{"paper_id":"85d5602c-7620-4269-b35b-58139f7fc2be","body_text":"De Novo Endometrial Implant Into the Colon After\nUterine Morcellation\nErin M. Mellano, MD, Christy M. Anthony, BS, Tamara Grisales, MD, Christopher M. Tarnay, MD\nDepartment of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, University of\nCalifornia, Los Angeles, David Geffen School of Medicine, Los Angeles, CA, USA (all authors).\nABSTRACT\nInstances of iatrogenic endometriosis after laparoscopic supracervical hysterectomy are uncommon but have been\nreported in the literature in women undergoing hysterectomy for pelvic pain. A 41-year-old woman with no history of\nendometriosis developed cyclic pain and a mass in her lower abdominal wall after uterine morcellation for a laparoscopic\nsupracervical hysterectomy and sacrocolpopexy for uterocervical prolapse. Exploratory surgery revealed an endometrial\nimplant involving the peritoneum and omentum, with transmural involvement of the cecum at a site separate from the\ntrocar site. Aberrant endometrial cell implantation after morcellation of the uterine corpus has been reported; however,\nthis was a rare instance of transmural large bowel iatrogenic endometriosis, necessitating a partial bowel resection, in a\npatient without a history of endometriosis or pelvic pain, at a site remote from where the uterus was morcellated and\nremoved. In light of recent concerns over dissemination of occult cancerous cells, this case illustrates that dissemination\nof noncancerous cells can similarly have detrimental outcomes for patients.\nKey Words: Endometriosis, Laparoscopy, Supracervical hysterectomy, Uterine morcellation.\nINTRODUCTION\nEndometriosis is defined by the presence of endometrial\nglands and stroma outside the lining of the endometrial cavity.\nSites that may be seeded with these endometrial glands\ninclude the ovaries, peritoneum, rectovaginal septum, ab-\ndominal wall, bowel, ureter, and even lung paren-\nchyma.\n1,2 Endometriosis affects approximately 6% to 10%\nof all reproductive-aged women and accounts for 35% to\n50% of women who experience cyclic chronic pelvic pain\nand/or have complications with fertility. The severity of\nthe symptoms differs greatly among these women and has\nno correlation with the extent of disease.\n2\nCases of postoperative iatrogenic endometriosis after pel-\nvic surgery are rare. In women with known histories of\nendometriosis, surgical scar endometriomas have been\ndocumented after surgeries that involve the uterus, such\nas a Cesarean section or hysterectomy.\n3–5 The proposed\nmechanism for trocar-site or surgical-scar endometriosis is\nspillage of endometrial cells at the time of surgery, im-\nplantation of these cells, and proliferation to form endo-\nmetriomas.\n6\nMore than 200,000 women undergo surgical correction for\npelvic organ prolapse each year. Advances in minimally\ninvasive surgical techniques facilitate the ability of sur-\ngeons to perform sacrocolpopexy procedures for vault\nprolapse with decreased morbidity.\n7,8 For women who\nhave uteri at the time of the procedure, a supracervical\nhysterectomy is generally performed to allow a durable\nrepair, while minimizing the risk for mesh complications.\nAs the number of laparoscopic sacrocolpopexy proce-\ndures increases, uterine morcellation will be performed\nmore frequently.\nUterine morcellation may potentiate dissemination of en-\ndometrial cells in the peritoneal cavity. In reproductive-\naged women, abnormal seeding of endometrial cells may\nrespond to hormonal fluxes and produce new-onset\nsymptoms of endometriosis in women with histories of it.\nEvidence of implantation of endometriomas after laparo-\nCitation Mellano EM, Anthony CM, Grisales T, Tarnay CM. De novo endometrial implant into the colon after uterine morcellation. CRSLS e2014.00403. DOI:\n10.4293/CRSLS.2014.00403.\nCopyright © 2014 SLS This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-ShareAlike 3.0 Unported\nlicense, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original author and source are c redited.\nAddress correspondence to: Erin M. Mellano, MD, University of California, Los Angeles, David Geffen School of Medicine, Department of Obstetrics an d Gynecology,\nDivision of Female Pelvic Medicine and Reconstructive Surgery, 10833 Le Conte Avenie, Box 951740, Los Angeles, CA 90095-1740, USA. Telephone: 310-2 67-5918,\nFax: 310-794-6635; E-mail: emellano@mednet.ucla.edu\n1e2014.00403 CRSLS MIS Case Reports from SLS.org\nCASE REPORT\n\nscopic supracervical hysterectomy has been documented\nin women without evidence of the disease before surgery.