Novel technique of extracorporeal intrauterine morcellation after total laparoscopic hysterectomy: Three emblematic case reports

BACKGROUND In the presence of a large uterus,total laparoscopic hysterectomy(TLH),always requires morcellation to allow removal of the tissues from the abdominal cavity.However,uncontained morcellation has been scrutinized because of the possible spread of occult leiomyosarcoma.Therefore,in-bag extracorporeal morcellation has been developed.However,tissue containment and extraction are extremely challenging,especially when considering the increasing uterine size to be removed through minimally invasive surgery.CASE SUMMARY Herein,we describe a novel technique for extracorporeal intrauterine morcellation using the uterus outermost layer as a bag to achieve tissue extraction of very large uteri with suspected occult leiomyosarcoma after TLH.The study enrolled patients who were planned for TLH for large uteri(weight>500 g).TLH was performed following the procedure reported in our previous studies.The novel technique has been described step-by-step in a video,which representatively describes the preoperative imaging and morcellation procedure of three very large uteri weighing 1500 g,1700 g,and 3700 g,respectively.The procedures were performed without any complications.The patients had an uneventful postoperative course,and in all cases,the pathology was benign leiomyoma.CONCLUSION Extracorporeal intrauterine morcellation using the uterus outmost layer as a bag was found to be a feasible technique that allows a careful diagnosis and safe removal of suspected occult malignancies.The technique herein presented may be adopted in surgical practice,by adding it to the other available techniques of contained morcellation.It may represent a valid and feasible alternative,especially useful in cases of very large uteri exceeding the capacity of specimen retrieval bags.

Laparoscopic uncontained power morcellation-induced dissemination of ovarian endodermal sinus tumors:A case report

BACKGROUND Endodermal sinus tumors(ESTs),which arise primarily in children and adolescents,account for 20%of malignant ovarian germ cell tumors,but constitute only 1%of all ovarian malignancies.Treatment of ESTs consists of surgical staging with fertility-sparing surgery and chemotherapy.CASE SUMMARY A 15-year-old nulliparous patient was diagnosed with disseminated ovarian ESTs after laparoscopic unilateral salpingo-oophorectomy using uncontained power morcellation for treatment of a ruptured solid adnexal mass in another hospital.Exploratory laparotomy;total abdominal hysterectomy,right salpingooophorectomy,and lymphadenectomy were performed with optimal debulking,and surgical stage 3C was assigned to the patient.CONCLUSION In 2014,the Food and Drug Administration noted that power morcellation was probably associated with a risk of disseminating suspected cancerous tissue.Furthermore,the use of power morcellation to remove solid adnexal mass is considered a contraindication because of the potential for a malignant tumor.This case report aims to warn of the dangers of using uncontained power morcellation to treat solid adnexal masses.

Parasitic leiomyoma in the trocar site after laparoscopic myomectomy:A case report

BACKGROUND Laparoscopic myomectomy is increasingly used for resecting gynecological tumors.Leiomyomas require morcellation for retrieval from the peritoneal cavity.However,morcellated fragments may implant on the peritoneal cavity during retrieval.These fragments may receive a new blood supply from an adjacent structure and develop into parasitic leiomyomas.Parasitic leiomyomas can occur spontaneously or iatrogenically;however,trocar-site implantation is an iatrogenic complication of laparoscopic uterine surgery.We describe a parasitic leiomyoma in the trocar-site after laparoscopic myomectomy with power morcellation.CASE SUMMARY A 50-year-old woman presented with a palpable abdominal mass without significant medical history.The patient had no related symptoms,such as abdominal pain.Computed tomography findings revealed a well-defined contrast-enhancing mass measuring 2.2 cm,and located on the trocar site of the left abdominal wall.She had undergone laparoscopic removal of uterine fibroids with power morcellation six years ago.The differential diagnosis included endometriosis and neurogenic tumors,such as neurofibroma.The radiologic diagnosis was a desmoid tumor,and surgical excision of the mass on the abdominal wall was successfully performed.The patient recovered from the surgery without complications.Histopathological examination revealed that the specimen resected from the trocar site was a uterine leiomyoma.CONCLUSION Clinicians should consider the risks and benefits of laparoscopic vs laparotomic myomectomy for gynecological tumors.Considerable caution must be exercised for morcellation to avoid excessive tissue fragmentation.

