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Vargas M, Arora Y, Alejandro Bueno M, Gerardo Rodriguez C. Adverse outcomes related to morcellation in Total Laparoscopic Hysterectomy. Eur J Obstet Gynecol Reprod Biol 2024; 294:231-237. [PMID: 38301502 DOI: 10.1016/j.ejogrb.2024.01.031] [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: 10/08/2023] [Revised: 12/20/2023] [Accepted: 01/24/2024] [Indexed: 02/03/2024]
Abstract
OBJECTIVE This study aimed to comprehensively evaluate the complications associated with morcellation in Total Laparoscopic Hysterectomy (TLH) procedures, providing evidence-based insights to enhance patient safety and surgical efficacy. DATA SOURCES A comprehensive literature search was conducted using multiple databases, including PubMed, EMBASE, Google Scholar, and Cochrane Central Register of Controlled Trials. The inclusion criteria were Studies that focused on morcellation and morcellation-related complications were included. The risk of bias in the included studies was assessed using established evaluation scales. METHODS OF STUDY SELECTION Thirteen studies investigating complications associated with morcellation in TLH (Total Laparoscopic Hysterectomy) were included in this review.This review covers intraoperative blood loss, length of hospital stay, loss of bag integrity, mean uterine specimen and weight, morcellation time, operation time, and TLH morcellation complications. TABULATION, INTEGRATION, AND RESULTS The selected studies covered different approaches and aspects related to this procedure, providing valuable insights into the factors associated with complications and efficacy of the technique in various clinical settings.This review highlights the importance of evaluating and considering complications associated with morcellation in TLH. CONCLUSION The findings of this review provide valuable insights into complications associated with morcellation in TLH. Clinicians could use this information to make informed decisions, implement safe protocols, and improve patient care. Addressing these complications will enhance the safety and efficacy of morcellation for TLH. Ethical Compliance: All procedures performed in this study involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.
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Obrzut B, Kijowska M, Obrzut M, Mrozek A, Darmochwał-Kolarz D. Contained Power Morcellation in Laparoscopic Uterine Myoma Surgeries: A Brief Review. Healthcare (Basel) 2023; 11:2481. [PMID: 37761678 PMCID: PMC10531049 DOI: 10.3390/healthcare11182481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 09/05/2023] [Accepted: 09/06/2023] [Indexed: 09/29/2023] Open
Abstract
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.
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Affiliation(s)
- Bogdan Obrzut
- Department of Obstetrics and Gynecology, Institute of Medical Sciences, Medical College, University of Rzeszów, Rejtana 16 C, 35-959 Rzeszow, Poland
| | - Marta Kijowska
- Department of Obstetrics and Gynecology, Provincial Clinical Hospital No. 2 Rzeszow, Lwowska 60, 35-301 Rzeszow, Poland
| | - Marzanna Obrzut
- Institute of Health Sciences, Medical College, University of Rzeszow, Warzywna 1a, 35-310 Rzeszow, Poland
| | - Adam Mrozek
- Department of Obstetrics and Gynecology, Institute of Medical Sciences, Medical College, University of Rzeszów, Rejtana 16 C, 35-959 Rzeszow, Poland
| | - Dorota Darmochwał-Kolarz
- Department of Obstetrics and Gynecology, Institute of Medical Sciences, Medical College, University of Rzeszów, Rejtana 16 C, 35-959 Rzeszow, Poland
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Güven CM, Uysal D. In-bag abdominal manual morcellation versus contained power morcellation in laparoscopic myomectomy: a comparison of surgical outcomes and costs. BMC Surg 2023; 23:106. [PMID: 37118798 PMCID: PMC10148462 DOI: 10.1186/s12893-023-02007-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 04/13/2023] [Indexed: 04/30/2023] Open
Abstract
BACKGROUND To compare the surgical outcomes and costs of in-bag abdominal manual morcellation (AMM) and contained power morcellation (PM) in laparoscopic myomectomy. METHODS A total of 61 patients were divided into two groups based on their myomectomy specimen extraction methods: AMM group (n = 33) and electromechanical contained PM group (n = 28). The surgical outcomes and cost were compared between groups. During AMM, a glove bag (in 27 patients) and an endo bag were used (in 6 patients) according to the myoma size. RESULTS Morcellation time (18 ± 9.2 min vs. 37.4 ± 14.1 min) and total operation time (100 ± 24.3 min vs. 127 ± 33.1 min) were significantly lower in the AMM group compared to those in the PM group. Other surgical outcomes, which were similar between groups, included delta hemoglobin, length of hospital stay and VAS score at 12 and 24 h postoperatively. There were no per- or postoperative complications in both group with no conversion to laparotomy. One patient was transfused with two units of erythrocyte suspension postoperatively in the PM group. Sarcoma was not diagnosed in any of the cases in both group. CONCLUSION The in-bag AMM or contained PM for specimen extraction resulted in similar outcomes in terms of delta hemoglobin, postoperative pain intensity (VAS score at 12 and 24 h postoperatively), the need for additional analgesia, and the length of hospital stay; however, total operation time and morcellation time were significantly shorter in the AMM group, indicating a prominent advantage. Significant cost-effectiveness is also a critical advantage of in-bag AMM compared to containing PM.
