Power Morcellation Research Articles

Power Morcellation with Contained Tissue Extraction – A Retrospective Chart Review

Study Objective To evaluate the clinical performance of power morcellation (PM) with contained tissue extraction (CTE) (PneumoLiner, Advanced Surgical Concepts, Limited, Wicklow, Ireland) for presumed benign indications for minimally invasive gynecological surgery (MIGS). Design Multi-center, retrospective, IRB-approved chart review conducted by a version-controlled protocol. The primary endpoint was operative time and was measured from skin incision to skin closure. Secondary endpoints included complications related to the surgical procedure, morcellator, or tissue containment device; integrity of the tissue containment device following post-operative inspection; specimen histopathology; 30-day hospital readmission; and device deficiencies. Data were pooled and descriptive statistics were used for per-protocol analysis. Setting Three tertiary care institutions in the United States Patients or Participants 211 cases including females ≥ 18 years of age indicated for MIGS (robotic or laparoscopic) using PM and CTE were included in this study. Cases were excluded if patients were peri- or post-menopausal, had a known malignancy, were candidates for en bloc tissue removal, had undiagnosed uterine bleeding, had suspected allergies to polyurethane, or had abdominal wall thickness > 10cm. Interventions N/A Measurements and Main Results Mean age and body mass index was 41.2±6.7 years and 30.9±7.1 kg/m2 respectively. Common surgical indications included: uterine fibroids 70% (148), abnormal uterine bleeding 63% (133), and endometriosis 19% (40). Mean operative time was 82±36.7 minutes. Post-operative complications were reported in 2.4% (5) of patients, including umbilical port site (3) and urinary tract infections (2); all were related to the surgical procedure. Integrity of the tissue containment device was maintained in 100% (211) of cases. Histopathology confirmed malignancy in 0.5% (1) of patients. There were no hospital readmissions or device deficiencies. Conclusion Power morcellation with contained tissue extraction is feasible in patients with presumed benign indications for minimally invasive gynecologic surgery.

2080 Strategies for Difficult Hysterectomies

Video Objective Demonstrate alternative surgical approaches for difficult hysterectomies. Setting Multiple Cases of Hysterectomies with Challenging circumstances. Interventions Multiple Cases of Hysterectomies with Challenging circumstances with strategies for getting an alternative approach. 1. 30° angle Scope for better visualization 2. Decompression for vaginal extraction 3. Traction of the angles of vaginal cuff 4. Bladder Distention 5. Blunt Dissection 6. Cold Dissection 7. Power Morcellation 8. Identify Retroperitoneal Structures. Conclusion These strategies are useful to perform complex surgery and reduce the risk of complications

Laparoscopic Approach to the Difficult Trachelectomy: Surgical Tips and Tricks

Video Objective The objective of this video is to present a stepwise approach to completing difficult trachelectomies and to review relevant anatomy. Setting Supracervical hysterectomy was once a popular procedure, accounting for 7.5% of hysterectomies in 2004, secondary to purported benefits over total hysterectomy. With mounting evidence that there are no advantages to this technique, in addition to limitations on the use of power morcellators, the supracervical approach has fallen out of favor. Five to 10% of patient will continues to have bothersome bleeding following a supracervical hysterectomy. In this video we present a patient with complaints of pelvic pain and vaginal bleeding nine years after undergoing supracervical hysterectomy for dysmenorrhea. She reports that the planned procedure was a total hysterectomy, however at the time of surgery, obliteration of the anterior culdesac was encountered and the planned procedure was not completed. She desired definitive management. Interventions Laparoscopic trachelectomy with ureteral stent placement and removal via cystoscopy. Conclusion Post-hysterectomy laparoscopic trachelectomies can be challenging in the presence of known pelvic adhesive disease. Success is achievable through familiarity with key anatomical structures and relationships along with following a stepwise approach.

