Contained power morcellation within an insufflated isolation bag. Obstet Gynecol. 2014;124:491-497. [PMID: 25162248 DOI: 10.1097/aog.0000000000000421]

Factors affecting gasless reduced-port laparoscopic myomectomy (GRP-LM) using a subcutaneous abdominal wall lifting method: a retrospective analysis of a large cohort of 966 cases in Japan

OBJECTIVE

To evaluate the usefulness of gasless reduced-port laparoscopic myomectomy (GRP-LM) using a subcutaneous abdominal wall lifting method.

METHODS

In GRP-LM, after lifting the abdominal wall by a subcutaneous abdominal wall lifting method, a 1.5-cm incision is made in the lateral abdomen, Lap Protector® is placed. The operation is performed by two surgeons, one who inserts multiple forceps from the Lap Protector and performs the operation, and an assistant who operates the laparoscope and uterine manipulator. The surgical outcome of GRP-LM and the factors that affect it were investigated.

RESULTS

GRP-LM was performed in 966 patients. Complications (0.5%) and blood transfusions (0.3%) were remarkably rare, and there were no cases of conversion to open surgery. With regard to the correlation between the number of fibroids extracted and each factor, the number of fibroids extracted correlated with fibroid weight and operation time, but not with blood loss. The average number of sutures per case was 21, and the average suture and ligation time per suture was 77 s. Comparing the cost of GRP-LM with that of the conventional insufflation LM, a saving of $875 was possible with GRP-LM.

CONCLUSION

GRP-LM is a suitable for multiple fibroids, and is cosmetic and economical, because it allows rapid and reliable suture and ligation, despite having only one port for the procedure.

Extrauterine adenomyoma: A case report and systematic review of the literature

OBJECTIVE

To describe a case of extrauterine adenomyoma (EA) and review all the cases of EA in the literature.

METHODS

Pubmed/MEDLINE, Embase, and Google Scholar from 1807 to December 2022. All studies reporting the histologic diagnosis of an EA. We collected the following data: patient's age, size and location of adenomyoma, presence of endometriosis and adenomyosis, past gynecologic treatment, symptoms, diagnostic imaging, surgical intervention, alternative/adjuvant treatment, associated malignancy, and follow up.

RESULTS

Sixty-seven studies with 85 patients were included. Pain was the most frequent symptom (69.5%). Among diagnostic examinations, ultrasonography was used in 60 out of 81 reported cases, with several radiologic features described. EA was located inside the pelvis in 77.6% of patients. Adnexa were the most frequent site of the disease (24, 28.2%). History of endometriosis or adenomyosis was described in 35 patients (35, 41.2%). Uterine tissue morcellation was reported in 6 of the 85 patients (7.1%). Associated malignancy was detected in 9 out of 85 patients with available data (10.6%). There were two recurrences of disease.

CONCLUSION

Specific imaging features of EA are yet to be described in the literature. History of endometriosis and adenomyosis or uterine tissue morcellation may be suggestive of EA. Histologic examination can give a definitive diagnosis and exclude malignant transformation.

In-bag extraction of tissue through an incision in the posterior vaginal wall in laparoscopic myomectomy: a large retrospective study

BACKGROUND

Our purpose was to describe the outcomes of transvaginal in-bag tissue extraction tissue through an incision in the posterior vaginal wall the middle part incision of posterior vagina in laparoscopic myomectomy.

METHODS

This was a retrospective study of patients who received laparoscopic myomectomy and in-bag tissue extraction through an incision in the posterior vaginal wall between January 2016 and December 2022. Patient characteristics, intra- and post-operative complications, and outcomes were collected and analyzed.

RESULTS

A total of 511women were included in the analysis. The mean largest myoma diameter was 8.44 ± 3.56 cm; mean specimen weight was 789.23 ± 276.97 g; mean operative time was 129.01 ± 53.13minutes; and mean blood loss was 175.99 ± 210.96 mL. Within 30-days of surgery, no fever, infection, or vaginal bleeding was noted in any patient, and the vaginal incisions of all patients had healed well. There were no incisional hernias, pelvic infections, and vaginal adhesions noted at follow-up 3 months after the operation. There were 37 cases of vaginal delivery of the patients after surgery, and there were no lacerations of the posterior wall vaginal incision.

CONCLUSIONS

Transvaginal in-bag extraction though an incision in the posterior vaginal wall is feasible and safe for removing tissue after laparoscopic myomectomy.

Contained Power Morcellation in Laparoscopic Uterine Myoma Surgeries: A Brief Review

Uterine fibromas are the most common benign uterine tumors. Although the majority of leiomyomas remain asymptomatic, they can cause serious clinical problems, including abnormal uterine bleeding, pelvic pain, and infertility, which require effective gynecological intervention. Depending on the symptoms as well as patients' preferences, various treatment options are available, such as medical therapy, non-invasive procedures, and surgical methods. Regardless of the extent of the surgery, the preferred option is the laparoscopic approach. To reduce the risk of spreading occult malignancy and myometrial cells associated with fragmentation of the specimen before its removal from the peritoneal cavity, special systems for laparoscopic contained morcellation have been developed. The aim of this review is to present the state-of-the-art contained morcellation. Different types of available retrieval bags are demonstrated. The advantages and difficulties associated with contained morcellation are described. The impact of retrieval bag usage on the course of surgery, as well as the effects of the learning curve, are discussed. The role of contained morcellation in the overall strategy to optimize patient safety is highlighted.

Risk of leakage with a new detachable multi-hard-port containment system for power morcellation during gynecologic laparoscopy: An in vitro study

BACKGROUND

Laparoscopic surgery has been a milestone for minimally invasive surgeries. But safe removal of large uterine tissue is a challenge for minimally invasive procedures, and there still exists concern about the dissemination of benign or occult malignant uterine tissue during the use of the morcellator. Different tissue containment systems have been used in laparoscopic power morcellation. However, a risk of leakage still exists in clinical practice. In this study, we aimed to evaluate leakage and tissue dissemination associated with a new detachable multi-hard-port containment system for tissue removal during laparoscopic myomectomy morcellation.

