Tissue Extraction Techniques During Laparoscopic Uterine Surgery

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.

Defining a Uterine Extraction Score based on a Volume/Access Ratio in Total Hysterectomy: a retrospective cohort study

Background

Regardless of the technique used, extraction of the uterus is a crucial step in hysterectomy. There is currently no scoring system to predict its feasibility.

Objectives

Our main objective was to determine a predictive score of uterine extraction feasibility to optimise surgical planning of total hysterectomy. As secondary objectives, we examined the correlation between uterine volume predicted by preoperative ultrasound and the final weight of the surgical specimen and analysed the impact of the uterine extraction modality on operative and hospitalisation times.

Materials and Methods

We defined a Uterine Extraction Score (UES) based on the ratio between uterine sizes and vaginal access. This score was retrospectively applied to a cohort of 178 patients who were hysterectomised for benign conditions between January 2019 and December 2022.

Main outcome measures

The UES allows identification of three groups of decreasing feasibility of vaginal extraction, symbolised by traffic light colours: green - vaginal extraction without morcellation, orange -vaginal extraction with morcellation, red - abdominal morcellation by mini-laparotomy or primary laparotomy.

Results

The results show that the UES--predicted, and the observed routes of extraction concord in 92% of cases. There is a strong correlation between estimated volume and final uterine weight. Uterine morcellation lengthens the operative time and the hospital stay.

Conclusions

The UES seems to be a reliable tool to predict the route of uterine extraction in total hysterectomy.

What is new?

The development of a new scoring system empowers surgeons with decisive information to enhance perioperative outcomes.

Surgical management of uterine fibroids

PURPOSE OF REVIEW

Fibroids are benign pelvic masses and constitute the most common gynaecological condition. They create a significant health and social burden to many women because of heavy menstrual bleeding and fibroid pressure symptoms. Many women will be faced with the dilemma of surgical management to improve their symptoms at some point of their reproductive age. The aim of this article is to identify current surgical management of fibroids describing the technical steps, advantages, disadvantages and risks of each method.

RECENT FINDINGS

The surgical management of fibroids remains challenging, as the overall prevalence, the clinical experience and the patient awareness is increasing because of an upgrade in our sonographic and magnetic resonance diagnostic tools. Unfortunately not every patient is able to benefit from tailor-made surgery that holistically evaluates individual needs including fertility aspirations.

SUMMARY

This article provides the most current synopsis of every available surgical modality for fibroid management. Large prospective multicentre cohort studies are needed to definitely determine the most suitable operation for any individual suffering with fibroids; and perhaps artificial intelligence may offer a valuable tool in the future data analysis.

Mechanical and leakage integrity testing considerations for evaluating the performance of tissue containment systems

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.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

Background

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

Objectives

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

Materials and Methods

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

Main outcome measures

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

Results

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

Conclusion/What is new?

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

A Novel Multi-Port Containment System for Laparoscopic Power Morcellation to Prevent Tumoral Spread: A Retrospective Cohort Study

Objective

To report a novel multi-port containment (NMC) system for laparoscopic power morcellation to prevent tumoral spread and to evaluate its safety, validity, and feasibility.

Methods

This retrospective study included women who underwent laparoscopic myomectomy (LM) between January 2014 and August 2020 at a single academic institution. The NMC system was used in the study group (n = 193); the control group underwent unprotected LM (n = 1753).

Results

After 1:1 propensity score matching, no significant differences in the baseline characteristics were observed between 193 matched pairs. Bag damages were detected in two cases in the study group before morcellation, and the NMC systems were replaced. There were no significant differences between the two groups in terms of the complications, total operative time, estimated blood loss, or postoperative hospitalization duration. In the study group, all operations were completed and no system rupture or leakage was observed. The median follow-up times were 21 and 54 months in the study and control groups, respectively. There was no peritoneal tissue spread in the study group. However, three (3/5, 0.6%) and six (6/1,753, 0.3%) patients in the control group experienced malignant and benign peritoneal tissue spread, respectively.

Conclusion

The NMC system for laparoscopic power morcellation is valid, safe, and feasible for preventing a tumor spread.

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

BACKGROUND

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

CASE SUMMARY

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

CONCLUSION

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

Predictive factors of the need to morcellate in total laparoscopic hysterectomy

BACKGROUND

Specimen extraction is a major challenge in total laparoscopic hysterectomy (TLH) and tissue morcellation may be needed to extract a large uterus.