1803 Post Morcellation Endometriosis: Is it Real?

Study Objective To describe the clinical characteristics of patients diagnosed with endometriosis following laparoscopic supracervical hysterectomy (LSH) with uncontained power morcellation. Design A systematic retrospective chart review was performed. The clinical presentation and histopathology were reviewed in each case for the incident and subsequent procedures. The menstrual phase at the time of LSH was determined from the pathology reports. Descriptive statistics were performed for the cohort. Setting N/A. Patients or Participants Patients who underwent LSH with uncontained power morcellation at Kaiser Permanente Southern California Medical Centers between 2006-2013. From a total of 47,010 hysterectomies, 5154 were LSH with uncontained power morcellation. We focused on the 261 LSH patients who then underwent a subsequent surgery. Interventions N/A. Measurements and Main Results The mean age and BMI of patients undergoing second surgery were 43.2 yrs. ± 0.8 and 29.4±0.7 respectively. Of the 261 patients who underwent subsequent surgery, a pathological diagnosis of endometriosis was confirmed in 58 patients: this was a new diagnosis in 93% (54/58). Patients with endometriosis were more likely to present with new onset pelvic pain and a mass (p Conclusion Morcellation seems to contribute to the development of endometriosis in some patients through an unknown mechanism. While uncontained power morcellation is no longer a common clinical scenario, it may still be necessary to consider that manual morcellation has potentially adverse consequences. Further study of the sequelae of non-power morcellation is warranted.

Parasitic Leiomyoma After Laparoscopic Total Hysterectomy and Bilateral Salpingo-Oophorectomy, a Mimicker of Pelvic Neoplasm

Abstract Parasitic leiomyomas are rare occurrences that may mimic malignancy and thus present a diagnostic dilemma. They are thought to arise from a pedunculated subserosal leiomyoma that undergoes torsion and detaches from the uterus, surviving by revascularization from adjacent structures, or from iatrogenic implantation during surgery, more common with the clinical popularity of laparoscopic surgery and power morcellation. We report a case of parasitic leiomyoma with degenerative changes in a 57-year-old female who was initially found to have a 6.5-cm left adnexal mass and multiple submucosal and intramural masses consistent with leiomyoma by abdominal pelvic computerized tomography test (CT) 7 years prior to presentation. She experienced severe abdominal discomfort that persisted after total abdominal hysterectomy and a 7.8-cm mass was found in the left pelvic cavity on reevaluation. Grossly, the pelvic mass was a 6.5-cm tan-gray ovoid firm mass with a 4.0-cm cystic cavity. The cut surfaces of the solid areas/cyst wall were gray-white and firm with focal yellow streaks. Microscopically, there was central cystic degeneration, with cyst wall showing extensive granulation tissue. The solid portion also showed extensive hyaline degeneration, fibrosis, and perinodular hydropic degeneration. Smooth muscle differentiation was evident at the periphery of the mass, confirmed by strong staining with desmin and smooth muscle actin. This represents a parasitic leiomyoma left behind following the first procedure and it developed degenerative changes. In addition to the high index of suspicion for malignancy in assessing adnexal masses, degenerating parasitic leiomyomas should be included in the differential diagnosis of such mass lesions.

Parasitic Pelvic and Infradiaphragmatic Leiomyomatosis Following Laparoscopic Myomectomy

Purpose: Uterine leiomyomas are the most common indication for gynecological surgery. The use of power morcellators has facilitated myomectomy, but appears to be associated with leiomyoma seeding, leading to parasitic leiomyomatosis. This is a case report of a patient with parasitic leiomyomatosis following laparoscopic myomectomy, which was detected incidentally during elective gallbladder surgery. Case Report: A 42-year-old female was treated for symptomatic cholelithiasis in July 2018 by elective laparoscopic cholecystectomy. Three years earlier, the patient had undergone laparoscopic myomectomy using a power morcellator for the removal of a subserosal uterine fibroid 21 cm in diameter. During laparoscopy, a firm nodule, roughly 2 cm in diameter was observed on the right infradiaphragmatic surface, and two smaller, similar pelvic nodules. The infradiaphragmatic nodule was excised and histopathological examination identified it as leiomyoma tissue, confirming the case as parasitic leiomyomatosis. Discussion: Parasitic leiomyomatosis is a rare entity first described in 1909. Reports of its incidence have increased since the advent of laparoscopic surgery for the treatment of uterine fibroids and there appears to be an association with the use of power morcellators for fragmentation of large myomas, which may promote seeding. Parasitic myoma cells display increased expression of estrogen and progesterone receptors, and increased angiogenetic capacities compared with their uterine counterparts. Further studies are required to ascertain whether power morcellators play a key role in myoma dissemination, and to evaluate possible therapeutic solutions.

