Morcellator Safety Communication. Obstet Gynecol 2017; 130:1057-1063. [DOI: 10.1097/aog.0000000000002309] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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10
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Taylan E, Sahin C, Zeybek B, Akdemir A. Contained Morcellation: Review of Current Methods and Future Directions. Front Surg 2017; 4:15. [PMID: 28352629 PMCID: PMC5348539 DOI: 10.3389/fsurg.2017.00015] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 02/28/2017] [Indexed: 11/30/2022] Open
Abstract
Power morcellation of surgical specimen during laparoscopic surgery is a practical technology that provides the opportunity to perform several minimally invasive procedures. However, this technology brought forward additional risks and complications associated with dissemination of both benign and malignant tissues inside the abdominal cavity. Based on startling cases, Food and Drug Administration (FDA) announced a discouraging statement on the use of power morcellators that decreased the number of minimally invasive approaches in the following period. As a response to these concerns and negative impacts of the FDA statement, researchers developed several new approaches resulting in contained or in-bag morcellation methods. In this review, we aimed to discuss these current methods and provide an insight for future developments.
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Affiliation(s)
- Enes Taylan
- Laboratory of Molecular Reproduction and Fertility Preservation, Division of Reproductive Medicine, Department of Obstetrics and Gynecology, New York Medical College, New York, NY, USA; Department of Obstetrics and Gynecology, Ege University School of Medicine, Izmir, Turkey
| | - Cagdas Sahin
- Department of Obstetrics and Gynecology, Ege University School of Medicine , Izmir , Turkey
| | - Burak Zeybek
- Department of Obstetrics and Gynecology, University of Texas Medical Branch , Galveston, TX , USA
| | - Ali Akdemir
- Department of Obstetrics and Gynecology, Ege University School of Medicine , Izmir , Turkey
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Abstract
BACKGROUND AND OBJECTIVES The well-known advantages of minimally invasive surgery make the approach well suited for hysterectomy and other gynecological procedures. The removal of specimens excised during surgery has been a challenge that has been answered by the use of power morcellation. With this study we sought to assess the feasibility of power morcellation within a specimen bag. METHODS This was a retrospective cohort study including patients from a private practice in suburban Chicago, Illinois, who underwent contained electromechanical power morcellation during a laparoscopic or robot-assisted hysterectomy or myomectomy from May 2014 through December 2015. Contained power morcellation was performed with the Espiner EcoSac 230 (Espiner Medical Ltd., North Somerset, United Kingdom) specimen bag. Descriptive statistics were performed for both categorical and continuous data. RESULTS Of the 187 procedures performed, 73.8% were myomectomies, and 26.2% were hysterectomies. The patients' mean age was 40 (range, 25-54) years and mean body mass index was 28.7 (range, 17.3-57.6). The average specimen weight was 300 g, with the largest weighing 2134 g. Estimated blood loss averaged 98.4 mL. The postoperative admission rate was 12.3%, most of which were due to nausea and urinary retention. Seventeen patients (9.1%) had postoperative complications, most of which were minor, and 4 (2.1%) were readmitted. There were no bag failures or complications that were due to the use of the specimen bag or to power morcellation. CONCLUSIONS Performing electromechanical power morcellation within the Espiner EcoSac 230 specimen bag was successfully performed in 187 patients with no bag-related complications. This method of contained power morcellation is feasible, reliable, and reproducible, even for a large specimen.
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Affiliation(s)
| | - Aarathi Cholkeri-Singh
- Minimally Invasive Gynecology, Advocate Lutheran General Hospital, Park Ridge, Illinois, USA
| | | | - Charles E Miller
- Minimally Invasive Gynecology, Advocate Lutheran General Hospital, Park Ridge, Illinois, USA
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Kerbage Y, Azaïs H, Estevez JP, Merlot B, Collinet P. [Current controversies regarding power morcellation and future directions]. ACTA ACUST UNITED AC 2016; 44:417-23. [PMID: 27363612 DOI: 10.1016/j.gyobfe.2016.05.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Accepted: 05/23/2016] [Indexed: 12/29/2022]
Abstract
Modern surgery tends to the improvement of minimally invasive strategies. Laparoscopy, rooted in practices for years, supplanted laparotomy in many directions. Regarding the extraction of large uterus, morcellation is currently the only way to externalize surgical specimens (myomas, uterine), without increasing the skin opening while allowing to reduce postoperative complications compared to laparotomy. However, in 2014, the Food and Drug Administration (FDA) discourages the use of uterine morcellation because of oncological risk. This recommendation has been challenged by a part of the profession. Our review has sought to identify the evidence for and against the use of morcellation. We also tried to quantify surgical risk and the current means of prevention. The incidence of uterine sarcomas is still poorly identified and preoperative diagnostic facilities remain inadequate. The small number of retrospective studies currently available could not enable any recommendation. The evaluation of morcellation devices and the improvement of preoperative diagnosis modalities (imaging, preoperative biopsy) are to continue to minimize the oncological risk.