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Affiliation(s)
- Cenk Mustafa Güven
- Department of Obstetrics and Gynecology, Izmir Private Can Hospital, İzmir, Turkey.
| | - Dilek Uysal
- Department of Obstetrics and Gynecology, Atatürk Training and Research Hospital, University of Katip Çelebi, İzmir, Turkey
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Herman A, Duraiswamy N, Nandy P, Price V, Gibeily G, Hariharan P. Mechanical and leakage integrity testing considerations for evaluating the performance of tissue containment systems. Sci Rep 2023; 13:5104. [PMID: 36991010 PMCID: PMC10060240 DOI: 10.1038/s41598-023-31847-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 03/17/2023] [Indexed: 03/31/2023] Open
Abstract
Tissue containment systems (TCS) are medical devices that may be used during morcellation procedures during minimally invasive laparoscopic surgery. TCS are not new devices but their use as a potential mitigation for the spread of occult malignancy during laparoscopic power morcellation of fibroids and/or the uterus has been the subject of interest following reports of upstaging of previously undetected sarcoma in women who underwent a laparoscopic hysterectomy. Development of standardized test methods and acceptance criteria to evaluate the safety and performance of these devices will speed development, allowing for more devices to benefit patients. As a part of this study, a series of preclinical experimental bench test methods were developed to evaluate the mechanical and leakage performance of TCS that may be used in power morcellation procedures. Experimental tests were developed to evaluate mechanical integrity, e.g., tensile, burst, puncture, and penetration strengths for the TCS, and leakage integrity, e.g., dye and microbiological leakage (both acting as surrogates for blood and cancer cells) through the TCS. In addition, to evaluate both mechanical integrity and leakage integrity as a combined methodology, partial puncture and dye leakage was conducted on the TCS to evaluate the potential for leakage due to partial damage caused by surgical tools. Samples from 7 different TCSs were subjected to preclinical bench testing to evaluate leakage and mechanical performance. The performance of the TCSs varied significantly between different brands. The leakage pressure of the TCS varied between 26 and > 1293 mmHg for the 7 TCS brands. Similarly, the tensile force to failure, burst pressure, and puncture force varied between 14 and 80 MPa, 2 and 78 psi, and 2.5 N and 47 N, respectively. The mechanical failure and leakage performance of the TCS were different for homogeneous and composite TCSs. The test methods reported in this study may facilitate the development and regulatory review of these devices, may help compare TCS performance between devices, and increase provider and patient accessibility to improved tissue containment technologies.
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Affiliation(s)
- Alexander Herman
- Center for Devices and Radiological Health, Food & Drug Administration, Silver Spring, MD, USA
| | - Nandini Duraiswamy
- Center for Devices and Radiological Health, Food & Drug Administration, Silver Spring, MD, USA
| | - Poulomi Nandy
- Center for Devices and Radiological Health, Food & Drug Administration, Silver Spring, MD, USA
| | - Veronica Price
- Center for Devices and Radiological Health, Food & Drug Administration, Silver Spring, MD, USA
| | - George Gibeily
- Center for Devices and Radiological Health, Food & Drug Administration, Silver Spring, MD, USA
| | - Prasanna Hariharan
- Center for Devices and Radiological Health, Food & Drug Administration, Silver Spring, MD, USA.
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Wright JD, Chen L, Melamed A, Clair CMS, Hou JY, Khoury-Collado F, Gockley A, Accordino M, Hershman DL, Xu X. Containment Bag Use Among Women Who Undergo Hysterectomy With Laparoscopic Power Morcellation. Obstet Gynecol 2022; 140:371-380. [PMID: 35926199 DOI: 10.1097/aog.0000000000004886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 05/19/2022] [Indexed: 01/05/2023]
Abstract
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.