\nIn these cases, the patients undergoing hysterectomy pre-\noperatively reported dysmenorrhea or pelvic pain sug-\ngesting preexisting endometriosis.\n9 –13 The present case\nreport is unique in that an endometrial implant developed\nwell away from the site of morcellation, involving the\nlarge bowel and peritoneum, in a woman with no history\nof pelvic pain or signs of endometriosis at the time of her\nindex operation.\nCASE\nA 41-year-old, parous 2 woman was referred to our office\nfor symptomatic stage 3 pelvic organ prolapse and urinary\nstress incontinence for which she desired surgical correc-\ntion. She underwent a laparoscopic supracervical hyster-\nectomy, sacrocolpopexy, posterior colporrhaphy, perine-\norrhaphy, retropubic midurethral sling, and cystoscopy.\nThe procedure was uncomplicated, and the pelvic anat-\nomy was visually normal, including the ovaries, which\nwere left in situ. The uterus was morcellated intraperi-\ntoneally with a power morcellator and was removed\nthrough a 12-mm umbilical incision under direct visu-\nalization with the camera in the 12-mm right lower\nquadrant assistant port. Her postoperative course was\nuncomplicated, and she was discharged home on post-\noperative day 2.\nApproximately 5 months after her surgery, the patient\nbegan to experience cyclic pain and vaginal spotting. The\nvaginal spotting was attributed to residual endometrial\nglands in the endocervical canal. She had no history of\ndysmenorrhea and no overt endometriosis noted at the\ntime of her surgery. The results of physical examination\nwere unremarkable, and an in-office ultrasound study\nrevealed normal-appearing adnexal structures. She was\ntreated with nonsteroidal anti-inflammatory medication\nfor her pain.\nOver the next year, she continued to be vexed with right\nlow abdominal wall pain at the site of a self-reported\nabdominal firmness that expanded and regressed in size\ncyclically with menstruation. Interval imaging studies, in-\ncluding ultrasound and computed tomography (CT), were\nperformed and were unable to locate an abnormality in\nthe anterior abdominal wall. Of note, an inflammatory\nfocus along the lower margin of the cecum in the right\nlower quadrant, 15 mm in size with some fat stranding and\ntrace fluid, interpreted as postsurgical changes, was seen\non CT /H1102212 months after her surgery. Attempts to treat her\npain with local anesthetic and oral analgesics were largely\nunsuccessful. Given the cyclic nature of the pain, a\n1-month trial of a gonadotropin-releasing hormone ago-\nnist was administered. The patient noticed a dramatic\nimprovement of her pain with hormonal suppression.\nEighteen months after surgery, she was examined while\non her menstrual cycle, and a palpable mass was appre-\nciated, medial and inferior to the right lower quadrant\nassistant laparoscopic port site in the anterior abdominal\nwall. Her symptoms and the response to hormonal sup-\npression were suggestive of endometriosis, despite un-\ncharacteristic location, distant from the umbilical port\nwhere the morcellation and uterine tissue had been re-\nmoved. Magnetic resonance imaging (MRI) performed\nduring menstruation did not demonstrate any visually\nenhancing lesions in the abdominal wall. Despite nondi-\nagnostic imaging results, the presumptive clinical conclu-\nsion was an endometriotic implant. Given the debilitating\nnature of this pain, the patient elected to undergo an\nexploration and excision of this mass.\nOn examination under anesthesia, a 3 /H110034 cm palpable\nmass in the anterior abdominal wall was identified. The\npalpable mass was below the level of the fascia, and upon\nentry into the peritoneum, a lobulated 3 /H110035 cm mass was\nencountered. This was adherent to the peritoneum and\nomentum, with a gross appearance consistent with endo-\nmetriosis. The conglomerate involved the nearby viscera,\nwith transmural involvement of the cecum ( Figure 1 ).\nThe mass, a portion of the cecum, and the adjacent ap-\npendix were resected with the assistance of a general\nsurgeon ( Figure 2 ).