Karen C. Wang

Contained power morcellation within an insufflated isolation bag.

OBJECTIVE: To describe a technique for contained power morcellation within an insufflated isolation bag at the time of uterine specimen removal during minimally invasive gynecologic procedures. METHODS: Over the study period of January 2013 to April 2014, 73 patients underwent morcellation of the uterus or myomas within an insufflated isolation bag at the time of minimally invasive hysterectomy or myomectomy. This technique involves placing the specimen into a large plastic bag within the abdomen, exteriorizing the opening of the bag, insufflating the bag within the peritoneal cavity, and then using a power morcellator within the bag to remove the specimen in a contained fashion. Procedures were performed at four institutions and included multiport laparoscopy, single-site laparoscopy, multiport robot-assisted laparoscopy, or single-site robot-assisted laparoscopy. Demographic and perioperative characteristics were collected for the cases. RESULTS: Surgical specimen morcellation within an insufflated isolation bag was successfully used in all cases. The median operative time was 114 minutes (range 32–380 minutes), median estimated blood loss was 50 mL (range 10–500 mL), and the median specimen weight was 257 g (range 53–1,481 g). There were no complications related to the contained morcellation technique nor was there visual evidence of tissue dissemination outside of the isolation bag. CONCLUSION: Morcellation within an insufflated isolation bag is a feasible technique. Methods for morcellating uterine tissue in a contained manner may provide an option to minimize the risks of open power morcellation while preserving the benefits of minimally invasive surgery. LEVEL OF EVIDENCE: II

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.

In-Bag Morcellation

In-bag morcellation seems to be a viable alternative to open power morcellation and offers the advantage of minimal to no spillage of tissue or fluids during morcellation. We report our initial experience and technique using this approach.

Risk of Leakage and Tissue Dissemination With Various Contained Tissue Extraction (CTE) Techniques: An in Vitro Pilot Study

STUDY OBJECTIVE To evaluate risk of leakage and tissue dissemination associated with various contained tissue extraction (CTE) techniques. DESIGN In vitro study (Canadian Task Force classification: II-1). SETTING Academic hospital simulation laboratory. INTERVENTION Beef tongue specimens weighing 400 to 500 g were stained using 5 mL indigo carmine dye and morcellated under laparoscopic guidance within a plastic box trainer. CTE was performed via 3 different techniques: a stitch-sealed rip-stop nylon bag and multi-port approach; a one-piece clear plastic 50 × 50-cm isolation bag and multi-port approach; or a 1-piece clear plastic 50 × 50-cm isolation bag and single-site approach. Four trials of each CTE method were performed and compared with an open morcellation control. All bags were insufflated to within 10 to 25 mmHg pressure with a standard CO2 insufflator. Visual evidence of spilled tissue or dye was recorded, and fluid washings of the box trainer were sent for cytologic analysis. MEASUREMENTS AND MAIN RESULTS Blue dye spill was noted in only 1 of 12 CTE trials. Spillage was visualized from a seam in 1 of the 4 stitch-sealed rip-stop nylon bags before morcellation of the specimen. The only trial in which gross tissue chips were visualized in the box trainer after morcellation was the open morcellation control. However, cytologic examination revealed muscle cells in the open morcellation washings and in the washings from the trial with dye spill. Muscle cells were not observed at cytologly in any of the other samples. CONCLUSION CTE did not result in any leakage or tissue dissemination with use of the single-site or multi-port approach when using a 1-piece clear plastic 50 × 50-cm isolation bag. Further studies are needed to corroborate these findings in an in vivo context and to evaluate use of alternate bag options for specimen containment.

Vaginal cuff dehiscence: risk factors and associated morbidities.

Background and Objectives: To evaluate whether the route and surgical technique by which hysterectomy is performed influence the incidence of vaginal cuff dehiscence. Methods: We performed a retrospective analysis of total hysterectomy cases performed at Brigham and Womans Hospital or Faulkner Hospital during 2009 through 2011. Results: During the study period, 2382 total hysterectomies were performed; 23 of these (0.96%) were diagnosed with cuff dehiscence, and 4 women had recurrent dehiscence. Both laparoscopic (odds ratio, 23.4; P = .007) and robotic (odds ratio, 73; P = .0006) hysterectomies were associated with increased odds of cuff dehiscence in a multivariate regression analysis. The type of energy used during colpotomy, mode of closure (hand sewn, laparoscopic suturing, or suturing assisted by a device), and suture material did not differ significantly between groups; however, continuous suturing of the cuff was a protective factor (odds ratio, 0.24; P = .03). Women with dehiscence had more extensive procedures, as well as an increased incidence of additional major postoperative complications (17.4% vs 3%, P = .004). Conclusion: The rate of cuff dehiscence in our cohort correlates with the current literature. This study suggests that the risk of dehiscence is influenced mainly by the scope and complexity of the surgical procedure. It seems that different colpotomy techniques do not influence the rate of cuff dehiscence; however, continuous suturing of the cuff may be superior to interrupted suturing.