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Affiliation(s)
- Jason D Wright
- Columbia University College of Physicians and Surgeons, the Joseph L. Mailman School of Public Health, Columbia University, the Herbert Irving Comprehensive Cancer Center, and NewYork-Presbyterian Hospital, New York, New York; and Yale University School of Medicine, New Haven, Connecticut
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Krentel H, Tchartchian G, Torres de la Roche L, De Wilde R. Total surgical time in laparoscopic supracervical hysterectomy with laparoscopic in-bag-morcellation compared to laparoscopic supracervical hysterectomy with uncontained morcellation. Facts Views Vis Obgyn 2022; 14:59-68. [PMID: 35373549 PMCID: PMC9612860 DOI: 10.52054/fvvo.14.1.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
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.
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Abstract
ABSTRACT Morcellation is a surgical technique used to reduce the size of the uterus or myomas by creating smaller pieces to allow the tissue to be removed through small incisions or with laparoscopic instruments. Open (uncontained) morcellation of the uterus and myomas has been scrutinized because of the possible spread of an unsuspected leiomyosarcoma while using a power morcellator during a hysterectomy or myomectomy for presumed symptomatic uterine leiomyomas. Before considering morcellation of the uterus, a woman should be evaluated to determine if she is at increased risk of malignancy of the uterine corpus. Morcellation of a malignancy is contraindicated and women should be evaluated preoperatively to identify malignancy. However, leiomyosarcoma cannot be reliably diagnosed preoperatively; thus, there is a risk that a woman with a presumed leiomyoma may have a malignancy that may be spread through morcellation, leading to a potentially worsened prognosis. Although an abdominal hysterectomy or myomectomy may reduce the chance of spreading cancer cells in women with undiagnosed leiomyosarcoma, it is associated with increased morbidity when compared with minimally invasive approaches. The obstetrician-gynecologist and patient should engage in shared decision making, including informed consent, explaining the risks and benefits of each approach to surgery for presumed leiomyomas, the risks and benefits of morcellation, and alternatives to morcellation.
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Macciò A, Sanna E, Lavra F, Calò P, Madeddu C. Novel technique of extracorporeal intrauterine morcellation after total laparoscopic hysterectomy: Three emblematic case reports. World J Clin Cases 2021; 9:5655-5660. [PMID: 34307621 PMCID: PMC8281410 DOI: 10.12998/wjcc.v9.i20.5655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 05/10/2021] [Accepted: 05/24/2021] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Antonio Macciò
- Department of Gynecologic Oncology, Businco Hospital, ARNAS G. Brotzu, Cagliari 09100, Italy
| | - Elisabetta Sanna
- Department of Gynecologic Oncology, Businco Hospital, ARNAS G. Brotzu, Cagliari 09100, Italy
| | - Fabrizio Lavra
- Department of Gynecologic Oncology, Businco Hospital, ARNAS G. Brotzu, Cagliari 09100, Italy
| | - Piergiorgio Calò
- Department of Surgical Sciences, University of Cagliari, Cagliari 09100, Italy
| | - Clelia Madeddu
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari 09100, Italy
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Mynbaev OA, Sparic R, Stark M, Malvasi A, Marinelli E, Zaami S, Tinelli A. The Medical Device Applied to Uterine Fibroids Morcellation: Analysis of Critical Biological Issues and Drawbacks from A Medical-Legal Prospective. Curr Pharm Des 2020; 26:318-325. [PMID: 32013843 DOI: 10.2174/1381612826666200204093737] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2019] [Accepted: 01/27/2020] [Indexed: 12/23/2022]
Abstract
Following the FDA safety communication of 2014 increasing attention has been to the treatment of uterine fibroids, due to the suspicion of a potential leiomyosarcoma (ULM). FDA banned the use of power morcellation in the US, since this technique is likely to spread malignant cells from an unsuspected ULM. We criticized the medical legal consequences of this banning among gynecologists and patients, focusing on the drawbacks of biology and surgery. The authors analyzed literature data on one side, on the incidence, diagnosis and treatment of leiomyoma and ULM, and the other side, on the power morcellations and related critical issues, trying to highlight their main controversial aspects and to outline the possible impact on patients and on medical responsibility. The alternative methods to power morcellation are more invasive surgical solutions (as mini laparotomy or culdotomy), which inevitably involve associated risks with the surgical procedure as such and always request the containing bags. Although the in-bag morcellation is a promising technique, currently the used devices are largely off-label. This highlights the surgical risk, in case of complications, of suffering for malpractice claims both for not having used a containment system, favoring the spread of the neoplasm, and for its off-label use. Since the diagnosis of ULM is by histology after surgery, the fear of legal consequences or medical malpractice for unknown ULM power morcellation, should be targeted to analyze, in terms of cost/benefit ratio, the surgical priority. It should focus on the prevention of the risk of having a rare and statistically limited ULM or on the surgical-related complications, often linked to a slowdown minimally invasive surgery, or on the use of the authorized in-bag morcellations.