\nIntraoperative frozen section was consistent with endo-\nmetriosis. No additional lesions or masses were visualized\nin the peritoneal cavity. The patient had an uneventful\nrecovery and was discharged home 2 days postopera-\ntively. Final pathology confirmed the mass to be an irreg-\nular 5 /H110033.4 /H110032.0 cm fragment of yellow-gray, fibrofatty,\nindurated tissue with focal cavities filled with blood, sug-\nFigure 1. Cecal involvement of endometriotic implant.\nDe Novo Endometrial Implant Into the Colon After Uterine Morcellation, Mellano EM et al.\n2e2014.00403 CRSLS MIS Case Reports from SLS.org\n\ngestive of endometrioma. The cecum was noted to have\ntransmural infiltration of the endometrioma.\nDISCUSSION\nOur patient presented postoperatively with a clinical pic-\nture classic for endometriosis, with cyclic pain and a\npalpable, tender mass on examination. Although cases of\niatrogenic endometriotic implants have been reported af-\nter pelvic surgery, this case is unique in that the patient\nhad no history suggestive of endometriosis, nor were\nthere any intraoperative findings of endometriosis at the\ntime of her index surgery. Case reports of de novo endo-\nmetriosis after uterine morcellation have been notable in\npatients with preoperative symptoms of pelvic pain, sug-\ngestive of preexisting endometriosis.\n9 –13\nThe absence of preoperative pelvic pain or intraoperative\nsigns of preexisting endometriosis implies that the most\nlikely etiology of our patient’s endometrioma was direct\nseeding of endometrial cells after morcellation. What is\ninteresting about this particular case is that the endometri-\notic implant did not involve a laparoscopic port site.\nFurthermore, it was just inferior to the right lateral trocar\nsite, where the laparoscope was used during morcellation\nthrough the umbilical port. It is possible that the viewing\nangle in relationship to the right lower quadrant port site\nprecluded the surgeons from recognizing a fragment of\nretained uterine tissue.\nTraditional imagining techniques used to diagnose endo-\nmetriosis include ultrasound, MRI, and CT. It is unusual to\nbe unable to identify abdominal wall endometriotic im-\nplants with MRI. The sensitivity of MRI in detecting endo-\nmetriosis ranges from 78% to 96.3%, with specificity of\n73% to 100%.\n14 –16 Although the palpable lesion in this\npatient was thought to be in the anterior abdominal wall,\nthe true transcecal location made it significantly more\nchallenging to identify on imaging. Ultrasound, double-\ncontrast barium enema, CT, and MRI have all been used to\ndiagnose bowel endometriosis, but they have limita-\ntions.\n17 The sensitivity of these techniques can be reduced\nby bowel peristalsis, even after bowel preparation. An\nantispasmodic may be helpful in visualizing intestinal en-\ndometriosis by preventing artifacts from peristalsis.\n15 Gad-\nolinium may help enhance a study, but there is no con-\nsensus of benefit. Recent studies advocate for the use of\n3.0-T MRI to increase sensitivity and specificity in detect-\ning deep infiltrating endometriosis, compared with the\nroutine 1.5-T pelvic MRI protocol.\n14 Regardless of imaging\nmodality, high clinical suspicion should not be dissuaded\nby negative imaging.\nA laparoscopic supracervical hysterectomy performed at\nthe time of colpopexy mandates that the uterus be mor-\ncellated to remove the specimen. With advances in mini-\nmally invasive endoscopic surgery, surgeons should be\naware of the potential complications, although the overall\nincidence of these complications is difficult to determine.\nClearly, morcellating devices have the potential for great\nvisceral injury, but the risks associated with dissemination\nof small tissue fragments are more difficult to delineate.\nCase repots of ectopic leiomyoma, endometriosis, adeno-\nmyosis, ovarian tissue, and sarcoma exist in the literature,\nbut the overall incidence is unknown.\n18 In a case-control\nstudy comparing the rate of de novo endometriosis after\nhysterectomy with and without morcellation, the overall\nincidence was found to be 1% in both groups, suggesting\nno additional risk with morcellation.\n6 Instances of atypical\nendometrial implants found years after supracervical hys-\nterectomy with benign pathology demonstrate the poten-\ntial capability of transformation into abnormal histology.