An in-depth analysis of the tissue-extraction technique of morcellation, used in gynaecological surgery.

1. Mechanical
Morcellation
DR RANJANA
JOSHI
MBBS(CMC
Vellore),MD(BHU)
Head of Department(OB-
GYN)
Tinplate Hospital
Laying the controversy to rest.

2. FINANCIAL DISCLOSURE
I HAVE NO FINANCIAL INTEREST IN THE SUBJECT MATTER OF THIS
PRESENTATION.

3. INTRODUCTION
 Gynaecological surgery often employs tissue extraction techniques to
remove a large Myoma or uterus through a small incision. A
common extraction technique is Morcellation.
 Initially, Morcellation was performed using a Scalpel at the time of
Vaginal surgery and Laparotomy.
 As Laparoscopic and Robotic techniques were adopted , there was
the advent of Electromagnetic Morcellation that utilized rapidly
rotating blades to quickly core and remove the specimen through
the small ports.

4. INTRODUCTION(CONT’D)
 As minimally invasive surgical techniques evolved, Power
Morcellation became a mainstay of gynaecologic surgery.
 In 2014, concerns were raised that Morcellation may disseminate
tumour cells in cases in which an undiagnosed Uterine
malignancy was present .
 This prompted action by the US FDA , resulting in new
guidelines for the use of Electromagnetic Morcellation and a
subsequent decrease in the use of devices .

5. MECHANICAL MORCELLATOR

6. MECHANICAL MORCELLATOR

7. TIMELINE
1993- THE FIRST MECHANICAL MORCELLATOR MANUFACTURED – STEINE
MORCELLATOR
1995- APPROVAL OF THE FIRST LAPAROSCOPIC MORCELLATOR BY US FDA.
2009- VAGINAL HYSTERECTOMY IS ASSOCIATED WITH BETTER OUTCOMES AND FEWER
COMPLICATIONS THAN LAPAROSCOPIC OR ABD HYSTERECTOMY(ACOG)
ACOG REAFFIRMS THIS STATEMENT IN 2011.

8. TIMELINE (CONTD)
2012- RATE OF UNEXPECTED LEIOMYOSARCOMA FOUND TO BE 0.09%
- 9-FOLD HIGHER THAN THE 1-IN-10,000 RATE TYPICALLY QUOTED TO PATIENTS
PATIENTS PREOPERATIVELY (BOSTON)
OCTOBER 2013: BOSTON-BASED ANAESTHESIOLOGIST AMY REED UNDERGOES
MIS WITH POWER MORCELLATION AT BRIGHAM AND WOMEN’S HOSPITAL.
LATER FINDS OUT THAT THE MASS IS CANCEROUS

9. TIMELINE (CONTD)
DECEMBER 2013: MORCELLATION OF AN OCCULT TUMOUR MAY OCCUR IN 1IN 400 TO 1IN
1000 WOMEN WHO HAVE THIS PROCEDURE (ROBERT BARBIERI)
JANUARY 2014: AAGL ANNOUNCES THAT IT IS CREATING A TASK FORCE TO EXAMINE THE RISKS
THE RISKS INVOLVED IN POWER MORCELLATION
MARCH 2014: SURGEONS TOLD TO USE POWER MORCELLATORS INSIDE A SURGICAL BAG ONLY (
B&M)
APRIL 2014 : THE FDA RECOMMENDS - LAPAROSCOPIC POWER MORCELLATORS NO LONGER BE
USED FOR HYSTERECTOMY OR MYOMECTOMY FOR UTERINE FIBROIDS.
2015 : 58.7% OF GYNAECOLOGISTS CHANGED THEIR SURGICAL PRACTICE AFTER FDA SAFETY
COMMUNICATION.(MANDATO ET AL)

10. TURNING POINT
CASE OF DR . AMY REID
 Was diagnosed with Multiple Fibroids in 2013.
 Was recommended Lap Hysterectomy with Morcellation.
 Post operatively, Dr Reid learnt that she had a Uterine
Leiomyosarcoma which may have disseminated during the Surgery.

11. DISAPPOINTING NEWS
RATE OF UNEXPECTED LEIOMYOSARCOMA
• Seedman (2012)- 0.09% in 1091 women who underwent Morcellation
•
ACOG Study (2014) – 1in 500 will have a postop diagnosis of Stromal
Sarcoma and Leiomyosarcomas
• US Food and Drug Administration(2014) – found the Risk to be
1:352 – for Sarcoma
1:458 -- for Leiomyosarcoma

12. FACTS ABOUT
LEIOMYOSARCOMAS
Uterine Sarcomas are Rare.
Comprises :
< 1% of all Gynaecological tumours
• 7-8% of all Uterine carcinomas
• Most common Uterine Sarcoma – Leimyosarcoma – 43%
of all Sarcomas
• 60% present in Stage 1
• Patient has a very poor prognosis even in Early Stage
Disease.

