Surgeon’s Corner
ajog.org
Safe vaginal uterine morcellation following total laparoscopic hysterectomy Andreas R. Gu¨nthert, MD; Corina Christmann, MD; Plamen Kostov, MD; Michael D. Mueller, MD
The minimally invasive approach for hysterectomy with proven benefits and lower morbidity has become the gold standard, even in women with large uterine masses. Most women with a malignant condition present with abnormal vaginal bleeding and/or suspicious imaging such that few are diagnosed by final histopathology after surgery. However, if a malignancy is not diagnosed preoperatively, intraabdominal morcellation for uterus extraction has an increased risk for potential tumor spread and peritoneal metastases, especially in cases of unexpected leiomyosarcoma. We describe a simple method to wrap the uterus in a contained environment with a plastic bag through the posterior vaginal fornix prior to conventional coring morcellation for vaginal extraction in total laparoscopic hysterectomy. We further describe our experience with a risk stratification and treatment algorithm to implement this procedure in daily routine. A video and an illustrating sketch demonstrate the simplicity and safety of the procedure. Key words: morcellation, total laparoscopic hysterectomy, uterine leiomyosarcoma Cite this article as: Gu¨nthert AR, Christmann C, Kostov P, et al. Safe vaginal uterine morcellation following total laparoscopic hysterectomy. Am J Obstet Gynecol 2015;212:546.e1-4.
Problem: risk of intraabdominal tumor Intraabdominal morcellation is an easy and safe method to extract large uterine fibroids or a uterus as part of total laparoscopic hysterectomy (TLH), but it bares the risk of intraabdominal tumor spread if the specimen contains a malignancy, peritoneal metastases, and
poor outcome (Figure 1).1-3 Wright et al4 reported a 0.27% rate of uterine cancer in women who underwent morcellation during a minimally invasive hysterectomy. The low risk of intraabdominal
dissemination of tumor might be reduced by preoperative risk assessment and morcellation of uncertain specimens in a bag.
Our solution We developed a simple method to wrap the uterus in a contained environment with a plastic bag (Auto Suture EndoCatch II 15 mm; Covidien/Tyco Healthcare, Norwalk, CT) through the posterior vaginal fornix prior to conventional coring morcellation for vaginal extraction in TLH (Figures 2 and 3 and Video). After completing the circular colpotomy, the uterine manipulator was removed and replaced by the EndoCatch II system embedded in a Colpo-Pneumo-Occluder system (CooperSurgical, Pleasanton, CA) to avoid the loss of intraabdominal air pressure. The dissected uterus was wrapped with the bag device through the posterior vaginal fornix, beginning
FIGURE 1
Patient with peritoneal metastases of leiomyosarcoma during secondlook laparoscopy
Department of Gynecology and Obstetrics, Cantonal Hospital of Lucerne, Lucerne (Drs Günthert, Christmann, and Kostov), Department of Gynecology and Obstetrics, Inselspital, Bern University Hospital and University of Bern (Drs Günthert, Kostov, and Mueller), and Department of Gynecology and Obstetrics, See-Spital Horgen (Dr Kostov), Switzerland. Received Sept. 9, 2014; revised Nov. 14, 2014; accepted Nov. 17, 2014. The authors report no conflict of interest. Corresponding author: A. R. Günthert, MD. [email protected] 0002-9378/$36.00 ª 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajog.2014.11.020
Click Supplementary Content under the article title in the online Table of Contents
Forty-seven year old patient with peritoneal metastases of leiomyosarcoma during second-look laparoscopy 6 weeks after morcellation of a uterus with assumed leiomyoma. Günthert. Vaginal uterine in-bag morcellation. Am J Obstet Gynecol 2015.
546.e1 American Journal of Obstetrics & Gynecology APRIL 2015
Surgeon’s Corner
ajog.org
FIGURE 2
Intraoperative setting after completion of colpotomy
A
B
C
D
A, The device enters the abdomen through the posterior vaginal fornix and the bag is open. B, The uterus is wrapped with an EndoCatch II plastic bag (Covidien/Tyco Healthcare), assisted by laparoscopic forcipes. C, After complete wrapping, the orifice is delivered to the vulva. D, The uterus is morcellated by conventional coring in the plastic bag. Günthert. Vaginal uterine in-bag morcellation. Am J Obstet Gynecol 2015.
