Carl R. Della Badia

Iatrogenic endometriosis caused by uterine morcellation during a supracervical hysterectomy

BACKGROUND Iatrogenic endometriosis is a rare complication associated with laparoscopic supracervical hysterectomy. CASE A parous woman in her 30s underwent a laparoscopic supracervical hysterectomy for a leiomyomatous uterus. The uterus was amputated and removed from the abdominal cavity with an electric morcellator. She presented 6 months later complaining of cyclic pelvic pain. Diagnostic laparoscopy revealed endometrial implants in the pelvis. A laparoscopic trachelectomy, left salpingo-oophorectomy, and excision of endometrial implants was performed. She has since remained without symptoms. CONCLUSION Spillage and implantation of viable endometrial tissue might occur during uterine morcellation during laparoscopic supracervical hysterectomy. This case emphasizes the importance of minimizing spillage and vigorous irrigation of the abdomen and pelvis before closing the incisions.

Endometrial Stromal Sarcoma Diagnosed after Uterine Morcellation in Laparoscopic Supracervical Hysterectomy

Endometrial stromal sarcoma is a rare uterine cancer with no reliable method for preoperative diagnosis. A 30-year-old parous woman underwent laparoscopic supracervical hysterectomy because of a leiomyoma. The uterus was removed from the abdominal cavity with an electric morcellator with a spinning blade. The pathology report revealed low-grade endometrial stromal sarcoma. Two months after the initial surgery, a second laparoscopic procedure was performed. The final pathology report confirmed low-grade endometrial stromal sarcoma involving the ovary, fallopian tube, and ovarian artery. It was concluded that morcellation of leiomyomas at laparoscopic supracervical hysterectomy may potentially increase metastasis if the tumor is a sarcoma.

Postablation risk factors for pain and subsequent hysterectomy.

OBJECTIVE: To assess patient characteristics associated with pain and hysterectomy after endometrial ablation. METHODS: A retrospective cohort study was performed using data from two large academic medical centers. Three hundred patients who underwent endometrial ablation between January 2006 and May 2013 were identified for study. Data collected included baseline characteristics at the time of ablation, relevant medical history, and ablation technique. Univariate tests of association and logistic regression were used to evaluate risk factors for postablation pain or hysterectomy. RESULTS: Of the 300 women who had endometrial ablation performed during the study period, 270 had follow-up data for analysis. Twenty-three percent developed new or worsening pain after ablation and 19% underwent a hysterectomy. A history of dysmenorrhea gave a 74% higher risk of developing pain (adjusted odds ratio [OR] 1.74, 95% confidence interval [CI] 1.06–2.87) and tubal sterilization conferred more than double the risk (adjusted OR 2.06, 95% CI 1.14–3.70). Women of white race were 45% less likely to develop pain (adjusted OR 0.55, 95% CI 0.34–0.89). For hysterectomy, a history of cesarean delivery more than doubled the risk (adjusted OR 2.33, 95% CI 1.05–5.16), whereas uterine abnormalities on imaging, including leiomyoma, adenomyosis, thickened endometrial strip, and polyps, quadrupled the risk (adjusted OR 3.96, 95% CI 1.25–12.56). A procedure performed in the operating room decreased the risk of hysterectomy by 76% (adjusted OR 0.24, 95% CI 0.07–0.77). Hysterectomies for the indication of pain occurred more than 3 years sooner than for other indications (P<.001). CONCLUSION: Patient characteristics should be considered when counseling patients about the possible outcomes of endometrial ablation. A significant portion of ablations are complicated by postablation pain. LEVEL OF EVIDENCE: II

Electric Morcellation-related Reoperations After Laparoscopic Myomectomy and Nonmyomectomy Procedures