Laparoscopic Hysterectomy Route, Resource Use, and Outcomes: Change After Power Morcellation Warning.

To examine changes in utilization of different types of laparoscopic hysterectomy, as well as their associated resource use and surgical outcomes, after the U.S. Food and Drug Administration (FDA) safety statement in April 2014 regarding power morcellation. We retrospectively analyzed data from the 2012-2016 American College of Surgeons National Surgical Quality Improvement Program and identified 145,746 women undergoing hysterectomy for benign indications. We measured use of laparoscopic supracervical hysterectomy compared to total laparoscopic hysterectomy (including laparoscopic-assisted vaginal hysterectomy) in these patients, as well as operative time, surgical setting (inpatient vs outpatient), length of stay, and 30-day surgical outcomes (wound complication, medical complication, reoperation, and readmission). We used an interrupted time series analysis to examine the association between FDA warning and changes in utilization and outcomes of laparoscopic hysterectomy. After adjusting for patient characteristics and background trends in practice, use of laparoscopic supracervical hysterectomy was significantly lower in the postwarning than prewarning period (odds ratio [OR]=0.49, 95% CI 0.45-0.53), whereas use of total laparoscopic hysterectomy was not affected (OR 1.01, 95% CI 0.96-1.06). Overall, after an initial reduction, use of laparoscopic hysterectomy (laparoscopic supracervical hysterectomy and total laparoscopic hysterectomy combined) increased over time in the postwarning period (adjusted OR of utilization for each calendar quarter elapsed=1.03, 95% CI 1.02-1.03). After the FDA warning, operative time for laparoscopic supracervical hysterectomy increased by 11.45 minutes (95% CI 6.22-16.69), whereas the decreasing trend in the likelihood of inpatient stay for total laparoscopic hysterectomy was attenuated (OR for each calendar quarter elapsed=0.92 in prewarning period, 95% CI 0.91-0.93; and 0.97 in postwarning period, 95% CI 0.97-0.98). There was no significant change in 30-day surgical outcomes after the FDA warning. Rates of laparoscopic supracervical hysterectomy fell in association with power morcellation safety warnings, whereas rates of other laparoscopic hysterectomies continued to rise. There was no change in patient outcomes among laparoscopic hysterectomies.

Incidence of Leiomyosarcoma at Surgery for Presumed Uterine Myomas in Different Age Groups

To evaluate the incidence of leiomyosarcoma (LMS) at surgery for presumed uterine myomas according to different age groups. A retrospective cohort study. A tertiary referral hospital. All women undergoing surgery for presumed uterine myomas between January 1, 2006, and December 31, 2016. Laparoscopic myomectomy, laparotomic myomectomy, total hysterectomy, or hysteroscopic myomectomy. A total of 1398 patients underwent surgery for presumed uterine myomas. The incidence of LMS was 2.15 per 1000 surgeries (n = 3, 1/466, 0.2%). In women under 40 years old, the incidence of occult LMS was 0 (0/561). In women between 40 and 49 years old, 190 myomectomies were performed (28% of the surgeries), and the rate of LMS was 1.49 per 1000 (n = 1, 1/673, 0.15%). In women over 49 years old, a total hysterectomy was performed in 82.3% of the cases, and the incidence of LMS was 12.2 per 1000 surgeries (n = 2, 1/82, 1.2%). The incidence of occult LMS in patients under 40 years old undergoing surgery for presumed uterine myomas was 0. These findings are suggestive that the use of power morcellation in this population may be safe.

