I was involved in a case of a patient who had a Total Abdominal Hysterectomy (TAH) for a large fibroid uterus. Apparently, the operation was unexpectedly challenging due to the rather large uterine size.
Due to the large uterine size, the gynaecological surgeon decided to transect the uterus at the level of the isthmus to gain easier access to the pelvis. Unfortunately some spillage of uterine content was noted and postoperatively, histopathology confirmed the presence of a uterine sarcoma.
In the US, the FDA expressed concern that the use of power morcellators will spread tumour cells into the peritoneal surfaces of the pelvis and the abdomen if the “fibroid uterus” turns out to harbour malignant cells. Tumours that are potentially curable, are become deadly and unsurvivable through the use of free morcellation. Hence, the FDA advocates for the ban of power morcellators in gynaecological surgery. Lawsuits against gynaecological surgeons who used power morcellators to extract myomas and other specimens are underway.
One particular patient lobbies for the total ban of power morcellators in gynaecological surgery. She was incidentally diagnosed with a leimyosarcoma of the uterus that was spread during her laparoscopic hysterectomy. While the patient received adjuvant treatment, she developed 2 recurrences already and her overall prognosis is believed to be poor.
Before the adoption of laparoscopic hysterectomy we have seen manually bivalved specimens from vaginal hysterectomies. Unfortunately, not all uterine malignancies will ever be diagnosed prior to hysterectomy.
The common thread of all these cases is:
- It is virtually impossible to guarantee the absence of a malignancy (even after extensive investigations) in gynaecological surgery,
- Disturbing the integrity of a specimen can spill tumour,
- Spillage of tumour may have a profoundly detrimental effect on the patient’s prognosis.
- Morcellation and spillage of tumour is not limited to laparoscopic surgery.
Since then, surgical devices have become available, that allow the morcellation of a specimen within a containment system. I believe thes containment devices might become a game-changer because it allows the morcellation of a specimen within a bag and thereby protects the patient from tumour spillage.
Recently, I operated on a 40+ year old nulliparous woman who had dysfunctional uterine bleeding affecting her daily quality of life for some time. In addition she noticed her uterus was multifibroid and quite enlarged. A vaginal hysterectomy was not feasible due to the disproportion of uterine size and vaginal width.
With the help of a containment bag and the a transvaginal tube we were able to give her a laparoscopic hysterectomy using four 5 mm ports. The ovaries were preserved but the fallopian tubes were removed. Once the hysterectomy was completed we introduced the containment bag into the pelvis transvaginally, wrapped the mass in it and morcellated the uterus within the bag in very short time. The plastic bag system contained the entire specimen. There was no spillage into the peritoneal cavity.
We could have also used a large endocatch bag but the Containment system comes with an Alexis ring that holds the open end of the bag open at all times. I did not require an assistant to keep the bag open and had both my hands free to morcellate the specimen. By contrast, traditional bags will collapse.
I felt reassured that there was no spillage of any specimen. After I reviewed the video I felt a strong sense that …
- The discussion about morcellation should be separate of power morcellators or manual bivalving the specimen or transecting the uterus etc. Disturbing the integrity of the uterus or ovary means spillage, regardless how it is done.
- The discussion about morcellation has taken the wrong direction. Consideration should be given not focus on banning morcellation but rather on containing the spillage into a safe bag.
- Spillage but not morcellation should be avoided under all circumstances – regardless of the surgical approach; vaginal, laparoscopic or open. You can never be 100% certain about the presence or absence of a malignancy.
Please check out the 3-minute video on this procedure.