\n2\nEven more rare are cases of leiomyomatosis peritonealis\ndisseminata after morcellation of leiomyoma for benign\nindications, quoted at a rate of 0.1%.\n19\nThe risk for disseminating occult cancerous cells with\nmorcellation is low, but the morbidity of such an occur-\nrence is significant. The baseline rate of port-site metas-\ntases in laparoscopic gynecologic oncology surgery is 1%\nto 2%, which is similar to the incisional metastatic rate for\nequivalent exploratory laparotomy procedures.\n20 The\nAmerican College of Obstetricians and Gynecologists rec-\nommends that adequate assessment of the endometrial\ncavity be performed before morcellation; however, this is\nnot routinely done for asymptomatic women who are\nundergoing surgery for prolapse.\n21,22 Endometrial biopsy\nis a sensitive and specific method for identifying endome-\ntrial abnormalities, but there are no reliable diagnostic\nFigure 2. Gross specimen of endometrial implant sent to pa-\nthology.\n3e2014.00403 CRSLS MIS Case Reports from SLS.org\n\ntests to identify rare instances of leiomyosarcoma\n(LMS).18,23 LMS is typically diagnosed after surgery for a\npresumed leiomyoma. The incidence of unexpectedly di-\nagnosing a leiomyoma variant, leiomyoma atypia, or a\nmalignant sarcoma after morcellation is estimated at 0.09%\nto 1%.\n18,19,24 The Society of Gynecologic Oncology re-\nleased a statement in December 2013 that morcellation is\ncontraindicated in the presence of documented or sus-\npected malignancy and may be inadvisable in premalig-\nnant conditions or risk-reducing surgery.\n25 Morcellation of\nLMS increases the rate of abdominopelvic dissemination\nand adversely affects disease-free and overall survival.\n23 In\ncases of occult sarcoma after morcellation, evidence of\nperitoneal dissemination was seen up to 64% of the time\non subsequent evaluation.\n19,24 Regardless of whether the\ntumor is removed intact or morcellated, the Society of\nGynecologic Oncology statement emphasizes that LMS\nhas an extremely poor prognosis.\n25\nCurrent power morcellation devices do not provide a\nfail-safe method for preventing intraperitoneal spread of\nmorcellated tissue. Ultimately, the only way to avoid the\nspread of cells of the morcellated tissue would be to have\nan enclosed morcellation system. Some have suggested\nthat specimens should be placed in endoscopic bags and\nbrought up to the port site to be manually morcellated for\nremoval.\n18 This is a cumbersome technique that may not\nbe feasible for large or partially calcified specimens. In-\ncreased interest in developing devices to prevent spill\nduring morcellation have been reported, such as power\nmorcellation within a bag or special enclosed wire-mesh\nmorcellators.\n18,26 As of yet, these devices are experimen-\ntal, and until contained morcellation devices become\navailable, precautions should be taken to prevent perito-\nneal spread or seeding of morcellated tissues. We suggest\nirrigation of the peritoneal cavity, along with careful in-\nspection through an additional port site to ensure that no\nfragments of tissue are missed. In this particular case,\nreevaluating the peritoneal cavity from the umbilical cen-\ntral port site might have identified retained tissue previ-\nously unrecognized. As we grapple with the ramifications\nof morcellation in the rare cases of cancer, this case\nhighlights the sequelae of morcellation even in benign\ndisease. In concordance with the recommendations of the\nSociety of Gynecologic Oncology and the American Col-\nlege of Obstetricians and Gynecologists, surgeons should\nhave transparent discussions with their patients regarding\nrisks, benefits, and alternatives of all procedures so that\npatients can make informed decisions in their medical\ncare.\n22,25\nReferences:\n1. Horton JD, Dezee KJ, Ahnfeldt EP, Wagner M. Abdominal\nwall endometriosis: a surgeon’s perspective and review of 445\ncases. Am J Surg. 2008;196(2):207–212.\n2. Burney RO, Giudice LC. Pathogenesis and pathophysiology\nof endometriosis. Fertil Steril. 2012;98(3):511–519.\n3. Dwivedi AJ, Agrawal SN, Silva YJ. Abdominal wall endo-\nmetriomas. Dig Dis Sci. 2002;47(2):456 – 461.\n4. Song JY, Borncamp E, Mehaffey P, Rotman C. Large abdom-\ninal wall endometrioma following laparoscopic hysterectomy.\nJSLS. 2011;15(2):261–263.