Comparison of mini laparotomy and morcellation for large specimen retrieval in robotic gynecologic surgery

Abstract

<h3>Objectives:</h3> Minimally invasive surgery (MIS) is the standard of care for gynecologic and gynecologic oncology conditions. For large specimen retrieval, morcellation is a controversial option due to concerns of undetected malignancy and dissemination. Our objective was to compare safety and discharge outcomes for patients with mini-laparotomy (ML) versus morcellation for large specimen retrieval during robotic cases. <h3>Methods:</h3> In this retrospective cohort study of patients who underwent robotic gynecologic surgery (RGS) from January 2013 to June 2016, we compared intraoperative and postoperative outcomes for patients undergoing ML or morcellation. Mode of specimen delivery was at the discretion of the surgeon. The ML group consisted of patients who at the completion of RGS underwent an abdominal ML incision and the morcellation group consisted of patients who underwent manual or power morcellation for specimen delivery. Outcomes were analyzed using Mann-Whitney U test, Chi-squared/Fisher's exact tests, and multivariate logistic models. <h3>Results:</h3> Of the 2,126 patients undergoing RGS, 154 (7.2%) underwent a ML for specimen retrieval and 834 (39.2%) underwent specimen removal with morcellation. Median age was greater for the ML compared to morcellation (45 [IQR 37.1-52.8] vs 40 [IQR 35.0-46.0]; p<0.001), but median body mass index (26.1 [IQR 22.6-32.2] vs 25.7 22.6-30.2]; p=0.31) and proportion of patients with ≥3 comorbidities (9.1% vs 6.5%; p=0.32) were similar between groups. Twenty-one (13.6%) patients with ML were undergoing surgery for cancer diagnosis, compared to 1 (0.1%) patient with morcellation (p<0.001). Patients with ML had significantly heavier specimen weights, (median 386.3 g [IQR 245.0-641.0] vs 280.0 g [IQR 114.0-510.0]; p<0.001), estimated blood loss (EBL, median 122.5 mL [IQR 50.0-250.0] vs 100.0 mL [IQR 50.0-250.0]; p=0.03), and longer operative time (median 211.0 min [IQR 162.3-67.0] vs 178.0 min [IQR 135.0-233.7]; p<0.001). Both groups had similar times to discharge (median 7.5 hour [IQR 4.9-17.4] vs 7.5 hour [IQR 5.5-11.0]; p=0.81), but patients with ML were less likely to have same day discharge (67.5% vs 77.0%; p=0.02). Complications (13.6% vs 9.7%; p=0.19), wound infection (1.9% vs 1.9%; p=1.00), post-operative blood transfusion (0.6% vs 0.5%; p=0.57), and re-admission (1.3% vs 1.1%; p=0.69) were similar between ML and morcellation groups. In multivariable analysis, there was no difference in same day discharge between ML and morcellation groups after controlling for age, cancer diagnosis, and operative time (odds ratio=0.94; 95% CI (0.59-1.46); p=0.78). <h3>Conclusions:</h3> Despite increased EBL and operative time, ML for specimen retrieval does not affect postoperative outcomes such as time to discharge, wound infection, complications, need for blood transfusion, or re-admission rates. These results highlight that ML may play an important role when removing large specimens while still enabling patients to have a successful MIS procedure and same day discharge.