Contained Morcellation for Laparoscopic Myomectomy Within a Specially Designed Bag

A technique of contained morcellation of uterine myomas within a bag specially designed for 2-port morcellation during laparoscopic myomectomy is described. Ten patients underwent in-bag morcellation of myomas with a tissue isolation bag (MorSafe) between November 2014 and January 2015. The MorSafe tissue isolation bag is a retort-shaped bag made of medical-grade flexible plastic material with the wider opening of 134 mm in diameter and the tail end measuring 4 mm in diameter, allowing easy accomodation of specimens up to 12 cm in diameter. This technique involves placing the myomas into the isolation bag within the abdomen, exteriorizing the tail end of the bag, insufflating the bag within the peritoneal cavity, and morcellating the myomas under vision. Demographic and perioperative characteristics were studied. The mean operative time was 117 minutes (range, 75-195 minutes), the mean time for specimen introduction into the bag was 12.5 minutes (range, 7-22 minutes), and the mean time for morcellation and bag removal was 24.8 minutes (range, 10-50 minutes). There were no complications related to the in-bag morcellation technique, and there was no visual evidence of damage to the isolation bag. In-bag morcellation using this new bag is a feasible technique for morcellating uterine myomas in a contained manner and may provide an option to minimize the risks of open power morcellation while preserving the benefits of minimally invasive surgery.

Extracorporeal Manual Morcellation of Very Large Uteri Within an Enclosed Endoscopic Bag: Our 5-Year Experience

STUDY OBJECTIVES

To describe a technique to manually morcellate large uteri within a polyurethane endoscopic bag at the time of laparoscopic hysterectomy, and report perioperative outcomes from our 5 years of experience.

STUDY DESIGN

Retrospective review of all consecutive hysterectomies with uterine weight >500 g performed between January 2010 and December 2014 in which the uterus was manually morcellated within an endoscopic bag by either an abdominal or vaginal approach (Canadian Task Force Classification Level III).

SETTING

Tertiary care academic medical center.

PATIENTS

A total of 104 women with a uterine weight >500 g who underwent laparoscopic hysterectomy using a manual morcellation technique.

INTERVENTION

Manual morcellation was done extracorporeally, within a partially exteriorized specimen bag, using a scalpel under direct visualization by the operating surgeon.

MEASUREMENTS AND MAIN RESULTS

A total of 104 laparoscopic hysterectomies were performed in women with a uterus weighing >500 g using a manual morcellation technique for specimen extraction. The median patient age was 48.1 years (range, 34-69 years), and the median body mass index was 31.0 kg/m(2) (range, 19.1-56.7 kg/m(2)). The median blood loss and specimen weight were 200 mL (range, 20-1200 mL) and 741.5 g (range, 500-1930 g), respectively. Morcellation was performed through an abdominal approach in 58.7% of the patients and through a vaginal approach in 41.3%. The median duration of morcellation was 14.8 minutes (range, 4.5-21.6 minutes) for the abdominal route and 11.7 minutes (range, 5.2-16.8 minutes) for the vaginal route. Occult malignancy was identified in 2 patients. There were no complications related to the morcellation technique or gross bag rupture.

CONCLUSION

Manual morcellation within an endoscopic bag allows for the extraction of large uteri without the use of a power morcellator. In our 5 years of experience, we have not experienced any incidence of gross spillage, visually noted bag rupture, or complications associated with our morcellation technique.

Power Morcellation Using a Contained Bag System

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.

Laparoscopic In-Bag Morcellation Compared with Conventional Morcellation of Myomas and Uterus with Myomas

STUDY OBJECTIVE

To evaluate contained bag electromechanical morcellation for removal of myomas and uterus with myomas, laparoscopically (Study group B), and compare it with uncontained laparoscopic morcellation (Control group A) in patients with similar parameters done earlier.

DESIGN

Retrospective Cohort Comparative Study (Canadian Task Force 2-1).

SETTING

Advanced Gynaecologic MAS, university recognized tertiary centre, Mumbai, India.