in the cul de sac, assisted by laparoscopic forcipes. The orifice of the bag and the cervix uteri were then delivered to the vulva. The completely covered specimen was then morcellated by conventional coring in the vagina for safe extraction without intraabdominal dissemination or destruction of the serous surface of the uterus (Figures 2 and 3 and Video). Technical limitations were extreme vaginal narrowing or a transversal uterine diameter exceeding 15 cm. There was no significant learning
curve of this minimally invasive approach with wrapping time less than 5 minutes on average. For larger uterine specimens, bigger bags without frame (LapSac; Cook Medical, Bloomington, IN) were applied, although the placement and wrapping were more difficult and took much more time. We implemented this procedure, along with a risk stratification algorithm, in 2 tertiary referral hospitals, both of which were specialized centers for gynecological endoscopic
surgery and gynecological oncology (Inselspital Bern in 2010 and Cantonal Hospital of Lucerne in January 2013). All women planning TLH underwent preoperative imaging assessment by transvaginal ultrasound including power Doppler sonography; if incomplete or nonconclusive, a magnetic resonance imaging was performed. We defined concerning history as a growing uterine mass or uterus after menopause or fastgrowing uterine fibroids in premenopausal women.
APRIL 2015 American Journal of Obstetrics & Gynecology
546.e2
Surgeon’s Corner
ajog.org
FIGURE 3
Illustration of wrapping and coring procedure
The illustration shows wrapping and coring procedure, which avoids spillage of specimen and also avoids destruction of the serous surface of the uterus for histopathology evaluation and correct staging in case of unexpected malignancy. Günthert. Vaginal uterine in-bag morcellation. Am J Obstet Gynecol 2015.
Our preoperative risk assessment defined 3 groups of patients: first, assumed/confirmed malignancy; second, uncertain; and third, low risk. Women who preferred surgical treatment with TLH, had a uterine mass 15 cm or smaller, and were of uncertain risk were treated by TLH with subsequent vaginal in-bag morcellation, if required. (Women of uncertain risk with a uterine mass exceeding a transverse diameter of 15 cm were treated with laparotomy.) In women planning TLH who were deemed of low risk, the uterine specimen was morcellated intraabdominally or transvaginally without a bag, if required. Women with assumed or confirmed malignancy were not offered morcellation. Clinical data were retrospectively analyzed by chart review. The local ethics committee of Bern and Lucerne approved the study. From 2010 to June 2014, we performed 503 TLH/total intrafascial laparoscopic hysterectomy procedures
and performed vaginal in-bag morcellation of the uterus in 61 women categorized as uncertain risk. Of the 503 patients, there were 9 cases of uterine leiomyosarcoma (Figure 4). Two were preoperatively classified as assumed malignant and were evacuated without morcellation. Six were preoperatively classified as uncertain, and all were evacuated without abdominal contamination by vaginal in-bag morcellation. After a follow-up of at least 6 months, these women remained disease free (range, 6e36 months). The final case of leiomyosarcoma occurred in the preoperatively defined low-risk group. Her extraction was done by vaginal morcellation without a bag. Second-look laparoscopy 3 months later showed no metastases. After we recognized the underestimated risk of tumor spread by morcellation of incidental uterine cancers in 2010,5 we established our described strategy. Removing pelvic
546.e3 American Journal of Obstetrics & Gynecology APRIL 2015
masses by laparoscopy and extraction through the posterior vaginal fornix in a retrieval specimen bag was already reported in 2002 by Ghezzi et al.6 During the last few years, comparable methods of intraabdominal or vaginal in-bag morcellation procedures have been introduced.7-11 We describe our experience in a large sample of women. Our method is simple and allows the removal of the speciman by safe in-bag coring without disseminating uncertain benign or malignant cells and without destroying the serous surface of the uterus, which allows for adequate histopathological evaluation and appropriate staging in case of unexpected malignancy. In our opinion, in-bag morcellation methods should not be used in cases of suspected or confirmed malignancy. In our case series, no rupture or perforation of the bag occurred, but morcellation bears this potential risk and adequate histopathology workup and
Surgeon’s Corner
ajog.org
FIGURE 4
Flowchart of patient characteristics
Flowchart of risk assessment, procedure algorithm, and number of cases. In total we found 9 cases of LMS. LMS, leiomyosarcoma. Günthert. Vaginal uterine in-bag morcellation. Am J Obstet Gynecol 2015.
staging of a morcellated uterus might be difficult. REFERENCES 1. Steiner RA, Wight E, Tadir Y, Haller U. Electrical cutting device for laparoscopic removal of tissue from the abdominal cavity. Obstet Gynecol 1993;81:471-4. 2. Morice P, Rodriguez A, Rey A, et al. Prognostic value of initial surgical procedure for patients with uterine sarcoma: analysis of 123 patients. Eur J Gynaecol Oncol 2003;24:237-40. 3. Rekha W, Amita M, Sudeep G, Hemant T. Unexpected complication of uterine myoma morcellation. Aust N Z J Obstet Gynaecol 2005;45:248-9.
