Uterine tissue extraction by morcellation: Techniques and clinical issues
- Elizabeth A Stewart, MD
Elizabeth A Stewart, MD
- Consultant and Professor of Obstetrics and Gynecology
- Division of Reproductive Endocrinology, Department of Obstetrics and Gynecology
- Mayo Clinic and Mayo Medical School
- Section Editors
- Robert L Barbieri, MD
Robert L Barbieri, MD
- Editor-in-Chief — Obstetrics, Gynecology and Women's Health
- Section Editor — General Gynecology and Female Reproductive Endocrinology
- Kate Macy Ladd Professor of Obstetrics, Gynecology and Reproductive Biology
- Harvard Medical School
- Barbara Goff, MD
Barbara Goff, MD
- Section Editor — Gynecologic Oncology
- Professor of Gynecologic Oncology
- University of Washington
- Tommaso Falcone, MD, FRCSC, FACOG
Tommaso Falcone, MD, FRCSC, FACOG
- Section Editor — Minimally Invasive Gynecologic Surgery
- Professor of Obstetrics and Gynecology
- Cleveland Clinic Lerner College of Medicine
Gynecologic surgery often employs tissue extraction techniques to remove a large specimen (uterus or leiomyomas) through a small incision. A common tissue extraction technique is morcellation (cutting a specimen into small pieces). Initially, morcellation was performed using a scalpel at the time of vaginal procedures or laparotomy. As laparoscopic techniques were adopted, there was the advent of electro-mechanical electro-mechanical morcellators (also referred to as electro-mechanical morcellators) that utilize rapidly rotating blades to quickly core and remove specimens during laparoscopic or robotic procedures. In 2014, concerns were raised that morcellation may disseminate tumor cells in cases in which an undiagnosed uterine malignancy was present. This prompted action by the US Food and Drug Administration, new guidelines for the use of electro-mechanical morcellators, and a decrease in use of these devices .
Uterine morcellation techniques are reviewed here. General principles of the treatment of leiomyomas are discussed separately. (See "Overview of treatment of uterine leiomyomas (fibroids)" and "Abdominal myomectomy" and "Laparoscopic myomectomy and other laparoscopic treatments for uterine leiomyomas (fibroids)".)
●Morcellation – Cutting tissue into small pieces. This is typically performed to remove a large tissue specimen through a small incision.
●Electro-mechanical morcellation – Morcellation of tissue with an electric device. This is usually used only in laparoscopic procedures.
●Scalpel morcellation – Morcellation of tissue using a scalpel. The specimen is cut into fewer pieces, and pieces are less likely to be distributed throughout the abdomen or left in the abdomen after surgery in contrast with electro-mechanical morcellation. In gynecologic surgery, this is typically done to remove a bulky uterine specimen during vaginal hysterectomy and sometimes during a myomectomy or hysterectomy through a minilaparotomy incision.
- Wright JD, Chen L, Burke WM, et al. Trends in Use and Outcomes of Women Undergoing Hysterectomy With Electric Power Morcellation. JAMA 2016; 316:877.
- http://www.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/MedicalDevices/MedicalDevicesAdvisoryCommittee/ObstetricsandGynecologyDevices/UCM404148.pdf (Accessed on November 24, 2014).
- Parker WH, Fu YS, Berek JS. Uterine sarcoma in patients operated on for presumed leiomyoma and rapidly growing leiomyoma. Obstet Gynecol 1994; 83:414.
- Leung F, Terzibachian JJ, Gay C, et al. [Hysterectomies performed for presumed leiomyomas: should the fear of leiomyosarcoma make us apprehend non laparotomic surgical routes?]. Gynecol Obstet Fertil 2009; 37:109.
- Leibsohn S, d'Ablaing G, Mishell DR Jr, Schlaerth JB. Leiomyosarcoma in a series of hysterectomies performed for presumed uterine leiomyomas. Am J Obstet Gynecol 1990; 162:968.
- Takamizawa S, Minakami H, Usui R, et al. Risk of complications and uterine malignancies in women undergoing hysterectomy for presumed benign leiomyomas. Gynecol Obstet Invest 1999; 48:193.