METHODS

Beef tongue specimens were stained with methylene blue solution and morcellated in a plastic trainer box under laparoscopic guidance. The morcellation test in vitro conditions comprised two different containment systems to simulate laparoscopic power morcellation, specifically a polyurethane bag with two pipes (control group) and a detachable multi-hard-port containment system (experimental group). Insufflation pressure was set at 14 mmHg. Three methods are used to detect the leakage The procedure times were recorded. Thirty trials were performed using a multi-port approach and the two tissue containment systems.

RESULTS

The leakage rate was 0.03% (n = 30) for the experimental group and 26.6% (n = 30) for the control group (p < 0.005). Morcellation time was significantly shorter in the experimental group than in the control group (p < 0.001). Median bag introduction time was shorter in the experimental group than in the control group; however, removal time differences were not significant.

CONCLUSIONS

This study quantified the low leakage rate during morcellation and the improved convenience of operation provided by a new tissue containment system.

The Future of Minimal-Access Myoma Surgery with In-Bag Contained Morcellation

Contained electromechanical morcellation has emerged as a safety approach for laparoscopic myomatous tissue retrieval. This retrospective single-center analysis evaluated the bag deployment practicability and safety of electromechanical in-bag morcellation when used for big surgical benign specimens. The main age of patients was 39.3 years (range 21 to 71); 804 myomectomies, 242 supracervical hysterectomies, 73 total hysterectomies, and 1 retroperitoneal tumor extirpation were performed. A total of 78.7% of specimens weighed more than 250 g (n = 881) and 9% more than 1000 g. The largest specimens, weighing 2933 g, 3183 g, and 4780 g, required two bags for complete morcellation. Neither difficulties nor complications related to bag manipulation were recorded. Small bag puncture was detected in two cases, but peritoneal washing cytology was free of debris. One retroperitoneal angioleiomyomatosis and three malignancies were detected in histology (leiomyosarcoma = 2; sarcoma = 1); therefore, patients underwent radical surgery. All patients were disease-free at 3 years follow-up, but one patient presented multiple abdominal metastases of the leiomyosarcoma in the third year; she refused subsequent surgery and was lost from follow-up. This large series demonstrates that laparoscopic bag morcellation is a safe and comfortable method to remove large and giant uterine tumors. Bag manipulation takes only a few minutes, and perforations rarely occur and are easy to detect intraoperatively. This technique did not result in the spread of debris during myoma surgery, potentially avoiding the additional risk of parasitic fibroma or peritoneal sarcoma.

Laparoscopic subtotal hysterectomy followed by in-bag transvaginal corpus uteri morcellation and extraction: A case series

OBJECTIVES

Laparoscopic subtotal hysterectomy (LSH) is a possible treatment for patients with benign uterine disease. Once the hysterectomy has been completed, morcellation and extraction of the corpus uteri is a crucial step of the procedure. We here present a case series to evaluate the feasibility of the in-bag transvaginal specimen retrieval following LSH.

STUDY DESIGN

We report a case series of consecutive patients who underwent LSH followed by in-bag transvaginal specimen retrieval. LSH was accomplished in a standard fashion. Once the uterus was detached from the cervix, a 2 cm posterior colpotomy was performed laparoscopically with a monopolar hook under direct view to insert a specimen retrieval bag into the abdomen. The corpus uteri was placed into the bag and transvaginal contained manual morcellation was performed. The colpotomy was then sutured transvaginally. Baseline patients' characteristics and surgical data were collected. Postoperative complications, same-hospital readmissions, and reoperations were registered if occurred within 30 days from surgery.

RESULTS

Patients' median age and BMI were 45,5 and 22,7, respectively. Median operative time was 71.5 min (range 34-143) and uterus weight ranged from 60 g to 470 g (median 210 g). The estimated blood loss was 100 mL (median) and no blood transfusion was required. No conversions to open surgery, nor intraoperative complications occurred. Median hospital stay was 2 days (1-3) and no postoperative complications within 30 days from surgery were recorded.

CONCLUSIONS

LSH followed by in-bag transvaginal specimen extraction is a promising technique and might be considered a reliable and safe option to further reduce the invasiveness of the procedure.

Containment Bag Use Among Women Who Undergo Hysterectomy With Laparoscopic Power Morcellation

OBJECTIVE

To estimate trends in use of laparoscopic power morcellators in women undergoing minimally invasive hysterectomy and to examine use of containment systems in these patients in relation to safety guidance from the U.S. Food and Drug Administration (FDA).

METHODS

We examined data that were recorded in the Premier Healthcare Database from patients who underwent laparoscopic supracervical hysterectomy from 2010 to 2018. Patients were stratified based on use of laparoscopic power morcellators. The cohort was further stratified as either pre-FDA guidance (2010 quarter 1-2014 quarter 1) or post-FDA guidance (2014 quarter 2-2018 quarter 2). Interrupted time series analyses were performed to determine the effect of FDA guidance on the use of laparoscopic power morcellators and containment bags.

RESULTS

Among 67,115 patients, laparoscopic power morcellator use decreased from 66.7% in 2013 quarter 4 to 13.3% by 2018 quarter 2. The likelihood of laparoscopic power morcellator use decreased by 9.5% for each quarter elapsed in the post-FDA warning period (risk ratio [RR] 0.91, 95% CI 0.90-0.91). Containment bag use rose from 5.2% in 2013 quarter 4 to 15.2% by 2018 quarter 2. The likelihood of containment bag use increased by 3% for each quarter elapsed in the post-FDA warning period (RR 1.03, 95% CI 1.02-1.05). Among women who had laparoscopic power morcellator use, uterine cancers or sarcomas were identified in 54 (0.17%) before the FDA guidance compared with seven (0.12%) after the guidance ( P =.45). Containment bags were used in 11.1% of women with uterine cancers or sarcomas before the FDA guidance compared with 14.3% after the guidance ( P =.12). The perioperative complication rate was 3.3% among women who had laparoscopic power morcellator use without a containment bag compared with 4.5% ( P =.001) in those with a containment bag (aRR 1.35, 95% CI 1.12-1.64).

CONCLUSION

Use of laparoscopic power morcellators has decreased over time. Containment bag use increased after the FDA's 2014 guidance; however, most procedures employing laparoscopic power morcellators are still performed without a containment bag.

