The world of minimally invasive gynecologic surgery has been transformed over the past 10 months—specifically in regard to the option of open power morcellation. From individual hospital bans of the procedure to an official warning from the US Food and Drug Administration (FDA)1 and the potential for further government action, the change has been swift and certain. Johnson & Johnson has recalled all power morcellators, many institutions now have bans in place, and one major insurer has announced its plan to discontinue coverage of power morcellation in three states.
What effect have these actions had on the availability of minimally invasive approaches to benign hysterectomy and myomectomy? And given new information on the risk of occult malignancy during these surgeries, how has patient selection and preoperative assessment changed? To address these and other questions, OBG Management convened a panel of experts in minimally invasive gynecology and asked them to share their perspective. In this case-based discussion, they offer their views on the morcellation controversy and their current approach to hysterectomy, myomectomy, and tissue extraction. Next month, in Part 2 of their discussion, they address patient counseling and FDA actions.
What is your preferred approach?
OBG Management: In light of the morcellation controversy, what is your preferred approach for benign hysterectomy?
Kimberly Kho, MD, MPH: Whenever possible and appropriate, vaginal hysterectomy is my preferred route. However, many surgical cases require evaluation of the abdominal cavity for pain, endometriosis, or a concerning adnexal mass. In such cases, and in cases involving a very large uterus, I prefer laparoscopic hysterectomy—either laparoscopic-assisted vaginal hysterectomy or total laparoscopic hysterectomy (TLH). I tend to perform TLH more frequently in these cases if the uterus lacks descent or the patient’s anatomy restricts vaginal access. Even in these cases, and with very large myomas and uteri, I have been successful removing the uterus vaginally, although this approach frequently involves vaginal morcellation with a scalpel.
Arnold P. Advincula, MD: My preferred approach for both benign hysterectomy and myomectomy is robot-assisted laparoscopy. I have used this approach over the past 13 years. In my hands, it is reproducible, safe, efficient, and cost-effective and affords me the ability to tackle a wide range of complex cases.
Cheryl Iglesia, MD: Like Dr. Kho, I prefer vaginal hysterectomy.
Jason D. Wright, MD: I also prefer the vaginal approach. In fact, I believe it should be the preferred approach for hysterectomy for benign gynecologic disease whenever it is feasible. And the laparoscopic and robot-assisted approaches carry less perioperative morbidity than abdominal hysterectomy.
Given the recent concerns about open power morcellation, I prefer to perform either vaginal hysterectomy or minimally invasive hysterectomy without morcellation. If neither approach is feasible, given anatomic considerations, I counsel the patient about the risks and benefits of abdominal hysterectomy, compared with minimally invasive hysterectomy with morcellation.
Linda D. Bradley, MD: For women who meet minimally invasive surgical criteria, I prefer the laparoscopic approach because of its many benefits, including a shorter hospital stay (which reduces the risk of hospital-acquired infection and iatrogenic complications of hospitalization), lower risk of incisional infection, lower requirement for pain medications, and faster return to work.
OBG Management: What about myomectomy? Would your approach be different?
Dr. Bradley: Many myomectomy cases can be done hysteroscopically. I would like to point out, however, that when we talk about hysteroscopy, the morcellation issue is moot. Although there are hysteroscopic surgical devices that have used the word “morcellator” in their names, hysteroscopic morcellation is performed within a closed system—the uterine cavity—and so carries none of the risks of laparoscopic morcellation.
I prefer to perform nonhysteroscopic cases using a laparoscopic approach, creating a small mini-laparotomy to remove the fibroid intact or using a knife to morcellate the tissue outside of the peritoneal cavity.
Dr. Kho: I use a similar laparoscopic approach for myomectomy, using laparoscopy to assess the uterus and fibroids, enucleate the fibroid and remove it from the uterus, and then creating a mini-laparotomy incision
3 cm to 4 cm in length to manually remove or morcellate the fibroid and reapproximate the myometrium.
Dr. Iglesia: I rarely perform myomectomy but would likely do it laparoscopically or robotically to achieve minimally invasive benefits such as fewer adhesions and less postoperative pain.
How do you manage tissue extraction?
OBG Management: What methods of tissue extraction do you currently use during hysterectomy and myomectomy?
Dr. Advincula: I currently utilize a contained, extracorporeal, transumbilical, manual scalpel-morcellation technique for all myomectomy cases, as well as hysterectomy cases not amenable to transvaginal extraction.
Dr. Iglesia: I rely on vaginal removal of tissue and vaginal morcellation.