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Affiliation(s)
- Y Kerbage
- Faculté de médecine, université de Lille, CHU de Lille, 59000 Lille, France; Service de gynécologie-obstétrique, CHU de Lille, 59000 Lille, France.
| | - H Azaïs
- Faculté de médecine, université de Lille, CHU de Lille, 59000 Lille, France; Service de gynécologie-obstétrique, CHU de Lille, 59000 Lille, France
| | - J P Estevez
- Service de gynécologie-obstétrique, CHU de Lille, 59000 Lille, France
| | - B Merlot
- Service de gynécologie-obstétrique, CHU de Lille, 59000 Lille, France
| | - P Collinet
- Faculté de médecine, université de Lille, CHU de Lille, 59000 Lille, France; Service de gynécologie-obstétrique, CHU de Lille, 59000 Lille, France
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Surgical treatment: Myomectomy and hysterectomy; Endoscopy: A major advancement. Best Pract Res Clin Obstet Gynaecol 2016; 34:104-21. [DOI: 10.1016/j.bpobgyn.2015.11.021] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Accepted: 11/26/2015] [Indexed: 12/12/2022]
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Deffieux X, Vinchant M, Thubert T. [How I perform… a uterine morcellation in an isolation bag?]. ACTA ACUST UNITED AC 2016; 44:250-2. [PMID: 27032762 DOI: 10.1016/j.gyobfe.2016.02.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2015] [Accepted: 02/15/2016] [Indexed: 11/30/2022]
Affiliation(s)
- X Deffieux
- Service de gynécologie-obstétrique et médecine de la reproduction, hôpital Antoine-Béclère, AP-HP, GHU Sud, 92141 Clamart, France.
| | - M Vinchant
- Service de gynécologie-obstétrique et médecine de la reproduction, hôpital Antoine-Béclère, AP-HP, GHU Sud, 92141 Clamart, France
| | - T Thubert
- Service de gynécologie-obstétrique et médecine de la reproduction, hôpital Antoine-Béclère, AP-HP, GHU Sud, 92141 Clamart, France
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Harris JA, Swenson CW, Uppal S, Kamdar N, Mahnert N, As-Sanie S, Morgan DM. Practice patterns and postoperative complications before and after US Food and Drug Administration safety communication on power morcellation. Am J Obstet Gynecol 2016; 214:98.e1-98.e13. [PMID: 26314519 DOI: 10.1016/j.ajog.2015.08.047] [Citation(s) in RCA: 101] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 08/11/2015] [Accepted: 08/19/2015] [Indexed: 01/20/2023]
Abstract
BACKGROUND In April 2014, the US Food and Drug Administration (FDA) published its first safety communication discouraging "the use of laparoscopic power morcellation during hysterectomy or myomectomy for the treatment of women with uterine fibroids." Due to the concern of worsening outcomes for patients with occult uterine malignancy, specifically uterine leiomyosarcoma, the FDA recommended a significant change to existing surgical planning, patient consent, and surgical technique in the United States. OBJECTIVE We sought to report temporal trends in surgical approach to hysterectomy and postoperative complications before and after the April 17, 2014, FDA safety communication concerning the use of power morcellation during myomectomy or hysterectomy. STUDY DESIGN A retrospective cohort study was performed with patients undergoing hysterectomy for benign indications in the Michigan Surgical Quality Collaborative from Jan. 1, 2013, through Dec. 31, 2014. The rates of abdominal, laparoscopic, and vaginal hysterectomy, as well as the rates of major postoperative complications and 30-day hospital readmissions and reoperations, were compared before and after April 17, 2014, the date of the original FDA safety communication. Major postoperative complications included blood transfusions, vaginal cuff infection, vaginal cuff dehiscence, ureteral obstruction, vesicovaginal fistula, deep and organ space surgical site infection, acute renal failure, respiratory failure, sepsis, pulmonary embolism, deep vein thrombosis requiring therapy, cerebral vascular accident, cardiac arrest, and death. We calculated the median episode cost related to hysterectomy readmissions using Michigan Value Collaborative data. Analyses were performed using robust multivariable multinomial and logistic regression models. RESULTS There were 18,299 hysterectomies available for analysis during the study period. In all, 2753 cases were excluded due to an indication for cancer, cervical dysplasia, or endometrial hyperplasia, and 174 cases were excluded due to missing covariate data. Compared to the 15 months preceding the FDA safety communication, in the 8 months afterward, utilization of laparoscopic hysterectomies decreased by 4.1% (P = .005) and both abdominal and vaginal hysterectomies increased (1.7%, P = .112 and 2.4%, P = .012, respectively). Major surgical complications not including blood transfusions significantly increased after the date of the FDA safety communication, from 2.2-2.8% (P = .015), and the rate of hospital readmission within 30 days also increased from 3.4-4.2% (P = .025). The rate of all major surgical complications or hospital reoperations did not change significantly after the date of the FDA communication (P = .177 and P = .593, respectively). The median risk-adjusted total episode cost for readmissions was $5847 (interquartile range $5478-10,389). CONCLUSION Following the April 2014 FDA safety communication regarding power morcellation, utilization of minimally invasive hysterectomy decreased, and major surgical, nontransfusion complications and 30-day hospital readmissions increased.