POMMS: Pre-operative misoprostol in myomectomy surgery: A randomised controlled pilot study

OBJECTIVE

To assess the effect of pre-operative sublingual misoprostol on intra-operative blood loss in abdominal myomectomy as compared to placebo.

STUDY DESIGN

Double-blind randomised controlled pilot study. A single tertiary Gynaecology Unit in Melbourne, Australia. Women ≥ 18 years old undergoing laparoscopic or open myomectomy. Women undergoing laparoscopic or open myomectomy for symptomatic uterine leiomyomas were randomised to pre-operative sublingual 400mcg misoprostol or placebo. Intra-operative blood loss was measured via accurate record keeping of the post-operative volume in the suction canister and weighed packs, minus any irrigation fluid used.

RESULTS

Intraoperative blood loss in the misoprostol treatment group was 306 ml ± 281 ml, compared to 325 ± 352 ml in the placebo group; P = 0.83. Fibroid volume was a consistent predictor of intra-operative blood loss. For each 1 ml increase in fibroid volume there is an increase in blood loss by 0.26 ml (95 % CI: 0.07 - 0.46).

CONCLUSIONS

In this study, we found that there was no significant difference in blood loss between women who received and did not receive sublingual misoprostol before abdominal myomectomy. This is an exploratory study laying the foundation for further randomised clinical trials.

Total surgical time in laparoscopic supracervical hysterectomy with laparoscopic in-bag-morcellation compared to laparoscopic supracervical hysterectomy with uncontained morcellation

Background

A possible solution to the problem of cell dissemination through laparoscopic uncontained morcellation during laparoscopic supracervical hysterectomy (LASH) is the use of laparoscopic in-bag morcellation. One criticism regarding the use of in-bag morcellation is the additional surgical time associated with this procedure.

Objectives

In this retrospective study we compared the total surgical time in LASH with laparoscopic in-bag morcellation (107 cases from 2016-2018) and LASH with uncontained morcellation (47 cases from 2015-2017).

Materials and Methods

All surgeries were performed in the same department of minimally invasive gynaecological surgery by a total of three experienced surgeons for the indication of bleeding disorder and / or dysmenorrhea.

Main outcome measures

We measured and compared total surgical time, surgical outcome, blood loss and complications in LASH with in-bag morcellation and with uncontained morcellation.

Results

Total surgical time in both procedures do not show a significant difference. Considering the learning curve in laparoscopic bag use, the total surgical time in LASH with laparoscopic in-bag morcellation is shorter than total surgical time in LASH with uncontained morcellation. Laparoscopic in-bag morcellation consumes time for bag use and handling, but saves time as it eliminates the need for meticulous sampling of lost tissue fragments and the complex lavage of the peritoneal cavity after morcellation. There is no difference between both groups in terms of blood loss, complications and surgical results.

Conclusion/What is new?

We conclude that LASH with in-bag morcellation is not related to additional surgical time when compared to LASH with uncontained morcellation.

Successful Laparoscopic-Assisted Supracervical Hysterectomy in a 14-Week-Sized Fibroid Uterus: An Autobiographical Case Report

Uterine leiomyomas are a very common gynecological condition. This case report describes the author’s experience pursuing definitive treatment of a 14-week-sized fibroid uterus, the associated menometrorrhagia, and bulk symptoms. Barriers still remain if women of reproductive age prefer ovary-sparing hysterectomy. Laparoscopic supracervical hysterectomy with contained morcellation remains a well-tolerated and low-risk option dependent on surgeon expertise and informed patient consent. Literature review reveals the psychosocial and financial burden of uterine leiomyomas may present multiple challenges, affecting the quality of life.

Novel technique of extracorporeal intrauterine morcellation after total laparoscopic hysterectomy: Three emblematic case reports

BACKGROUND

In the presence of a large uterus, total laparoscopic hysterectomy (TLH), always requires morcellation to allow removal of the tissues from the abdominal cavity. However, uncontained morcellation has been scrutinized because of the possible spread of occult leiomyosarcoma. Therefore, in-bag extracorporeal morcellation has been developed. However, tissue containment and extraction are extremely challenging, especially when considering the increasing uterine size to be removed through minimally invasive surgery.

CASE SUMMARY

Herein, we describe a novel technique for extracorporeal intrauterine morcellation using the uterus outermost layer as a bag to achieve tissue extraction of very large uteri with suspected occult leiomyosarcoma after TLH. The study enrolled patients who were planned for TLH for large uteri (weight > 500 g). TLH was performed following the procedure reported in our previous studies. The novel technique has been described step-by-step in a video, which representatively describes the preoperative imaging and morcellation procedure of three very large uteri weighing 1500 g, 1700 g, and 3700 g, respectively. The procedures were performed without any complications. The patients had an uneventful postoperative course, and in all cases, the pathology was benign leiomyoma.

CONCLUSION

Extracorporeal intrauterine morcellation using the uterus outmost layer as a bag was found to be a feasible technique that allows a careful diagnosis and safe removal of suspected occult malignancies. The technique herein presented may be adopted in surgical practice, by adding it to the other available techniques of contained morcellation. It may represent a valid and feasible alternative, especially useful in cases of very large uteri exceeding the capacity of specimen retrieval bags.

Robotic single-site versus multi-port myomectomy: a case-control study

Background

This study aimed to evaluate the compatibility of robotic single-site (RSS) myomectomy in comparison with the conventional robotic multi-port (RMP) myomectomy to achieve successful surgical outcomes with reliability and reproducibility.

Methods

This retrospective case–control study was performed on 236 robotic myomectomies at a university medical center. After 1:1 propensity score matching for the total myoma number, total myoma diameter, and patient age, 90 patients in each group (RSS: n = 90; RMP: n = 90) were evaluated. Patient demographics, preoperative parameters, intraoperative characteristics, and postoperative outcome measures were analyzed.

