Electromechanical Morcellation Research Articles

Good practice with fluid management in operative hysteroscopy.

Hysteroscopic surgery requires a balance of continuous controlled irrigation and aspiration to distend the endometrial cavity to a degree that provides the clear and stable visual environment necessary for diagnostic and therapeutic procedures. Whereas the preferred distending solution should be isotonic and isonatremic, radiofrequency (RF) electrosurgery with monopolar instrumentation can only be performed with non-ionic (hyponatremic) solutions. Absorption of as little as 500 mL and certainly more than 1000 mL of non-ionic solutions can result in fluid overload and/or dilutional hyponatremia with potentially serious adverse effects under certain conditions and patient characteristics. Both hysteroscopic RF electrosurgery with bipolar instrumentation and electro-mechanical morcellation and aspiration systems use isotonic and isonatremic solutions. Depending on the clinical context, absorption of more than 1500 mL of isonatremic solutions can also result in serious adverse effects. Automated fluid management systems are preferred and recommended, and surgeons should aim to maintain the maximum allowable intravasation of distending media below 1000 and 1500 mL for non-ionic and ionic fluids, respectively.

The Future of Minimal-Access Myoma Surgery with In-Bag Contained Morcellation.

Contained electromechanical morcellation has emerged as a safety approach for laparoscopic myomatous tissue retrieval. This retrospective single-center analysis evaluated the bag deployment practicability and safety of electromechanical in-bag morcellation when used for big surgical benign specimens. The main age of patients was 39.3 years (range 21 to 71); 804 myomectomies, 242 supracervical hysterectomies, 73 total hysterectomies, and 1 retroperitoneal tumor extirpation were performed. A total of 78.7% of specimens weighed more than 250 g (n = 881) and 9% more than 1000 g. The largest specimens, weighing 2933 g, 3183 g, and 4780 g, required two bags for complete morcellation. Neither difficulties nor complications related to bag manipulation were recorded. Small bag puncture was detected in two cases, but peritoneal washing cytology was free of debris. One retroperitoneal angioleiomyomatosis and three malignancies were detected in histology (leiomyosarcoma = 2; sarcoma = 1); therefore, patients underwent radical surgery. All patients were disease-free at 3 years follow-up, but one patient presented multiple abdominal metastases of the leiomyosarcoma in the third year; she refused subsequent surgery and was lost from follow-up. This large series demonstrates that laparoscopic bag morcellation is a safe and comfortable method to remove large and giant uterine tumors. Bag manipulation takes only a few minutes, and perforations rarely occur and are easy to detect intraoperatively. This technique did not result in the spread of debris during myoma surgery, potentially avoiding the additional risk of parasitic fibroma or peritoneal sarcoma.

7554 Pneumoliner Containment System Using Power Morcellation: Case Report of Two Unexpected Uterine Malignancies

<h3>Study Objective</h3> Few reports have documented the outcomes of uterine malignancies after power morcellation in a containment system. Here we describe two cases of an unexpected fibroid malignancy (Leiomyosarcoma and STUMP tumor) that was morcellated in a contained tissue extraction system. <h3>Design</h3> Case study. <h3>Setting</h3> University Hospital. <h3>Patients or Participants</h3> We present two cases: 35-year-old African American female with secondary dysmenorrhea and uterine fibroids and a 37-year-old Hispanic female with Abnormal Uterine Bleeding and uterine fibroids. <h3>Interventions</h3> Electromechanical morcellation (LINA) was introduced into a large containment system (PneumoLiner) during Laparoscopic tissue extraction. <h3>Measurements and Main Results</h3> The first case describes a 35-year-old patient that underwent a laparoscopic myomectomy for an intramural fibroid (8 cm) that was removed via power morcellation in a containment system. The pathology documented a multifocal Leiomyosarcoma within the Leiomyoma with a grossly intact bag. Two months after her myomectomy procedure, the patient underwent a Total Laparoscopic Hysterectomy and pathology confirmed no evidence of uterine malignancy with negative peritoneal washings. The second case describes a 37-year-old Hispanic female that underwent a laparoscopic myomectomy for multiple uterine fibroids (removal of 9 fibroids) that was removed via power morcellation in a containment system with a grossly intact bag. The patient underwent a Total Laparoscopic Hysterectomy 12 weeks after her myomectomy. Her final pathology confirmed a STUMP tumor, and the post-operative staging was negative. In both cases, the containment tissue extraction system was evaluated intraoperatively for bag rupture with a water-seal leak test and also sent to pathology for gross inspection. <h3>Conclusion</h3> The diagnosis of an unsuspected fibroid malignancy after a myomectomy is very rare, however may result in a worse prognosis if morcellated in an uncontained fashion. We report 2 cases of contained morcellation with fibroid malignancy with a 1-year follow-up.