13. FACTS ABOUT
LEIMYOSARCOMAS (CONTD)
Increased Risk seen in :
• 1. Black women – 2 fold increased risk ( also
have a 2 fold increased baseline risk Uterine
Fibroids )
• 2. Increased Age – Non Specific
• 3 Postmenopausal Status – Non specific
• 4 Tamoxifen use for > 5 years
• 5 Childhood Retinoblastomas

14. PRE –OP EVALUATIONOF
LEIOMYOSARCOMAS
• 1. Endometrial Sampling – yields a pre- op diagnosis in
33% - 68 %of women with Uterine sarcomas .
• 2. MRI – No specific findings- ?Ill-defined margins
- Absence of Calcification
– consistent
• 3. PET – Too expensive / non specific
• PER OP SUSPICION – soft, yellow, loss of
whorled appearance , absence of bulging surface when
the capsule is cut.

15. ADVANTAGES OF EMM
• 1. Morcellation - Integral part of making Laparoscopic
surgery possible for the removal of large uterine fibroids
2. Increases efficiency during these procedures.
• 3. Myospindle cells were detected in the Peritoneal cavity
following Myomectomy with Morcellation (Toubia et al)
But it has been proved that Myospindle cells were
found even during Myomectomy without Morcellation.

16. ADVANTAGES OF MINIMALLY
INVASIVE SURGERY
1. No large abdominal laparotomy incision
2. Faster healing and recovery from surgery
3. Less post op pain
4. Lower risk of surgical site infection
5. More rapid return to normal activities.

17. DISADVANTAGES OF EMM
1 . DISSEMINATION of tumour - benign or
malignant throughout the intraperitoneal cavity
2. HINDERS a proper histological examination of the
uterine specimen.
3. Dissemination of the tumour can WORSEN the
prognosis.
4. TRAUMA to surrounding structures – small and
large Bowels, Ureter , Bladder , Diaphragm.

18. DISADVANTAGES OF EMM
(CONTD)
5. ACUTE complications – PerItonitis, Intraabdominal
abscesses, Intestinal Obstruction
6. CHRONIC Complications – Disseminated Fibroid tumour(
seen in fibroids with abnormal karyotype- translocation
between chromosome 12 & 14, and this causes
Leiomyomatosis)
7. Endometriosis
8. SEEDING of the cancer throughout the Peritoneal cavity

19. GUIDELINES FOR POWER
MORCELLATION
SPECIFIC GUIDELINES for the use of Power Morcellation :
• Preoperative evaluation before Hysterectomy -- Cervical cytology ,
Endometrial biopsy and Pelvic imaging.
• If preoperative evaluation raises suspicion for malignancy, Morcellation
clearly should be avoided.
• Morcellation - avoided in patients with a history of tamoxifen use, pelvic
radiation, or increased genetic risk for malignancy.
• Surgeons should review surgical alternatives -- Laparotomy, Mini-
laparotomy and Colpotomy with manual morcellation vaginally or within an
endoscopic bag.

20. CONTAINED BAGS

21. CONTAINED TISSUE
EXTRACTION- ABDOMINAL
• 1 In 2014, Einarsson et al. “Sydney in bag
morcellation” technique
•
2 Rimbach et al. -More-Cell-Safe.
3 Paul et al. designed isolation bag
(MorSafe) for two-port morcellation method .

22. CONTAINED TISSUE
EXTRACTION-CONTD• The current body of evidence suggests
that contained PM is a time efficient
and feasible method in laparoscopic
surgery.

23. VAGINAL APPROACH TO
CONTAINED TISSUE EXTRACTION
• Commonly used Vaginal Morcellation techniques include
bivalving, wedge resection, coring, myomectomy.
• Vaginal Morcellation can be performed within a
containment bag to prevent tissue dissemination.

24. CONCLUSION
• Morcellation of the specimen in an enclosed fashion
should be the preferred method
• Nonetheless, in patients with suspicion for occult uterine
malignancy after an appropriate preoperative evaluation,
Morcellation should be avoided .
• Minilaparotomy or vaginal retrieval in a containment
bag is a feasible option

25. CONCLUSION
• An advanced innovative surgical method providing an
enclosed space not only for the Morcellation procedure
but also for the preceding myomectomy procedure can be
developed in the future.
• It should be emphasized that there is currently no
available method for tissue extraction that completely
eliminates the risk of cellular dissemination.
.

26. TAKE HOME MESSAGE
• Since the initial Food and Drug administration warning
about Morcellation in 2014, subsequent studies do not
support the FDA’s high incidence of occult uterine cancer.
• MIS techniques have revolutionised Gynaecology,
drastically reducing the need for open procedures.
• To maximise patient’s safety while preserving the rapid
recovery and low morbidity of laparoscopic and vaginal
approaches, current research continues focusing on
methods of CONTAINED tissue Morcellation.

27. Thank You
For
Listening!