Results

The body mass index, parity, preoperative hemoglobin levels, mean maximal myoma diameter, and anatomical type of myoma showed no mean differences between RSS and RMP myomectomies. The RSS group was younger, had lesser number of myomas removed, and had a smaller sum of the maximal diameter of total myomas removed than the RMP group. After propensity score matching, the total operative time (RSS: 150.9 ± 57.1 min vs. RMP: 170 ± 74.5 min, p = 0.0296) was significantly shorter in the RSS group. The RSS group tended to have a longer docking time (RSS: 9.8 ± 6.5 min vs. RMP: 8 ± 6.2 min, p = 0.0527), shorter console time (RSS: 111.1 ± 52.3 min vs. RMP: 125.8 ± 65.1 min, p = 0.0665), and shorter time required for in-bag morcellation (RSS: 30.1 ± 17.2 min vs. RMP: 36.2 ± 25.7 min, p = 0.0684). The visual analog scale pain score 1 day postoperatively was significantly lower in the RSS group (RSS: 2.4 ± 0.8 days vs. RMP: 2.7 ± 0.8 days, p = 0.0149), with similar consumption of analgesic drugs. The rate of transfusion, estimated blood loss during the operation, and length of hospital stay were not different between the two modalities. No other noticeable complications were observed in either group.

Conclusions

Da Vinci RSS myomectomy is a compatible option with regard to reproducibility and safety, without significantly compromising the number and sum of the maximal diameter of myomas removed. The advantage of shorter total operative time and less pain with the same amount of analgesic drugs in RSS myomectomy will contribute to improving patient satisfaction.

Complete Laparoscopic Removal and Staging of a Large Ovarian Malignancy: A Case Report

BACKGROUND Advances in minimally invasive surgery are essential for the improvement of patient care, overall health care efficiency, and total cost reductions. Morcellation, the technique used in the present case, is often used to aid minimally invasive laparoscopic procedures, whereby larger tissue specimens are broken down and divided to be removed via smaller incisions. Morcellation has become controversial in the medical community owing to the risk of the procedure spreading an occult malignancy. CASE REPORT A 47-year-old woman with obesity presented with right-sided pelvic pain and suspicion of ovarian torsion. The patient experienced severe acute pain and was taken to the operating room for laparoscopy to remove the left-sided adnexal mass seen on imaging. During surgery, there was no evidence of torsion, and the mass was perfused. During removal of the entire tumor, blunt instruments were utilized for in-bag manual morcellation to avoid spillage of the contents of the bag, which were then sent for frozen section analysis, and a diagnosis of adenocarcinoma of the ovary was made. Once the tumor was removed, a board-certified gynecologic oncologist was consulted to assist with the remainder of the procedure. Following this, the ovarian cancer staging procedure was able to be completed laparoscopically. CONCLUSIONS This technique of in-bag manual morcellation using blunt instruments allows laparoscopic procedures to be performed on large tissue specimens with potential malignancies without spreading cancerous tissue, overcoming the associated risks of dissemination of malignancy. This technique is therefore more beneficial to patients.

Seven-year survival analysis in women with unsuspected uterine malignancy after laparotomic versus laparoscopic hysterectomy: A national claim data retrospective cohort study

OBJECTIVE

The primary aim was to compare the overall survival of women with unsuspected uterine malignancy (UUM) diagnosed after laparotomic versus laparoscopic hysterectomy for benign gynecologic diseases. The secondary aim was to evaluate the incidence of UUM.

METHODS

A national health insurance database was analyzed from 2006 to 2010.

RESULTS

From the database (24 million women annually), 157 232 women who received hysterectomy for benign diseases were extracted. These women were divided into a laparotomic group (n = 103 631) and a laparoscopic group (n = 53 601). The overall incidences of UUM, unsuspected endometrial cancer, and unsuspected uterine malignancy other than endometrial cancer (UUMOEC) were 0.66%, 0.46%, and 0.19%, respectively. Kaplan-Meier survival analysis and Cox regression analysis showed that the laparoscopic group was associated with more favorable overall survival than the laparotomic group, especially in UUMOEC (P < 0.001).

CONCLUSION

In women with UUM diagnosed after hysterectomy for benign diseases, overall survival up to 7 years favors laparoscopy over laparotomy, especially in UUMOEC and the incidence of UUM is relatively low. However, considering the devastating effect of intraperitoneal dissemination of UUM, surgeons should fully explain this issue to patients preoperatively and try to avoid intraperitoneal spread of tumor cells intraoperatively.

Safety of Minimally Invasive Tissue Extraction in Myoma Management: A Systematic Review

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.

Ectopic leiomyoma as a late complication of laparoscopic hysterectomy with power morcellation: a case report and review of the literature

Introduction: Electromechanical power morcellation is a widely used technique to extract uterine fibroids during laparoscopic hysterectomy. Although the complication rate of morcellators is low, ectopic leiomyoma can appear several years after their use.Patients and methods: We present a case of an ectopic leiomyoma and a literature review of power morcellation-induced complications and ectopic leiomyoma.Results: A 49-year-old female presented with epigastric pain 12 years after laparoscopic subtotal hysterectomy with morcellation of the specimen. Radiological examinations revealed an epigastric mass of 45 mm that was laparoscopically removed. Histological examination confirmed the diagnosis of an ectopic leiomyoma. Complications of power morcellation are rarely reported and include perioperative injuries to bowel, vascular and urinary tract, spreading of ectopic leiomyoma and occult malignancy.Conclusions: Ectopic leiomyoma are a late and rare complication of a laparoscopic hysterectomy with power morcellation of the uterus.

Morcellation During Total Laparoscopic Hysterectomies: Implications of the Use of a Contained Bag System

OBJECTIVE

This study sought to report the feasibility and clinical implications of in-bag morcellation for total laparoscopic hysterectomy (TLH).

METHODS

Women who required uterine morcellation during TLH from January 2017 to December 2018 (at the Centre Hospitalier Universitaire de Québec - CHUL, Québec, QC) were included. Women with a preoperative suspicion of malignancy were excluded (Canadian Task Force classification II-2).

RESULTS

During the 2-year study period, uterine morcellation was required in 42% (106 of 252) of women undergoing TLH. Mean uterine weight of morcellated uterus was 541 ± 291 g, with 11 of 106 uteri weighing >1000 g. In-bag morcellation was attempted in 84 of 106 (79%) and successfully performed in 79 of 84 (94%) women. Failures resulted from inability to insert the specimen into the bag or apparent perforation. Uncontained morcellation was chosen for 22 of 106 (21%) women, most of whom underwent vaginal morcellation of the uterus. Total operative time was 40 minutes longer for the in-bag morcellation group (170 ± 48 vs. 130 ± 43 min; P < 0.001), although this difference can be partly explained by the higher mean uterine size compared with the uncontained morcellation group (580 ± 309 vs. 391 ± 122 g; P = 0.01). In a subgroup analysis of 16 women, the mean times of installation and extraction of the bag were estimated to be 17 ± 9 and 4 ± 3 minutes, respectively. Complications were infrequent (2 of 106) and occurred in the in-bag morcellation group.