8724 Routes of Specimen Extraction in Laparoscopic Surgery

<h3>Study Objective</h3> To demonstrate the operative techniques of three entry methods for in-bag, extracorporeal specimen morcellation including vaginal approach, umbilical mini-laparotomy and suprapubic mini-laparotomy. <h3>Design</h3> We present a surgical video with narration which demonstrates three entry techniques for specimen morcellation. <h3>Setting</h3> Morcellation is a surgical technique which has been used for decades to allow removal of the uterus through the vagina or smaller abdominal incisions². Electromechanical morcellation gained popularity in the early 1990s due its ease of use and efficiency, however concern for the spread of cancer cells in cases of uterine sarcomas led to the practice of manual morcellation using containment bags¹. The American College of Obstetricians and Gynecologists continues to endorse a minimally invasive approach to hysterectomy when possible if the specimen is too large to be removed intact or removing the uterus intact through an abdominal incision². <h3>Patients or Participants</h3> Patients undergoing laparoscopic hysterectomy. <h3>Interventions</h3> We demonstrate three entry routes for manual uterine morcellation: vaginally following colpotomy, umbilical mini-laparotomy and suprapubic mini-laparotomy. <h3>Measurements and Main Results</h3> Specimen extraction via minimally invasive routes. <h3>Conclusion</h3> Vaginal entry following colpotomy, umbilical mini-laparotomy and suprapubic mini-laparotomy are three safe, effective entry methods for the morcellation of large, fibroid uteri which offers a minimally invasive approach for the removal of uterine specimens following laparoscopic hysterectomy.

MRI Evaluation of Uterine Masses for Risk of Leiomyosarcoma: A Consensus Statement.

Laparoscopic myomectomy, a common gynecologic operation in premenopausal women, has become heavily regulated since 2014 following the dissemination of unsuspected uterine leiomyosarcoma (LMS) throughout the pelvis of a physician treated for symptomatic leiomyoma. Research since that time suggests a higher prevalence than previously suspected of uterine LMS in resected masses presumed to represent leiomyoma, as high as one in 770 women (0.13%). Though rare, the dissemination of an aggressive malignant neoplasm due to noncontained electromechanical morcellation in laparoscopic myomectomy is a devastating outcome. Gynecologic surgeons' desire for an evidence-based, noninvasive evaluation for LMS is driven by a clear need to avoid such harms while maintaining the availability of minimally invasive surgery for symptomatic leiomyoma. Laparoscopic gynecologists could rely upon the distinction of higher-risk uterine masses preoperatively to plan oncologic surgery (ie, potential hysterectomy) for patients with elevated risk for LMS and, conversely, to safely offer women with no or minimal indicators of elevated risk the fertility-preserving laparoscopic myomectomy. MRI evaluation for LMS may potentially serve this purpose in symptomatic women with leiomyomas. This evidence review and consensus statement defines imaging and disease-related terms to allow more uniform and reliable interpretation and identifies the highest priorities for future research on LMS evaluation.

Robotic Myomectomy: Five Modifications in Our Practice.

