The minimally invasive approach for hysterectomy with proven benefits and lower morbidity has become the gold standard, even in women with large uterine masses. Most women with a malignant condition present with abnormal vaginal bleeding and/or suspicious imaging such that few are diagnosed by final histopathology after surgery. However, if a malignancy is not diagnosed preoperatively, intraabdominal morcellation for uterus extraction has an increased risk for potential tumor spread and peritoneal metastases, especially in cases of unexpected leiomyosarcoma. We describe a simple method to wrap the uterus in a contained environment with a plastic bag through the posterior vaginal fornix prior to conventional coring morcellation for vaginal extraction in total laparoscopic hysterectomy. We further describe our experience with a risk stratification and treatment algorithm to implement this procedure in daily routine. A video and an illustrating sketch demonstrate the simplicity and safety of the procedure.
Problem: risk of intraabdominal tumor
Click Supplementary Content under the article title in the online Table of Contents
Our solution
We developed a simple method to wrap the uterus in a contained environment with a plastic bag (Auto Suture EndoCatch II 15 mm; Covidien/Tyco Healthcare, Norwalk, CT) through the posterior vaginal fornix prior to conventional coring morcellation for vaginal extraction in TLH ( Figures 2 and 3 and Video ). After completing the circular colpotomy, the uterine manipulator was removed and replaced by the EndoCatch II system embedded in a Colpo-Pneumo-Occluder system (CooperSurgical, Pleasanton, CA) to avoid the loss of intraabdominal air pressure. The dissected uterus was wrapped with the bag device through the posterior vaginal fornix, beginning in the cul de sac, assisted by laparoscopic forcipes. The orifice of the bag and the cervix uteri were then delivered to the vulva. The completely covered specimen was then morcellated by conventional coring in the vagina for safe extraction without intraabdominal dissemination or destruction of the serous surface of the uterus ( Figures 2 and 3 and Video ).
Technical limitations were extreme vaginal narrowing or a transversal uterine diameter exceeding 15 cm. There was no significant learning curve of this minimally invasive approach with wrapping time less than 5 minutes on average. For larger uterine specimens, bigger bags without frame (LapSac; Cook Medical, Bloomington, IN) were applied, although the placement and wrapping were more difficult and took much more time.
We implemented this procedure, along with a risk stratification algorithm, in 2 tertiary referral hospitals, both of which were specialized centers for gynecological endoscopic surgery and gynecological oncology (Inselspital Bern in 2010 and Cantonal Hospital of Lucerne in January 2013).
All women planning TLH underwent preoperative imaging assessment by transvaginal ultrasound including power Doppler sonography; if incomplete or nonconclusive, a magnetic resonance imaging was performed. We defined concerning history as a growing uterine mass or uterus after menopause or fast-growing uterine fibroids in premenopausal women.
Our preoperative risk assessment defined 3 groups of patients: first, assumed/confirmed malignancy; second, uncertain; and third, low risk. Women who preferred surgical treatment with TLH, had a uterine mass 15 cm or smaller, and were of uncertain risk were treated by TLH with subsequent vaginal in-bag morcellation, if required. (Women of uncertain risk with a uterine mass exceeding a transverse diameter of 15 cm were treated with laparotomy.) In women planning TLH who were deemed of low risk, the uterine specimen was morcellated intraabdominally or transvaginally without a bag, if required. Women with assumed or confirmed malignancy were not offered morcellation.
Clinical data were retrospectively analyzed by chart review. The local ethics committee of Bern and Lucerne approved the study.
From 2010 to June 2014, we performed 503 TLH/total intrafascial laparoscopic hysterectomy procedures and performed vaginal in-bag morcellation of the uterus in 61 women categorized as uncertain risk. Of the 503 patients, there were 9 cases of uterine leiomyosarcoma ( Figure 4 ). Two were preoperatively classified as assumed malignant and were evacuated without morcellation. Six were preoperatively classified as uncertain, and all were evacuated without abdominal contamination by vaginal in-bag morcellation.
