E. Manoucheri

Open Power Morcellation Versus Contained Power Morcellation Within an Insufflated Isolation Bag: Comparison of Perioperative Outcomes

STUDY OBJECTIVE To compare perioperative outcomes, particularly operative time, between uncontained and in-bag power morcellation of uterine tissue at the time of laparoscopic surgery. DESIGN Canadian Task Force classification II-3. SETTING Academic tertiary care hospitals. PATIENTS Women undergoing laparoscopic hysterectomy or myomectomy who required morcellation of uterine tissue for specimen extraction. INTERVENTIONS Outcomes among patients who had in-bag power morcellation were compared with outcomes among patients who had traditional power morcellation. The technique for in-bag morcellation entails placing the specimen into a large containment bag within the abdomen, insufflating the bag within the peritoneal cavity, and then using a power morcellator to remove the specimen from inside the bag. MEASUREMENTS AND MAIN RESULTS The cohort consisted of 85 consecutive patients who underwent surgery with morcellation of uterine tissue. Prospective data collected from 36 patients who underwent in-bag morcellation were compared with retrospective data collected from the immediately preceding 49 patients who had uncontained power morcellation. Baseline demographics were comparable between the 2 groups although women who underwent in-bag morcellation were on average older than the open morcellation group (mean age in years [standard deviation], 49.19 [1.12] vs 44.06 [8.93]; p = .01). The mean operating room time was longer in the in-bag morcellation group (mean time in minutes [standard deviation], 119.0 [55.91] vs 93.13 [44.90]; p = .02). The estimated blood loss, specimen weight, hospital length of stay, and perioperative complication rate did not vary between the 2 groups. Operative times did not vary significantly by surgeon. There were no cases of malignancy or isolation bag disruption. CONCLUSIONS In-bag power morcellation, a tissue extraction technique developed to reduce the risk of tissue dissemination, results in perioperative outcomes comparable with the traditional laparoscopic approach. In this cohort, the mean operative time was prolonged by 26 minutes with in-bag morcellation but may potentially be reduced with further refinement of the technique.

Laparoscopic management of extrauterine pregnancy in caesarean section scar: description of a surgical technique and review of the literature

Caesarean scar pregnancy is an ectopic pregnancy embedded in the myometrium at the site of a previous caesarean section. Reported incidence has increased over the last decade because of an increased rate of caesarean sections and increased levels of suspicion, ranging between 1:1800 and 1:2216 of all pregnancies. Ultrasonography and hysteroscopy provide useful information for diagnosis. However, an early and accurate diagnosis remains a challenge; endovaginal ultrasound has a sensitivity of only 84.6%. Recently, evaluation by magnetic resonance imaging (MRI) has been suggested as a means of increasing diagnostic accuracy as well as better defining location and extent of invasion of the pregnancy into the myometrium; this helps in guiding optimal therapy. There is still lack of consensus regarding the adequacy of different treatment strategies including local injections of potassium chloride, methotrexate (MTX) or surgical treatment. No modality is entirely reliable, and none can guarantee uterine integrity. A review of the literature for studies reporting the results of laparoscopic treatment for pregnancy in scar yielded anecdotal case reports, describing several technique variations. The current report summarises our surgical technique and experience with this treatment modality along with a literature review.