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.
Dr. Kho: I infrequently perform supracervical hysterectomy, so almost all the hysterectomies I do are total hysterectomies. I remove the uterus through the vagina. In addition, because the size of the specimen frequently is too large to remove through a colpotomy intact, I morcellate the uterus manually with a scalpel using coring, wedge resection, and myomectomy. I find this to be an efficient and controlled method for tissue removal, with minimal tissue scattering. I also have begun to perform the same type of vaginal morcellation with the specimen enclosed in a bag.
That being said, the spread of occult malignancy has been reported after all types of morcellation—not just with power morcellation but also with vaginal and abdominal morcellation. So we are increasingly performing tissue extraction in an enclosed fashion using manual morcellation in a containment bag through a mini-laparotomy or posterior colpotomy to minimize the risk of leaving tissue fragments behind.
Dr. Wright: Although different methods of tissue extraction, including morcellation within a bag, are commonly discussed, data documenting the safety of these methods are extremely limited and patients should be counseled accordingly.
Similarly, the risk of adverse pathology increases substantially with age, and morcellation should be considered with great caution—if at all—in older women.
Given the risks associated with power morcellation, I try to avoid uterine disruption at the time of hysterectomy and perform either vaginal or minimally invasive total hysterectomy. In older women, because of the higher risk of underlying pathology, I prefer laparotomy if anatomic considerations preclude a vaginal or minimally invasive total hysterectomy. Younger women can be counseled about the risks and benefits of various routes of extraction. Patients with any suspicious findings during preoperative evaluation or surgery itself should have their uterus removed without disruption or fragmentation.
In regard to myomectomy specifically, a significant portion of the data we have on the risks of power morcellation derives from studies of hysterectomy. There are minimal data describing the risk of occult pathology at the time of minimally invasive myomectomy. Although younger patients likely are at relatively low risk for occult malignancy, they should be counseled that population-based estimates of cancer at the time of myomectomy are lacking.
Dr. Bradley: Since the controversy over morcellation arose, the Cleveland Clinic not only has banned the procedure but also removed all morcellators from its shelves, and it is unclear whether the option will be revisited after the FDA renders its final verdict. So my approach to tissue extraction is either vaginal morcellation or using a mini-laparotomy to remove the whole specimen intact or put it in a bag and morcellate it with a knife.
Case 1: A premenopausal patient scheduled for myomectomy
OBG Management: Let’s move on to a specific case. Let’s say the patient is a 35-year-old woman with a large fibroid, to be removed by myomectomy. How would you quantify her risk of occult malignancy? And what would preoperative assessment entail?
Dr. Iglesia: This patient’s risk of occult malignancy is low. I would obtain pelvic ultrasonography and endometrial biopsy, with cervical cytology included. Preoperative magnetic resonance imaging (MRI) would be indicated if there is a possibility that power morcellation will be performed. If power morcellation were selected, I would perform it using a bag.
Dr. Bradley: At the Cleveland Clinic, we now utilize the FDA risk estimates for occult malignancy of 1 in 300 to 1 in 350 women,1 and I counsel patients using these figures. In the past several years, we have begun to use MRI with and without contrast to determine the size, number, and location of the fibroids, to determine our surgical approach, and to guide our discussion with the patient of what we will be able to do—for example, laparoscopy versus laparotomy.
OBG Management: Would the FDA figures you give be applicable to a young woman such as this 35-year-old?
Dr. Bradley: We’re using those figures with all of our premenopausal patients.
OBG Management: And does the MRI pick up sarcomas?
Dr. Bradley: No imaging is 100% sensitive in detecting sarcoma. We do MRI, and if the fibroid has any areas of necrosis, irregularity, or poor tissue planes that would arouse our suspicion of adenomyoma or sarcoma, we perform the myomectomy via laparotomy. But as I mentioned earlier, we don’t use power morcellation at all anymore—so this patient you describe would likely undergo laparoscopic removal using a bag and a knife to extract it to the skin level.
Although every patient is different, in general, if we have a patient with a single large fibroid 10 cm or less in size, we try to remove it laparoscopically or with robot assistance rather than via laparotomy. We also perform endometrial biopsy.