We discuss five technical modifications made over 8 years in the technique of robotic myomectomy at our institution. Universal preoperative MRI was the first modification. Precise hysterotomy incisions were planned by accurate myoma mapping. The second modification was to reduce the number of ports. We performed surgery with one 12-mm-port for the camera and one 8-mm-port on either side of the patient for scissors and fenestrated bipolar forceps. Third modification was to reduce the number of robotic instruments by using laparoscopic myoma screw instead of robotic tenaculum during enucleation and discard the use of a second needle driver and prograsp forceps. So instead of six instruments in classical technique, we now use only three instruments thus reducing the cost of instruments by 40-50%. The fourth modification was to use a single 30 or 45cm barbed suture. A single long suture efficiently managed by wristed needle driver of robot was sufficient in most cases for hysterotomy closure. This reduces the time needed for multiple needle pass and cost due to reduced number of sutures used. The fifth modification was to not use the electro mechanical morcellator and commercially available bags. We do cold knife morcellation in indigenous plastic bags. Over a period of eight years, we have made robotic myomectomy efficient and reduced the cost of instruments by 40-50% as compared to the classical technique. This has enabled wider adoption of robotic myomectomy at our institution thus reducing open myomectomy in all types of myomas.

Preclinical safety testing and initial experience of a morcellation bag with four sealable ports

Electromechanical morcellation—so called power morcellation—is a minimally invasive approach to remove bulky lesions such as uterine fibroids. The spread of benign and malignant tissue due to morcellation is a major concern that might limit the use of laparoscopic interventions. We present an in vitro evaluation of the safety characteristics of a four-port endobag with closable trocar sleeves, and describe physical properties of the bag that may or may not allow passage through the hole. In addition, we report our preliminary experience of this tool when used for laparoscopic supracervical hysterectomies. The behavior of the endobag during the extraction process was analyzed by extracting opened and re-sealed bags filled with 20 ml blue dye solution through a wooden template, with incisions measuring 10 to 24 mm. The endobag was used in 50 subtotal hysterectomies during the morcellation procedure. In the in vitro test, no dye loss was recorded for incisions measuring 11–24 mm. The mean force required to pull the bag through the template was inversely proportional to incision size. No bag rupture occurred during the surgical procedures. The mean time taken to prepare the bag for morcellation was 7.1 min (range, 4–14 min), the mean duration of subtotal hysterectomy was 53.4 min (range, 20–194 min). The mean weight of the removed body of the uterus was 113.8 g (range, 13–896 g), the mean weight of tissue and fluid remaining in the bag after morcellation 7.9 g (range, 0–39 g). In the in vitro setting, the improved endobag signifies greater patient safety during bag extraction, along with less tissue traumatization due to a smaller incision in the abdominal wall. The improved ergonomic features of the bag permit the insertion of three trocars in the lower abdomen and avoid closure of unused access ports. Our preliminary experience has shown that the device can be used under routine conditions. Failure rates will be evaluated in future studies.

Impact of Morcellation Method and Site on Laparoscopic Hysterectomy Outcomes in Obese Patients

