Contained morcellation for benign gynecologic surgeries feasible, minimize surgical risk

1. Morcellation within a contained, insufflated bag was successfully reproduced in 73 minimally invasive gynecologic surgeries at multiple institutions. 

2. In all surgeries, the technique was not associated with complications or visual evidence of tissue dissemination. 

Evidence Rating Level: 4 (Below Average)         

Study Rundown: Minimally invasive routes of surgery, such as laparoscopic and robotic, have turned surgeries previously requiring multi-day hospital stays into overnight or even outpatient procedures. But to make minimally invasive surgery safe for use in gynecologic surgeries, such as hysterectomies and myomectomies (removal of the uterus or uterine fibroids), surgeons require the assistance of a morcellator, a tool that cuts the desired tissue into strips small enough to be removed through the laparoscopic port sites, which are often only one-half or one centimeter wide. Recently, morcellation has come under intense scrutiny because of the fear of leiomyosarcoma, a rare but deadly cancer that is definitively indistinguishable from benign fibroids prior to surgery. If a leiomyosarcoma is morcellated, as has occurred in a recent high profile case, cancer cells can be spread throughout the abdominal cavity, upstaging the patient to stage IV, which portends a poorer prognosis. While fear of potentially spreading cancer has triggered many surgeons to abandon morcellation, the benefits of minimally invasive surgery are compelling, particularly for obese, morbidly obese and supermorbidly obese women whose morbidity associated with open surgery is high. As such, there is high demand for new techniques that allow for the continued use of morcellation in benign gynecologic procedures.

In this study, researchers describe a technique where morcellation is completed within an insufflated bag inside the abdomen to prevent tissue spread. In a sample of 73 patients at 4 major surgical centers, the surgical technique was successfully used in all cases with no complications and no visual evidence of tissue spread. Strengths of this study include a diverse population of surgeons at multiple institutions, which increases applicability. This preliminary study has limitations. Lack of a control group and long-term follow-up disallow thorough evaluation of the effectiveness of the technique in preventing cancer spread. The study was underpowered to detect rare complications and there was no formal investigation of bag integrity or tissue spread; rather the operating surgeon made a visual assessment, which creates opportunity for bias. A randomized controlled trial comparing rate of spread with two bag techniques or types, as determined by careful examination of bag integrity and presence of intraabdominal spread by a blinded third party would provide additional information on the effectiveness of this technique.

Click to read the study in Obstetric & Gynecology

Click to read an accompanying editorial in Obstetrics & Gynecology

Relevant Reading: Laparoscopic Uterine Power Morcellation in Hysterectomy and Myomectomy: FDA Safety Communication

In-Depth [case series]: This study included all patients at 4 major surgical centers who were planning to undergo minimally invasive myomectomy or hysterectomy using morcellation and opted to receive an experimental procedure: contained morcellation in an isolation bag (n=73). The technique, adaptable for both single and multiport laparoscopy, involves placing the specimen in a large plastic bag within the abdomen, exteriorizing the opening of the bag, and insufflating it prior to morcellation. Three of the sites collected data prospectively and one retrospectively. Outcomes were perioperative characteristics, including estimated blood loss, surgical complications, and intact status of isolation bag.

The procedure was successful in all cases, with a median operative time of 114 minutes (32-380min), a median estimated blood loss of 50mL (10-500mL), and a median specimen weight of 257g (53-1,481g). No complications related to the experimental technique were reported and by visual inspection, the integrity of the isolation bag was maintained in all cases.

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Image: PD

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