- Leung F, Terzibachian JJ. Re: "The impact of tumor morcellation during surgery on the prognosis of patients with apparently early uterine leiomyosarcoma". Gynecol Oncol 2012; 124:172.
- Durand-Réville M, Dufour P, Vinatier D, et al. [Uterine leiomyosarcomas: a surprising pathology. Review of the literature. Six case reports]. J Gynecol Obstet Biol Reprod (Paris) 1996; 25:710.
- Seidman MA, Oduyebo T, Muto MG, et al. Peritoneal dissemination complicating morcellation of uterine mesenchymal neoplasms. PLoS One 2012; 7:e50058.
- Theben JU, Schellong AR, Altgassen C, et al. Unexpected malignancies after laparoscopic-assisted supracervical hysterectomies (LASH): an analysis of 1,584 LASH cases. Arch Gynecol Obstet 2013; 287:455.
- Sinha R, Hegde A, Mahajan C, et al. Laparoscopic myomectomy: do size, number, and location of the myomas form limiting factors for laparoscopic myomectomy? J Minim Invasive Gynecol 2008; 15:292.
- Hagemann IS, Hagemann AR, LiVolsi VA, et al. Risk of occult malignancy in morcellated hysterectomy: a case series. Int J Gynecol Pathol 2011; 30:476.
- Park JY, Park SK, Kim DY, et al. The impact of tumor morcellation during surgery on the prognosis of patients with apparently early uterine leiomyosarcoma. Gynecol Oncol 2011; 122:255.
- Kamikabeya TS, Etchebehere RM, Nomelini RS, Murta EF. Gynecological malignant neoplasias diagnosed after hysterectomy performed for leiomyoma in a university hospital. Eur J Gynaecol Oncol 2010; 31:651.
- http://www.aagl.org/wp-content/uploads/2014/05/Tissue_Extraction_TFR.pdf (Accessed on August 08, 2016).
- US Food and Drug Administration (FDA), Obstetrics and Gynecology Devices Advisory Committee. FDA executive summary: Laparoscopic power morcellation during uterine surgery for fibroids, Washington, DC 2014. http://www.fda.gov/advisorycommittees/calendar/ucm400221.htm (Accessed on July 10, 2014).
- Mahnert N, Morgan D, Campbell D, et al. Unexpected gynecologic malignancy diagnosed after hysterectomy performed for benign indications. Obstet Gynecol 2015; 125:397.
- Morice P, Rodriguez A, Rey A, et al. Prognostic value of initial surgical procedure for patients with uterine sarcoma: analysis of 123 patients. Eur J Gynaecol Oncol 2003; 24:237.
- Perri T, Korach J, Sadetzki S, et al. Uterine leiomyosarcoma: does the primary surgical procedure matter? Int J Gynecol Cancer 2009; 19:257.
- George S, Barysauskas C, Serrano C, et al. Retrospective cohort study evaluating the impact of intraperitoneal morcellation on outcomes of localized uterine leiomyosarcoma. Cancer 2014; 120:3154.
- Pritts EA, Parker WH, Brown J, Olive DL. Outcome of occult uterine leiomyosarcoma after surgery for presumed uterine fibroids: a systematic review. J Minim Invasive Gynecol 2015; 22:26.
- Graebe K, Garcia-Soto A, Aziz M, et al. Incidental power morcellation of malignancy: a retrospective cohort study. Gynecol Oncol 2015; 136:274.
- Bogani G, Cliby WA, Aletti GD. Impact of morcellation on survival outcomes of patients with unexpected uterine leiomyosarcoma: a systematic review and meta-analysis. Gynecol Oncol 2015; 137:167.
- Raine-Bennett T, Tucker LY, Zaritsky E, et al. Occult Uterine Sarcoma and Leiomyosarcoma: Incidence of and Survival Associated With Morcellation. Obstet Gynecol 2016; 127:29.
