Expert Commentary

Tissue extraction during minimally invasive Gyn surgery. First of 2 parts: Best practices for an environment in flux

In this roundtable discussion, five surgical experts weigh in on the state of minimally invasive gynecology and current age-based options for tissue extraction

Our expert panel

Arnold P. Advincula, MD, is Vice-Chair of Women’s Health and Chief of Gynecology, Department of ­Obstetrics and Gynecology, at Columbia University Medical Center in New York, New York. He serves on the OBG Management Board of Editors.
Linda D. Bradley, MD, is Professor of Surgery; Vice Chairman of the Obstetrics, Gynecology and Women’s Health Institute; and Director of the Center for ­Menstrual Disorders, Fibroids & Hysteroscopic Services at Cleveland Clinic in Cleveland, Ohio. She serves on the OBG Management Board of Editors.

Cheryl Iglesia, MD, is Director of the Section of Female Pelvic Medicine and Reconstructive Surgery at MedStar Washington Hospital Center and Professor, Departments of ObGyn and Urology, at Georgetown University School of Medicine in Washington, DC. She serves on the OBG Management Board of Editors.

Kimberly Kho, MD, MPH, is Assistant Professor, Department of Obstetrics and Gynecology, and Director of the Southwestern Center for Minimally Invasive Surgery, Gynecology, at the University of Texas Southwestern Medical Center in Dallas, Texas.

Jason D. Wright, MD, is Sol Goldman Associate Professor of Obstetrics and Gynecology and Chief of the Division of Gynecologic Oncology at Columbia University College of Physicians and Surgeons and New York ­Presbyterian Hospital in New York, New York.


Dr. Advincula reports that he is a consultant to Blue Endo, CooperSurgical, Intuitive Surgical, and SurgiQuest. He also receives royalties from CooperSurgical.Dr. Bradley reports that she receives grant or research support from Bayer Research as a principal investigator and contributor; is a consultant to BlueSpire, Boston Scientific, Endoceutics, Hologic, and Smith & Nephew; and is a speaker for Bayer Healthcare. Other reported financial relationships: royalties from Elsevier; as a member of the Editorial Advisory Board of MedScape and WebMD; and for articles published in Wolters Kluwer Health and UpToDate. Dr. Iglesia reports that she is a member of the FDA ObGyn Devices Panel.Dr. Kho reports no financial relationships relevant to this article. Dr. Wright reports that he receives grant or research support from Genentech.


 

References

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.

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