Laparoscopic Power Morcellation: Techniques to Avoid Tumoral Spread

Abstract

Study objective: To show 3 different techniques for achieving an endobag morcellation without adding extra time and cost to the surgery.

Design: Stepwise demonstration of the 3 techniques with narrated video footage.

Setting: Morcellation is a useful procedure for fragmenting and extracting specimens during laparoscopic surgery without the need to perform a laparotomy. Patients who otherwise would not be eligible for minimally invasive surgery (i.e., those with a large uterus or myomas) could benefit from laparoscopic advantages. However, morcellation has a major limitation: the risk of dissemination of unsuspected malignancies. In 2017, the Food and Drug Administration released an updated assessment of the use of laparoscopic power morcellators for treatment of leiomyomas. A total of 23 studies were included in the analysis, and 20 studies (90 910 women) contributed to the estimated prevalence of leiomyosarcoma at the time of surgery for presumed leiomyomas. Depending on the modeling methodology used, the estimated prevalence of uterine sarcoma was 1 in 305 to 1 in 360 women, and for leiomyosarcoma, the estimated prevalence was 1 in 570 to 1 in 750 women [1]. Currently available evidence has suggested that if an undiagnosed uterine malignancy is intra-abdominally morcellated, there is a risk of intraperitoneal dissemination of the disease [2]. Therefore, the European Society of Gynecological Oncology emitted a statement in 2016 recommending avoiding morcellation if there is any suspicion of sarcoma and using endobag containers for morcellation of the surgically removed uterine myomas [3]. In addition, in the United States, the Food and Drug Administration recommends performing laparoscopic power morcellation for myomectomy or hysterectomy only with a tissue containment system, legally marketed in the United States [4].

Interventions: There are several techniques described in the literature for contained uterine myomas morcellation [5]. In this video, we present 3 of them: First, an indirect-view morcellation is described. In this technique, we placed the myoma in the bag and exteriorize it through one of the trocars. Once outside the abdomen, we placed the morcellator through the bag opening and did the morcellation inside the bag while checking through the umbilicus camera. Special attention must be paid to avoid any damage to the bag because the visualization is limited in this technique. Second, a direct-view technique is described, in which we exteriorized the opening of a 15-mm bag through the suprapubic trocar and a closed end of the bag through the umbilicus. We made a hole in the umbilicus end of the bag and introduced the camera trocar through it. Once done, we introduced the morcellator through the opening and the camera in the umbilicus port. Third, a single-port-contained morcellation is explained. The bag was exteriorized through the umbilicus, and a skin retractor was placed. A glove was placed outside the retractor to isolate the bag. Once placed, 2 of the fingers were opened and used as trocars (one for the morcellator and the other for a 30° camera). After using this technique, the scope should be replaced to minimize the risk of contamination. The following are possible limitations of each technique: in the indirect-view technique, owing to the limited visualization, the surgeon must pay special attention to avoid tearing the bag while morcellating the specimen. In the direct-view technique method, the surgeon needs to ensure the proper closure of the bag before removing it from the abdomen to avoid possible dissemination risk. Finally, in the single-port technique, the surgeon must have previous experience in this type of approach, minimizing the risk of contamination by changing the scope after the morcellation process.

Conclusion: Laparoscopic power morcellation may provide several benefits for our patients, when performing a hysterectomy or a multiple myomectomy. We presented 3 different and feasible techniques for laparoscopic power morcellation using an endobag container.

Keywords: In-bag morcellation; Laparoscopic surgery; Morcellation; Myoma morcellation.