In-bag manual versus uncontained power morcellation for laparoscopic myomectomy

In-bag manual versus uncontained power morcellation for laparoscopic myomectomy

In Vitro Leakage Testing of Tissue Containment Bags When Subjected to Power Morcellation Forces

To determine the ability of tissue containment systems to prevent leakage of cancer cell surrogates when subjected to forces encountered during power morcellation procedures. In vitro study. Medical device research laboratory. Samples from 7 different legally marketed tissue containment bags (1 of which is indicated for power morcellation) were subjected to dye and bacteriophage penetration tests at pressures ranging from 0.5 to 50 times the insufflation pressure. The minimum pressure required to cause bag leakage was measured. Subsequently, the morcellation leakage safety factor for each bag was determined as the ratio of the minimum leakage pressure of the bag to the total pressure contributed from insufflation pressure and mechanical forces acting during the power morcellation procedure. The leakage performance of the bags varied markedly from brand to brand. No correlation was found between leakage pressure and the bag material or the total bag thickness. The leakage pressures ranged from 26 mmHg to >1293 mmHg for the 7 bags, and safety factors ranged from 1 to 50 when only the insufflation pressure was considered. However, if the morcellation forces were included in the calculation, the safety factor dropped by 6-fold for all brands and dropped below 1, indicating likelihood of leakage, for 2 of the 7 brands. This study provides a mechanism for more realistically simulating the conditions experienced by containment bags during morcellation and quantifying the level of safety provided by the bags.

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.

Two-port myomectomy using bag-contained manual morcellation: A comparison with three-port myomectomy using power morcellation

ObjectivesTo evaluate the feasibility and safety of two-port myomectomy using bag-contained manual morcellation compared to three-port myomectomy using power morcellation. Material and methodsA retrospective chart review was conducted for 428 cases of either two-port or three-port laparoscopic myomectomy performed by single operator in the university hospital between January 2011 and December 2016. ResultsThe cohorts of three-port myomectomy with power morcellation was consisted of two hundred and forty-eight patients. One hundred and eighty patients underwent two-port myomectomy with manual morcellation in contained bag. Two-port group showed shorter hospital stay (5.16 ± 1.39 d vs. 4.83 ± 1.19 d, p = 0.001), less estimated blood loss (61.8 ± 58.2 mL vs. 50.2 ± 52.4 mL, p = 0.001), and higher hemoglobin level at postoperative day 1 (10.7 ± 1.17 g/dL vs. 11.0 ± 1.14 g/dL, p = 0.028) with statistical significance. Morcellation time (25.8 ± 9.30 min vs. 18.9 ± 10.11 min, p = 0.001) and total operative time (82.4 ± 30.19 min vs. 76.4 ± 25.47 min, p = 0.047) were also significantly shorter in two-port group. There were no identified spillages of fibroids, ruptures of specimen bag during manual morcellation in two-port myomectomy. In both groups, there were no cases of leiomyosarcoma diagnosed postoperatively. ConclusionTwo-port laparoscopic myomectomy with bag-contained manual morcellation is a feasible and safe alternative for three-port with power morcellation. Its surgical outcomes were shown to be superior to conventional laparoscopic myomectomy according to our study but further evaluation in near future is needed.

Myomectomy Route and Adhesions at Subsequent Cesarean Delivery [39N

INTRODUCTION: To compare adhesions at cesarean delivery following open vs laparoscopic myomectomy. METHODS: In this retrospective cohort study, patients with an abdominal myomectomy were compared to those having conventional or robot-assisted laparoscopic myomectomy with regard to dense adhesions at the time of cesarean delivery. Logistic regression was used to control for potential confounders. RESULTS: 141 patients met inclusion criteria: 65 with abdominal and 76 with laparoscopic myomectomies. Patients in the abdominal group were more likely to have an anterior (72% vs 49%, P < .01) or posterior (74% vs 58%, P=.05) vs fundal uterine incision, and had more endometrial entry (43% vs 22%, P < .01), more fibroids removed (median 7 vs 2, P < .01), and more preexisting dense adhesions (28% vs 11%, P < .01). Patients in the laparoscopic group were more likely to have been exposed to barbed suture (15% vs 2%, P < .01) and uncontained power morcellation (96% vs 11%, P < .01) with no difference in the use of adhesion barriers. The abdominal group developed significantly more dense adhesions (56% vs 12%, P < .01), even after controlling for surgical factors plus age, race, and obesity (OR 9.88, 95% CI 1.54-63.39). The abdominal myomectomy group experienced more vertical skin incisions or hysterotomies (17% vs 1% for both, P < .01) and longer incision to delivery times (median 12 vs 9 min, P < .01), but no difference in neonatal Apgar scores. CONCLUSION: Prior abdominal myomectomy confers more risk for dense adhesions at the time of cesarean delivery than laparoscopic procedures.

