Manual Morcellation Research Articles

Charting Proficiency: The Learning Curve in Robotic Hysterectomy for Large Uteri Exceeding 1000 g.

Background/Objectives: This study evaluates the safety and surgical outcomes of performing robotic hysterectomy on uteri weighing over 1000 g, with a focus on the surgeon's learning curve. Methods: A retrospective analysis was conducted on 44 patients who underwent hysterectomy by a single surgeon from January 2020 to February 2024 using the DaVinci Xi System. Surgical procedures included total hysterectomy with bilateral salpingectomy, and specimens were removed via transvaginal manual morcellation. Operative times were segmented into docking, console, morcellation, and conversion times. Results: Results indicated an inflection point in the 20th case, suggesting proficiency after 20 surgeries. Comparison between early (Group A, cases 1-20) and later cases (Group B, cases 21-44) showed significant reductions in console time (CT) and morcellation time (MT) in Group B, leading to a shorter overall operative time (OT). Although estimated blood loss was higher in Group A, it was not statistically significant. Hemoglobin differences were significantly higher in Group B. No significant differences were observed in transfusion rates, postoperative analgesic usage, or complications between the groups. Conclusions: The study concludes that robotic hysterectomy for large uteri is safe and that surgical proficiency improves significantly after 20 cases, enhancing overall outcomes.

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

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

Comparison of perioperative surgical outcomes between contained and free manual vaginal morcellation of large uteruses following total laparoscopic hysterectomy.

To compare contained and free manual vaginal morcellation of large uteruses after total laparoscopic hysterectomy (TLH) in women at low risk of uterine malignancy in terms of feasibility and safety. A single-center, observational, retrospective, cohort study was carried out including all patients undergoing TLH requiring manual vaginal morcellation for specimen extraction of large uteruses from January 2015 to August 2021 at the Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria of Bologna, Bologna, Italy. Patients were divided into two groups according to the type of manual vaginal morcellation (contained or free), and compared in terms of demographic, clinical, and perioperative data. In all, 271 patients were included: 186 (68.6%) in the contained morcellation groupand 85 (31.4%) in the free morcellation group. The mean operative time was significantly lower in the contained morcellation group compared with the free morcellation group (median [interquartile range] 130 [45] vs. 155 [60] min; P < 0.001). No significant difference was found in complications related to the morcellation step, overall, intraoperative and postoperative complications, estimated blood loss, length of hospital stays, uterine weight, and rate of occult malignancy between the two groups. Contained vaginal manual morcellation of the uterus after total laparoscopic hysterectomy using a specimen retrieval bag appears to be a safe procedure with significantly lower operative time than free vaginal manual morcellation.

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

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. 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). Median CMM time was 11min (1 to 46) and specimen weight 62g (19 to 711). Median patient age was 56years (36 to 83), and patient BMI was 28 (18 to 44). Median EBL was 50ml (10 to 150). Median skin and fascial incision lengths were 3cm (1.5 to 7), and 3.5cm (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 5years after surgery patients were cancer free. 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.

In-bag abdominal manual morcellation versus contained power morcellation in laparoscopic myomectomy: a comparison of surgical outcomes and costs

BackgroundTo compare the surgical outcomes and costs of in-bag abdominal manual morcellation (AMM) and contained power morcellation (PM) in laparoscopic myomectomy.MethodsA total of 61 patients were divided into two groups based on their myomectomy specimen extraction methods: AMM group (n = 33) and electromechanical contained PM group (n = 28). The surgical outcomes and cost were compared between groups. During AMM, a glove bag (in 27 patients) and an endo bag were used (in 6 patients) according to the myoma size.ResultsMorcellation time (18 ± 9.2 min vs. 37.4 ± 14.1 min) and total operation time (100 ± 24.3 min vs. 127 ± 33.1 min) were significantly lower in the AMM group compared to those in the PM group. Other surgical outcomes, which were similar between groups, included delta hemoglobin, length of hospital stay and VAS score at 12 and 24 h postoperatively. There were no per- or postoperative complications in both group with no conversion to laparotomy. One patient was transfused with two units of erythrocyte suspension postoperatively in the PM group. Sarcoma was not diagnosed in any of the cases in both group.ConclusionThe in-bag AMM or contained PM for specimen extraction resulted in similar outcomes in terms of delta hemoglobin, postoperative pain intensity (VAS score at 12 and 24 h postoperatively), the need for additional analgesia, and the length of hospital stay; however, total operation time and morcellation time were significantly shorter in the AMM group, indicating a prominent advantage. Significant cost-effectiveness is also a critical advantage of in-bag AMM compared to containing PM.