PATIENTS

720 women had laparoscopic removal of myomas or large uterus with myomas during a study period of 6 years (from 13 May 2012 to 14 August 2018) with contained bag electromechanical or conventional morcellation.

INTERVENTIONS

Laparoscopic hysterectomy, laparoscopic myomectomy, conventional uncontained morcellation, contained in-bag morcellation.

MAIN OUTCOMES MEASURES

Laparoscopic contained in-bag morcellation was compared with conventional morcellation of myomas and uterus with large myomas during a study period of 6 years. Parameters assessed were operating time, time for insertion of bag, morcellation of tissues and removal of bag, blood loss, complications, conversion to open surgery and histopathologic findings of tissues. In Group A, in the first 3 years, 355 women underwent uncontained morcellation. Myoma size and weight varied from 5 cm to 26 cm and 200 g to 3740 g respectively. The myoma number ranged from 1 to 18. No case of leiomyosarcoma was reported. In Group B, in the next 3 years, 365 women underwent contained bag morcellation in 196 myomectomy cases and 169 hysterectomy cases. Myoma size and weight varied from 4 cm to 20 cm and 200 g to 2100 g respectively. The number of myomas varied from 1 to 17.

RESULTS AND CONCLUSION

Laparoscopic contained bag morcellation for myomas and uterus with large myomas were evaluated. In myomectomy group both conventional and in bag laparoscopic morcellation were comparable in terms of duration of the surgery and blood loss. When all cases ( hysterectomy and myomectomy combined together) and cases of hysterectomy with large fibroid were studied, laparoscopic in bag morcellation took less operative time and there was statistically significant difference in operative time . No case of leiomyosarcoma was found in our study of 720 cases of myomas or uterus with large myomas.

Unexpected Uterine Leiomyosarcoma During Laparoscopic Hysterectomy Treated 6 Months With Ulipristal Acetate and Contained Power Morcellation

DESIGN

A 45-year-old woman with a symptomatic uterine myoma suffering from heavy menstrual bleeding, incontinence, and pain pressure received ulipristal acetate (UPA [Esmya; Gideon Richter, Budapest, Hungary]) for 6 months.

SETTING

A Minimal Invasive Gynecology surgery Unit in Chopenhagen Denmark.

INTERVENTION

Her symptoms were reduced; however, after 3 months on UPA, she was then admitted because of increased pain. A high level of C-reactive protein was found, and necrosis of the myoma was assumed to be the reason. In December 2015, she opted for a laparoscopic hysterectomy because of the increasing symptoms and lack of conviction that the medical therapy would be sufficient.

MEASUREMENTS AND MAIN RESULTS

Ultrasound showed a 106 × 73 mm myoma with no abnormal blood flow or lacuna of fluid inside the myoma; there was no suspicion of malignancies. The video and the report have been approved by the local institutional review board. The weight of the contained morcellated uterus was 575 g, and pathology showed a malignant leiomyoma sarcoma. A postoperative positron emission tomographic scan showed 4 metastatic processes in the lungs.

CONCLUSIONS

The Food and Drug Administration has approved the PneumoLiner (Advanced Surgical Concepts, Dublin, Ireland); however, they also stress the point that the device "has not been proven to reduce the risk of spreading cancer." In this case, the UPA treatment actually led to a delay in the diagnosis, potentially with a larger or even metastatic tumor as a consequence.

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.

Single port access laparoscopic subtotal hysterectomy using contained manual morcellation: Experience from a tertiary referral center in Taiwan

OBJECTIVE

To describe the surgical outcomes of single port access laparoscopic subtotal hysterectomy (LSH) using in-bag manual morcellation and evaluate the feasibility of this procedure.

MATERIALS AND METHODS

Thirty patients with symptomatic leiomyoma or adenomyosis were enrolled. A 2-cm transverse incision was made at the umbilicus and single port apparatus (LagiPort) was applied. After dissection of vesicouterine peritoneum from the uterus, the uterine ligaments and vessels were secured and transected by Gyrus PK cutting forceps. Cervical amputation at the level of internal os was made by SupraLoop (Karl Storz). The uterine corpus was put into an Endobag before morcellation. The opening of Endobag was exteriorized from the umbilical incision and the uterine corpus was removed in a contained manner by manual morcellation with a scalpel.