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Affiliation(s)
- Ospan A Mynbaev
- Laboratory of Human Physiology, Phystech BioMed School, Faculty of Biological & Medical Physics, Moscow Institute of Physics and Technology (State University), Dolgoprudny, Moscow Region, Russian Federation
| | | | - Michael Stark
- Department of Obstetrics and Gynecology, GVM Care & Research Santa Maria Hospital, Bari, Italy. Laboratory of Human Physiology, Phystech BioMed School, Faculty of Biological & Medical Physics, Moscow Institute of Physics and Technology (State University), Dolgoprudny, Moscow Region, Russian Federation
| | - Antonio Malvasi
- Clinical Centre of Serbia, Clinic for Gynecology and Obstetrics, and University of Belgrade, School of Medicine, Belgrade, Serbia
| | - Enrico Marinelli
- Department of Anatomical, Histological, Forensic and Orthopedic Sciences, Sapienza University of Rome, Rome, Italy
| | - Simona Zaami
- Department of Anatomical, Histological, Forensic and Orthopedic Sciences, Sapienza University of Rome, Rome, Italy
| | - Andrea Tinelli
- Department of Obstetrics and Gynecology, "Veris delli Ponti" Hospital, Scorrano, Lecce, Italy
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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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11
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Morcellation During Total Laparoscopic Hysterectomies: Implications of the Use of a Contained Bag System. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2020; 42:839-845. [PMID: 32273084 DOI: 10.1016/j.jogc.2019.11.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2019] [Revised: 11/03/2019] [Accepted: 11/04/2019] [Indexed: 11/22/2022]
Abstract
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.
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Settnes A, Moeller C, Topsoee MF, Norrbom C, Kopp TI, Dreisler E, Joergensen A, Dueholm M, Rasmussen SC, Froeslev PA, Ottesen B, Gimbel H. Complications after benign hysterectomy, according to procedure: a population‐based prospective cohort study from the Danish hysterectomy database, 2004–2015. BJOG 2020; 127:1269-1279. [DOI: 10.1111/1471-0528.16200] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2020] [Indexed: 12/17/2022]
Affiliation(s)
- A Settnes
- Department of Gynaecology and ObstetricsNorth Zealand University Hospital Hilleroed Denmark
| | - C Moeller
- Department of Gynaecology and ObstetricsAarhus University Hospital Aarhus Denmark
| | - MF Topsoee
- Department of Gynaecology and ObstetricsNorth Zealand University Hospital Hilleroed Denmark
| | - C Norrbom
- Department of Gynaecology and ObstetricsNorth Zealand University Hospital Hilleroed Denmark
| | - TI Kopp
- The Danish Clinical Registries RKKP Frederiksberg Denmark
| | - E Dreisler
- Department of GynaecologyRigshospitaletCopenhagen University Hospital Copenhagen Denmark
| | - A Joergensen
- Department of Gynaecology and ObstetricsAalborg University Hospital Aalborg Denmark
| | - M Dueholm
- Department of Gynaecology and ObstetricsAarhus University Hospital Aarhus Denmark
| | - SC Rasmussen
- Department of GynaecologyCopenhagen University Hospital Copenhagen Denmark
| | - PA Froeslev
- The Danish Clinical Registries RKKP Frederiksberg Denmark
| | - B Ottesen
- RigshospitaletCopenhagen University Hospital Copenhagen Denmark
| | - H Gimbel
- Department of Gynaecology and ObstetricsZealand University Hospital Roskilde Denmark
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13
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Yang J, Song YJ, Na YJ, Kim HG. Two-port myomectomy using bag-contained manual morcellation: A comparison with three-port myomectomy using power morcellation. Taiwan J Obstet Gynecol 2019; 58:423-427. [PMID: 31122536 DOI: 10.1016/j.tjog.2019.01.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/12/2019] [Indexed: 12/18/2022] Open
Abstract
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.