4. Wright JD, Tergas AI, Burke WM, et al. Uterine pathology in women undergoing minimally invasive hysterectomy using morcellation. JAMA 2014;312:1253-5. 5. Jahns BG, Michael N, Brunnmayr G, et al. Primary or secondary laparoscopy for staging in patients with uterine sarcoma. Eur J Obstet Gynecol Reprod Biol 2010;154:230-1. 6. Ghezzi F, Raio L, Mueller MD, Gyr T, Butarelli M, Franchi M. Vaginal extraction of pelvic masses following operative laparoscopy. Surg Endosc 2002;16:1691-6. 7. Perri T, Korach J, Sadetzki S, Oberman B, Fridman E, Ben-Baruch G. Uterine leiomysarcoma: does the primary surgical procedure matter? Int J Gynecol Cancer 2009;19: 257-60.
8. Wang CJ, Yuen LT, Lee CL, Kay N, Soong YK. Laparoscopic myomectomy for large uterine fibroids. Surg Endosc 2006;20: 1427-30. 9. Favero G, Anton C, Silva e Silva A, et al. Vaginal morcellation: a new strategy for large gynecological malignant tumor extraction: a pilot study. Gynecol Oncol 2012;126:443-7. 10. Montella F, Riboni F, Cosma S, et al. A safe method of vaginal longitudinal morcellation of bulky uterus with endometrial cancer in a bag at laparoscopy. Surg Endosc 2014;28: 1949-53. 11. McKenna JB, Kanade T, Choi S, et al. The Sydney contained in bag morcellation technique. J Minim Invasive Gynecol 2014;21: 984-5.
APRIL 2015 American Journal of Obstetrics & Gynecology
546.e4
ajog.org
Safe vaginal uterine morcellation following total laparoscopic hysterectomy Andreas R. Gu¨nthert, MD; Corina Christmann, MD; Plamen Kostov, MD; Michael D. Mueller, MD
The minimally invasive approach for hysterectomy with proven benefits and lower morbidity has become the gold standard, even in women with large uterine masses. Most women with a malignant condition present with abnormal vaginal bleeding and/or suspicious imaging such that few are diagnosed by final histopathology after surgery. However, if a malignancy is not diagnosed preoperatively, intraabdominal morcellation for uterus extraction has an increased risk for potential tumor spread and peritoneal metastases, especially in cases of unexpected leiomyosarcoma. We describe a simple method to wrap the uterus in a contained environment with a plastic bag through the posterior vaginal fornix prior to conventional coring morcellation for vaginal extraction in total laparoscopic hysterectomy. We further describe our experience with a risk stratification and treatment algorithm to implement this procedure in daily routine. A video and an illustrating sketch demonstrate the simplicity and safety of the procedure. Key words: morcellation, total laparoscopic hysterectomy, uterine leiomyosarcoma Cite this article as: Gu¨nthert AR, Christmann C, Kostov P, et al. Safe vaginal uterine morcellation following total laparoscopic hysterectomy. Am J Obstet Gynecol 2015;212:546.e1-4.
Problem: risk of intraabdominal tumor Intraabdominal morcellation is an easy and safe method to extract large uterine fibroids or a uterus as part of total laparoscopic hysterectomy (TLH), but it bares the risk of intraabdominal tumor spread if the specimen contains a malignancy, peritoneal metastases, and
poor outcome (Figure 1).1-3 Wright et al4 reported a 0.27% rate of uterine cancer in women who underwent morcellation during a minimally invasive hysterectomy. The low risk of intraabdominal
dissemination of tumor might be reduced by preoperative risk assessment and morcellation of uncertain specimens in a bag.