<h3>Study Objective</h3> To investigate the effect of morcellation method and site on perioperative outcomes in patients with class 3 obesity (body mass indices [BMIs] ≥40). <h3>Design</h3> Retrospective cohort study analyzing morcellation method (manual or electromechanical) and morcellation site (vaginal or abdominal). Primary outcome was 30-day perioperative complications. <h3>Setting</h3> Academic tertiary care center. <h3>Patients or Participants</h3> 159 patients with BMI ≥40. <h3>Interventions</h3> Laparoscopic hysterectomy requiring morcellation from 1/2006-10/2019. <h3>Measurements and Main Results</h3> Thirty-three (21%) patients underwent electromechanical morcellation; 126 (79%) underwent manual morcellation. Of manual morcellation cases, 46 (37%) underwent vaginal morcellation, while 80 (63%) underwent abdominal morcellation. There were no significant differences in age, BMI, parity, prior surgery, or medical comorbidities among the groups. Median specimen weight was larger for patients with abdominal versus vaginal morcellation (808g versus 455g; p<0.01), without a difference in operative time (274 versus 246 minutes; p=0.06). Urinary tract infection was more common in cases with vaginal compared to abdominal morcellation (8.7% versus 0%; p=0.02). However, collectively, vaginal versus abdominal site did not differ significantly in incidence of minor (32.6% versus 20.0%; p=0.11), major (4.4% versus 5.0%, p>0.99), or total perioperative (37.0% versus 28.8%; p=0.34) complications. When abdominal manual morcellation sites were stratified into umbilical, suprapubic, and lateral locations, no differences in minor, major, or total perioperative complications were detected. Electromechanical and manual methods of morcellation did not have significantly different rates of minor (24.6% versus 30.3%; p=0.51), major (4.8% versus 3.0%; p>0.99), or total perioperative (31.8% versus 36.4%; p=0.61) complications. After controlling for potential confounders, there was no difference in complications between electromechanical versus manual (aOR: 2.28; 95% CI: 0.76–6.84) and vaginal versus abdominal (aOR: 1.72; 95% CI: 0.724.13) morcellation. <h3>Conclusion</h3> In women with BMI ≥40, abdominal morcellation was associated with significantly larger specimen sizes, compared to vaginal morcellation, without an increase in perioperative complications or operative time. Manual and electromechanical morcellation had similar perioperative complication frequencies.

81: Effect of morcellation site and route on minimally invasive hysterectomy outcomes in patients with class 3 obesity

To assess the effects of site and route of morcellation on perioperative outcomes in patients with body mass index (BMI) ≥40 (WHO class 3 obesity). We performed a retrospective cohort study of women with BMI ≥40 who required tissue morcellation during laparoscopic hysterectomy at an academic tertiary care center between January 2006 and March 2018. Morcellation site was either vaginal or abdominal, with abdominal sites including suprapubic, umbilical, or lateral locations. Morcellation route was either manual or electromechanical. The primary outcome was perioperative complication, classified by Clavien-Dindo grade (minor complications grade I to II, major complications grade III to V). Secondary outcomes included surgical time, surgical blood loss, and hospital length of stay. Chi-square, Fisher’s exact, and Wilcoxon tests were used where appropriate. Multivariable logistic regression was used to estimate the association between site or route of morcellation and perioperative complications. Of 96 identified patients, 57 (59.4%) underwent abdominal morcellation and 39 (40.6%) underwent vaginal morcellation. Abdominal morcellation included 38 (66.7%) umbilical, 11 (19.3%) suprapubic, and 8 (14.0%) lateral sites. The average BMI was 45.3 ± 6.8 kg/m2. There were no differences in age, hysterectomy year, BMI, parity, prior abdominal surgery, or medical comorbidities between abdominal and vaginal morcellation sites. Mean specimen weight was significantly larger for patients who underwent abdominal (829.0 ± 755.6g) versus vaginal morcellation (467.3 ± 334.8g, p<0.01), without a difference in surgical time (267.4 vs 237.4 min, p=0.17), surgical blood loss (196.4 vs 133.3mL, p=0.74), and hospital length of stay (2.0 vs 2.4 days, p=0.12). There was a nonsignificant trend towards increased perioperative complications in the vaginal versus abdominal morcellation group (33.3% vs 21.1%, p=0.18), with associated differences in minor complications (28.2% vs 12.3%, p=0.05). There was no difference in major complications between vaginal and abdominal morcellation (7.0% vs 5.1%, p>0.99). No difference was found for perioperative complications between electromechanical and manual morcellation (37.8% vs 25.3%, p=0.16). After controlling for hysterectomy year, race, specimen weight, parity, and BMI, there was no difference in perioperative complications between abdominal versus vaginal sites (aOR 0.52, 95% CI 0.17-1.55) or manual versus electromechanical routes (aOR 0.55, 95% CI 0.18-1.71) of morcellation. In women with class 3 obesity, abdominal morcellation was associated with a significantly larger specimen size without any increase in perioperative complications compared to vaginal morcellation. Manual versus electromechanical morcellation had no significant difference in perioperative outcomes.

