Abstract
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. In this sense, patients that otherwise would not be eligible for minimally invasive surgery (i.e. large uterus or fibroids) could benefit from laparoscopic advantages.
However, morcellation has a major limitation: the risk of dissemination of unsuspected malignancies. In 2017 the Food and Drugs Administration (FDA), 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 suggests that if an undiagnosed uterine malignancy is intraabdominally morcellated, there is risk of intraperitoneal dissemination of the disease. [2] Therefore, European Society of Gynecological Oncology (ESGO) emitted a statement in 2016 recommending avoiding morcellation if there is any suspicion of sarcoma and using endobag containers for morcellation of surgical removed uterine fibroids [3].
Additionally, in the United States, the FDA recommends performing laparoscopic power morcellation for myomectomy or hysterectomy only with a tissue containment system, legally marketed in the U.S. [4] INTERVENTIONS: There are several techniques described in the literature for contained uterine fibroids morcellation [5]. In this video, we present 3 of them: First, indirect view morcellation is described.
In this technique we place the fibroid in the bag and exteriorize it through one of the trocars. Once outside the abdomen we will place the morcellator through the bag opening and do the morcellation inside the bag while checking through the umbilicus camera.
Special attention must be paid in order to avoid any damage to the bag, as the visualization is limited in this technique. Second, direct view technique is described, where we exteriorize the opening of a 15mm bag through the suprapubic trocar and a closed end of the bag through the umbilicus.
A hole must be made in the umbilicus end of the bag and we should introduce the camera trocar through it. Once done, we introduce the morcellator trough the opening and the camera in the umbilicus port.
Third, single-port contained morcellation is explained. The bag is exteriorized through the umbilicus, and a skin retractor is placed.
A glove is placed outside the retractor to isolate the bag. Once placed, two of the fingers are opened and used as trocars (one for the morcellator a the other for a 30-degree camera).
After using this technique, the scope should be replaced in order to minimize the risk of contamination. The limitations of each technique could be the next: in the indirect view technique, due to the limited visualization, the surgeon must pay special attention to avoid bag tearing while morcellating the specimen.
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. Finally, in the third method, the surgeon needs to ensure the proper closure of the bag before removing it from the abdomen to avoid possible dissemination risk.
CONCLUSION: Laparoscopic power morcellation may provide several benefits for our patients, when performing a hysterectomy or a multiple myomectomy. We present 3 different and feasible techniques for laparoscopic power morcellation using an endobag container.