Uterine sarcoma: a clinical case and a literature review.

Uterine sarcomas are rare gynaecologic tumours representing 3-7% of all uterine malignancies. The aetiology of sarcomas is still unclear: it is thought, that chromosomal translocations have influence on wide histological variety of sarcomas. Presenting symptoms are vague and nonspecific. Usually sarcoma causes abnormal vaginal bleeding, can cause abdominal or pelvic pain, or manifests as a rapidly growing uterine tumour. The diagnosis of sarcoma is often made retrospectively after surgical removal of a presumed benign uterine neoplasm, because imaging modalities such as ultrasound, computed tomography, or magnetic resonance imaging cannot yet accurately and reliably distinguish between benign leiomyoma and malignant pathology. If there are certain clinical features that raise a suspicion of malignancy in the uterus, it is recommended to avoid the use of power morcellation through laparoscopic surgery in order to prevent disease dissemination. We present a clinical case of a 64-year-old patient, who was referred to hospital due to abdominal pain and tenesmus that lasted for two days. From a past medical history it was known that previously the patient had been diagnosed with uterine myoma. Transvaginal ultrasonography showed a 10.4 cm × 9.8 cm uterine tumour of nonhomogeneous structure with signs of necrosis and good vascularization. The patient refused urgent hysterectomy, that was advised to her. The patient was operated on one month later and total hysterectomy with bilateral salpingooforectomy was performed. Postoperative histological evaluation showed undifferentiated sarcoma uterus pT1b L/V0. Imaging modalities were made to evaluate possible dissemination of the disease. In the absence of signs of disease progression, the patient received radiotherapy and brachytherapy and was followed-up by doctors. Uterine sarcomas are highly malignant tumours that originate from smooth muscles and connective tissue elements of the uterus and make up 1% of all malignant gynaecological tumours and about 3-7% of all malignant uterine tumours. Imaging modalities cannot yet reliably distinguish benign myomas from malignant sarcomas. It is important not to damage the wholeness of uterus during operation in order to prevent dissemination of the disease in the abdominal cavity. The low-grade endometrial stromal sarcoma has the best survival prognosis, while carcinosarcoma and undifferentiated uterine sarcoma have the lowest survival rates.

Hysterectomy Practice Patterns in the Postmorcellation Era.

To characterize long-term national trends in surgical approach for hysterectomy after the U.S. Food and Drug Administration (FDA) warning against power morcellation for laparoscopic specimen removal. This was a descriptive study using data from the American College of Surgeons National Surgical Quality Improvement Program from 2012 to 2016. We identified hysterectomies using Current Procedural Terminology codes. We used an interrupted time-series analysis to evaluate abdominal and supracervical hysterectomy trends surrounding The Wall Street Journal article first reporting morcellation safety concerns and the FDA safety communication. We compared categorical and continuous variables using χ, t, and Wilcoxon rank sum tests. We identified 179,950 hysterectomies; laparoscopy was the most common mode of hysterectomy in every quarter. Before The Wall Street Journal article, there was no significant change in proportion of abdominal hysterectomies (0.3% decrease/quarter, P=.14). After The Wall Street Journal article, use of abdominal hysterectomy increased 1.1% per quarter for two quarters through the FDA warning (P<.001), plateaued for three quarters until March 2015 (P=.65), then decreased by 0.8% per quarter through 2016 (P<.001). Supracervical hysterectomy volume continuously decreased after the FDA warning (1.0% decrease per quarter, P<.001) and after three quarters (0.7% decrease per quarter, P=.01), then plateaued from April 2015 through 2016 (0.05% decrease per quarter, P=.40). Mode of supracervical hysterectomy was unchanged from 2012 to 2013 (P=.43), followed by two quarters of significant increase in proportion of supracervical abdominal hysterectomies (11.7%/quarter, P<.001). This change in mode of supracervical hysterectomy then plateaued through 2016 (P=.06). Despite early studies suggesting that minimally invasive hysterectomy decreased in response to safety concerns regarding power morcellation, we found that this effect reversed 1 year after the FDA safety communication. However, there was a sustained decline in supracervical hysterectomy, and the remaining supracervical hysterectomies were more likely to be performed using laparotomy.

