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    Power morcellation for uterine fibroids: What you need to know

    What you need to know

     

    Surgical alternatives to open power morcellation

    Laparotomy for hysterectomy or myomectomy is a definitive option for avoiding tissue morcellation, but it comes at the expense of increased morbidity and recovery time compared to minimally invasive approaches.28,29 When the uterine size is such that the specimen can be delivered vaginally, performing a vaginal hysterectomy or total laparoscopic hysterectomy, rather than supracervical hysterectomy, is also an option.

    Minilaparotomy is another alternative to open power morcellation for specimen retrieval.30,31 Depending on the size of the mass, the specimen can either be removed intact via the minilaparotomy incision (typically < 4 cm in length), or it can be placed into a bag and manually morcellated to avoid spillage at the level of the abdominal wall or within the peritoneal cavity. Minilaparotomy allows for perioperative outcomes similar to that for a laparoscopic approach.32-34 Specimen retrieval and/or contained manual morcellation also can be performed via colpotomy, even if total hysterectomy has not taken place.35-37 A small randomized trial comparing transumblical and transvaginal specimen removal found decreased postoperative pain with the transvaginal method, but similar patient satisfaction, cosmesis and sexual function.38

    Contained power morcellation is another promising option whereby tissue dissemination can be avoided. In these cases, electromechanical morcellation is performed in an enclosed environment within the abdomen, such as an endobag or artificial pneumoperitoneum.39

    Implications for practice

    The well-known benefits of minimally invasive gynecologic surgery must be measured along with the small but real risks associated with tissue morcellation. Taking into account patient-specific factors, appropriate preoperative screening for malignant conditions should be undertaken and open power morcellation avoided in cases of confirmed or likely malignancy.

    Surgeons who choose to use a power morcellator should be experienced with the device operation and make an effort to retrieve all specimen fragments from the peritoneal cavity following morcellation. Strong consideration should also be given to alternative specimen retrieval options that are associated with decreased risk of retained specimen fragments or cellular seeding. In particular, a focus on innovations in preoperative screening for uterine sarcomas as well as advanced morcellating technology is critical to improve patient outcomes.

     

    Next: Some institutions and groups defining stances on morcellation >>

     

    Sarah L. Cohen, MD, MPH
    Dr Cohen is an Assistant Professor in the Department of Obstetrics and Gynecology and Director of Research for the Division of Minimally ...

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    • Anonymous
      good article

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