- Gao Z, Li L, Meng Y. A Retrospective Analysis of the Impact of Myomectomy on Survival in Uterine Sarcoma. PLoS One 2016; 11:e0148050.
- Nemec W, Inwald EC, Buchholz S, et al. Effects of morcellation on long-term outcomes in patients with uterine leiomyosarcoma. Arch Gynecol Obstet 2016; 294:825.
- Lee JY, Kim HS, Nam EJ, et al. Outcomes of uterine sarcoma found incidentally after uterus-preserving surgery for presumed benign disease. BMC Cancer 2016; 16:675.
- Milad MP, Milad EA. Laparoscopic morcellator-related complications. J Minim Invasive Gynecol 2014; 21:486.
- Lu B, Xu J, Pan Z. Iatrogenic parasitic leiomyoma and leiomyomatosis peritonealis disseminata following uterine morcellation. J Obstet Gynaecol Res 2016; 42:990.
- Tulandi T, Leung A, Jan N. Nonmalignant Sequelae of Unconfined Morcellation at Laparoscopic Hysterectomy or Myomectomy. J Minim Invasive Gynecol 2016; 23:331.
- Mowers EL, Skinner B, McLean K, Reynolds RK. Effects of morcellation of uterine smooth muscle tumor of uncertain malignant potential and endometrial stromal sarcoma: case series and recommendations for clinical practice. J Minim Invasive Gynecol 2015; 22:601.
- Oduyebo T, Rauh-Hain AJ, Meserve EE, et al. The value of re-exploration in patients with inadvertently morcellated uterine sarcoma. Gynecol Oncol 2014; 132:360.
- Ordulu Z, Dal Cin P, Chong WW, et al. Disseminated peritoneal leiomyomatosis after laparoscopic supracervical hysterectomy with characteristic molecular cytogenetic findings of uterine leiomyoma. Genes Chromosomes Cancer 2010; 49:1152.
- Einstein MH, Barakat RR, Chi DS, et al. Management of uterine malignancy found incidentally after supracervical hysterectomy or uterine morcellation for presumed benign disease. Int J Gynecol Cancer 2008; 18:1065.
- Hill AJ, Carroll AW, Matthews CA. Unanticipated uterine pathologic finding after morcellation during robotic-assisted supracervical hysterectomy and cervicosacropexy for uterine prolapse. Female Pelvic Med Reconstr Surg 2014; 20:113.
- Frick AC, Walters MD, Larkin KS, Barber MD. Risk of unanticipated abnormal gynecologic pathology at the time of hysterectomy for uterovaginal prolapse. Am J Obstet Gynecol 2010; 202:507.e1.
- McPencow AM, Erekson EA, Guess MK, et al. Cost-effectiveness of endometrial evaluation prior to morcellation in surgical procedures for prolapse. Am J Obstet Gynecol 2013; 209:22.e1.
- Urman B, Ata B, Arslan T, et al. Parasitic Myomas and an Adenomyoma Obstructing the Ureter After Power Morcellation of Myomas and Endometriotic Nodule Resection. J Obstet Gynaecol Can 2016; 38:362.
- Balgobin S, Maldonado PA, Chin K, et al. Safety of Manual Morcellation After Vaginal or Laparoscopic-assisted Vaginal Hysterectomy. J Minim Invasive Gynecol 2016; 23:542.
- Zhang J, Li T, Zhang J, et al. Clinical Characteristics and Prognosis of Unexpected Uterine Sarcoma After Hysterectomy for Presumed Myoma With and Without Transvaginal Scalpel Morcellation. Int J Gynecol Cancer 2016; 26:456.
- https://www.sgo.org/newsroom/position-statements-2/morcellation/ (Accessed on March 10, 2014).
- http://www.acog.org/About-ACOG/News-Room/Statements/2014/ACOG-Statement-on-Power-Morcellation (Accessed on August 08, 2016).
- http://www.aagl.org/aaglnews/member-update-5-aagl-response-to-fda-guidance-on-use-of-power-morcellation-during-tissue-extraction-for-uterine-fibroids/ (Accessed on December 02, 2014).