Racial Disparities in Response to a US Food and Drug Administration Safety Communication Regarding the Use of Power Morcellation for the Treatment of Uterine Leiomyoma

Study ObjectiveTo investigate whether the rate of increase in the performance of abdominal myomectomy over a laparoscopic approach after the US Food and Drug Administration (FDA) safety communication regarding morcellator use for myomectomy differs among races. DesignRetrospective cohort study. SettingThe American College of Surgeons National Surgical Quality Improvement data. PatientsPatients aged 18 to 55 years who underwent either laparoscopic or abdominal myomectomy, excluding malignant cases, emergency cases, operations performed by nongynecologic specialists, and cases in which myomectomy was performed during cesarean section. InterventionsNone. Measurements and Main ResultsThe odds ratios of abdominal myomectomy over laparoscopic myomectomy before and after the release of the FDA communication were calculated in 3 race categories: white, African American, and other races. In a logistic regression analysis adjusted for possible confounders, including all races, the odds ratio of abdominal myomectomy before and after the FDA communication was 1.30 (95% confidence interval [CI], 1.20–1.41; p <.001). In a logistic regression analysis with a product term of FDA communication exposure and race as a possible effect modifier, the African American population showed a significantly greater change in the odds of abdominal myomectomy over laparoscopic myomectomy in comparison with the white population (1.22; 95% CI, 1.02–1.47; p = .03). In contrast, other races showed no significant change (.83; 95% CI, .64–1.08; p = .17). ConclusionAfter the FDA communication, the odds ratio of abdominal myomectomy was disproportionately increased in the African American population.

ACOG Committee Opinion No. 770: Uterine Morcellation for Presumed Leiomyomas.

Morcellation is a surgical technique used to reduce the size of the uterus or myomas by creating smaller pieces to allow the tissue to be removed through small incisions or with laparoscopic instruments. Open (uncontained) morcellation of the uterus and myomas has been scrutinized because of the possible spread of an unsuspected leiomyosarcoma while using a power morcellator during a hysterectomy or myomectomy for presumed symptomatic uterine leiomyomas. Before considering open morcellation of the uterus, a woman should be evaluated to determine if she is at increased risk of malignancy of the uterine corpus. Morcellation of a malignancy is contraindicated, and women should be evaluated preoperatively to identify malignancy. However, leiomyosarcoma cannot be reliably diagnosed preoperatively; thus, there is a risk that a woman with a presumed leiomyoma may have a malignancy that may be spread through morcellation, leading to a potentially worsened prognosis. Although an abdominal hysterectomy or myomectomy may reduce the chance of spreading cancer cells in women with undiagnosed leiomyosarcoma, it is associated with increased morbidity when compared with minimally invasive approaches. The obstetrician-gynecologist and patient should engage in shared decision making, including informed consent explaining the risks and benefits of each approach to surgery for presumed leiomyomas, the risks and benefits of morcellation, and alternatives to morcellation.

ACOG Committee Opinion No. 770 Summary: Uterine Morcellation for Presumed Leiomyomas.