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Affiliation(s)
- Juseok Yang
- Department of Obstetrics and Gynecology, Pusan National University Yangsan Hospital, Yangsan, South Korea; Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, South Korea
| | - Yong Jung Song
- Department of Obstetrics and Gynecology, Pusan National University Yangsan Hospital, Yangsan, South Korea; Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, South Korea
| | - Yong Jin Na
- Department of Obstetrics and Gynecology, Pusan National University Yangsan Hospital, Yangsan, South Korea; Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, South Korea
| | - Hwi Gon Kim
- Department of Obstetrics and Gynecology, Pusan National University Yangsan Hospital, Yangsan, South Korea; Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, South Korea.
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Abstract
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.
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Herman A, Duraiswamy N, Nandy P, Myers MR, Price V, Gibeily G, Hariharan P. In Vitro Leakage Testing of Tissue Containment Bags When Subjected to Power Morcellation Forces. J Minim Invasive Gynecol 2019; 27:655-664. [PMID: 31125722 DOI: 10.1016/j.jmig.2019.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Revised: 04/15/2019] [Accepted: 05/11/2019] [Indexed: 10/26/2022]
Abstract
STUDY OBJECTIVE To determine the ability of tissue containment systems to prevent leakage of cancer cell surrogates when subjected to forces encountered during power morcellation procedures. DESIGN In vitro study. SETTING Medical device research laboratory. INTERVENTIONS Samples from 7 different legally marketed tissue containment bags (1 of which is indicated for power morcellation) were subjected to dye and bacteriophage penetration tests at pressures ranging from 0.5 to 50 times the insufflation pressure. The minimum pressure required to cause bag leakage was measured. Subsequently, the morcellation leakage safety factor for each bag was determined as the ratio of the minimum leakage pressure of the bag to the total pressure contributed from insufflation pressure and mechanical forces acting during the power morcellation procedure. MEASUREMENT AND MAIN RESULTS The leakage performance of the bags varied markedly from brand to brand. No correlation was found between leakage pressure and the bag material or the total bag thickness. The leakage pressures ranged from 26 mmHg to >1293 mmHg for the 7 bags, and safety factors ranged from 1 to 50 when only the insufflation pressure was considered. However, if the morcellation forces were included in the calculation, the safety factor dropped by 6-fold for all brands and dropped below 1, indicating likelihood of leakage, for 2 of the 7 brands. CONCLUSION This study provides a mechanism for more realistically simulating the conditions experienced by containment bags during morcellation and quantifying the level of safety provided by the bags.
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Affiliation(s)
- Alexander Herman
- Division of Applied Mechanics, Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, Maryland (all authors), and Office of Product Evaluation and Quality, Center for Devices and Radiological Health, Food and Drug Administration (Ms. Price, Drs. Gibeily and Nandy)
| | - Nandini Duraiswamy
- Division of Applied Mechanics, Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, Maryland (all authors), and Office of Product Evaluation and Quality, Center for Devices and Radiological Health, Food and Drug Administration (Ms. Price, Drs. Gibeily and Nandy)
| | - Poulomi Nandy
- Division of Applied Mechanics, Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, Maryland (all authors), and Office of Product Evaluation and Quality, Center for Devices and Radiological Health, Food and Drug Administration (Ms. Price, Drs. Gibeily and Nandy)
| | - Matthew R Myers
- Division of Applied Mechanics, Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, Maryland (all authors), and Office of Product Evaluation and Quality, Center for Devices and Radiological Health, Food and Drug Administration (Ms. Price, Drs. Gibeily and Nandy)
| | - Veronica Price
- Division of Applied Mechanics, Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, Maryland (all authors), and Office of Product Evaluation and Quality, Center for Devices and Radiological Health, Food and Drug Administration (Ms. Price, Drs. Gibeily and Nandy)
| | - George Gibeily
- Division of Applied Mechanics, Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, Maryland (all authors), and Office of Product Evaluation and Quality, Center for Devices and Radiological Health, Food and Drug Administration (Ms. Price, Drs. Gibeily and Nandy)
| | - Prasanna Hariharan
- Division of Applied Mechanics, Center for Devices and Radiological Health, Food and Drug Administration, Silver Spring, Maryland (all authors), and Office of Product Evaluation and Quality, Center for Devices and Radiological Health, Food and Drug Administration (Ms. Price, Drs. Gibeily and Nandy)..