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First clinical experiences using a new in-bag morcellation system during laparoscopic hysterectomy. Arch Gynecol Obstet 2015; 294:83-93. [PMID: 26690354 DOI: 10.1007/s00404-015-3986-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 12/08/2015] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Endoscopic techniques have successfully reduced the invasiveness of hysterectomy, when compared to open procedures. Power morcellation, as a part of the minimal invasive concept, carries the risk of disseminating cells from the tissue specimen. The present observational study reports on first experiences using a new system (More-Cell-Safe, A.M.I., Austria) for contained in-bag morcellation during laparoscopic hysterectomy. MATERIALS AND METHODS The dual opening system allows two-port access without bag puncture. The optic is protected against spread cell contamination with a disposable sleeve. Application data were prospectively recorded on the first n = 7 consecutive patients and compared to n = 7 preceding patients undergoing uncontained morcellation. RESULTS Bag system use was surgically successful in 6 of 7 cases (85.7 %). Morcellated specimen weight ranged from 205 to 638 g (mean 413.33 ± 176.85; median 413). In one patient, the uterine specimen (1050 g) proved too large to be placed into the bag. Average time associated to the bag use was 16.2 ± 7.65 min, ranging from 8.5 to 26.5 min (median 14 min). Removed bags contained bloody fluid with residual tissue fragments weighing overall between 21 and 85 g. Spread spindle cells were detected in two cases after uncontained morcellation, but not after in-bag morcellation. CONCLUSION The experiences from our small pilot series prove technical feasibility in the clinical setting.
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Solima E, Scagnelli G, Austoni V, Natale A, Bertulessi C, Busacca M, Vignali M. Vaginal Uterine Morcellation Within a Specimen Containment System: A Study of Bag Integrity. J Minim Invasive Gynecol 2015. [DOI: 10.1016/j.jmig.2015.07.007] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Vaginal Morcellation Inside Protective Pouch: A Safe Strategy for Uterine Extration in Cases of Bulky Endometrial Cancers: Operative and Oncological Safety of the Method. J Minim Invasive Gynecol 2015; 22:938-43. [DOI: 10.1016/j.jmig.2015.04.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Revised: 04/16/2015] [Accepted: 04/16/2015] [Indexed: 12/28/2022]
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A new in-bag system to reduce the risk of tissue morcellation: development and experimental evaluation during laparoscopic hysterectomy. Arch Gynecol Obstet 2015; 292:1311-20. [PMID: 26093523 DOI: 10.1007/s00404-015-3788-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Accepted: 06/08/2015] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Minimal invasive approaches have proven beneficial for patients undergoing myomectomy and hysterectomy, but necessary tissue morcellation carries the risk of cell dissemination in rare cases of inadvertent malignancy. Performing the morcellation process within a contained bag system may prevent spilling and therefore enhance safety of the laparoscopic procedures. MATERIAL AND METHODS The present study describes the development and experimental evaluation of a new bag system in vitro and in vivo in a pig model of laparoscopic supracervical hysterectomies. RESULTS The main results on n = 8 procedures with in-bag morcellation compared to n = 8 controls without bag indicate reproducible feasibility and protective effect of the new bag, which is the first published to our knowledge that does not require puncturing in a standard multiport laparoscopy setting. Overall surgery time was significantly prolonged in the bag group by 12.86 min (P = 0.0052; 95 % confidence interval 4.64-21.07), but peritoneal washings were negative for muscle cells in all cases with bag use, compared to positive cytology in 5/8 cases without bag (P = 0.0256). CONCLUSION Clinical trials will now be necessary to investigate the reproducibility of these encouraging data in human application.
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Shokeir T. Safe vaginal uterine morcellation following total laparoscopic hysterectomy. Am J Obstet Gynecol 2015; 212:689. [PMID: 25530593 DOI: 10.1016/j.ajog.2014.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Accepted: 12/15/2014] [Indexed: 11/19/2022]
Affiliation(s)
- Tarek Shokeir
- Department of Obstetrics and Gynecology, Mansoura University Hospital, Mansoura Faculty of Medicine, Mansoura, Egypt.
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