Surgical Techniques

Cost-conscious minimally invasive hysterectomy: A case illustration

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Suture material

Aspects of minimally invasive gynecologic surgery that require the use of suture include, but are not limited to, closure of the vaginal cuff, oophoropexy, and reapproximation of the ovarian cortex after cystectomy. Synthetic and delayed absorbable sutures, such as PDS II, are used frequently. The barbed suture also has gained popularity because it anchors to tissue without the need for intracorporeal or extracorporeal knots (TABLE 1).

Tissue removal

Adnexae and pathologic tissue, such as dermoid cysts, can be removed intact from the peritoneal cavity using an Endo Catch Single Use Specimen Pouch, a polyurethane sac. Careful use, with placement of the ovary with the cyst into the pouch prior to cystectomy, can contain or prevent spillage outside the bag.

A large uterus that cannot be extracted through a colpotomy can be manually morcellated. Appropriate candidates can undergo power morcellation using an FDA-approved device. (TABLE 1), allowing for the removal of smaller pieces through a small laparoscopic incision or the colpotomy.

Issues surrounding morcellation continue to require that gynecologic surgeons understand FDA recommendations. In 2014, the FDA issued a safety communication that morcellation is “contraindicated in gynecologic surgery if tissue is known or suspected to be malignant; it is contraindicated for uterine tissue removal with presumed benign fibroids in perimenopausal women.”12 A black-box warning was issued that uterine tissue might contain unsuspected cancer.

A task force created by AAGL addressed key issues in this controversy.

AAGL then provided guidelines related to morcellation13:

  • Do not use morcellate in the setting of known malignancy.
  • Provide appropriate preoperative evaluation with up-to-date Pap smear screening and image analysis.
  • Increasing age significantly increases the risk of leiomyosarcoma, especially in a postmenopausal woman.
  • Fibroid growth is not a reliable sign of malignancy.
  • Do not use a morcellator if the patient is at high risk for malignancy.
  • If leiomyosarcoma is the presumed pathology, await the final pathology report before proceeding with hysterectomy.
  • Concomitant use of a bag might mitigate the risk of tissue spread.
  • Obtain informed consent before proceeding with morcellation.

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