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Devassy R, Cezar C, Krentel H, Verhoeven HC, Devassy R, de Wilde MS, Torres-de la Roche LA, de Wilde RL. Feasibility of myomatous tissue extraction in laparoscopic surgery by contained in – bag morcellation: A retrospective single arm study. Int J Surg 2019; 62:22-27. [DOI: 10.1016/j.ijsu.2018.12.013] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 12/07/2018] [Accepted: 12/18/2018] [Indexed: 12/24/2022]
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Aoki Y, Kanao H, Kikuchi I, Nomura H, Okamoto S, Hisa T, Sugihara T, Kitano R, Omatsu K, Tanigawa T, Takeshima N. Comparison of the Technical Feasibility and Safety of Three Contained Morcellation Techniques: A Pilot Study in an Animal Model. J Minim Invasive Gynecol 2018; 26:1288-1296. [PMID: 30562578 DOI: 10.1016/j.jmig.2018.12.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Revised: 12/05/2018] [Accepted: 12/08/2018] [Indexed: 10/27/2022]
Abstract
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.
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Affiliation(s)
- Yoichi Aoki
- Department of Gynecologic Oncology, Cancer Institute Hospital (Drs. Aoki, Kanao, Nomura, Okamoto, Hisa, Sugihara, Omatsu, Tanigawa, and Takeshima), Tokyo, Japan.
| | - Hiroyuki Kanao
- Department of Gynecologic Oncology, Cancer Institute Hospital (Drs. Aoki, Kanao, Nomura, Okamoto, Hisa, Sugihara, Omatsu, Tanigawa, and Takeshima), Tokyo, Japan
| | - Iwaho Kikuchi
- Department of Obstetrics and Gynecology, Juntendo Urayasu Hospital (Dr. Kikuchi), Urayasu, Japan
| | - Hidetaka Nomura
- Department of Gynecologic Oncology, Cancer Institute Hospital (Drs. Aoki, Kanao, Nomura, Okamoto, Hisa, Sugihara, Omatsu, Tanigawa, and Takeshima), Tokyo, Japan
| | - Syuhei Okamoto
- Department of Gynecologic Oncology, Cancer Institute Hospital (Drs. Aoki, Kanao, Nomura, Okamoto, Hisa, Sugihara, Omatsu, Tanigawa, and Takeshima), Tokyo, Japan
| | - Tsuyoshi Hisa
- Department of Gynecologic Oncology, Cancer Institute Hospital (Drs. Aoki, Kanao, Nomura, Okamoto, Hisa, Sugihara, Omatsu, Tanigawa, and Takeshima), Tokyo, Japan
| | - Takeru Sugihara
- Department of Gynecologic Oncology, Cancer Institute Hospital (Drs. Aoki, Kanao, Nomura, Okamoto, Hisa, Sugihara, Omatsu, Tanigawa, and Takeshima), Tokyo, Japan
| | - Rie Kitano
- Department of Obstetrics and Gynecology, Tsuchiura Kyodo General Hospital (Dr. Kitano), Tsuchiura, Japan
| | - Kohei Omatsu
- Department of Gynecologic Oncology, Cancer Institute Hospital (Drs. Aoki, Kanao, Nomura, Okamoto, Hisa, Sugihara, Omatsu, Tanigawa, and Takeshima), Tokyo, Japan
| | - Terumi Tanigawa
- Department of Gynecologic Oncology, Cancer Institute Hospital (Drs. Aoki, Kanao, Nomura, Okamoto, Hisa, Sugihara, Omatsu, Tanigawa, and Takeshima), Tokyo, Japan
| | - Nobuhiro Takeshima
- Department of Gynecologic Oncology, Cancer Institute Hospital (Drs. Aoki, Kanao, Nomura, Okamoto, Hisa, Sugihara, Omatsu, Tanigawa, and Takeshima), Tokyo, Japan
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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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Preoperative Factors That Predict the Need to Morcellate in Total Laparoscopic Hysterectomy. J Minim Invasive Gynecol 2018; 25:158-162. [DOI: 10.1016/j.jmig.2017.09.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2017] [Revised: 08/22/2017] [Accepted: 09/17/2017] [Indexed: 12/28/2022]
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23
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Tissue Extraction Techniques for Leiomyomas and Uteri During Minimally Invasive Surgery. Obstet Gynecol 2017; 130:1251-1260. [DOI: 10.1097/aog.0000000000002334] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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24
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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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Laparoscopic myomectomy and morcellation: A review of techniques, outcomes, and practice guidelines. Best Pract Res Clin Obstet Gynaecol 2017; 46:99-112. [PMID: 29078975 DOI: 10.1016/j.bpobgyn.2017.09.012] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 09/11/2017] [Indexed: 12/14/2022]
Abstract