CONCLUSION

In-bag morcellation is feasible in a high proportion of women undergoing laparoscopic hysterectomy and is associated with an increase in operative time. Larger studies will be required in order to better assess the risk of complications with in-bag morcellation and the potential benefits of this technique, namely, reducing the spread of tissue.

Laparoscopic approaches to the retropubic space: three alternatives with anatomical considerations

INTRODUCTION

Many urogynecological and surgical laparoscopic interventions require access to the retropubic space, also known as the space of Retzius. Especially in patients with a history of previous surgery in this area or in general in the lower abdomen, the preparation may be complicated by adhesions and scar tissue. The necessity to combine several laparoscopic procedures in one surgical session may require consideration of the most appropriate way to approach the retropubic space.

MATERIAL AND METHODS

We describe and discuss three different options to access the space of Retzius via laparoscopy: the medial transperitoneal, the extraperitoneal and the lateral transperitoneal approach. For all approaches, we used one umbilical trocar and two trocars in the lower abdomen.

RESULTS

An algorithm was developed to select the most appropriate access route to the retropubic space, depending on the history of previous surgeries and accompanying interventions.

CONCLUSION

The knowledge of different access routes to the retropubic space offers the possibility of adjusting the surgical procedure to the individual constellation of the patient.

Two-port myomectomy using bag-contained manual morcellation: A comparison with three-port myomectomy using power morcellation

OBJECTIVES

To evaluate the feasibility and safety of two-port myomectomy using bag-contained manual morcellation compared to three-port myomectomy using power morcellation.

MATERIAL AND METHODS

A retrospective chart review was conducted for 428 cases of either two-port or three-port laparoscopic myomectomy performed by single operator in the university hospital between January 2011 and December 2016.

RESULTS

The cohorts of three-port myomectomy with power morcellation was consisted of two hundred and forty-eight patients. One hundred and eighty patients underwent two-port myomectomy with manual morcellation in contained bag. Two-port group showed shorter hospital stay (5.16 ± 1.39 d vs. 4.83 ± 1.19 d, p = 0.001), less estimated blood loss (61.8 ± 58.2 mL vs. 50.2 ± 52.4 mL, p = 0.001), and higher hemoglobin level at postoperative day 1 (10.7 ± 1.17 g/dL vs. 11.0 ± 1.14 g/dL, p = 0.028) with statistical significance. Morcellation time (25.8 ± 9.30 min vs. 18.9 ± 10.11 min, p = 0.001) and total operative time (82.4 ± 30.19 min vs. 76.4 ± 25.47 min, p = 0.047) were also significantly shorter in two-port group. There were no identified spillages of fibroids, ruptures of specimen bag during manual morcellation in two-port myomectomy. In both groups, there were no cases of leiomyosarcoma diagnosed postoperatively.

CONCLUSION

Two-port laparoscopic myomectomy with bag-contained manual morcellation is a feasible and safe alternative for three-port with power morcellation. Its surgical outcomes were shown to be superior to conventional laparoscopic myomectomy according to our study but further evaluation in near future is needed.

Tissue Extraction in Gynecologic Surgery: Past, Present, and Future

Fibroid tissue extraction during hysterectomy and myomectomy has become increasingly controversial. A wave of research has tried to clarify difficult questions around the prevalence of occult malignancies, the effect of morcellation on cancer outcomes, proper informed consent, and surgical options for tissue extraction. This review examines the history of these controversies and discusses tissue extraction techniques and continued areas of debate in the field.

Effectiveness of adjuvant treatment for morcellated, International Federation of Gynecology and Obstetrics stage I uterine leiomyosarcoma: A Korean multicenter study

AIM

To evaluate the effectiveness of adjuvant treatment for morcellated, uterus-confined leiomyosarcoma in a multicenter setting.

METHODS

We identified patients with International Federation of Gynecology and Obstetrics stage I uterine leiomyosarcoma primarily treated with surgery between 2003 and 2016. Among them, patients who underwent one of the following morcellation methods were included: (i) power morcellation; (ii) intracorporeal morcellation using scalpels or electrocautery; and (iii) vaginal morcellation. Patients' survival outcomes were compared according to the implementation of adjuvant treatment.

RESULTS

From 13 institutions, 55 patients were included; 31 for adjuvant treatment group and 24 for surgery only group. The clinicopathological characteristics including the mass size, morcellation methods, extent of surgery, and mitotic count were similar between the groups. In the adjuvant treatment group, 67.7%, 19.4% and 12.9% of patients received chemotherapy, chemoradiation and radiation, respectively. After a median follow-up of 50.5 months, the adjuvant treatment and surgery only groups showed similar overall survival (5-year rate, 92.0% vs 90.4%; P = 0.959). No significant difference in progression-free survival was observed between the two groups (3-year rate, 46.1% vs 78.2%; P = 0.069). On multivariate analyses, adjuvant treatment did not affect progression-free survival (adjusted HR, 2.138; 95% CI, 0.550-8.305; P = 0.273). The adjuvant treatment group showed a trend towards more common distant metastasis, compared to the surgery only group (25.8% vs 4.2%; P = 0.062). The incidences of pelvic, retroperitoneal, and abdominal recurrences were not different between the groups.

CONCLUSION

Despite its frequent use in clinical practice, adjuvant treatment did not improve the survival outcomes of patients with morcellated, International Federation of Gynecology and Obstetrics stage I uterine leiomyosarcoma.