The merging of dual umbilical port-incisions for contained morcellation in laparoscopic myomectomy

Uncontained power morcellation during laparoscopic myomectomy may spread tissue fragments or malignant cells into the abdominal cavity. Recently, various approaches to contained morcellation, have been adopted to retrieve the specimen. However, each of these methods has its own drawbacks. Intraabdominal bag-contained power morcellation adopts a complex isolation system, which prolongs the operation and increases medical costs. Contained manual morcellation via colpotomy or mini-laparotomy increases the trauma and the risk of infection. Contained manual morcellation via umbilical incision during single-port laparoscopic myomectomy may be the most minimally invasive and cosmetic approach. But the popularization of single-port laparoscopy is challenging because of technical difficulties and high costs. We have therefore, developed a surgical technique using 2 umbilical port-incisions (5 mm and 10 mm), which are merged into 1 large umbilical incision (25-30mm) for contained manual morcellation during specimen retrieval, and one 5mm incision in the lower left abdomen for an ancillary instrument. As demonstrated in the video, this technique significantly facilitates surgical manipulation using conventional laparoscopic instruments while still keeping the incisions minimal. It is also economical because the use of an expensive single-port platform and special surgical instruments is avoided. In conclusion, the merging of dual umbilical port-incisions for contained morcellation adds a minimally invasive, cosmetic, and economical option to laparoscopic specimen retrieval that would enrich a gynecologist's skill set, which is particularly relevant in a low-resource settings.

Laparoscopic subtotal hysterectomy followed by in-bag transvaginal corpus uteri morcellation and extraction: A case series

ObjectivesLaparoscopic subtotal hysterectomy (LSH) is a possible treatment for patients with benign uterine disease. Once the hysterectomy has been completed, morcellation and extraction of the corpus uteri is a crucial step of the procedure. We here present a case series to evaluate the feasibility of the in-bag transvaginal specimen retrieval following LSH. Study designWe report a case series of consecutive patients who underwent LSH followed by in-bag transvaginal specimen retrieval. LSH was accomplished in a standard fashion. Once the uterus was detached from the cervix, a 2 cm posterior colpotomy was performed laparoscopically with a monopolar hook under direct view to insert a specimen retrieval bag into the abdomen. The corpus uteri was placed into the bag and transvaginal contained manual morcellation was performed. The colpotomy was then sutured transvaginally. Baseline patients’ characteristics and surgical data were collected. Postoperative complications, same-hospital readmissions, and reoperations were registered if occurred within 30 days from surgery. ResultsPatients’ median age and BMI were 45,5 and 22,7, respectively. Median operative time was 71.5 min (range 34–143) and uterus weight ranged from 60 g to 470 g (median 210 g). The estimated blood loss was 100 mL (median) and no blood transfusion was required. No conversions to open surgery, nor intraoperative complications occurred. Median hospital stay was 2 days (1–3) and no postoperative complications within 30 days from surgery were recorded. ConclusionsLSH followed by in-bag transvaginal specimen extraction is a promising technique and might be considered a reliable and safe option to further reduce the invasiveness of the procedure.

