Tissue morcellation is by no means a new concept in laparoscopic surgery, but recent concerns regarding open power morcellation in gynecologic procedures have called the practice into question.1 A hand-activated device for laparoscopic tissue removal was developed as early as 1973, and by 1993, the Steiner electromechanical morcellator was introduced.2,3
The advent of electromechanical morcellation allowed for marked improvements in ease and speed of specimen retrieval with minimally invasive approaches.4,5 As the field of minimally invasive gynecologic surgery has evolved to encompass increasingly challenging procedures, a number of power morcellation devices have been marketed to allow removal of large pathology via small incisions and avoid the morbidity associated with laparotomy. However, this innovation is not without risks, including potential for intraoperative injury and risk of seeding of cellular tissue during the morcellation process.
Gynecologic surgeons should give consideration to the balance of benefit and harm that accompanies laparoscopic tissue morcellation, in addition to exploring surgical alternatives and methods to mitigate complications.
Risks associated with morcellation
Rates of visceral and vascular injury associated with electromechanical morcellation devices are difficult to quantify due to limited reporting. A recent systematic review of all published articles as well as the FDA device database identified 55 morcellator-related injuries during gynecologic (hysterectomy, myomectomy) and non-gynecologic (nephrectomy, splenectomy) procedures.6 Vascular and bowel injuries were listed as the most common complications. In this review, surgeon inexperience was the most commonly listed risk factor for injury.
Aside from the risks inherent in surgical operation of morcellation devices, there is also concern about dissemination of tissue that can occur during an open power morcellation process. Fragments of tissue that are not retrieved may result in pain, infection and serious morbidity.7,8 Intracorporeal morcellation has also been reported to result in seeding of benign9-12 or malignant tissues.13-16 The incidence of such complications is difficult to quantify; the AAGL practice guidelines for laparoscopic subtotal/supracervical hysterectomy state that uterine morcellation does not appear to increase the risk of subsequent diagnosis of endometriosis and only rarely results in leiomyomatosis.17 Reported incidence of parasitic leiomyomata following laparoscopic procedures involving morcellation has been estimated at between 0.1% and 1% based on 2 retrospective studies.11,12
Of particular concern is the risk of morcellating an unidentified malignancy, with possible resultant upstaging of disease and worsened prognosis.18-20 In a recent statement, the Society of Gynecologic Oncology estimated that fewer than 1 woman in 1000 who undergoes hysterectomy for a presumed leiomyomata will have an occult malignancy, and advocated for open communication with patients regarding this issue.21 Unlike endometrial lesions, which are characterized by more reliable risk factors, symptomatology, and screening methods, uterine leiomyosarcomas are the subject of considerable concern because they are often difficult to differentiate from benign leiomyomata preoperatively. Leiomyosarcomas also are notoriously aggressive tumors associated with poor prognosis even in the absence of tissue morcellation.
Compounding the difficulties of diagnosis is the relative rarity of uterine leiomyosarcomas; incidence in the general population is estimated at 1 in 10,000 women, or approximately 1 in 1,000 women undergoing surgery for presumed fibroids.20,22-24 Suggested clinical factors that may heighten concern for malignancy include advancing patient age and presence of new or increasing uterine mass in a postmenopausal patient. The average age at presentation is 60 years; however, leiomyosarcomas have been reported in patients as young as their mid-20s.25 The rate of uterine growth has not been demonstrated to be a reliable predictor for malignancy.24 Screening techniques for uterine sarcomas are limited, but magnetic resonance imaging (MRI), particularly diffusion-weighted, and serum samples of lactate dehydrogenase (LDH) have been suggested as potential screening methods.26,27 One small prospective study demonstrated high sensitivity and specificity with the combination of dynamic MRI and measurement of total LDH and LDH isoenzyme type 3, but the results have not been reproduced on a larger scale.27
Surgical alternatives to open power morcellation
Laparotomy for hysterectomy or myomectomy is a definitive option for avoiding tissue morcellation, but it comes at the expense of increased morbidity and recovery time compared to minimally invasive approaches.28,29 When the uterine size is such that the specimen can be delivered vaginally, performing a vaginal hysterectomy or total laparoscopic hysterectomy, rather than supracervical hysterectomy, is also an option.
Minilaparotomy is another alternative to open power morcellation for specimen retrieval.30,31 Depending on the size of the mass, the specimen can either be removed intact via the minilaparotomy incision (typically < 4 cm in length), or it can be placed into a bag and manually morcellated to avoid spillage at the level of the abdominal wall or within the peritoneal cavity. Minilaparotomy allows for perioperative outcomes similar to that for a laparoscopic approach.32-34 Specimen retrieval and/or contained manual morcellation also can be performed via colpotomy, even if total hysterectomy has not taken place.35-37 A small randomized trial comparing transumblical and transvaginal specimen removal found decreased postoperative pain with the transvaginal method, but similar patient satisfaction, cosmesis and sexual function.38
Contained power morcellation is another promising option whereby tissue dissemination can be avoided. In these cases, electromechanical morcellation is performed in an enclosed environment within the abdomen, such as an endobag or artificial pneumoperitoneum.39
Implications for practice
The well-known benefits of minimally invasive gynecologic surgery must be measured along with the small but real risks associated with tissue morcellation. Taking into account patient-specific factors, appropriate preoperative screening for malignant conditions should be undertaken and open power morcellation avoided in cases of confirmed or likely malignancy.