RESULTS

This procedure was successfully performed on all patients. Neither laparotomic conversion nor additional port was needed. The mean age and mean BMI of the patients were 43.63 years and 24.02 kg/㎡. The mean operative time was 148 min and the estimated blood loss in most patients was less than 150 ml. The median weight of uterine corpus was 214 g. No intraoperative complications occurred in any patient. One patient was diagnosed with unexpected endometrioid adenocarcinoma FIGO grade 1 postoperatively. One patient reported cyclic bleeding and underwent a transvaginal trachelectomy 17 months later.

CONCLUSION

Single port access LSH using contained manual morcellation represents a safe and feasible alternative to conventional LSH using open power morcellation.

Contained specimen morcellation during robotics-assisted laparoscopic supracervical hysterectomy for pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

Robotics-assisted laparoscopic supracervical hysterectomy (RALSH) with concomitant apical robotics-assisted POP repair provides advantages of minimally invasive procedures; however specimen removal without intraperitoneal spillage of potential pathology remains challenging. The primary aim of our study is to determine the factors affecting contained manual morcellation (CMM) of specimens during RALSH for POP surgery. The secondary aim of the study is to report complications associated with CMM and on specimen pathology.

METHODS

A total of 67 sequential patients underwent RALSH with concomitant robotics-assisted sacrocolpopexy or uterosacral vaginal suspension. Factors analyzed to affect CMM were specimen weight, length of skin and fascia incisions, patient age, body mass index (BMI), and estimated blood loss (EBL).

RESULTS

Median CMM time was 11 min (1 to 46) and specimen weight 62 g (19 to 711). Median patient age was 56 years (36 to 83), and patient BMI was 28 (18 to 44). Median EBL was 50 ml (10 to 150). Median skin and fascial incision lengths were 3 cm (1.5 to 7), and 3.5 cm (1.5 to 8). CMM time was significantly dependent on specimen weight (p < 0.0001) and length of rectus fascia incision (p < 0.0126). There was no gross tissue spillage or bag ruptures. Uterine pathology revealed normal tissue (26%), leiomyoma (47%), adenomyosis (49%), and endometriosis (14%). 4.5% of specimens had evidence of microscopic neoplasm, and 5 years after surgery patients were cancer free.

CONCLUSION

Contained manual extraction of the uterus and/or adnexae at the time of RALSH for POP surgery is a viable, safe, and efficient method of specimen removal.

Dome-type extracorporeal manual morcellation during laparoscopic uterine surgery: Two years' experience in a teaching hospital

OBJECTIVE

This study aims to describe the dome-type manual morcellation technique, a modified form of C-type incision, its comparative advantages over existing morcellation methods, the perioperative outcomes of trainees with varying experience levels, and the variables influencing morcellation speed based on our two years of experience.

METHODS

This retrospective cohort study included women who underwent laparoscopic myomectomy or hysterectomy using dome-type morcellation for tissue extraction at a tertiary teaching hospital between May 2020 and September 2022. Morcellation was performed by either a single surgeon or a trainee (resident). Basic patient characteristics, perioperative outcomes, and morcellation time and speed were compared between the surgeon and trainee group. Regression models were employed to analyze variables influencing morcellation speed.

RESULTS

A total of 41 women were enrolled. Among them, 20 procedures were performed by a surgeon alone, while the remaining 21 procedures were completed by trainees under the surgeon's supervision. The median weight of the specimens was 378 g (range 91-1345 g), and the median time for morcellation was 10 min (range 1-55 min). The median morcellation speed of surgeon and trainees was 70.25 and 31.7 g/min, respectively. Trainees' level of experience was found to be associated with morcellation speed, particularly for soft specimens. Additionally, both incision size and specimen stiffness were significantly associated with morcellation speed. No morcellation-related complications or bag ruptures were observed.

CONCLUSION

Dome-type manual morcellation is an intuitive, efficient and safe method for specimen removal and is easy to learn for beginners.