Laparoscopic myomectomy is a minimally invasive surgical approach to treat symptomatic uterine fibroids in women wishing for a uterine-sparing procedure. With careful patient selection, these procedures are associated with favorable reproductive outcomes and low perioperative morbidity. Current available methods for specimen retrieval include power and hand morcellation. The 2014 FDA safety warnings regarding power morcellation arose from concerns about the spread of occult malignancy and prompted widespread use of containment systems that may limit spread of myometrial cells. Investigation into the clinical effects of laparoscopic myomectomy and uncontained morcellation on the prognosis and spread of occult leiomyosarcoma has yielded mixed results. Other complications of uncontained power morcellation exist, including the development of parasitic leiomyomas. The FDA safety warnings have greatly influenced trends in benign gynecologic surgery, and survey data reflect trends in providers' opinions of these trends. In conclusion, recommendations for the current practice of laparoscopic myomectomy and morcellation are reviewed.
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Clark NV, Cohen SL. Tissue Extraction Techniques During Laparoscopic Uterine Surgery. J Minim Invasive Gynecol 2017; 25:251-256. [PMID: 28866098 DOI: 10.1016/j.jmig.2017.07.030] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Revised: 07/24/2017] [Accepted: 07/25/2017] [Indexed: 10/18/2022]
Abstract
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.
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Affiliation(s)
- Nisse V Clark
- Division of Minimally Invasive Gynecologic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Sarah L Cohen
- Division of Minimally Invasive Gynecologic Surgery, Brigham and Women's Hospital, Boston, Massachusetts.
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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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Cohen A, Tulandi T. Long-term sequelae of unconfined morcellation during laparoscopic gynecological surgery. Maturitas 2017; 97:1-5. [DOI: 10.1016/j.maturitas.2016.11.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2016] [Revised: 11/13/2016] [Accepted: 11/14/2016] [Indexed: 12/12/2022]
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Bortoletto P, Hariton E, Salas S, Cohen SL. Update on Fibroid Morcellation. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2017. [DOI: 10.1007/s13669-017-0197-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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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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Gujral H, Vilkins A, Clark NV, Vogell AB, Wright KN. Determining a Learning Curve for Contained Hand Tissue Extraction: Perioperative Outcomes and Operative Time. J Minim Invasive Gynecol 2017; 24:103-107. [DOI: 10.1016/j.jmig.2016.09.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Revised: 09/19/2016] [Accepted: 09/26/2016] [Indexed: 01/11/2023]
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Techniques for Laparoscopic Contained Tissue Extraction. CURRENT OBSTETRICS AND GYNECOLOGY REPORTS 2016. [DOI: 10.1007/s13669-016-0185-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Sandberg EM, van den Haak L, Bosse T, Jansen FW. Disseminated leiomyoma cells can be identified following conventional myomectomy. BJOG 2016; 123:2183-2187. [DOI: 10.1111/1471-0528.14265] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/13/2016] [Indexed: 12/27/2022]
Affiliation(s)
- EM Sandberg
- Department of Gynaecology; Leiden University Medical Centre; Leiden the Netherlands
| | - L van den Haak
- Department of Gynaecology; Leiden University Medical Centre; Leiden the Netherlands
| | - T Bosse
- Department of Pathology; Leiden University Medical Centre; Leiden the Netherlands
| | - FW Jansen
- Department of Gynaecology; Leiden University Medical Centre; Leiden the Netherlands
- Department of BioMechanical Engineering; Delft University of Technology; Delft the Netherlands
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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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Lum DA, Sokol ER, Berek JS, Schulkin J, Chen L, McElwain CA, Wright JD. Impact of the 2014 Food and Drug Administration Warnings Against Power Morcellation. J Minim Invasive Gynecol 2016; 23:548-56. [DOI: 10.1016/j.jmig.2016.01.019] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Revised: 01/15/2016] [Accepted: 01/21/2016] [Indexed: 01/09/2023]
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Uncontained Compared With Contained Power Morcellation in Total Laparoscopic Hysterectomy. Obstet Gynecol 2016; 127:403. [PMID: 26942374 DOI: 10.1097/aog.0000000000001282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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In Reply. Obstet Gynecol 2016; 127:403-4. [PMID: 26942375 DOI: 10.1097/aog.0000000000001283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Clinical Characteristics and Prognosis of Unexpected Uterine Sarcoma After Hysterectomy for Presumed Myoma With and Without Transvaginal Scalpel Morcellation. Int J Gynecol Cancer 2016; 26:456-63. [DOI: 10.1097/igc.0000000000000638] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