Iatrogenic parasitic myoma and iatrogenic adenomyoma after laparoscopic morcellation: A mini-review

Laparoscopy is widely recognized as a procedure of choice for gynaecological surgery. Myomectomy and hysterectomy are the most frequently performed surgical procedures in gynaecology. A morcellator is often used in myomectomies or subtotal hysterectomies, but morcellation may cause rare complications, such as parasitic iatrogenic myoma or adenomyoma. To improve patient counselling, proper risk estimation as well as risk factor identification should be acknowledged. This article aimed to review the literature on parasitic myoma and adenomyoma and to compare these diseases in terms of clinical, surgical, and prognostic factors. All published literature (case series and case reports) on iatrogenic myoma and adenomyoma was reviewed using PubMed/MEDLINE and ScienceDirect resources. Despite both conditions having an iatrogenic origin, iatrogenic parasitic myoma and adenomyoma are two different entities in terms of clinical manifestations as well as intraoperative particularities, with a common point: iatrogenic complication. A possible solution to avoid these iatrogenic complications is by using in-bag morcellation or switching to another surgical procedure (e.g., a vaginal or abdominal approach). It is concluded that parasitic myoma and iatrogenic adenomyoma are two different iatrogenic morcellator-related complications. In patients with a history of uterus or myoma morcellation who report pelvic symptoms, iatrogenic parasitic myoma or adenomyoma should be considered in the differential diagnosis.

Occult Gynecologic Cancer in Women Undergoing Hysterectomy or Myomectomy for Benign Indications

OBJECTIVE

To estimate the prevalence of corpus uteri, cervix uteri, and ovarian malignancy in women undergoing hysterectomy or myomectomy for presumed benign indications.

METHODS

We conducted a secondary analysis of data from the 2014-2015 American College of Surgeons National Surgical Quality Improvement Program. Adult women undergoing hysterectomies and myomectomies without evidence for known or suspected cancer at the beginning of surgery were identified from the database. Our primary outcome measure was pathology-confirmed malignancy in the corpus uteri, cervix uteri, and ovary. We performed adjusted logistic regression analysis to examine the association of patient characteristics with the risk for malignancy.

RESULTS

Our sample included 24,076 women undergoing hysterectomy and 2,368 women undergoing myomectomy. Malignancy of the corpus uteri was found in 1.44% (95% CI 1.29-1.59%) of the women undergoing hysterectomy. The prevalence varied considerably across surgical routes with the rate being 0.23% (95% CI 0.06-0.58%) in laparoscopic supracervical hysterectomy and 1.89% (95% CI 1.65-2.14%) in total laparoscopic or laparoscopic-assisted vaginal hysterectomy. Older women were significantly more likely to have preoperatively undetected malignancy of the corpus uteri (adjusted odds ratio 6.46, 95% CI 4.96-8.41 for age 55 years or older vs age 40-54 years). Additionally, 0.60% (95% CI 0.50-0.70%) and 0.19% (95% CI 0.14-0.25%) of the women undergoing hysterectomy were found to have malignancy of the cervix uteri and the ovary, respectively. Among patients undergoing myomectomy, 0.21% (95% CI 0.03-0.40%) were found to have malignancy of the corpus uteri with no occult cervical or ovarian cancer identified.

CONCLUSION

Prevalence of occult corpus uteri, cervical, and ovarian malignancy was 1.44%, 0.60%, and 0.19%, respectively, among women undergoing hysterectomy and it varied by patient age and surgical route.

Uterine fibroids: an update on current and emerging medical treatment options

Uterine fibroids are the most common gynecological disorder, classically requiring surgery when symptomatic. Although attempts at finding a nonsurgical cure date back to centuries, it is only around the middle of the last century that serious attempts at a medical treatment were carried out. Initially, both progestins and estrogen–progestin combinations have been utilized, although proof of their usefulness is lacking. A major step forward was achieved when peptide analogs of the GnRH were introduced, first those with superagonist properties and subsequently those acting as antagonists. Initially, the latter produced side effects preventing their routine utilization; eventually, this problem was overcome following the synthesis of cetrorelix. Because both types of analogs produce hypoestrogenism, their use is limited to a maximum of 6 months and, for this reason, today they are utilized as an adjuvant treatment before surgery with overall good results. Over the last decade, new, nonpeptidic, orally active GnRH-receptor blockers have also been synthesized. One of them, Elagolix, is in the early stages of testing in women with fibroids. Another fundamental development has been the utilization of the so-called selective progesterone receptor modulators, sometimes referred to as “antiprogestins”. The first such compound to be applied to the long-term treatment of fibroids was Mifepristone; today, this compound is mostly used outside of Western Countries, where the substance of choice is Ulipristal acetate. Large clinical trials have proven the effectiveness of Ulipristal in the long-term medical therapy of fibroids, although some caution must be exercised because of the rare occurrence of liver complications. All selective progesterone receptor modulators produce unique endometrial changes that are today considered benign, reversible, and without negative consequences. In conclusion, long-term medical treatment of fibroids seems possible today, especially in premenopausal women.

Comparison of the Technical Feasibility and Safety of Three Contained Morcellation Techniques: A Pilot Study in an Animal Model

STUDY OBJECTIVE

To compare 3 laparoscopic contained morcellation techniques in terms of feasibility and safety.

DESIGN

Pilot study in an animal model (Canadian Task Force classification II-1).

SETTING

Gynecologic oncology department at a cancer institute in Japan.

PATIENTS

Porcine model.

INTERVENTIONS

Three contained morcellation techniques were tested, each multiple times in 1 of 3 anesthetized female pigs: manual morcellation (8 times), dual-site power morcellation (8 times), and single-site power morcellation (6 times). All were tested on beef tongue introduced abdominally.

MEASUREMENTS AND MAIN RESULTS

The following variables were compared: bag insertion time, morcellation time, bag removal time, total in-bag morcellation time, and the volume of pneumoperitoneum CO₂ consumed. Bag rupture was evaluated ex vivo on completion of the procedure. Bag insertion time (in minutes) was significantly greater for dual-site morcellation (10.91 ± 3.38) than for manual (4.58 ± 2.47, p = .003) or single-site power (7.25 ± .77, p = .014) morcellation. Bag removal time (in minutes) was also significantly greater for dual-site morcellation (.85 ± .11 vs .27 ± .14, p<.001, vs .33 ± .59, p = .001). Total in-bag morcellation time, although greatest for manual morcellation at 21.4 ± 10.2 minutes, did not differ significantly between techniques. CO₂ consumption was significantly low for manual morcellation. Visual inspection revealed no bag damage when manual morcellation was performed, but bag damage occurred in 3 dual-site cases and in 1 single-site case.