Morcellation is a surgical technique used to reduce the size of the uterus or myomas by creating smaller pieces to allow the tissue to be removed through small incisions or with laparoscopic instruments. Open (uncontained) morcellation of the uterus and myomas has been scrutinized because of the possible spread of an unsuspected leiomyosarcoma while using a power morcellator during a hysterectomy or myomectomy for presumed symptomatic uterine leiomyomas. Before considering open morcellation of the uterus, a woman should be evaluated to determine if she is at increased risk of malignancy of the uterine corpus. Morcellation of a malignancy is contraindicated, and women should be evaluated preoperatively to identify malignancy. However, leiomyosarcoma cannot be reliably diagnosed preoperatively; thus, there is a risk that a woman with a presumed leiomyoma may have a malignancy that may be spread through morcellation, leading to a potentially worsened prognosis. Although an abdominal hysterectomy or myomectomy may reduce the chance of spreading cancer cells in women with undiagnosed leiomyosarcoma, it is associated with increased morbidity when compared with minimally invasive approaches. The obstetrician-gynecologist and patient should engage in shared decision making, including informed consent explaining the risks and benefits of each approach to surgery for presumed leiomyomas, the risks and benefits of morcellation, and alternatives to morcellation.

47: Power morcellation in laparoscopic sacrocervicopexy with supracervical hysterectomy: a retrospective review of uterine pathology

To review uterine pathology of patients undergoing laparoscopic supracervical hysterectomy with electromechanical (power) uterine morcellation and sacrocervicopexy for uterovaginal prolapse. This retrospective cohort study used the electronic medical record to review the cases of 182 patients undergoing laparoscopic supracervical hysterectomy with uterine power morcellation and sacrocervicopexy performed by a single high-volume gynecologic surgeon at our institution between January 1, 2012 and December 31, 2017. Uterovaginal prolapse was the primary indication for surgery for all patients included. The electronic medical record was reviewed to determine demographic and operative variables, pathology reports, and any post-operative complications. Of the 182 patients undergoing this procedure, the mean age was 63.4 years (standard deviation: 9.73). 5.0% had a post-operative complication (3 with incisional cellulitis, 3 with trocar incision site herniation, 1 with urinary retention requiring an emergency department visit, 1 with severe constipation requiring disimpaction, and 1 with perforation of the cecum from a concurrent rectopexy performed by colorectal surgery requiring re-operation). No patient had a complication directly related to uterine power morcellation or uterine pathology. The median uterine mass was 55.5 grams (interquartile range: 38.8 - 81.0). 49.9% of patients had leiomyomas noted in the pathology report, 40.7% had adenomyosis, 11.5% had uterine polyps, and 4.4% had endometrial hyperplasia (4 with simple hyperplasia without atypia, 1 with simple hyperplasia with focal atypia, 1 with complex hyperplasia without atypia, and 1 with complex hyperplasia with focal atypia). None of the patients with endometrial hyperplasia had reported abnormal uterine or postmenopausal bleeding and as such had not had endometrial sampling prior to surgery. 100% of patients had at least one follow up visit with the surgeon. While there has been extensive examination of the use of uterine power morcellation in benign minimally invasive hysterectomy, there is minimal data specifically focusing on its use for patients whose primary indication for hysterectomy is uterovaginal prolapse. While our sample is limited to a single institution, our data suggests that malignant pathology may be even rarer than that found in hysterectomy for other benign indications. These variations should be considered when making decisions about the use of uterine power morcellation.

46: Laparoscopic resection of leiomyomatosis peritonealis disseminata

The objective of this video is to demonstrate laparoscopic resection of leiomyomatosis peritonealis disseminata, a rare condition, and reviews preoperative considerations as well as intraoperative advanced dissection techniques that can be utilized. Leiomyomatosis peritonealis disseminata (LPD) is a rare condition that can occur in prior cases of uncontained morcellation. This video shows course of management for the patient diagnosed with LPD, which initially started when she started experiencing pelvic pain years after her prior hysterectomy with uncontained power morcellation. In the images obtained by CT and MRI showed multiple solid pelvic masses on bilateral pelvic side walls close to critical anatomic structures. Intraoperatively, a sound understanding of pelvic anatomy and advanced laparoscopic techniques were needed to assist in removal of these parasitic masses. Leiomyomatosis peritonealis disseminata is a rare condition that can be treated safely laparoscopically with appropriately applied surgical techniques.