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In-bag manual versus uncontained power morcellation for laparoscopic myomectomy: randomized controlled trial. Fertil Steril 2016; 105:1369-1376. [PMID: 26801067 DOI: 10.1016/j.fertnstert.2015.12.133] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Revised: 12/10/2015] [Accepted: 12/21/2015] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To evaluate whether manualin-bag morcellation could be efficiently proposed as alternative to the uncontained power technique. DESIGN Randomized controlled trial. SETTING Academic hospital. PATIENT(S) One hundred fifty-two premenopausal women eligible for myomectomy were screened, and 104 were randomized. INTERVENTION(S) Patients were randomized into two groups. In the experimental group, "in-bag" protected morcellation was performed. In the control group, patients were treated by uncontained power myoma removal. MAIN OUTCOME MEASURE(S) The primary endpoint was the comparison of morcellation operative time (MOT). The secondary endpoints were the comparisons of total operative time (TOT), simplicity of morcellation (as defined by the surgeon using a visual analogue scale scale), intraoperative blood loss, rate of complications, and postoperative outcomes. RESULT(S) A sample size of 51 per group (n = 102) was planned. Between March 2014 and January 2015, patients were randomized as follows: 53 to the experimental group and 51 to the control group. Most demographic characteristics were similar across groups. MOT was observed to be similar in both study groups (16.18 ± 8.1 vs. 14.35 ± 7.8 minutes, in the experimental and control groups, respectively). Fibroid size was identified as the principal factor influencing morcellation time (Pearson coefficient 0.484 vs. 0.581, in the experimental and control groups, respectively). No significant difference in TOT, simplicity of morcellation, delta Hb, postoperative pain, and postoperative outcomes were observed between groups. CONCLUSION(S) The protected manual in-bag morcellation technique represents a time-efficient and feasible alternative, which does not interfere with surgical outcomes in women undergoing laparoscopic myomectomy. CLINICAL TRIAL REGISTRATION NCT02086435.
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Noel NL, Isaacson KB. Morcellation complications: From direct trauma to inoculation. Best Pract Res Clin Obstet Gynaecol 2015; 35:37-43. [PMID: 26879674 DOI: 10.1016/j.bpobgyn.2015.12.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 12/02/2015] [Indexed: 12/30/2022]
Abstract
Morcellation is the fragmentation of tissue to facilitate removal of the specimen through small incision in minimally invasive surgery. This technique is not unique to gynecology and is used in general surgery with the goal of improved surgical outcomes including decreased pain, cost, hospital length of stay, and rapid return to normal activities and work. Gynecologic laparoscopic power morcellation (LPM) has come under increased scrutiny over the last 2 years due to widespread attention to a known but rare complication, an unanticipated dissemination of malignancy, namely occult uterine leiomyosarcoma. This chapter focuses on complications associated with gynecologic tissue morcellation from inoculation of benign or malignant tissue fragments within the peritoneal cavity and direct trauma from morcellation techniques. We also include a review of the various morcellation techniques from knife to electrical and the use of intraperitoneal specimen containment systems.
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Affiliation(s)
- Nyia L Noel
- Newton-Wellesley Hospital, Harvard Medical School, Newton, MA, USA.
| | - Keith B Isaacson
- Newton-Wellesley Hospital, Harvard Medical School, Newton, MA, USA.
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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: 22] [Impact Index Per Article: 2.4] [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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Mutch DG. Premature Judgment of Uterine Morcellation: Look at the Data Before You Leap. J Natl Cancer Inst 2015; 107:djv283. [PMID: 26449387 DOI: 10.1093/jnci/djv283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- David G Mutch
- Department of Obstetrics and Gynecology, Washington University School of Medicine, St. Louis, MO.
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