8890 Robotic Hysterectomies with Mini-Laparotomies for Enlarged Uteri

<h3>Study Objective</h3> Robotic surgical system assistance in hysterectomies has gained significant popularity amongst gynecologists for its ease of employment, improved visualization and minimally invasive approach in attempts to decrease intra-/post-operative complications and improve clinical outcomes. Assessment of clinical outcomes, specifically length of hospitalization and postoperative complication rates, of patients undergoing robotic hysterectomy with the addition of mini-laparotomy and in bag manual morcellation for extraction of enlarged uteri specimen was analyzed. <h3>Design</h3> Retrospective case series analysis of patients who received the treatment in question pooled from a private practice Obstetrics and Gynecology group. <h3>Setting</h3> N/A. <h3>Patients or Participants</h3> Surgical database of this private practice was reviewed and analyzed between 2015 and 2021 for patients undergoing this procedure for benign indications with enlarged uteri (namely uterine fibroids) yielding 52 eligible participants. <h3>Interventions</h3> After completion of a robotic-assisted laparoscopic hysterectomy of an enlarged uterus using the standard technique, the resulting specimen which could not easily be delivered vaginally, was placed into a surgical bag, brought through a mini-laparotomy (≤5cm) and manually morcellated to facilitate specimen extraction. <h3>Measurements and Main Results</h3> A total of 52 patients were included in the retrospective analysis revealing a 90.4% (47/52) same day discharges with 5 post-operative admissions; one for uncontrolled blood glucose and four for post-operative pain. The minimum uterine size requiring mini-laparotomy for extraction was found to be 12cm with at least a 366g weight. The average uterine size and weight requiring said intervention were found to be 18cm and 853g, respectively. Complications were also found to be rare with seven total reports of post-operative fever of which 5 pelvic collections were found and three microbiologically confirmed as pelvic abscesses necessitating drainage and parenteral antibiotics. <h3>Conclusion</h3> Mini-laparotomy within bag manual morcellation for enlarged uteri is a beneficial adjunct technique to robotic-assisted laparoscopic hysterectomies allowing the preservation of the benefits of minimally invasive surgery while also maintaining low complication rates.

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.

Getting square pegs out through round holes: A survey of Australian and New Zealand Gynaecologists regarding specimen retrieval.

To evaluate morcellation practices among Fellows of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG). RANZCOG Fellows were invited to complete an online survey. This anonymous, cross-sectional survey consisted of 29 questions regarding demographics and morcellation practices. Four hundred and thirty eight (19.04%) of 2300 RANZCOG Fellows responded, and of these 258 (11.22%) completed the entire survey; analysis was undertaken on data from the latter respondents. Respondents were broadly representative of all RANZCOG Fellows regarding gender, age, and location. Of the respondents, 53.10% considered themselves advanced laparoscopic surgeons. Of respondents who had worked as gynaecology consultants prior to 2014, 39.39% used uncontained power morcellation prior to 2014, compared to 17.58% since (a decrease of 44.63%). The most common reasons for utilising uncontained power morcellation less often were the 2014 Food and Drug Administration warnings (40.31%), risk of adverse outcomes (33.72%), and recommendations from colleges such as RANZCOG (27.13%). When undertaking an operation that required specimen extraction, the most common methods used were: employing an open approach from the get-go (utilised by respondents in 31.01% of such cases); contained manual morcellation (28.90%); and conversion to intra-operative laparotomy (10.10%). There has been a strong trend away from uncontained power morcellation since 2014, with a 36.00% increase in clinicians who never use uncontained power morcellation, and an 80.65% decrease in clinicians who always use this method of specimen extraction. The most common reason cited for employing uncontained power morcellation less often was the 2014 Food and Drug Administration's warnings.