- Beckmann MW, Juhasz-Böss I, Denschlag D, et al. Surgical Methods for the Treatment of Uterine Fibroids - Risk of Uterine Sarcoma and Problems of Morcellation: Position Paper of the DGGG. Geburtshilfe Frauenheilkd 2015; 75:148.
- Brölmann H, Tanos V, Grimbizis G, et al. Options on fibroid morcellation: a literature review. Gynecol Surg 2015; 12:3.
- Deffieux X, Rochambeau Bd, Chene G, et al. Hysterectomy for benign disease: clinical practice guidelines from the French College of Obstetrics and Gynecology. Eur J Obstet Gynecol Reprod Biol 2016; 202:83.
- Parker WH, Kaunitz AM, Pritts EA, et al. U.S. Food and Drug Administration's Guidance Regarding Morcellation of Leiomyomas: Well-Intentioned, But Is It Harmful for Women? Obstet Gynecol 2016; 127:18.
- Wright JD. Electric Power Morcellation in Gynecology: The Path Forward. Obstet Gynecol 2016; 127:7.
- Garry R. Laparoscopic morcellation: an acceptable risk or an Achilles heel? BJOG 2015; 122:458.
- http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm424443.htm (Accessed on November 24, 2014).
- Barron KI, Richard T, Robinson PS, Lamvu G. Association of the U.S. Food and Drug Administration Morcellation Warning With Rates of Minimally Invasive Hysterectomy and Myomectomy. Obstet Gynecol 2015; 126:1174.
- Lum DA, Sokol ER, Berek JS, et al. Impact of the 2014 Food and Drug Administration Warnings Against Power Morcellation. J Minim Invasive Gynecol 2016; 23:548.
- http://www.healthycanadians.gc.ca/recall-alert-rappel-avis/hc-sc/2014/39409a-eng.php (Accessed on February 25, 2015).
- Nieboer TE, Johnson N, Lethaby A, et al. Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev 2009; :CD003677.
- Patient safety must be a priority in all aspects of care. Lancet Oncol 2014; 15:123.
- Kho KA, Nezhat CH. Evaluating the risks of electric uterine morcellation. JAMA 2014; 311:905.
- Kho KA, Anderson TL, Nezhat CH. Intracorporeal electromechanical tissue morcellation: a critical review and recommendations for clinical practice. Obstet Gynecol 2014; 124:787.
- Mandato VD, Torricelli F, Pirillo D, et al. Impact of the Food and Drug Administration Safety Communication on the Use of Power Morcellator in Daily Clinical Practice: An Italian Survey. J Minim Invasive Gynecol 2016; 23:206.
- http://www.ethicon.com/healthcare-professionals (Accessed on April 30, 2014).
- http://www.reuters.com/article/2014/07/30/jj-withdrawal-idUSL2N0Q536P20140730?type=companyNews&feedType=RSS (Accessed on July 31, 2014).
- Zuo Z, Zhang L, Leng X, Huang Z. Iron-catalyzed asymmetric hydrosilylation of ketones. Chem Commun (Camb) 2015; 51:5073.
- Serur E, Lakhi N. Laparoscopic hysterectomy with manual morcellation of the uterus: an original technique that permits the safe and quick removal of a large uterus. Am J Obstet Gynecol 2011; 204:566.e1.
- Einarsson JI, Cohen SL, Fuchs N, Wang KC. In-bag morcellation. J Minim Invasive Gynecol 2014; 21:951.
- Cohen SL, Einarsson JI, Wang KC, et al. Contained power morcellation within an insufflated isolation bag. Obstet Gynecol 2014; 124:491.
- Cholkeri-Singh A, Miller CE. Power morcellation in a specimen bag. J Minim Invasive Gynecol 2015; 22:160.
- McKenna JB, Kanade T, Choi S, et al. The Sydney Contained In Bag Morcellation technique. J Minim Invasive Gynecol 2014; 21:984.
- http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm494650.htm (Accessed on April 13, 2016).
- Trivedi PH, Patil SS, Parekh NA, et al. Laparoscopic Morcellation of Fibroid and Uterus In-Bag. J Obstet Gynaecol India 2015; 65:396.