STUDY OBJECTIVE To identify, collate, and summarize the most common causes and pathologies of electric morcellation-related reoperations after laparoscopic myomectomy and nonmyomectomy procedures. DESIGN A systematic review of published medical literature from January 1990 to February 2014 reporting morcellation-related reoperations after laparoscopic myomectomy and nonmyomectomy procedures involving the use of intracorporeal electric tissue morcellators. Publications were included in this review if patients underwent a second surgical procedure because of the onset of new clinical symptoms after a primary surgical procedure that involved intracorporeal morcellation or if histopathology of the morcellated surgical specimen revealed malignancy (Canadian Task Force classification II-3). SETTING All case reports and case series were reported from community and academic hospitals in the United States and the rest of the world. PATIENTS We identified 66 patients from 32 publications. INTERVENTIONS Reoperation after laparoscopic myomectomy and nonmyomectomy procedures involving intracorporeal electric tissue morcellation. MEASUREMENTS AND MAIN RESULTS For patients who presented with new clinical symptoms requiring reoperation, we recorded the follow-up period, nature and duration of the new symptoms, details of the second surgical procedure, intraoperative findings during the second surgical procedure, and the final histopathologic diagnosis. When histopathology of the morcellated specimen revealed malignancy, we recorded the specific type of malignancy, the corresponding surgical treatment that the patient underwent, and the follow-up period. Percentages and 95% confidence intervals were calculated for all categoric variables. Twenty-four (36.4%) patients underwent laparoscopic myomectomies, of which 19 (79.2%) and 5 (20.8%) patients required a second surgical procedure because of new clinical symptoms and the diagnosis of malignancy in the morcellated surgical specimen, respectively. Forty-two (63.6%) patients underwent laparoscopic hysterectomies; of these, 25 (59.5%) patients required a second surgical procedure because of the onset of new clinical symptoms, whereas the remaining 17 (40.5%) patients underwent a second surgical procedure because of the diagnosis of malignancy in the morcellated surgical specimen. The most common benign pathology was parasitic leiomyomata (22 patients, 33.3%). The most common malignant pathology was leiomyosarcoma (16 patients, 24.2%). CONCLUSION Dispersion of tissue fragments into the peritoneal cavity at the time of morcellation continues to be a concern. It was previously thought that morcellated tissue fragments are resorbed by the peritoneal cavity; however, there is some evidence highlighting the long-term sequelae related to the growth and propagation of these dispersed tissue fragments in the form of parasitic leiomyomata, iatrogenic endometriosis, and cancer progression. Yet, the majority of laparoscopic myomectomy and nonmyomectomy procedures involving the use of intracorporeal electric tissue morcellators are uncomplicated, and institutions having no women with endometriosis or cancer are very unlikely to report surgical outcomes of uneventful electric morcellation. Thus, prospective studies are still required to validate the role of electric intracorporeal tissue morcellation in the pathogenesis of parasitic leiomyomata, iatrogenic endometriosis, and cancer progression.

Acute Hemorrhage Related to a Residual Cervical Pregnancy: Management with Curettage, Tamponade, and Cerclage

Cervical ectopic pregnancy is uncommon, with no universally accepted protocol for conservative management of acute hemorrhage due to residual cervical ectopic pregnancy. Herein is presented the case of a 33-year-old woman with profuse vaginal bleeding 3 months after receiving treatment including intraamniotic potassium chloride injection, systemic methotrexate, and uterine artery embolization because of a cervical ectopic pregnancy. A residual cervical pregnancy was suspected. Hemorrhage was controlled using curettage, tamponade with a Bakri balloon, and cerclage. The balloon and cerclage were removed on postoperative day 2, with no recurrence of symptoms. Our experience suggests that a combination of curettage, balloon tamponade, and cerclage may be considered in the management of cervical ectopic pregnancies with acute hemorrhage, in particular in patients desiring future childbearing.

Asymptomatic Serosalized Essure Microinsert in the Distal Ileum

Introduction: Perforation of the uterus or fallopian tube during microinsert placement, with subsequent migration of the microinsert into the abdominopelvic cavity, is a known complication. Case Description: A 38-year-old woman underwent hysteroscopic tubal sterilization with Essure microinserts (Conceptus, Mountain View, California). She returned 4 months later for hysterosalpingography, during which only part of the right microinsert was identified in the right cornu of the uterus. The remaining part of the microinsert was suspected to be in the pelvic cavity. Laparoscopy showed one fragment of the right microinsert projecting from the right cornu; the remaining fragment was incorporated into the serosa of the distal ileum. After an intraoperative consultation with the colorectal surgery team, both fragments of the microinsert were left as is, and tubal fulguration for sterilization was performed. Discussion: Although perforated microinserts can cause small-bowel obstruction or perforation, our case highlights the asymptomatic incorporation of a microinsert into the serosa of the distal ileum.