The incidence of unexpected uterine malignancies in hysterectomies carried out for benign indications

PurposeThe aim of the present study was to evaluate the incidence of unexpected uterine malignancies in patients undergoing hysterectomy for benign indications and to evaluate their clinical characteristics.MethodsWe conducted a retrospective review of patients who underwent benign hysterectomy in the Department of Gynecology, the First Hospital of Shanxi Medical University from January 2015 to December 2020. The clinical data of these patients were retrieved and collected.ResultsTheir median age was 49.8 years (31–82 years). The mean parity was 1.86 ± 2.54. Their mean BMI was 27.5 ± 7.6 kg/m2. 42.90% were (2438/5683) postmenopausal. The benign indications of procedure were as follows: symptomatic uterine leiomyomas 2218/5683 (39.02%), pelvic organ prolapse 1406/5683 (24.74%), symptomatic endometriosis or adenomyosis 1132/5683 (19.91%), and 927/5683 (16.31%) to treat other benign conditions such as abnormal uterine bleeding, infection, polyps, and endometrial hyperplasia without atypia. In minimally invasive surgery subgroups, 1560/2621 (59.52%) specimens were removed by in-bag manual morcellation through vaginal cuff. The mean operative time of minimally invasive surgery with in-bag morcellation was shorter than abdominal hysterectomy (96.75 ± 35.7 vs. 140 ± 32.6, P < .001), and the estimated blood loss was also less than abdominal hysterectomy (47.35 ± 42.3 vs. 170 ± 60.4, P < .001). A total of 19/5683 (0.33%) unexpected uterine malignancies were recorded, of which 14/5683 (0.26%) were unexpected endometrial carcinomas and 5/5683 (0.08%) were unexpected uterine sarcomas.ConclusionPreoperative examination in the context of benign hysterectomy must be undertaken with care, and patients should be educated about the very slight possibility of a malignant diagnosis.

Successful Application of Manual Hand Morcellation Technique in Giant Leiomyoma: A Case Report

Introduction: Uterine leiomyoma is the most common benign neoplasm of the female reproductive tract. However, he use of the laparoscopy approach for giant myomas is still controversial and rarely performed. Only few cases have been published in the literature. Retrieval of giant myoma in laparoscopy is difficult and still challenging even by a power morcellator.&#x0D; Case presentation: A 39 years old para 3 woman was referred to the gynaecology department with abdominal swelling during the previous 3 years. No family history, past medical and gynaecology history disease was reported. A physical examination revealed a firm huge palpable abdominal mass with identifiable borders. The mass extended to her umbilicus. The abdominal ultrasound revealed a markedly enlarged and lobular uterus containing intramural uterine leiomyoma measuring 15 x14 cm without ascites. No additional pathology was noted. The results of the laboratory examination were within normal limit. She was offered laparoscopy removal of myoma.&#x0D; Conclusion: The case concludes the efficiency, reliability, and safety of laparoscopy surgery to treat huge leiomyoma and try to consider manual hand morcellation to remove the entire myoma to reduce spreading malignancy through electrical morcellation. Although a laparoscopic approach for a huge myoma has several challenges, it does represent an option for minimally invasive removal of giant myoma.&#x0D; Keywords: Giant leiomyoma, Laparoscopy, Leiomyoma, Morcellation, Manual morcellation

Technique for transvaginal removal of large specimen using an Alexis Contained Extraction System during laparoscopic hysterectomy

ObjectiveTransvaginal removal of large specimens during laparoscopic hysterectomy can be a complex surgical procedure that poses a risk of organ injury and tissue spillage into the abdominal cavity and is associated with extraction of the specimen and manual morcellation. Our objective was to demonstrate a technique for transvaginal removal of large specimens using the Alexis Contained Extraction System (CES) in laparoscopic hysterectomy.MethodsThe technique used for transvaginal removal of large specimens using the Alexis CES was presented in this video. Surgery was performed at a tertiary hospital.ResultsFollowing resection of the specimen during laparoscopic hysterectomy, the Alexis CES was inserted into the abdominal cavity through the umbilical trocar wound. The specimen was placed in a bag to prevent tissue spillage. The ring retractor was guided to the vagina and pulled out transvaginally. By repeatedly turning the ring retractor, tension was applied to the specimen bag, and the vaginal wall was unfolded all around to enable a secure surgical field. During manual morcellation of the specimen in the bag, the retractor was pulled and additionally turned to roll and re-tension the specimen bag when the bag was loosened. The specimen was pushed out of the vagina and safely and effectively extracted without concerns about tissue spillage in the abdominal cavity or related organ injuries.ConclusionThe technique for transvaginal removal of large specimens using the Alexis CES enables simple, effective, and safe tissue extraction with contained manual morcellation during laparoscopic hysterectomy.