Our solution We developed a simple method to wrap the uterus in a contained environment with a plastic bag (Auto Suture EndoCatch II 15 mm; Covidien/Tyco Healthcare, Norwalk, CT) through the posterior vaginal fornix prior to conventional coring morcellation for vaginal extraction in TLH (Figures 2 and 3 and Video). After completing the circular colpotomy, the uterine manipulator was removed and replaced by the EndoCatch II system embedded in a Colpo-Pneumo-Occluder system (CooperSurgical, Pleasanton, CA) to avoid the loss of intraabdominal air pressure. The dissected uterus was wrapped with the bag device through the posterior vaginal fornix, beginning
FIGURE 1
Patient with peritoneal metastases of leiomyosarcoma during secondlook laparoscopy
Department of Gynecology and Obstetrics, Cantonal Hospital of Lucerne, Lucerne (Drs Günthert, Christmann, and Kostov), Department of Gynecology and Obstetrics, Inselspital, Bern University Hospital and University of Bern (Drs Günthert, Kostov, and Mueller), and Department of Gynecology and Obstetrics, See-Spital Horgen (Dr Kostov), Switzerland. Received Sept. 9, 2014; revised Nov. 14, 2014; accepted Nov. 17, 2014. The authors report no conflict of interest. Corresponding author: A. R. Günthert, MD. [email protected] 0002-9378/$36.00 ª 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajog.2014.11.020
Click Supplementary Content under the article title in the online Table of Contents
Forty-seven year old patient with peritoneal metastases of leiomyosarcoma during second-look laparoscopy 6 weeks after morcellation of a uterus with assumed leiomyoma. Günthert. Vaginal uterine in-bag morcellation. Am J Obstet Gynecol 2015.
546.e1 American Journal of Obstetrics & Gynecology APRIL 2015
Surgeon’s Corner
ajog.org
FIGURE 2
Intraoperative setting after completion of colpotomy
A
B
C
D
A, The device enters the abdomen through the posterior vaginal fornix and the bag is open. B, The uterus is wrapped with an EndoCatch II plastic bag (Covidien/Tyco Healthcare), assisted by laparoscopic forcipes. C, After complete wrapping, the orifice is delivered to the vulva. D, The uterus is morcellated by conventional coring in the plastic bag. Günthert. Vaginal uterine in-bag morcellation. Am J Obstet Gynecol 2015.
in the cul de sac, assisted by laparoscopic forcipes. The orifice of the bag and the cervix uteri were then delivered to the vulva. The completely covered specimen was then morcellated by conventional coring in the vagina for safe extraction without intraabdominal dissemination or destruction of the serous surface of the uterus (Figures 2 and 3 and Video). Technical limitations were extreme vaginal narrowing or a transversal uterine diameter exceeding 15 cm. There was no significant learning
curve of this minimally invasive approach with wrapping time less than 5 minutes on average. For larger uterine specimens, bigger bags without frame (LapSac; Cook Medical, Bloomington, IN) were applied, although the placement and wrapping were more difficult and took much more time. We implemented this procedure, along with a risk stratification algorithm, in 2 tertiary referral hospitals, both of which were specialized centers for gynecological endoscopic
surgery and gynecological oncology (Inselspital Bern in 2010 and Cantonal Hospital of Lucerne in January 2013). All women planning TLH underwent preoperative imaging assessment by transvaginal ultrasound including power Doppler sonography; if incomplete or nonconclusive, a magnetic resonance imaging was performed. We defined concerning history as a growing uterine mass or uterus after menopause or fastgrowing uterine fibroids in premenopausal women.
APRIL 2015 American Journal of Obstetrics & Gynecology
546.e2
Surgeon’s Corner
ajog.org
FIGURE 3
Illustration of wrapping and coring procedure
The illustration shows wrapping and coring procedure, which avoids spillage of specimen and also avoids destruction of the serous surface of the uterus for histopathology evaluation and correct staging in case of unexpected malignancy. Günthert. Vaginal uterine in-bag morcellation. Am J Obstet Gynecol 2015.