CONCLUSION

Considering preventing specimen leakage as the main aim of contained morcellation, the bag used for power morcellation needs improvement. Although manual morcellation requires an umbilical wound of about 25 mm, the absence of bag damage, acceptable total morcellation time, relatively low CO₂ consumption, and nonuse of a power device, which translate to an economic benefit, lead us to conclude that manual morcellation will remain advantageous into the future.

Laparoscopic specimen retrieval and attitudes towards morcellation: a questionnaire survey of gynaecology consultants in the United Kingdom

The aim of this study was to evaluate the practices of laparoscopic specimen retrieval among Gynaecologists in the United Kingdom and to determine any variation in practice. A survey of Consultant Gynaecologist members of the British Society of Gynaecological Endoscopy (BSGE) was conducted using Survey Monkey™. Of the 460 registered consultants, 187 (40%) responded to the questionnaire. Sixty-two percent (62%) of the respondents considered themselves to be advanced laparoscopic surgeons whilst 34% considered themselves to be intermediate laparoscopic surgeons. The umbilical port was the most commonly used port for specimen retrieval and it was used to remove 49% of ectopic pregnancies, 43% of ovarian cysts and 43% of endometrioma. Most respondents would not insert an extra port or extend the existing port just for the retrieval of a specimen. The level of laparoscopic experience and the gender did not affect the method of specimen retrieval in cases of ectopic pregnancies, endometrioma and ovarian cysts (p value >.05, not significant). The majority of respondents used power morcellation for a laparoscopic myomectomy (85% of respondents) and laparoscopic subtotal hysterectomy (93% of respondents), despite the recent concerns surrounding power morcellation. Impact statement What is already known on this subject? There is a paucity of literature regarding laparoscopic specimen retrieval in gynaecology. In view of recent controversy pertaining to the potential upstaging of leiomyosarcoma with morcellation, other methods of specimen retrieval are gaining an importance. What do the results of this study add? This study shows that the umbilical port is the most commonly used port for specimen retrieval among UK gynaecologists and that most gynaecologists would not insert an additional port purely for specimen retrieval. Most respondents would still use power morcellation for a laparoscopic myomectomy and subtotal hysterectomy, despite the recent concerns over morcellation and its safety. What are the implications of these findings for clinical practice and/or further research? This paper demonstrates the need for development of a database of morcellation practices to enable analysis of both benefits and potential adverse outcomes. This paper will also encourage future research and the audit of specimen retrieval.

Safety and feasibility of contained uterine morcellation in women undergoing laparoscopic hysterectomy

Background

Widespread concerns have been raised regarding the safety of power morcellation of uterine specimens because of the potential to disseminate occult malignancy. We sought to assess the safety and feasibility of contained manual uterine morcellation within a plastic specimen bag among women with uterine neoplasms.

Methods

A retrospective single-institution descriptive cohort study was conducted from 2003 to 2014. Patients with leiomyoma and/or uterine malignancy who underwent minimally invasive surgery with contained uterine manual morcellation were identified from surgical logs. Demographic data, pathology results, operative details and adjuvant treatments were abstracted.

Results

Eighty-eight patients were identified; 35 with leiomyoma and 53 with endometrial cancer. The mean age was 48 and 60, respectively. Uterine size/weight was greater in women with leiomyoma compared to those with cancer (15.1 weeks/448 g vs. 10.7 weeks/322 g). Mean operative time was 206 min (range 115–391) for leiomyoma cases and 238 min (range 131–399) for cancer cases. Median length of stay was 1 day (range 0–3 days). There were no cases of occult leiomyosarcoma and all specimens were successfully manually morcellated within a bag. There were no intraoperative complications. Thirty-day postoperative complications occurred in 7 patients, including one readmission for grade (G) 1 vaginal cuff separation after intercourse, G1 port-site hematoma (1), G2 port-site cellulitis (1), G2 vaginal cuff cellulitis (2), G2 bladder infection (2), G2 pulmonary edema (1), and G1 musculoskeletal injury (1).

Conclusions

Contained uterine hand morcellation is a feasible procedure with low peri-operative complication rates that allows for minimally invasive surgical procedures for women with large uterine neoplasms. Further evaluation is needed to assess survival outcomes for uterine malignancies.

Towards spill-free in-bag morcellation: a health failure mode and effects analysis

BACKGROUND

To assess potential risks of new surgical procedures and devices before their introduction into daily practice, a prospective risk inventory (PRI) is a required step. This study assesses the applicability of the Health Failure Mode and Effects Analysis (HFMEA) as part of a PRI of new technology in minimally invasive gynecologic surgery.

METHODS

A reference case was defined of a patient with presumed benign leiomyoma undergoing a laparoscopic hysterectomy or myomectomy including in-bag power morcellation; however, pathology defined a stage I uterine leiomyosarcoma. Using in-bag morcellation as a template, a HFMEA was performed. All steps of the in-bag morcellation technique were identified. Next, the possible hazards of these steps were explored and possible measures to control these hazards were discussed.

RESULTS

Five main steps of the morcellation process were identified. For retrieval bags without openings to accommodate instruments inside the bag, 120 risks were identified. Of these risks, 67 should be eliminated. For containment bags with openings 131 risks were identified of which 68 should be eliminated. Of the 10 causes most at risk to cause spillage, two can be eliminated by using appropriate bag materials. Myomectomy appears to be more at risk for residual tissue spillage compared to total hysterectomy.

CONCLUSION

The HFMEA has provided important new insights regarding potential weaknesses of the in-bag morcellation technique, particularly with respect to hazardous steps in the morcellation process as well as requirements that bags should meet. As such, this study has shown HFMEA to be a valuable method that identifies and quantifies potential hazards of new technology.

In Search for the Best Minimally Invasive Hysterectomy Approach for the Large Uterus: A Review

Review of literature is conducted to determine the best minimally invasive hysterectomy (MIH) route for large uterus, identify preoperative considerations and describe alternative techniques to power morcellation. Studies after 2010 revealed multiple MIH approaches. Vaginal hysterectomy is preferred over laparoscopic and laparoscopic assistance with less operative time and hospital cost. In morbidly obese patients with large uteri, total laparoscopic hysterectomy is superior to vaginal hysterectomy with lesser odds of blood transfusion and lower length of hospital stay. Although MIH for the large uterus is feasible, many questions remain unanswered. Well-designed multicenter prospective trial incorporating clinical pathways to compare outcomes is needed.

