The Experts below are selected from a list of 1008 Experts worldwide ranked by ideXlab platform

Fulvio Zullo - One of the best experts on this subject based on the ideXlab platform.

  • in bag manual versus uncontained power Morcellation for laparoscopic myomectomy
    Cochrane Database of Systematic Reviews, 2019
    Co-Authors: Fulvio Zullo, Roberta Venturella, Antonio Raffone, Gabriele Saccone
    Abstract:

    Background Uterine leiomyomas, also referred to as myomas or fibroids, are benign tumours arising from the smooth muscle cells of the myometrium. They are the most common pelvic tumour in women. The estimated rate of leiomyosarcoma, found during surgery for presumed benign leiomyomas, is about 0.51 per 1000 procedures, or approximately 1 in 2000. Treatment options for symptomatic uterine leiomyomas include medical, surgical, and radiologically-guided interventions. Laparoscopic myomectomy is the gold standard surgical approach for women who want offspring, or otherwise wish to retain their uterus. A limitation of laparoscopy is the inability to remove large specimens from the abdominal cavity through the laparoscope. To overcome this challenge, the Morcellation approach was developed, during which larger specimens are broken into smaller pieces in order to remove them from the abdominal cavity via the port site. However, intracorporeal power Morcellation may lead to scattering of benign tissues, with the risk of spreading leiomyoma or endometriosis. In cases of unsuspected malignancy, power Morcellation can cause unintentional dissemination of malignant cells, and lead to a poorer prognosis by upstaging the occult cancer. A strategy to optimise women's safety is to morcellate the specimens inside a bag. In-bag Morcellation may avoid the dissemination of tissue fragments. Objectives To evaluate the effectiveness and safety of protected in-bag extracorporeal manual Morcellation during laparoscopic myomectomy compared to intra-abdominal uncontained power Morcellation. Search methods On 1 July 2019, we searched; the Cochrane Gynaecology and Fertility Group Specialized Register of Controlled Trials, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, LILACS, PubMed, Google Scholar, and two trials registers. We reviewed the reference lists of all retrieved full-text articles, and contacted experts in the field for additional and ongoing trials. Selection criteria We included all randomised controlled trials comparing in-bag extracorporeal manual Morcellation versus intracorporeal uncontained power Morcellation during laparoscopic myomectomy in premenopausal women. Data collection and analysis We followed standard Cochrane methods. Two review authors independently reviewed the eligibility of trials, extracted data, and evaluated the risk of bias. Data were checked for accuracy. The summary measures were reported as risk ratios (RR) or mean differences (MD) with 95% confidence interval (CI). The outcomes of interest were a composite of intraoperative and postoperative complications, operative times, ease of Morcellation, length of hospital stay, postoperative pain, conversion to laparotomy, and postoperative diagnosis of leiomyosarcoma. Results for the five main outcomes follow. Main results We included two trials, enrolling 176 premenopausal women with fibroids, who underwent laparoscopic myomectomy. The experimental group received in-bag manual Morcellation, during which each enucleated myoma was placed into a specimen retrieval bag, and manually morcellated with scalpel or scissors. In the control group, intracorporeal uncontained power Morcellation was used to reduce the size of the myomas. No intraoperative complications, including accidental Morcellation of the liver, conversion to laparotomy, endoscopic bag disruption, bowel injury, bleeding, accidental injury to any viscus or vessel, were reported in either group in either trial. We found very low-quality evidence of inconclusive results for total operative time (MD 9.93 minutes, 95% CI -1.35 to 21.20; 2 studies, 176 participants; I² = 35%), and ease of Morcellation (MD -0.73 points, 95% CI -1.64 to 0.18; 1 study, 104 participants). The Morcellation operative time was a little longer for the in-bag manual Morcellation group, however the quality of the evidence was very low (MD 2.59 minutes, 95% CI 0.45 to 4.72; 2 studies, 176 participants; I² = 0%). There were no postoperative diagnoses of leiomyosarcoma made in either group in either trial. We are very uncertain of any of these results. We downgraded the quality of the evidence due to indirectness and imprecision, because of limited sites in high-income settings and countries, small sample sizes, wide confidence intervals, and few events. Authors' conclusions There are limited data on the effectiveness and safety of in-bag Morcellation at the time of laparoscopic myomectomy compared to uncontained power Morcellation. We were unable to determine the effects of in-bag Morcellation on intraoperative complications as no events were reported in either group. We are uncertain if in-bag Morcellation improves total operative time or ease of Morcellation compared to control. Regarding Morcellation operative time, the quality of the evidence was also very low and we cannot be certain of the effect of in-bag Morcellation compared to uncontained Morcellation. No cases of postoperative diagnosis of leiomyosarcoma occurred in either group. We found only two trials comparing in-bag extracorporeal manual Morcellation to intracorporeal uncontained power Morcellation at the time of laparoscopic myomectomy. Both trials had Morcellation operative time as primary outcome and were not powered for uncommon outcomes such as intraoperative complications, and postoperative diagnosis of leiomyosarcoma. Large, well-planned and executed trials are needed.