Our preoperative risk assessment defined 3 groups of patients: first, assumed/confirmed malignancy; second, uncertain; and third, low risk. Women who preferred surgical treatment with TLH, had a uterine mass 15 cm or smaller, and were of uncertain risk were treated by TLH with subsequent vaginal in-bag morcellation, if required. (Women of uncertain risk with a uterine mass exceeding a transverse diameter of 15 cm were treated with laparotomy.) In women planning TLH who were deemed of low risk, the uterine specimen was morcellated intraabdominally or transvaginally without a bag, if required. Women with assumed or confirmed malignancy were not offered morcellation. Clinical data were retrospectively analyzed by chart review. The local ethics committee of Bern and Lucerne approved the study. From 2010 to June 2014, we performed 503 TLH/total intrafascial laparoscopic hysterectomy procedures
and performed vaginal in-bag morcellation of the uterus in 61 women categorized as uncertain risk. Of the 503 patients, there were 9 cases of uterine leiomyosarcoma (Figure 4). Two were preoperatively classified as assumed malignant and were evacuated without morcellation. Six were preoperatively classified as uncertain, and all were evacuated without abdominal contamination by vaginal in-bag morcellation. After a follow-up of at least 6 months, these women remained disease free (range, 6e36 months). The final case of leiomyosarcoma occurred in the preoperatively defined low-risk group. Her extraction was done by vaginal morcellation without a bag. Second-look laparoscopy 3 months later showed no metastases. After we recognized the underestimated risk of tumor spread by morcellation of incidental uterine cancers in 2010,5 we established our described strategy. Removing pelvic
546.e3 American Journal of Obstetrics & Gynecology APRIL 2015
masses by laparoscopy and extraction through the posterior vaginal fornix in a retrieval specimen bag was already reported in 2002 by Ghezzi et al.6 During the last few years, comparable methods of intraabdominal or vaginal in-bag morcellation procedures have been introduced.7-11 We describe our experience in a large sample of women. Our method is simple and allows the removal of the speciman by safe in-bag coring without disseminating uncertain benign or malignant cells and without destroying the serous surface of the uterus, which allows for adequate histopathological evaluation and appropriate staging in case of unexpected malignancy. In our opinion, in-bag morcellation methods should not be used in cases of suspected or confirmed malignancy. In our case series, no rupture or perforation of the bag occurred, but morcellation bears this potential risk and adequate histopathology workup and
Surgeon’s Corner
ajog.org
FIGURE 4
Flowchart of patient characteristics
Flowchart of risk assessment, procedure algorithm, and number of cases. In total we found 9 cases of LMS. LMS, leiomyosarcoma. Günthert. Vaginal uterine in-bag morcellation. Am J Obstet Gynecol 2015.
staging of a morcellated uterus might be difficult. REFERENCES 1. Steiner RA, Wight E, Tadir Y, Haller U. Electrical cutting device for laparoscopic removal of tissue from the abdominal cavity. Obstet Gynecol 1993;81:471-4. 2. Morice P, Rodriguez A, Rey A, et al. Prognostic value of initial surgical procedure for patients with uterine sarcoma: analysis of 123 patients. Eur J Gynaecol Oncol 2003;24:237-40. 3. Rekha W, Amita M, Sudeep G, Hemant T. Unexpected complication of uterine myoma morcellation. Aust N Z J Obstet Gynaecol 2005;45:248-9.
4. Wright JD, Tergas AI, Burke WM, et al. Uterine pathology in women undergoing minimally invasive hysterectomy using morcellation. JAMA 2014;312:1253-5. 5. Jahns BG, Michael N, Brunnmayr G, et al. Primary or secondary laparoscopy for staging in patients with uterine sarcoma. Eur J Obstet Gynecol Reprod Biol 2010;154:230-1. 6. Ghezzi F, Raio L, Mueller MD, Gyr T, Butarelli M, Franchi M. Vaginal extraction of pelvic masses following operative laparoscopy. Surg Endosc 2002;16:1691-6. 7. Perri T, Korach J, Sadetzki S, Oberman B, Fridman E, Ben-Baruch G. Uterine leiomysarcoma: does the primary surgical procedure matter? Int J Gynecol Cancer 2009;19: 257-60.
8. Wang CJ, Yuen LT, Lee CL, Kay N, Soong YK. Laparoscopic myomectomy for large uterine fibroids. Surg Endosc 2006;20: 1427-30. 9. Favero G, Anton C, Silva e Silva A, et al. Vaginal morcellation: a new strategy for large gynecological malignant tumor extraction: a pilot study. Gynecol Oncol 2012;126:443-7. 10. Montella F, Riboni F, Cosma S, et al. A safe method of vaginal longitudinal morcellation of bulky uterus with endometrial cancer in a bag at laparoscopy. Surg Endosc 2014;28: 1949-53. 11. McKenna JB, Kanade T, Choi S, et al. The Sydney contained in bag morcellation technique. J Minim Invasive Gynecol 2014;21: 984-5.
APRIL 2015 American Journal of Obstetrics & Gynecology
546.e4