\n5. Leite GK, Carvalho LF, Korkes H, et al. Scar endometrioma\nfollowing obstetric surgical incisions: retrospective study on 33\ncases and review of the literature. Sao Paolo Med J. 2009;127(5):\n270 –277.\n6. Schuster MW, Wheeler TL II, Richter HE. Endometriosis after\nlaparoscopic supracervical hysterectomy with uterine morcella-\ntion: a case control study. J Minim Invasive Gynecol. 2012;19(2):\n183–187.\n7. Paraiso MR, Walters MD, Rackley RR, Melek S, Hugney C.\nLaparoscopic and abdominal sacral colpopexies: a comparative\ncohort study. Am J Obstet Gynecol. 2005;192(5):1752–1758.\n8. Klauschie JL, Suozzi BA, O’Brien MM, McBride AW. A com-\nparison of laparoscopic and abdominal sacral colpopexy: objec-\ntive outcome and perioperative differences. Int Urogynecol J\nPelvic Floor Dysfunct. 2009;20:273–279.\n9. Kill LM, Kapetanakis V, McCullough AE, Magrina JF. Pro-\ngression of pelvic implants to complex atypical endometrial\nhyperplasia alter uterine morcellation. Obstet Gynecol. 2011;\n117(2 Pt 2):447– 449.\n10. Sepilian V, Della Badia C. Iatrogenic endometriosis caused\nby uterine morcellation during a supracervical hysterectomy.\nObstet Gynecol. 2003;102(5 Pt 2):1125–1127.\n11. Wilson H, Shaxted E. Implantation endometrioma at port site\nafter laparoscopic abdominal supracervical hysterectomy.Gynaecol\nEndosc. 1999;8:245–247.\n12. Bektas¸ H, Bilsel Y, Sari YS, et al. Abdominal wall endometri-\noma; a 10-year experience and brief review of the literature.\nJ Surg Res. 2010;164(1):e77– e81.\n13. Seydel AS, Sickel JZ, Warner ED, Sax HC. Extrapelvic endo-\nmetriosis: diagnosis and treatment. Am J Surg. 1996;171(2):239.\n14. Bianek-Bodzak A, Szurowska E, Sawicki S, Liro M. The\nimportance and perspective of magnetic resonance imaging in\nthe evaluation of endometriosis. Biomed Res Int. 2013;2013:\n436589.\n15. Chamie´ LP, Blasbalg R, Gonc ¸alves, Carvalho FM, Abra ˜o\nMS, de Oliveira IS. Accuracy of magnetic resonance imaging\nDe Novo Endometrial Implant Into the Colon After Uterine Morcellation, Mellano EM et al.\n4e2014.00403 CRSLS MIS Case Reports from SLS.org\n\nfor diagnosis and preoperative assessment of deeply\ninfiltrating endometriosis. Int J Gynaecol Obstet. 2005;90:\n218 –222.\n16. Bazot M, Lafont C, Rouzier R, Roseau G, Thomassin-Naggara\nI, Daraï E. Diagnostic accuracy of physical examination, trans-\nvaginal sonography, rectal endoscopic sonography and mag-\nnetic resonance imaging to diagnose deep infiltrating endome-\ntriosis. Fertil Steril. 2009;92(6):1825–1833.\n17. Choudhary S, Fasih N, Papadatos D, Venkateswar SR. Un-\nusual imaging appearances of endometriosis. AJR Am J Roent-\ngenol. 2009;192:1632–1644.\n18. Kho KA, Nezhat CH. Evaluating the risks of electric uterine\nmorcellation. JAMA. In press.\n19. Sizzi O, Rossetti A, Malzoni M, et al. Italian multicenter study\non complications of laparoscopic myomectomy. J Minim Inva-\nsive Gynecol. 2007;14(4):453– 462.\n20. Ramirez PT, Wolf JK, Levenback C. Laparoscopic port-site\nmetastases: etiology and prevention. Gynecol Oncol. 2003;91(1):\n179 –189.\n21. Ramm O, Gleason JL, Segal S, Antosh DD, Kenton KS. Utility\nof preoperative endometrial assessment in asymptomatic\nwomen undergoing hysterectomy for pelvic floor dysfunction.\nInt Urogynecol J. 2012;23:913–917.\n22. American College of Obstetricians and Gynecologists. ACOG\nCommittee Opinion 388: supracervical hysterectomy. November 2007,\nreaffirmed 2013. Available at: http://www.acog.org/Resources_And_\nPublications/Committee_Opinions/Committee_on_Gynecologic_\nPractice/Supracervical_Hysterectomy. Accessed February 11,\n2014.\n23. Park JY, Park SK, Kim DY, et al. The impact of tumor\nmorcellation during surgery on the prognosis of patients with\napparently early uterine leiomyosarcoma. Gynecol Oncol. 2011;\n122(2):255–259.\n24. Seidman MA, Oduyebo T, Mutu MG, Crum CP, Nucci MR,\nQuade BJ. Peritoneal dissemination complicating morcellation of\nuterine mesenchymal neoplasms. PLoS One. 2012;7(11):e50058.\n25. Society of Gynecologic Oncology. Morcellation. December\n2013. Available at: https://www.sgo.org/newsroom/position-\nstatements-2/morcellation/. Accessed February 12, 2014.\n26. Isakov A, Murdaugh KM, Burke WC. A new laparoscopic\nmorcellator using an actuated wire mesh and bag. J Med Devices.\n2014;8(1):110091–110097.\n5e2014.00403 CRSLS MIS Case Reports from SLS.org","source_license":"CC0","license_restricted":false}