Morcellation has become safe

Posted 10 years ago by Andreas Obermair

This week our team reviewed a case of a patient who had a Total Abdominal Hysterectomy (TAH). Apparently, the operation was unexpectedly challenging due to the rather large uterine size. I am not aware if a diagnostic biopsy was taken prior to hysterectomy to exclude a cancer of the uterus.

The gynaecological surgeon decided to transect the uterus at the level of the bladder to gain easier access to the pelvis. Unfortunately some spillage of uterine content was noted and indeed, histopathology testing confirmed the presence of an aggressive uterine malignant tumour.

In the US, the FDA express growing concern that the use of power morcellators will spread tumour cells into the peritoneal surfaces of the pelvis and the abdomen.  Tumours that have been potentially curable are disseminated by the use of morcellators and become deadly. 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 come across manually bivalved specimens from vaginal hysterectomies with an incidental finding of cancer in those specimens.  The common thread of all these cases is:

• It is virtually impossible to guarantee the absence of a malignancy in a quickly growing uterus or ovary (even after extensive investigations),
• Disturbing the integrity of a specimen can spill tumour,
• Spillage of tumour may have a profoundly detrimental effect on the patient’s prognosis,
• Morcellation of specimens and spillage of tumour are not limited to laparoscopic surgery as the examples have shown.

In Australia, Applied Medical released a new surgical device, which allows the morcellation of a specimen within a containment system. I believe this device might become a game-changer because it allows the morcellation of a specimen within a bag and thereby protects the patient from tumour spillage.

I used this device last week when I operated on a 40+ year patient who had not had children before and who suffered from bad and heavy periods with clotting and pain affecting her daily quality of life for some time. In addition she noticed her uterus was multifibroid and quite enlarged. A vaginal hysterectomy was simply not doable because of the large size of the womb.

Instead of opening the abdomen to do an abdominal hysterectomy (implying increased pain and prolonged recovery from surgery), we were able to give her a laparoscopic hysterectomy using 5 mm ports only. The ovaries were preserved so that she would not become menopausal but the fallopian tubes were removed to reduce her ovarian cancer risk. 

Once the laparoscopic hysterectomy all we had to do was to remove the uterus from the patient;s pelvis. With the help of the Applied Contained Extraction System we wrapped the uterus into a sterile, surgical plastic bag and morcellated the uterus within the safety of the bag in very short time. The containment bag kept al specimen parts and no spillage of contents occurred.

I felt incredibly assured that there was no spillage of any specimen. A procedure that was associated with some risk turned into a perfectly safe one. After I debriefed with my team we all felt a strong sense that

• A uterus should never be split, halved or morcellated into the free pelvic cavity. Disturbing the integrity of the uterus means spillage, regardless how it is done.
• Surgeons do not need to worry about morcellation but should give consideration to containing the spillage into a safe bag.
• Spillage but not morcellation should be avoided under all circumstances.

For those who appreciate watching surgical videos, click here to watch this 4-minute video.