Полипы эндометрия в постменопаузе. Место электромеханической морцелляции в лечении полипов эндометрия

Полипы эндометрия в постменопаузе. Место электромеханической морцелляции в лечении полипов эндометрия

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

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. Retrospective Cohort Comparative Study (Canadian Task Force 2-1). Advanced Gynaecologic MAS, university recognized tertiary centre, Mumbai, India. 720 women had laparoscopic removal of myomas or large uterus with myomas during a study period of 6years (from 13 May 2012 to 14 August 2018) with contained bag electromechanical or conventional morcellation. Laparoscopic hysterectomy, laparoscopic myomectomy, conventional uncontained morcellation, contained in-bag morcellation. Laparoscopic contained in-bag morcellation was compared with conventional morcellation of myomas and uterus with large myomas during a study period of 6years. 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 3years, 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 3years, 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. 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.

Robotic Assisted Laparoscopic Myomectomy-5 Modifications at Apollo Hospital Hyderabad, India

Study Objective To make Robotic Assisted Laparoscopic Myomectomy (RALM) feasible and cost effective. Design We discuss 5 modifications over 7 years. Setting Apollo Hospital using DaVinci SI system. Patients or Participants 158 cases who underwent RALM were included. Interventions The first modification was a preoperative MRI in each case, for accurate myoma mapping, differentiated myomas from adenomyosis and helped plan precise incisions. Reducing the number of robotic instrument was the next step. Laparoscopic myoma screw via 5 mm assistant port instead of robotic tenaculum. The fenestrated bipolar during suturing instead of prograsp or second needle holder. Instead of SIX instruments, we now use only THREE instruments. The third modification was to reduce the number of ports by Rail Road technique. We have one 12 mm port for the camera, one 8 mm on right side for scissors and on the left side we combine the 8mm over 11mm as one port by a rail road technique. The fourth modification was to use a single 30 or 45 cm barbed suture. This is contrary to what is taught during laparoscopy to use a length of 8-10 cms for effective non entangled suturing. A single suture was sufficient for hysterotomy closure, reducing the time needed for multiple needle pass and cost. The last modification was to do away with the electro mechanical morcellator & predesigned bags. Cold knife morcellation in an indigenous plastic bag via either umbilicus, vaginal or rarely suprapubic. Measurements and Main Results Over 7 years we have reduced OR time by 7% and instruments cost by 14.9%. Conclusion Using these modifications, we have made Robot Assisted Myomectomy feasible and cost effective in Indian Scenario. This has enabled us to offer this surgery to women and reduce incidence of open myomectomy in all types of myomas.

1364 Tips & Tricks: Step by Step How to Do Two-Port Contained Power Morcellation in A Specialized Bag

Video Objective To explain and demonstrate: 1. Laparoscopic port placement, 2. Step by step technique for the two-port contained power morcellation in a specialized bag (Morcellation Containment System by Espiner Medical), 3. Tips and tricks on each step of contained morcellation Setting Risks of electromechanical morcellation are spreading undiagnosed cancer, diffuse leiomyomatosis, and visceral injury. Food and Drug Administration (FDA) safety communication discouraged use of power morcellators for leiomyoma extraction after the case of disseminated leiomyosarcoma following a laparoscopic hysterectomy. Since FDA warning, laparoscopic contained (in bag) morcellation became popular. However, it can be challenging. Interventions A 27 years old, G0P0, woman was presented with heavy periods and pelvic pain. Her medical and surgical history was unremarkable. Ultrasound showed and anterior/broad ligament fibroid with size of 7.6 × 5.2 × 5.5 cm. After discussing the treatment option, she was consented and had laparoscopic myomectomy and two-port contained morcellation in a specialized bag. Post-operative care was uneventful. Patient was discharged home same day. Histopathology showed benign fibroid. Conclusion The Morcellation Containment System is a feasible tool to extract a pelvic mass. However, it is important to be aware of its challenges like any other contained morcellation system.

