Specimen Removal During Supracervical Hysterectomy
Although the uterus is primarily a thick-walled muscle, it is the lining that bleeds, not the uterine wall. For anything to influence how heavy a woman bleeds it has to involve or be right up against the uterine lining.
Every organ in your body has different tissue types. Each tissue type within a given organ can develop its own set of tumors, both benign and malignant. When an organ develops a tumor, it will be of a tissue type normally contained within that organ. A muscular organ like the uterus makes muscle tumors. There is nothing fibrous about fibroids. Fibroids are muscle tumors. We refer to them as myomas (“myo” means muscle; “oma” means new growth or tumor). Leiomyoma, refers to the fact that it is the smooth muscle of an organ as opposed to the striated muscle of skeleton. Myomas can become malignant in less than half of 1% of cases, so myomas are generally benign, and polyps (benign growth of the endometrium) have the same low risk of malignancy.
Fibroids that are deep within the uterine wall, trans-mural, or subserosal, we can do laparoscopic myomectomy, where the uterine fibroids are removed and the uterine wall is repaired. Fibroids that are very large or the uterine wall is filled with many fibroids, then the uterine body along with all the fibroids is removed and the patient can keep the cervix and ovaries.
In medicine, it is Not how often a problem occurs, rather it is how serious the problem is when it does occur. In the small chance that a uterine fibroid is malignant, morcellation (removing the tumor in pieces) could spread and upstage the uterine fibroid malignancy. Therefore, a controversy in medicine is how to remove the specimen from the abdomen without endangering the patient in the chance that the uterus/fibroids contain malignancy.
Options include the following:
- Unconfined morcellation. This can be accomplished manually with a scalpel or by mechanical morcellator. Mechanical morcellator takes a large specimen and removes the specimen in longitudinal pieces.
- Contained morcellation. This approach introduces a large bag into the abdominal cavity, the specimen to be removed is placed in the bag, and manual or mechanical morcellation is carried out inside the bag.
- Mini-laparotomy. Specimen is removed by enlarging one of the incision sites.
- Bowel, ovarian masses are examples of specimens that are placed into an endoscopic specimen bag and removed intact, without morcellation.
Surgeons are using one or more of these techniques to remove uterus and uterine fibroid specimens. For years, unconfined morcellation was used with excellent results. Since the controversy regarding morcellation, many surgeons and medical centers no longer perform unconfined morcellation to avoid the possible spread of tumor. Contained morcellation is used to allow safer removal of the uterine/fibroid specimen without enlarging an incision. My concern is that once the uterine body is separated from the cervix, or once an incision is made into the wall of the uterus to remove the uterine fibroid tumor, the abdomen is already exposed to the uterine cells, so I am not sure how much protection is achieved by working inside the bag.
Mechanical morcellation worked well in my hands for many years, but given the current concerns and controversy, I no longer use mechanical morcellation. I have had excellent results with specimen removal by mini-laparotomy. I have found that as long as the procedure is accomplished by laparoscopy, and the abdominal incision is only used to remove the specimen, the patients have very minimal pain from the mini-laparotomy incision. There is restriction on heavy lifting for 6 weeks, but general recovery is as rapid as total laparoscopic approach.