Current Methods of Tissue Extraction in Minimally Invasive Surgical Treatment of Uterine Fibroids.

Background and Objectives:Since the 2014 Food and Drug Administration communication regarding the use of power morcellation, gynecologists have adopted alternative tissue extraction strategies. The objective of this study is to investigate the current techniques used by gynecologic surgeons for tissue extraction following minimally invasive hysterectomy or myomectomy for fibroids.Methods:An online survey was distributed to all AAGL members and responses were collected between March 26, 2019 and April 17, 2019.Results:Four hundred thirty-six respondents completed the survey. For hysterectomy, the most common methods of tissue extraction were manual morcellation through the colpotomy (72.4%) or minilaparotomy (66.9%). Nearly one-third (31.7%) endorsed using power morcellation. For myomectomy, manual morcellation via minilaparotomy (71.9%) was the most common approach, followed by power morcellation (35.7%). Use of containment bags was common. Minilaparotomy incisions were typically three cm and most often at the umbilicus.Geographic differences were detected, particularly with power morcellation. During hysterectomy, 18.4% of US-based surgeons reported its use, compared to 56.9% of nonUS-based surgeons. During myomectomy, 20.5% of US-based surgeons reported its use compared to 67.5% of their international counterparts. Age, years in practice, fellowship training, and practice location were all significantly associated with power morcellator use.Conclusion:A large majority of practitioners are performing manual morcellation through the colpotomy or minilaparotomy. Use of containment bags is common with all routes of tissue removal. Power morcellation use is less common in the United States than in other countries.

In-Bag Abdominal Manual Morcellation Versus Contained Power Morcellation in Laparoscopic Myomectomy: A Comparison of Surgical Outcomes and Costs

In-Bag Abdominal Manual Morcellation Versus Contained Power Morcellation in Laparoscopic Myomectomy: A Comparison of Surgical Outcomes and Costs

Contained and uncontained morcellation in hysterectomy and myomectomy: A systematic review and meta-analysis

We sought to analyze all high-quality studies available regarding the possible differences in contained and uncontained techniques for morcellation of fibroids and uteri. We systematically searched PubMed, Cochrane Central, Scopus, ClinicalTrials.Gov, MEDLINE and Web of Science from September 2010 to September 2020 for our search terms. We included studies that specifically enrolled patients undergoing power morcellation myomectomy or power morcellation hysterectomy procedures. In our search, we had no restriction to age, country, or publication date.We extracted data related to study design, baseline characteristics of patients, and perioperative outcomes such as total operative time, total blood loss, and duration of hospital stay. We found no substantial difference in total operative time between contained power morcellation and uncontained manual morcellation myomectomy (p=0.52), but contained power morcellation had a significantly longer total operative time than uncontained power morcellation for hysterectomy and myomectomy [135.50 vs. 93.33 minutes, (p=0.003)]. Total blood loss was comparable for contained power morcellation versus uncontained manual morcellation myomectomy (p=0.32) and contained power morcellation versus uncontained power morcellation myomectomy or hysterectomy (p=0.91). Contained power morcellation and uncontained manual morcellation myomectomy had comparable hospital stay periods (p=0.5). Contained power morcellation leads to a longer operating time than uncontained power morcellation for both hysterectomy and myomectomy. No differences were found in comparisons of blood loss, operative time, or comparison to manual methods of morcellation.

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.