Posterior Colpotomy: A Technique for Myomectomy Specimen Removal that Does Not Require Enlargement of Abdominal Incisions or Intracorporeal Specimen Size Reduction

Video Objective Laparoscopic or robotic myomectomy produces specimens that are typically larger than the abdominal incisions used for instrumentation. In the post electromechanical morcellation era, other options must be used for specimen removal. Setting MIS operating room. Interventions A posterior colpotomy incision is made, through which myomectomy specimens are removed intact vaginally. The colpotomy incision is closed laparoscopically, but could also be closed vaginally. Conclusion This video demonstrates the technique for intact vaginal removal of myomectomy specimens, through a posterior colpotomy incision, obviating the need for enlargement of abdominal incisions or intracorpeal specimen size reduction.

Emerging complication of laparoscopic power morcellation: a rare case of parasitic leiomyoma

Introduction A parasitic leiomyoma is considered an extremely rare variant of extra uterine leiomyoma. It presents as a peritoneal pelvic benign smooth muscle mass separate from the uterus. We report a case of a 36-year-old female who presented with generalized abdominal pain and was found to have a parasitic fibroid which may have occurred following laparoscopic myomectomy, and along with it a review on current literature of parasitic fibroids. Parasitic leiomyoma presents with vague symptoms and the diagnosis is challenging. In prevention of this condition, various alternatives must be utilized when using electromechanical power morcellation for myomectomy.

Cell Spillage after Contained Electromechanical Morcellation Using a Specially Designed In-Bag System for Laparoscopic Myomectomy: Prospective Cohort Pilot Study

Study ObjectiveFew reports have investigated the use of endoscopic retrieval bags in the context of laparoscopic myomectomy with electromechanical morcellation. We performed a leak test of a specially designed endoscopic bag system in women undergoing laparoscopic myomectomy with contained electromechanical morcellation. Design ClassificationProspective study. SettingUniversity hospital. PatientsThirty-one women undergoing laparoscopic myomectomy with contained electromechanical morcellation. InterventionsElectromechanical morcellation was introduced for large specimen extraction during laparoscopic procedures. Complications such as retained/disseminated parasitic tissue were documented. Measurements and Main ResultsSystematic peritoneal washings were performed at 3 specific times: at baseline, T1, once the peritoneal cavity was accessed laparoscopically; T2, when the myometrial incision was closed after myomectomy; and T3, after contained electromechanical morcellation. After retrieval of the endoscopic bag from the abdominal cavity, visual inspection and water test on the bag with NaCl infiltration were performed to detect leaks attributed to intraoperative perforations. A pathologist performed cytologic analyses on the 3 washings. The mean endoscopic bag procedure duration was 9 minutes. The use of a specially designed endoscopic bag system was found to be easy in 45% of cases, and no complications were reported. Cytologic washings were positive for smooth muscle cell detection in 8 cases (25.8%) at T2 and 3 cases (9.7%) at T3. All positive cases at T3 already had detectable smooth muscle cells at T2. After retrieval from the abdominal cavity, perforations on the optic access of the endoscopic bag were observed in 3 cases. ConclusionThe results from this pilot study are encouraging. The use of a specially designed endoscopic bag system could be an adjuvant to reduce the risk of disseminating cells during myomectomy.