Surgeons who choose to use a power morcellator should be experienced with the device operation and make an effort to retrieve all specimen fragments from the peritoneal cavity following morcellation. Strong consideration should also be given to alternative specimen retrieval options that are associated with decreased risk of retained specimen fragments or cellular seeding. In particular, a focus on innovations in preoperative screening for uterine sarcomas as well as advanced morcellating technology is critical to improve patient outcomes.
Next: Some institutions and groups defining stances on morcellation >>
1. Levitz, J. Doctors eye cancer risk in uterine procedure: popular technique to remove growths comes under question. The Wall Street Journal. http://online.wsj.com/news/articles/SB1000142405270230417370457926467392.... Accessed January 28, 2014.
2. Jain, N. Laparosopic tissue retrieval. In: Jain, N, ed. State of the Art Atlas of Endoscopic Surgery in Infertility and Gynecology. New York, New York: McGraw-Hill Professional; 2004; 90–93.
3. Steiner RA, Wight E, Tadir Y, Haller U. Electrical cutting device for laparoscopic removal of tissue from the abdominal cavity. Obstet Gynecol. 1993;81(3):471–474.
4. Carter JE, McCarus SD. Laparoscopic myomectomy. Time and cost analysis of power vs. manual morcellation. J Reprod Med. 1997;42(7):383–388.
5. Wang CJ, Yuen LT, Lee CL, Kay N, Soong YK. A prospective comparison of morcellator and culdotomy for extracting of uterine myomas laparascopically in nullipara. J Minim Invasive Gynecol. 2006;13(5):463–466.
6. Milad MP, Milad EA. Laparoscopic morcellator-related complications. J Minim Invasive Gynecol. 2013; pii: S1553-4650(13)01434–9.
7. Lieng M, Istre O, Busund B, Qvigstad E. Severe complications caused by retained tissue in laparoscopic supracervical hysterectomy. J Minim Invasive Gynecol. 2006;13:231–233.
8. Hutchins FL Jr, Reinoehl EM. Retained myoma after laparoscopic supracervical hysterectomy with morcellation. J Am Assoc Gynecol Laparosc. 1998;5:293–295.
9. Sepilian V, Della Badia C. Iatrogenic endometriosis caused by uterine morcellation during a supracervical hysterectomy. Obstet Gynecol. 2003;102(5pt2):1125–1127.
10. Donnez O, Squifflet J, Leconte I, Jadoul P, Donnez J. Posthysterectomy pelvic adenomyotic masses observed in 8 cases out of a series of 1405 laparoscopic subtotal hysterectomies. J Minim Invasive Gynecol. 2007;14(2):156–160.
11. Cucinella G, Granese R, Calagna G, Somigliana E, Perino A. Parasitic myomas after laparoscopic surgery: an emerging complication in the use of morcellator? Description of four cases. Fertil Steril. 2011;96(2):e90–96.
12. Leren V, Langebrekke A, Qvigstad E. Parasitic leiomyomas after laparoscopic surgery with morcellation. Acta Obstet Gynecol Scand. 2012;91(10):1233–1236.
13. Turner T, Secord AA, Lowery WJ, Sfakianos G, Lee PS. Metastatic adenocarcinoma after laparoscopic supracervical hysterectomy with morcellation: A case report. Gynecol Oncol Case Rep. 2013;5:19–21.
14. Della Badia C, Karini, H. Endometrial stromal sarcoma diagnosed after uterine morcellation in laparoscopic supracervical hysterectomy. J Min Invas Gynecol. 2010;17(6):791–793.
15. Anupama R, Ahmad SZ, Kuriakose S, Vijaykumar DK, Pavithran K, Seethalekshmy NV. Disseminated peritoneal leiomyosarcomas after laparoscopic “myomectomy” and morcellation. J Min Invas Gynecol. 2011;18(3):386–389.
16. Oduyebo T, Rauh-Hain AJ, Meserve EE, et al. The value of re-exploration in patients with inadvertently morcellated uterine sarcoma. Gynecol Oncol. 2013; pii: S0090-8258(13)01351–6.
17. AAGL Practice Report: Practice Guidelines for Laparoscopic Subtotal/Supracervical Hysterectomy (LSH). J Minim Invasive Gynecol. 2014;21(1):9–16.