Prevention and Management of Complications in Laparoscopic Myomectomy

Myomectomy aims to preserve fertility, treat abnormal uterine bleeding, and alleviate pain. It should cause minimal damage to the endometrium, while being tolerable and durable, and reduce the incidence of myoma recurrence and complications including bleeding, hematoma, adhesions, and gravid uterus perforation. Training and experience are crucial to reduce complications. The surgical strategy depends on imaging information on the myomas. The position of the optical and secondary ports will determine the degree of ergonomic surgery performance, time and difficulty of myoma enucleation, and the suturing quality. Appropriate hysterotomy length relative to myoma size can decrease bleeding, coagulation, and suturing times. Bipolar coagulation of large vessels, while avoiding carbonization and myometrium gaps after suturing, may decrease the risk of myometrial hematoma. Quality surgery and the use of antiadhesive barriers may reduce the risk of postoperative adhesions. Slow rotation of the beveled morcellator and good control of the bag could reduce de novo myoma and endometriosis. Low intra-abdominal CO2 pressure may reduce the risk of benign and malignant cell dissemination. The benefits a patient gains from laparoscopic myomectomy are greater than the complication risks of laparoscopic morcellation. Recent publications on laparoscopic myomectomies demonstrate reduced hospitalization stays, postoperative pain, blood loss, and recovery compared to open surgery.

In-bag power morcellation technique in single-port laparoscopic myomectomy

OBJECTIVE

This study introduces and evaluates the feasibility, safety, and surgical outcomes of the in-bag power morcellation technique during single-port assisted (SPA) laparoscopic myomectomy in comparison with manual scalpel morcellation.

METHODS

This is a retrospective review of a total of 58 patients who underwent SPA laparoscopic myomectomy employing in-bag power morcellation (n=27) or manual scalpel morcellation (n=31), performed between December 2014 and December 2016. Surgical outcomes, including total operation time, estimated blood loss, postoperative hemoglobin changes, postoperative hospital stay, postoperative pain (visual analog scale), perioperative and postoperative complications were evaluated.

RESULTS

The demographics and patient characteristics were similar between both groups. The median patient age was 34 years and median body mass index was 20.84 kg/m2. The median specimen weight was 110 g. The median operating time was 138 minutes. The median estimated blood loss was 50 mL and the median postoperative hemoglobin change was 2.2 g/dL. The median postoperative hospital stay was 2 days and the median postoperative pain scores were 5 after 6 hours, 3 after 24 hours, and 2 after 48 hours. Occult malignancy was not identified in any patients. There were no intraoperative complications such as LapBag ruptures or gross spillage.

CONCLUSION

In-bag power morcellation for SPA laparoscopic myomectomy is feasible and safe, minimizing the risks of open power morcellation. There were also no statistically significant differences in surgical outcomes.

In-Bag Morcellation as a Routine for Laparoscopic Hysterectomy

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.

Laparoscopic Supracervical Hysterectomy with In-Bag Morcellation in Very Large Uterus

Laparoscopic supracervical hysterectomy (LASH) is a safe and fast minimally invasive approach in hysterectomy. In order to extract the uterine body from the abdominal cavity, one condition for LASH is the morcellation of the tissue. The intra-abdominal dissemination of benign and occult malignant uterine cells is a possible risk of this method, which can be avoided by the use of special bags for laparoscopic in-bag morcellation. We present a case of laparoscopic supracervical hysterectomy with in-bag morcellation in a uterus of more than 1400 g. and describe that this minimal-access surgery is safe and feasible even in very large uteri. This case report is registered in Research Registry under the UIN researchregistry1810.

Pushing the boundaries of laparoscopic myomectomy: a comparative analysis of peri-operative outcomes in 323 women undergoing laparoscopic myomectomy in a tertiary referral centre

Background

The aim of this study was to analyse the demographic data and peri-operative outcomes of women undergoing a laparoscopic myomectomy and assess what factors, if any, precluded using the laparoscopic approach.

Methods

A single surgeon observational study of 323 patients undergoing a laparoscopic myomectomy was undertaken. Data was collected prospectively over a 12-year period and analysed using SPSS. Surgical outcomes included operating time, estimated blood loss, conversion to laparotomy, intraoperative and postoperative complications and duration of inpatient stay.

Results

A total of 323 patients underwent a laparoscopic myomectomy over the 12-year period. The majority of fibroids removed were intramural (49%) and subserosal (33%). The mean size of fibroids removed was 7.66 ± 2.83 (7.34–7.99) cm, and the mean number was 4 ± 3.62 (3.6–4.39), with the greatest being 22 removed from a single patient. Average blood loss was 279.14 ± 221.10 (254.59–303.69) ml with mean duration of surgery and inpatient stay recorded as 112.92 ± 43.21 (107.94–117.91) min and 1.88 ± 0.95 (1.77–1.99) days, respectively. No major intraoperative complications were noted, and the conversion to laparotomy rate was 0.62%. All histology following morcellation was benign. Over the 12-year period despite increasingly large and more numerous fibroids being tackled, increasing experience resulted in a simultaneous reduction in overall blood loss, operating time and duration of inpatient stay.

Conclusions

Laparoscopic myomectomy is a safe and efficacious procedure that should be considered the gold standard surgical treatment option for fibroids. With experience, the procedure can be undertaken with minimal complications, a low risk of conversion to laparotomy and early discharge from hospital, even in cases of large and multiple fibroids that historically would have required the open approach. This allows even the most complex of cases to now benefit for the advantages of the minimal access approach.

Reducing the spread of occult uterine sarcoma at the time of minimally invasive gynecologic surgery

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.

Tissue Extraction Techniques During Laparoscopic Uterine Surgery

Morcellation allows minimally invasive approaches to surgery even in the presence of large uteri or myomas. Recent restrictions in the use of power morcellation, as well as concerns regarding the potential for morcellation to disseminate malignant tissue, have initiated investigation and innovation to find safer methods. This review examines current techniques for tissue extraction during uterine surgery, with a focus on contained power morcellation and contained manual morcellation via mini-laparotomy or colpotomy. Videos are included to demonstrate these methods.