Contained specimen morcellation during robotics-assisted laparoscopic supracervical hysterectomy for pelvic organ prolapse

Introduction and hypothesis Robotics-assisted laparoscopic supracervical hysterectomy (RALSH) with concomitant apical robotics-assisted POP repair provides advantages of minimally invasive procedures; however specimen removal without intraperitoneal spillage of potential pathology remains challenging. The primary aim of our study is to determine the factors affecting contained manual morcellation (CMM) of specimens during RALSH for POP surgery. The secondary aim of the study is to report complications associated with CMM and on specimen pathology.

A total of 67 sequential patients underwent RALSH with concomitant robotics-assisted sacrocolpopexy or uterosacral vaginal suspension. Factors analyzed to affect CMM were specimen weight, length of skin and fascia incisions, patient age, body mass index (BMI), and estimated blood loss (EBL).

Median CMM time was 11 min (1 to 46) and specimen weight 62 g (19 to 711). Median patient age was 56 years (36 to 83), and patient BMI was 28 (18 to 44). Median EBL was 50 ml (10 to 150). Median skin and fascial incision lengths were 3 cm (1.5 to 7), and 3.5 cm (1.5 to 8). CMM time was significantly dependent on specimen weight (p < 0.0001) and length of rectus fascia incision (p < 0.0126). There was no gross tissue spillage or bag ruptures. Uterine pathology revealed normal tissue (26%), leiomyoma (47%), adenomyosis (49%), and endometriosis (14%). 4.5% of specimens had evidence of microscopic neoplasm, and 5 years after surgery patients were cancer free.

Contained manual extraction of the uterus and/or adnexae at the time of RALSH for POP surgery is a viable, safe, and efficient method of specimen removal. Similar content being viewed by others