18. Park JY, Park SK, Kim DY, et al. The impact of tumor morcellation during surgery on the prognosis of patients with apparently early uterine leiomyosarcoma. Gynecol Oncol. 2011;122(2):255–259.
19. Einstein MH, Barakat RR, Chi DS, et al. Management of uterine malignancy found incidentally after supracervical hysterectomy or uterine morcellation for presumed benign disease. Int J Gynecol Cancer. 2008;18(5):1065–1070.
20. Seidman MA, Oduyebo T, Muto MG, Crum CP, Nucci MR, Quade BJ. Peritoneal dissemination complicating morcellation of uterine mesenchymal neoplasms. PLoS One. 2012;7(11):e50058.
21. Society of Gynecologic Oncology. Morcellation. https://www.sgo.org/newsroom/position-statements-2/morcellation/. Accessed January 28, 2014.
22. Brooks SE, Zhan M, Cote T, Baquet CR. Surveillance, epidemiology, and end results analysis of 2677 cases of uterine sarcoma 1989-1999. Gynecol Oncol. 2004;93(1):204–208.
23.Theben JU, Schellong AR, Altgassen C, Kelling K, Schneider S, Grosse-Drieling D. Unexpected malignancies after laparoscopic-assisted supracervical hysterectomies (LASH): an analysis of 1,584 LASH cases. Arch Gynecol Obstet. 2013; 287(3):455–462.
24. Parker WH, Fu YS, Berek JS. Uterine sarcoma in patients operated on for presumed leiomyoma and rapidly growing leiomyoma. Obstet Gynecol. 1994;83(3):414.
25. Giuntoli RL II, Metzinger DS, DiMarco CS, et al. Retrospective review of 208 patients with leiomyosarcoma of the uterus: Prognostic indicators, surgical management, and adjuvant therapy. Gynecol Oncol. 2003;89(3):460.
26. Sato K, Yuasa N, Fujita M, Fukushima Y. Clinical application of diffusion-weighted imaging for preoperative differentiation between uterine leiomyoma and leiomyosarcoma. Am J Obstet Gynecol. 2013; pii: S0002-9378(13)02239–4.
27. Goto A, Takeuchi S, Sugimura K, Maruo T. Usefulness of Gd-DTPA contrast-enhanced dynamic MRI and serum determination of LDH and its isozymes in the differential diagnosis of leiomyosarcoma from degenerated leiomyoma of the uterus. Int J Gynecol Cancer. 2002;12(4):354–361.
28. Nieboer TE, Johnson N, Lethaby A, et al. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev. 2009;(3):CD003677.
29. Jin C, Hu Y, Chen XC, et al. Laparoscopic versus open myomectomy—A meta-analysis of randomized controlled trials. Eur J Obstet Gynecol Reprod Biol. 2009;145(1):14–21.
30. Serur E, Lakhi N. Laparoscopic hysterectomy with manual morcellation of the uterus. Am J Obstet Gynecol. 2011; 204: 566e1–2.
31. Tusheva OA, Cohen SL, Einarsson JI. Hand-assisted approach to laparoscopic myomectomy and hysterectomy. J Min Invasive Gynecol. 2013; 20: 234–237.
32. Smorgick N, Dalton VK, Patzkowsky KE, Hoffman MR, Advincula AP, As-Sanie S. Comparison of 2 minimally invasive routes for hysterectomy of large uteri. Int J Gynaecol Obstet. 2013;122(2):128–131.
33. Kumar A, Pearl M. Mini-laparotomy versus laparoscopy for gynecologic conditions. J Minim Invasive Gynecol. 2014;21(1):109–114.
34. Fanfani F, Fagotti A, Bifulco G, Ercoli A, Malzoni M, Scambia G. A prospective study of laparoscopy versus minilaparotomy in the treatment of uterine myomas. J Minim Invasive Gynecol. 2005;12(6):470–474.
35. 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: 443–447.
36.Ucella S, Cromi A, Bogni G, Casarin J, Serati M, Ghezzi F. Transvaginal specimen extraction at laparoscopy without concomitant hysterectomy: our experience and systematic review of the literature. J Minim Invasive Gynecol. 2013;20(5):583–590.
37. Ghezzi F, Raio L, Mueller MD, Gyr T, Buttarelli M, Franchi M. Vaginal extraction of pelvic masses following operative laparoscopy. Surg Endosc. 2002;16(12):1691–1696.
38. Ghezzi F, Cromi A, Uccella S, Bogani G, Serati M, Bolis P. Transumbilical versus transvaginal retrieval of surgical specimens at laparoscopy: a randomized trial. Am J Obstet Gynecol. 2012;207(2):112.e1–6.
39. Shibley KA. Feasibility of Intra-Abdominal Tissue Isolation and Extraction, within an Artificially Created Pneumoperitoneum, at Laparoscopy for Gynecologic Procedures. In: Proceedings from the American Association of Laparoscopic Gynecologists; November 5-9, 2012; Las Vegas, Nevada.