6636 Removal of a Fibroid Uterus through a Posterior Colpotomy

<h3>Study Objective</h3> To describe a contained tissue extraction technique through a posterior colpotomy during a laparoscopic supracervical hysterectomy. <h3>Design</h3> surgical video. <h3>Setting</h3> Operating Room. <h3>Patients or Participants</h3> Single patient undergoing a supracervical hysterectomy. <h3>Interventions</h3> Manual morcellation of a fibroid uterus through a posterior colpotomy. <h3>Measurements and Main Results</h3> Successful removal of the specimen. <h3>Conclusion</h3> Posterior colpotomy is a safe and efficient method of specimen retrieval for patients undergoing a supracervical hysterectomy. It allows for use of smaller skin incisions and removal of a specimen in a contained fashion.

Impact of Intraoperative Tumor Spillage in Uterine Leiomyosarcoma: a Retrospective Single-Institution Analysis.

Uterine leiomyosarcoma is a rare female reproductive system tumor which is difficult to distinguish from uterine leiomyoma preoperatively. Manual and power morcellation are used to remove the large uterus through the vagina or small abdominal incision. Worse outcome with use of power morcellation is now clear but impact of manual morcellation on survival outcome not established till date. The objective of the present study was to find impact of tumor spillage and to evaluate influencing factors for oncological outcome and prognosis in uterine leiomyosarcoma patients. This is a single-institutional retrospective cohort study including all uterine leiomyosarcoma patients from January 2005 to December 2017. Role of intraoperative tumor spillage and other influencing factors on oncological outcome were assessed. Thirty-three patients with median follow-up period of 49.7months were evaluated. Stage 1 and absence of tumor spill had significant association with prolonged progression-free survival. Stage 1 uterine leiomyosarcoma (56.8 vs 6.8months, p = < 0.001), intraoperative tumor spillage (p = 0.03) and progression-free survival > 15months (68.5 vs 12.2months, p = < 0.001) were favourable prognostic factors to predict better survival outcome but unable to establish significance on multivariate analysis. Survival plot did not reach median limit for stage I uterine leiomyosarcoma patients with preoperative suspicion. Age, site of recurrence and mitotic index had no significant association with better survival in the present study. Stage I disease and absence of tumor spillage during surgery improved progression-free survival but did not affect overall survival. Progression-free survival more than 15months can predict better overall survival.

In Vitro User Assessment of a Novel Wound Protection and Specimen Extraction System for Laparoscopic Procedures Involving Morcellation

Introduction: The risk of unknowingly disseminating leiomyosarcoma by morcellation in women undergoing laparoscopic hysterectomy has massively impacted gynaecological practice. Here, we present the results of an in vitro assessment of a novel protection system developed to mitigate this hazard. Methods: The Tissue Containment System for Manual Morcellation (Guardenia™, Advanced Surgical Concepts, Wicklow, Ireland) is an evolved wound protection/specimen extraction guarded bag system compatible with any 12mm trocar. Device use was assessed by device-naïve gynaecological and general surgeon volunteers (providing expert and inexpert morcellation cohorts, respectively) on a bench model consisting of biological tissue in a custom-built moulded rig with camera control after the operators were instructed in its use. Results: Twenty surgeons (10 gynaecologists/10 general surgeons, median duration of practice experience: 8 years, median annual number of laparoscopic operative procedures: 150 and 80, respectively) completed the user assessment. All subjects understood and correctly performed each step; i.e., (i) placement of the bag through the trocar, (ii) specimen bagging, (iii) incision extension (range 25-60 mm) after tethering the bag through the port, (iv) insertion of the device guard through the mouth of the bag after trocar removal, and (v) sufficient tissue morcellation within the bag to enable complete specimen removal (mean specimen weight 390g, range 201-1800g). There was 100% bag integrity by water-leak testing following use, despite scalpel contact with the guard in 14/20 cases (70%). Conclusion: Among first-time clinical users, this novel device enabled complete containment of morcellation debris and removal of a laparoscopic specimen, which would support further submission for regulatory approval.