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A Less Risky Approach to Power Morcellation for Hysterectomy and Myomectomy?

Summary and Comment |
August 5, 2014

A Less Risky Approach to Power Morcellation for Hysterectomy and Myomectomy?

  1. Andrew M. Kaunitz, MD

Does performing it within a bag make this minimally invasive surgery safer?

  1. Andrew M. Kaunitz, MD

As cases of disseminated uterine sarcoma associated with minimally invasive hysterectomy using power morcellation continue to generate concern and the FDA finalizes guidance regarding its use, high-volume gynecologic surgeons with specialized training in minimally invasive surgery have described a technique for power morcellation contained within an isolation bag. In this retrospective cohort study, 73 cases of hysterectomy and myomectomy were performed between January 2013 and April 2014 employing power morcellation under laparoscopic visualization within an insufflated a 50×50-cm clear plastic bag.

Inspection of the bag by the surgeon following specimen extraction revealed no visible perforations except, in cases involving multiport procedures, punctures associated with use of 5-mm trocars. Median operative time was 114 minutes, estimated blood loss 50 mL, and specimen weight 257 g. Complications were few, and none appeared related to this off-label use of the bag for specimen extraction. More than 75% of patients were discharged home the same day.

Comment

Recently, the largest producer of power morcellation devices for gynecologic surgery announced it had suspended sales of these devices (Physician's First Watch Aug 1 2014). This underscores the impact of both the FDA hearings and new data on likelihood of preexisting malignancy at the time of minimally invasive hysterectomy (NEJM JW Womens Health Jul 22 2014) — and perhaps renders moot the development of safer surgical strategies employing morcellation. Although the use of this isolation bag for power morcellation seems promising, several caveats apply; for example, the ability of obstetrician-gynecologist generalists to safely employ the technique is unknown. Only a long-term (preferably randomized) trial can assess how much this technique minimizes tissue dissemination. In the meantime, anecdotal reports suggest that, as use of power morcellation is curtailed, more hysterectomies and myomectomies are being performed with traditional laparotomy: a surgical route associated with its own downsides.

  • Disclosures for Andrew M. Kaunitz, MD at time of publication Consultant / Advisory board Actavis plc; Bayer AG; Merck; Teva Pharmaceutical Industries Limited; UpToDate Royalties UpToDate Grant / Research support Trimel Pharmaceuticals Corp; TherapeuticsMD; NIH Editorial boards Contraception; Menopause; Contraceptive Technology Update; OBG Management; Medscape OB/GYN & Women’s Health Leadership positions in professional societies North American Menopause Society (Secretary)

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