Haya N, Feiner B, Baessler K, Christmann-Schmid C, Maher C. Perioperative interventions in pelvic organ prolapse surgery. Cochrane Database Syst Rev. 2018;8:CD013105. Lindner BJ, Occhino JA, Habermann EB, Glasgow AE, Bews KA, Gershman B. A national contemporary analysis of perioperative outcomes of open versus minimally invasive sacrocolpopexy. J Urol. 2018. https://doi.org/10.1016/j.juro.2018.03.131. Diana M, Marescaux J. Robotic surgery. Br J Surg. 2015;102(2):e15–28. https://doi.org/10.1002/bjs.9711. Dallas K, Taich L, Kuhlmann P, et al. Supracervical hysterectomy is protective against mesh complications after minimally invasive abdominal sacrocolpopexy: a population-based cohort study of 12,189 patients. J Urol. 2022;207(3):669–76. https://doi.org/10.1097/JU.0000000000002262. FDA Safety Communication. Laparoscopic uterine morcellation in hysterectomy and myomectomy. 2014. Slopnick EA, Roberts K, Sheyn DD, Chapman GC, El-Nashar S, Mahajan ST. Factors influencing selection of concomitant total versus supracervical hysterectomy at the time of sacrocolpopexy and associated perioperative outcomes. Female Pelvic Med Reconstr Surg. 2021;27(7):415–20. Cohen SL, Clark NV, Ajao MO, et al. Prospective evaluation of manual morcellation techniques: minilaparotomy versus vaginal approach. J Minim Invasive Gynecol. 2019;26:702–8. Ackernborn MF, Giugale LE, Wang Y, Shepherd JP. Incidence of occult uterine pathology in women undergoing hysterectomy with pelvic organ prolapse repair. Female Pelvic Med Reconstruct Surg. 2016;22:332–5. 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. https://doi.org/10.1016/j.gynor.2013.03.002. 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. https://doi.org/10.1371/journal.pone.0050058. Campagna G, Morciano A, Rossitto C, et al. A new approach to supracervical hysterectomy during laparoscopic sacrocolpopexy for pelvic organ prolapse: a randomized clinical trial. Neurourol Urogynecol. 2017;36:798–802. Parsons LHP, Pedersen R, Richardson DL, Kho KA. The prevalence of occult endometrial cancer in women undergoing hysterectomy for benign indications. Eur J Obstet Gynecol Reprod Biol. 2018;223:108–12. Tarr ME, Brancato SJ, Cunkelman JA, Polcari A, Nutter B, Kenton K. Comparison of postural ergonomics between laparoscopic and robotic sacrocolpopexy: a pilot study. J Minim Invasive Gynecol. 2015;22:234–8. Hong MK, Wei YC, Chu TY, Wang JH, Ding DC. Safety and efficacy of contained manual morcellation during laparoscopic or robotic gynecological surgery. Int J Gynaecol Obstet. 2020;148(2):168–73. https://doi.org/10.1002/ijgo.13062. Serur E, Zambrano N, Brown K, Clemetson E, Lakhi N. Extracorporeal manual morcellation of very large uteri within an enclosed endoscopic bag: our 5-year experience. J Minim Invasive Gynecol. 2016;23:903–8. American College of Obstetricians and Gynecologists’ Committee on Gynecologic Practice. Uterine morcellation for presumed leiomyomas: ACOG committee opinion, number 822. Obstet Gynecol. 2021;137(3):e63–74. https://doi.org/10.1097/AOG.0000000000004291. (Erratum in: Obstet Gynecol. 2021 Aug 1;138(2):313). Liu FW, Galvan-Turner VB, Pfaendler KS, Longoria TC, Bristow RE. A critical assessment of morcellation and its impact on gynecologic surgery and the limitations of the existing literature. Am J Obstet Gynecol. 2015;212(6):717–24. https://doi.org/10.1016/j.ajog.2015.01.012. Sanderson DJ, Sanderson R, Cleason D, Seaman C, Ghomi A. Manual morcellation compared to power morcellation during robotic myomectomy. J Robot Surg. 2018. https://doi.org/10.1007/s11701-018-0837-y. Awad N, Mustafa S, Amit A, Deutsch M, Eldor-Itskovitz J, Lowenstein L. Implementation of a new procedure: laparoscopic versus robotic sacrocolpopexy. Arch Gynecol Obstet. 2013;287:1181–6. Wasson M, Butler K, Magtibay P, Temkit M, Magrina J. Prognostic factors for morcellation during vaginal hysterectomy. Obstet Gynecol. 2016;127:752–7. Rimbach S, Schempershofe M. In-bag morcellation as a routine for laparoscopic hysterectomy. Biomed Res Int. 2017;2017:6701916. https://doi.org/10.1155/2017/6701916. Zullo F, Venturella R, Raffone A, Saccone G. In-bag manual versus uncontained power morcellation for laparoscopic myomectomy. Cochrane Database Syst Rev. 2020;5(5):CD013352. https://doi.org/10.1002/14651858.CD013352.pub2. Van den Haak L, van der Eijk AC, Sandberg EM, et al. Towards spill-free in bag morcellation: a health failure mode and effects analysis. Surg Endosc. 2018;32:4357–62. Gerges B, Mongelli M, Casikar I, Bognardi T, Condous G. Three-dimensional transvaginal sonographic assessment of uterine volume as preoperative predictor of need to morcellate in women undergoing laparoscopic hysterectomy. Ultrasound Obstet Gynecol. 2017;50:255–60. Pados G, Tsolakidis D, Theodoulidis V, Makedos A, Zaramboukas T, Tarlatzis B. Prevalence of occult leiomyosarcomas and atypical leiomyomas after laparoscopic morcellation of leiomyomas in reproductive-age women. Hum Reprod. 2017;32:2036–41. Hassani DB, Mangel JM, Mahajan ST, Hijaz AK, El-Nashar S, Sheyn D. Survey of pelvic reconstructive surgeons on performance of opportunistic salpingectomy at the time of pelvic organ prolapse repair. Int Urogynecol J. 2018. https://doi.org/10.1007/s00192-018-3652-0. Lange S, Pluchino N, Fehlmann A, et al. Prevalence of undiagnosed uterine leiomyosarcoma in women undergoing hysterectomy or myomectomy for benign indications. Eur J Obstet Gynecol Reprod Biol. 2017;216:239–44. Taylan E, Sahin C, Zeybek B, Akdemir A. Contained morcellation: review of current methods and future directions. Front Surg. 2017;4:15. https://doi.org/10.3389/fsurg.2017.00015. Vaughan MH, Modesitt SC, Mo Y, Trowbridge ER. Serous tubal intraepithelial carcinoma: an incidental finding at the time of prophylactic bilateral salpingo-oophorectomy. Case Rep Obstet Gynecol. 2015;2015:760429. Graebe K, Garcia-Soto A, Aziz M, et al. Incidental power morcellation of malignancy: a retrospective cohort study. Gynecol Oncol. 2015;136:274–7. Author information Authors and Affiliations Contributions Nicole Falus: manuscript writing/editing, data analysis, data management; George Lazarou: data analysis, manuscript writing/editing; Iwona Gabriel: data collection, manuscript writing; Nicholas Sabatino: project development; Bogdan Grigorescu: data collection, data analysis, manuscript writing. Corresponding author Ethics declarations Conflicts of interest None. 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