Clinical Use of the Intrauterine Morcellator: A Single Academic Center’s Experience

Objective: To reveal the breadth of experience for the intrauterine morcellator amongst gynecologists in a single US academic center. Design: Retrospective Descriptive. Setting: University Hospital. Patients: In total, 33 hysteroscopic procedures, with intrauterine morcellation, were performed for 28 patients for benign endometrial disease at?Magee―Womens Hospital at the University of Pittsburgh Medical center between October 2006 and February 2012. Intervention: Operative Hysteroscopy with an intrauterine morcellator. Measurement and Main Results: The major indication for hysteroscopic surgery was endometrial polyp (54.5%), followed by intrauterine fibroids (18.2%), filling defect on sonohysterogram (15.2%), abnormal uterine bleeding (9.1%), and uterine synechiae (3%). The mean greatest diameter for all intrauterine pathology resected was 1.14 ± 0.46 cm (Range 0.6 - 1.9 cm), and, notably, the largest fibroid resected was 1.5 cm in greatest diameter. The average operative time was 39 ± 29 minutes (range 15 - 122 minutes), and average hysteroscopic fluid deficit was 286 ± 479.5 mL (range 30 - 2000 mL). There were only 2 patients for whom the deficit was greater than 1 L, one of whom underwent a myomectomy with total operative time of 26 minutes, while the other underwent a hysteroscopic adhesiolysis and had a total operative time of 122 minutes. The complication rate was 6.0%, and complications reported included uterine perforation (n = 1) and cervical injury (n = 1). Conclusion: The intrauterine morcellator is a useful tool for surgical treatment of intrauterine pathology that confers a low operative risk.

Actual Use of Rigid Hysteroscope Intrauterine BIGATTI Shaver (IBS^®) with a Morcellator System

Hysteroscopic resection of endometrial lesions has recently gained popularities. We here report the usefulness and safety of hysteroscopic surgery using Intrauterine BIGATTI Shaver (IBS®). We performed this surgery for 6 patients: 4 endometrial polyps and 2 intrauterine myoma. The average operation time was 25.7 ± 13.2 minutes. Only a small amount of bleeding was noted in all cases. There were no surgical complications. Two out of four patients who desired childbearing became pregnant. Hysteroscopic surgery using IBS® can safely and reliably remove intrauterine protruding lesions under aspiration without using a heat source. Less endometrial damage may help preserve fertility.

Proportion of Uterine Malignant Tumors in Patients with Laparoscopic Myomectomy： A National Multicenter Study in China

Background： The Food and Drug Administration recently announced that the use of morcellation may cause fibroids or pelvic dissemination and metastasis of uterine sarcoma; therefore, the use of morcellation is limited in the USA. A large sample study is necessary to assess the proportion of uterine malignant tumors found in patients with laparoscopic myomectomy. Methods： A national multicenter study was performed in China. From 2002 to 2014, 33,723 cases were retrospectively selected. We calculated the prevalence and recorded the clinical characteristics of the patients with malignancy after morcellation application. A total of 62 cases were finally pathologically confirmed as malignant postoperatively. Additionally, the medical records of the 62 patients were analyzed in details. Results： The proportion of postoperative malignancy after morcellation application was 0.18% （62/33,723） for patients who underwent laparoscopic myomectomy. Nearly 62.9% （39/62） of patients had demonstrated blood flow signals in the uterine fibroids before surgery. And, 23 （37.1%） patients showed rapid growth at the final preoperative ultrasound. With respect to the pathological types, 38 （61.3%） patients had detectable endometrial stromal sarcoma, 13 （21.0%） had detectable uterine leiomyosarcoma, only 3 （3.2%） had detectable carcinosarcoma, and 5 （8.1%） patients with leiomyoma had an undetermined malignant potential. Conclusions： The proportion of malignancy is low after using moreellation in patients who undergo laparoscopie myomectomy. Patients with fast-growing uterine fibroids and abnormal ultrasonic tumor blood flow should be considered for malignant potential, and morcellation should be avoided.

Myometrial smooth muscle cells spillage during open myomectomy:Is it True or a myth?

Background:Uncontained morcellation of myoma during laparoscopic surgery has been discouraged because of unknown malignancy.Even the safety of contained morcellation has been questioned because muscle cells have been detected in washings obtained during laparoscopic procedures.The possibility of myoma cell dissemination has been observed in open abdominal surgery,even after hysterectomy.Thus myomectomy would be unsafe from an oncological point of view,regardless of surgical approach.Methods:This is an observational cohort study involving 30 patients who underwent open abdominal myomectomy.Peritoneal abdominal washings were obtained two times during the open abdominal myomectomy:before uterus incision and after the myomectomy itself.Cytological,cell block,and immunohistochemical evaluations were performed.Results:All washings obtained immediately after abdominal peritoneal cavity opening were negative for fibroid cells.Both the first and second washings were free of myoma cells.Cytologic evaluation did not reveal any smooth muscle cells.The results of desmin and smooth muscle actin staining,performed on the pre-and postmyomectomy samples,were negative.Conclusion:Our results demonstrated,for the first time to our knowledge,that there is no dissemination of myoma cells during conservative abdominal surgery.It could represent an additional oncological safety.Further data are needed.