Abstract
Background
Electromechanical power morcellation is an important tool of modern laparoscopy. Recent reports on the spread of previously undetected malignancy by power morcellation indicate the need for additional protective devices to reduce this risk. We conducted a study to obtain the first data concerning the safety of an endobag with three closable ports during morcellation and subsequent bag extraction under in vitro conditions, mimicking the settings in our operating theater. The second purpose of the study was to establish a minimal width of the skin incision necessary to safely extract the sealed bag after morcellation.
Methods
The morcellation test was carried out on 11 stained porcine muscle tissue samples with one additional sample as a control. The insufflation pressure was set at 12 mmHg. After filling the endobag with blue dye solution, an additional extraction test was conducted by pulling the closed bag through a template with apertures of various diameters. For each opening, a series of ten bag extractions was carried out.
Results
No loss of solid material or fluid was recorded during the morcellation test. The extraction test showed a loss of fluid for template openings smaller than 18 mm. The force necessary to extract the bag was inversely related to the width of the aperture.
Conclusions
The data suggest that under the evaluated conditions, the use of a closable morcellation bag can considerably improve the patient’s safety during morcellation. Further studies are necessary to evaluate the influence of the bag on operating time, intervention costs and complications.
Similar content being viewed by others
References
Milad MP, Sokol E (2003) Laparoscopic morcellator-related injuries. J Am Assoc Gynecol Laparosc 10:383–385
Milad MP, Milad EA (2014) Laparoscopic morcellator-related complications. J Minim Invasive Gynecol 21:486–491
Nieboer TE, Johnson N, Lethaby A, Tavender E, Curr E, Garry R, van Voorst S, Mol BW, Kluivers KB (2009) Surgical approach to hysterectomy for benign gynaecological disease. Cochrane Database Syst Rev (3):CD003677. doi:10.1002/14651858.CD003677.pub4
Brown J (2014) AAGL advancing minimally invasive gynecology worldwide: statement to the FDA on power morcellation. J Minim Invasive Gynecol 21:970–971
http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm393576.htm. Accessed 21 Feb 2015
Nezhat C, Kho K (2010) Iatrogenic myomas: new class of myomas? J Minim Invasive Gynecol 17:544–550
D’Angelo E, Prat J (2010) Uterine sarcomas: a review. Gynecol Oncol 116:131–139
Kho KA, Nezhat CH (2014) Evaluating the risks of electric uterine morcellation. JAMA 311:905–906
Zhang J, Zhang J, Dai Y, Zhu L, Lang J, Leng J (2015) Clinical characteristics and management experience of unexpected uterine sarcoma after myomectomy. Int J Gynaecol Obstet 130:195–199
Seidman MA, Oduyebo T, Muto MG, Crum CP, Nucci MR, Quade BJ (2012) Peritoneal dissemination complicating morcellation of uterine mesenchymal neoplasms. PLoS One 7:e50058
Oduyebo T, Rauh-Hain AJ, Meserve EE, Seidman MA, Hinchcliff E, George S, Quade B, Nucci MR, Del Carmen MG, Muto MG (2014) The value of re-exploration in patients with inadvertently morcellated uterine sarcoma. Gynecol Oncol 132:360–365
Einarsson JI, Cohen SL, Fuchs N, Wang KC (2014) In-bag morcellation. J Minim Invasive Gynecol 21:951–953
Kondrup JD, Anderson F, Sylvester B, Branning M (2014) Laparoscopic morcellation and tissue spillage containment using the LI endofield bag. Surg Technol Int 25:162–166
Cohen SL, Einarsson JI, Wang KC, Brown D, Boruta D, Scheib SA, Fader AN, Shibley T (2014) Contained power morcellation within an insufflated isolation bag. Obstet Gynecol 124:491–497
Cholkeri-Singh A, Miller CE (2015) Power morcellation in a specimen bag. J Minim Invasive Gynecol 22:160
Rimbach S, Holzknecht A, Nemes C, Offner F, Craina M (2015) A new in-bag system to reduce the risk of tissue morcellation: development and experimental evaluation during laparoscopic hysterectomy. Arch Gynecol Obstet 292(6):1311–1320
Cohen SL, Greenberg JA, Wang KC, Srouji SS, Gargiulo AR, Pozner CN, Hoover N, Einarsson JI (2014) Risk of leakage and tissue dissemination with various contained tissue extraction (CTE) techniques: an in vitro pilot study. J Minim Invasive Gynecol 21:935–939
Schurr MO, Prosst W, Kunert M, Wehrmann M, Vagner J, Buess GF (1996) Laparoscopic tissue fragmentation under visual control: concept and experimental experience. Minim Invasive Ther Allied Technol 5:121–127
Cohen SL, Morris SN, Brown DN, Greenberg JA, Walsh BW, Gargiulo AR, Isaacson KB, Wright KN, Srouji SS, Anchan RM, Vogell AB, Einarsson JI (2016) Contained tissue extraction using power morcellation: prospective evaluation of leakage parameters. Am J Obstet Gynecol 214(257):e251–e256
Cai Y, Jacobson A, Marcovich R, Lowe D, El-Hakim A, Shah DK, Smith AD, Lee BR (2003) Electrical prostate morcellator: an alternative to manual morcellation for laparoscopic nephrectomy specimens? An in vitro study. Urology 61:1113–1117 (discussion 1117)
Goggins ER, Greenberg JA, Cohen SL, Morris SN, Brown DN, Einarsson JI (2015) Efficacy of contained tissue extraction for minimizing tissue dissemination during laparoscopic hysterectomy and myomectomy [66]. Obstet Gynecol 125(Suppl 1):29S
Montella F, Riboni F, Cosma S, Dealberti D, Prigione S, Pisani C, Rovetta E (2014) A safe method of vaginal longitudinal morcellation of bulky uterus with endometrial cancer in a bag at laparoscopy. Surg Endosc 28:1949–1953
Wu SD, Lesani OA, Zhao LC, Johnston WK, Wolf JS Jr, Clayman RV, Nadler RB (2009) A multi-institutional study on the safety and efficacy of specimen morcellation after laparoscopic radical nephrectomy for clinical stage T1 or T2 renal cell carcinoma. J Endourol 23:1513–1518
Acknowledgments
We thank Mr. Eberhard Bless (Technical Department of the Community Hospital Dormagen) for his support. We also thank Ms. Dawn Rüther (Kiel School of Gynecological Endoscopy) for editing the manuscript.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Disclosures
Drs. Michael Anapolski, Dimitrios Panayotopoulos, Ibrahim Alkatout, Stefan Soltesz, Sven Schiermeier, Günter Noé have no conflicts of interest or financial ties to disclose.
Rights and permissions
About this article
Cite this article
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 31, 494–500 (2017). https://doi.org/10.1007/s00464-016-4969-8
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00464-016-4969-8