Essure Surgical Removal and Subsequent Symptom Resolution: Case Series and Follow-Up Survey.

Transcervical sterilization is a minimally invasive option for permanent contraception with high reported rates of patient satisfaction. A small percentage of women subsequently choose to have the tubal inserts removed due to regret or perceived side effects. There is limited information with regard to the improvement in the symptom profile following surgical removal of the tubal inserts. We present a retrospective case series of 11 women who underwent surgical removal of Essure by hysteroscopy, salpingectomy, and/or hysterectomy. The predominant symptom at presentation was pain (n = 10; 90.91%), as well as bleeding (n = 6; 54.54%) and/or dyspareunia (n = 5; 45.45%). After surgical removal, the majority of patients (n = 8; 72.72%) reported an improvement of their symptoms. However, 3 (27.27%) patients continued to have persistent symptoms after surgery. Before surgical removal of Essure, it is important to thoroughly discuss the risk of continuing symptoms with patients.

Dilute versus concentrated vasopressin administration during laparoscopic myomectomy: a randomised controlled trial

To determine if higher‐volume, fixed‐dose administration of vasopressin further reduces blood loss at the time of minimally invasive myomectomy.

The sticky business of adhesion prevention in minimally invasive gynecologic surgery

Purpose of review The negative impact of postoperative adhesions has long been recognized, but available options for prevention remain limited. Minimally invasive surgery is associated with decreased adhesion formation due to meticulous dissection with gentile tissue handling, improved hemostasis, and limiting exposure to reactive foreign material; however, there is conflicting evidence on the clinical significance of adhesion-related disease when compared to open surgery. Laparoscopic surgery does not guarantee the prevention of adhesions because longer operative times and high insufflation pressure can promote adhesion formation. Adhesion barriers have been available since the 1980s, but uptake among surgeons remains low and there is no clear evidence that they reduce clinically significant outcomes such as chronic pain or infertility. In this article, we review the ongoing magnitude of adhesion-related complications in gynecologic surgery, currently available interventions and new research toward more effective adhesion prevention. Recent findings Recent literature provides updated epidemiologic data and estimates of healthcare costs associated with adhesion-related complications. There have been important advances in our understanding of normal peritoneal healing and the pathophysiology of adhesions. Adhesion barriers continue to be tested for safety and effectiveness and new agents have shown promise in clinical studies. Finally, there are many experimental studies of new materials and pharmacologic and biologic prevention agents. Summary There is great interest in new adhesion prevention technologies, but new agents are unlikely to be available for clinical use for many years. High-quality effectiveness and outcomes-related research is still needed.

Vasopressin Administration During Laparoscopic Myomectomy: A Randomized Controlled Trial.

Hysteroscopic Endometrial Resection Versus Laparoscopic Supracervical Hysterectomy for Abnormal Uterine Bleeding: Long Term Follow-Up of a Prospective Randomized Trial Zupi E, Centini G, Lazzeri L, Finco A, Zullo F, Exacoustos C. Obstetrics and Gynecology, Department of Molecular and Developmental Medicine, University of Siena, Siena, Italy; Department of Biomedicine and Prevention Obstetrics and Gynecological Clinic, University of Rome ‘Tor Vergata,’ Rome, Italy; Department of Obstetrics and Gynecology, University ‘‘Magna Graecia’’ Catanzaro, Catanzaro, Italy

Authors’ reply re: Dilute versus concentrated vasopressin administration during laparoscopic myomectomy: a randomised controlled trial

Sir, The authors thank Dr. Thangaswamy for his thoughts regarding our study on the administration of vasopressin at the time of laparoscopic myomectomy. Dr. Thangaswamy raises the interesting question of whether we can mitigate the physiologic changes related to vasopressin administration by altering the rate of injection while highlighting the dearth of information on this potential avenue for practice improvement. Details regarding shifts in pulse or blood pressure parameters were not measured in our study and are of unknown clinical significance. As noted in our manuscript, it is the practice of each author to notify the anesthesiology team prior to injection of vasopressin in order to monitor for hemodynamic changes. There were no anesthesiology concerns or adverse events related to vasopressin injection in either group and we concluded that both concentrations under study appeared safe. Much of what we know about vasopressin use is based on expert opinion alone, and although our study was welldesigned to address one aspect of vasopressin use, many unanswered questions remain. In the absence of further evidence on this topic, we are unable to extrapolate our findings to further comment on safety guidelines such as the small aliquot dosing recommended by Dr. Thangaswamy. Future prospective controlled studies are necessary to determine factors such as the minimal useful dose of vasopressin, variation of effect with location of injection or time elapsed since administration, and optimal interval for re-dosing if desired.&