AIMS

The study aims to determine preoperative factors that could predict the need for uterine morcellation in TLH, and also find the best cut-off values of each measured parameter leading to optimum sensitivity and specificity.

MATERIALS AND METHODS

This was a cross-sectional study of women from August 2019 to May 2020 who underwent TLH, with or without salpingo-oophorectomy in our department. We performed bimanual exams preoperatively to estimate the uterine size and recorded the uterine ultrasonographic dimensions and myoma size in myomatous uteri. Receiver operating characteristic (ROC) were used to establish cut-offs that maximised the sensitivity and specificity of each factor in predicting the need for morcellation. Poisson regression was used to calculate the relative risks (RR) of each cut-off.

RESULTS

One hundred and sixty-two women were recruited in the study. ROC curves demonstrated maximum sensitivities and specificities with a cross-sectional area of 36.5 cm² , the largest leiomyoma dimension of 40 mm, uterine length of 10 cm, and bimanual uterine size of 13 weeks. Multiple modified Poisson regression revealed that the strongest predictors of morcellation were the largest leiomyoma diameter of >40 mm (RR: 3.58), the uterine cross-sectional area of >36.5 cm² (RR: 6.38), and uterine size in the bimanual exam of >13 weeks pregnancy (RR: 3.57).

CONCLUSION

The largest leiomyoma diameter, uterine cross-sectional area, and size on a bimanual exam can all be used to predict needing morcellation preoperatively in TLH.

Hospital variation in responses to safety warnings about power morcellation in hysterectomy

BACKGROUND

Safety warnings about power morcellation in 2014 considerably changed hysterectomy practice, especially for laparoscopic supracervical hysterectomy that typically requires morcellation to remove the corpus uteri while preserving the cervix. Hospitals might vary in how they respond to safety warnings and altered hysterectomy procedures to avoid use of power morcellation. However, there has been little data on how hospitals differ in their practice changes.

OBJECTIVE

This study aimed to examine whether hospitals varied in their use of laparoscopic supracervical hysterectomy after safety warnings about power morcellation and compare the risk of surgical complications at hospitals that had different response trajectories in use of laparoscopic supracervical hysterectomy.

STUDY DESIGN

This was a retrospective analysis of data from the New York Statewide Planning and Research Cooperative System and the State Inpatient Databases and State Ambulatory Surgery and Services Databases from 14 other states. We identified women aged ≥18 years undergoing hysterectomy for benign indications in the hospital inpatient and outpatient settings from October 1, 2013 to September 30, 2015. We calculated a risk-adjusted utilization rate of laparoscopic supracervical hysterectomy for each hospital in each calendar quarter after accounting for patient clinical risk factors. Applying a growth mixture modeling approach, we identified distinct groups of hospitals that exhibited different trajectories of using laparoscopic supracervical hysterectomy over time. Within each trajectory group, we compared patients' risk of surgical complications in the prewarning (2013Q4-2014Q1), transition (2014Q2-2014Q4), and postwarning (2015Q1-2015Q3) period using multivariable regressions.

RESULTS

Among 212,146 women undergoing benign hysterectomy at 511 hospitals, the use of laparoscopic supracervical hysterectomy decreased from 15.1% in 2013Q4 to 6.2% in 2015Q3. The use of laparoscopic supracervical hysterectomy at these 511 hospitals exhibited 4 distinct trajectory patterns: persistent low use (mean risk-adjusted utilization rate of laparoscopic supracervical hysterectomy changed from 2.8% in 2013Q4 to 0.6% in 2015Q3), decreased medium use (17.0% to 6.9%), decreased high use (51.4% to 24.2%), and rapid abandonment (30.5% to 0.8%). In the meantime, use of open abdominal hysterectomy increased by 2.1, 4.1, 7.8, and 11.8 percentage points between the prewarning and postwarning periods in these 4 trajectory groups, respectively. Compared with the prewarning period, the risk of major complications in the postwarning period decreased among patients at "persistent low use" hospitals (adjusted odds ratio, 0.88; 95% confidence interval, 0.81-0.94). In contrast, the risk of major complications increased among patients at "rapid abandonment" hospitals (adjusted odds ratio, 1.48; 95% confidence interval, 1.11-1.98), and the risk of minor complications increased among patients at "decreased high use" hospitals (adjusted odds ratio, 1.31; 95% confidence interval, 1.01-1.72).

CONCLUSION

Hospitals varied in their use of laparoscopic supracervical hysterectomy after safety warnings about power morcellation. Complication risk increased at hospitals that shifted considerably toward open abdominal hysterectomy.

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

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