Technique for Tissue Containment and Extraction in the Complex Minimally Invasive Myomectomy Setting

To achieve tissue containment and extraction for numerous and large myomas in the complex minimally invasive difficult myomectomy setting via a surgical tutorial including technical pointers and suggestions DESIGN: A step-by-step explanation of the .surgery using video (instructive video) (Canadian Task Force classification III). Institutional review board approval was not required for this study. George Washington University Hospital, Washington, DC. Multiple patients with a high number or large size of leiomyomata. Four reproducible techniques that enable the minimally invasive gynecologic surgeon to perform complex tissue containment and extraction: MEASUREMENTS AND MAIN RESULTS: One of the main challenges encountered with minimally invasive myomectomy procedures includes myoma containment and extraction. Given the potential risks for leiomyomatosis and the spread of leiomyosarcoma, the Food and Drug Administration banned electromechanical morcellation device usage [1]. After implementation of the ban and fueled by the increasing size and number of myomas removed through minimally invasive techniques, tissue containment and extraction are becoming increasingly challenging. This shift is partly reflected by the number of complications attributable to surgeon experience [2,3]. With the increase in the number of myomas removed during a minimally invasive myomectomy, the risk of myoma retention in the abdominal cavity is amplified. Also, the increase in the myoma size removed through minimally invasive surgery renders tissue extraction through contained, extracorporeal, manual morcellation more challenging [2-5]. Inefficiencies in tissue containment and extraction could potentially be hazardous to the patient's safety and detrimental to the operating room efficiency, and the AAGL Practice Report on tissue extraction emphasizes that the use of specimen retrieval pouches should be investigated further [2-6]. Patients underwent uncomplicated complex minimally invasive myomectomy. Mastering these reproducible techniques maximizes patient safety and operating room efficiency during minimally invasive myomectomy procedures.

Morcellation during Uterine Tissue Extraction: An Update

Morcellation is a mechanism to reduce the size of large tissue specimens with the intent to remove them via small openings in the body and has been used in gynecologic surgery for over 90 years. While traditionally performed manually via scalpel or scissors, surgeons have more recently employed electromechanical morcellation devices in conjunction with laparoscopic surgery. The first electromechanical morcellation device was approved by the US Food and Drug Administration (FDA) in 1995; over the succeeding two decades numerous such devices have been developed and marketed.

Irrigation after Laparoscopic Power Morcellation and the Dispersal of Leiomyoma Cells: A Pilot Study

Study ObjectiveTo evaluate if copious irrigation and suctioning after electromechanical power morcellation will reduce myoma cell dissemination and if there is a difference between sterile water and normal saline. DesignProspective single-center cohort pilot study (Canadian Task Force classification II-2). SettingAcademic tertiary referral center. PatientsSixteen women undergoing laparoscopic myomectomy with 1 surgeon between January 1, 2017 and August 31, 2017. InterventionsPeritoneal washings were collected 3 specific times during surgery: after dissection of myoma(s) and hysterotomy repair but before morcellation, after morcellation, and after irrigation with 3 L normal saline or sterile water. The primary outcome was the detection of benign spindle cells (BSCs) in peritoneal washings. Measurements and Main ResultsSixteen patients were enrolled in the study. Eight were randomized to the normal saline group and 8 to the sterile water group. In the normal saline group BSCs were detected in 3 of 8 patients (37.5%) after closure of the hysterotomy but before morcellation, in 3 of 8 (37.5%) after morcellation, and in 0 of 8 (0%) after irrigation and suctioning of the peritoneal cavity with 3 L normal saline. In the sterile water group BSCs were detected in 3 of 8 patients (37.5%) after closure of the hysterotomy but before morcellation, 2 of 8 (25%) after morcellation, and in 0 of 8 (0%) after irrigation and suctioning with 3 L sterile water. Thus, no differences were found between the normal saline and sterile water groups. ConclusionIn this pilot study myoma cells were disseminated before electromechanical morcellation. Irrigation and suctioning with 3 L normal saline or sterile water after morcellation may reduce myoma cell dissemination.

Incidence of Occult Uterine Malignancy Following Vaginal Hysterectomy With Morcellation

(Abstracted from J Minim Invasive Gynecol 2017;24:665–669) The availability of electromechanical morcellation has allowed many women to undergo minimally invasive hysterectomy. However, there has been increasing concern over possible inadvertent morcellation of uterine malignancy.