- Aoki Y, Matsuura M, Matsuno T, Yamamoto T. Single-site in-bag morcellation achieved via direct puncture of the pneumoperitoneum cap, a cordless electric morcellator, and a 5-mm flexible scope. Eur J Obstet Gynecol Reprod Biol 2016; 201:126.
- Anapolski M, Panayotopoulos D, Alkatout I, et al. Power morcellation inside a secure endobag: a pilot study. Minim Invasive Ther Allied Technol 2016; 25:203.
- Anapolski M, Panayotopoulos D, Alkatout I, et al. Preclinical safety testing for morcellation and extraction for an endobag with sealable ports: in vitro pilot study. Surg Endosc 2016.
- Vargas MV, Cohen SL, Fuchs-Weizman N, et al. Open power morcellation versus contained power morcellation within an insufflated isolation bag: comparison of perioperative outcomes. J Minim Invasive Gynecol 2015; 22:433.
- Winner B, Porter A, Velloze S, Biest S. Uncontained Compared With Contained Power Morcellation in Total Laparoscopic Hysterectomy. Obstet Gynecol 2015; 126:834.
- Venturella R, Rocca ML, Lico D, et al. In-bag manual versus uncontained power morcellation for laparoscopic myomectomy: randomized controlled trial. Fertil Steril 2016; 105:1369.
- Cohen SL, Morris SN, Brown DN, et al. Contained tissue extraction using power morcellation: prospective evaluation of leakage parameters. Am J Obstet Gynecol 2016; 214:257.e1.
- Cohen SL, Greenberg JA, Wang KC, et al. Risk of leakage and tissue dissemination with various contained tissue extraction (CTE) techniques: an in vitro pilot study. J Minim Invasive Gynecol 2014; 21:935.
- Rimbach S, Holzknecht A, Schmedler C, et al. First clinical experiences using a new in-bag morcellation system during laparoscopic hysterectomy. Arch Gynecol Obstet 2016; 294:83.
- Ikhena DE, Paintal A, Milad MP. Feasibility of Washings at the Time of Laparoscopic Power Morcellation: A Pilot Study. J Minim Invasive Gynecol 2016; 23:793.
- Solima E, Scagnelli G, Austoni V, et al. Vaginal Uterine Morcellation Within a Specimen Containment System: A Study of Bag Integrity. J Minim Invasive Gynecol 2015; 22:1244.
- Serur E, Zambrano N, Brown K, et al. Extracorporeal Manual Morcellation of Very Large Uteri Within an Enclosed Endoscopic Bag: Our 5-Year Experience. J Minim Invasive Gynecol 2016; 23:903.
- http://links.lww.com/AOG/A547 (Accessed on February 25, 2015).
- http://links.lww.com/AOG/A548 (Accessed on August 08, 2016).
- Favero G, Anton C, Silva e Silva A, et al. Vaginal morcellation: a new strategy for large gynecological malignant tumor extraction: a pilot study. Gynecol Oncol 2012; 126:443.
- Wyman A, Fuhrig L, Bedaiwy MA, et al. A Novel Technique for Transvaginal Retrieval of Enlarged Pelvic Viscera during Minimally Invasive Surgery. Minim Invasive Surg 2012; 2012:454120.
- CLINICAL APPLICATIONS
- RISKS OF MORCELLATION
- Tissue dissemination and worsened prognosis
- - Uterine sarcoma
- - Leiomyoma variants
- - Endometrial carcinoma
- - Other conditions
- Surgical complications
- Power versus scalpel morcellation
- Other procedures
- POLICY STATEMENTS
- Government agencies
- Professional societies
- PREOPERATIVE EVALUATION
- Evaluation for uterine cancer
- Patient selection
- MORCELLATION DEVICES AND TECHNIQUES
- Power morcellation
- - Intraperitoneal
- - Containment systems
- Scalpel morcellation
- ALTERNATIVE TECHNIQUES
- SUMMARY AND RECOMMENDATIONS