  • in bag manual versus uncontained power Morcellation for laparoscopic myomectomy randomized controlled trial
    Fertility and Sterility, 2016
    Co-Authors: Roberta Venturella, Morena Rocca, Daniela Lico, Nicolo La Ferrera, Roberto Cirillo, Salvatore Gizzo, Michele Morelli, E Zupi, Fulvio Zullo
    Abstract:

    Objective To evaluate whether manualin-bag Morcellation could be efficiently proposed as alternative to the uncontained power technique. Design Randomized controlled trial. Setting Academic hospital. Patient(s) One hundred fifty-two premenopausal women eligible for myomectomy were screened, and 104 were randomized. Intervention(s) Patients were randomized into two groups. In the experimental group, "in-bag" protected Morcellation was performed. In the control group, patients were treated by uncontained power myoma removal. Main Outcome Measure(s) The primary endpoint was the comparison of Morcellation operative time (MOT). The secondary endpoints were the comparisons of total operative time (TOT), simplicity of Morcellation (as defined by the surgeon using a visual analogue scale scale), intraoperative blood loss, rate of complications, and postoperative outcomes. Result(s) A sample size of 51 per group (n = 102) was planned. Between March 2014 and January 2015, patients were randomized as follows: 53 to the experimental group and 51 to the control group. Most demographic characteristics were similar across groups. MOT was observed to be similar in both study groups (16.18 ± 8.1 vs. 14.35 ± 7.8 minutes, in the experimental and control groups, respectively). Fibroid size was identified as the principal factor influencing Morcellation time (Pearson coefficient 0.484 vs. 0.581, in the experimental and control groups, respectively). No significant difference in TOT, simplicity of Morcellation, delta Hb, postoperative pain, and postoperative outcomes were observed between groups. Conclusion(s) The protected manual in-bag Morcellation technique represents a time-efficient and feasible alternative, which does not interfere with surgical outcomes in women undergoing laparoscopic myomectomy. Clinical Trial Registration NCT02086435.

Sarah L Cohen - One of the best experts on this subject based on the ideXlab platform.

  • safety of minimally invasive tissue extraction in myoma management a systematic review
    Journal of Minimally Invasive Gynecology, 2021
    Co-Authors: Kristen Pepin, Jon I Einarsson, Adela G Cope, Jacqueline Cellini, Sarah L Cohen
    Abstract:

    ABSTRACT Objective This review seeks to establish the incidence of adverse outcomes associated with minimally invasive tissue extraction at the time of surgical procedures for myomas. Data Sources Articles published in the following databases without date restrictions: PubMed, EMBASE, Web of Science, Cochrane Database of Systematic Reviews and Trials. Search was conducted on March 25, 2020. Methods of Study Selection Included studies evaluated minimally invasive surgical procedures for uterine myomas involving Morcellation. This review did not consider studies of nonuterine tissue Morcellation, studies involving uterine procedures other than hysterectomy or myomectomy, studies involving Morcellation of known malignancies, nor studies concerning hysteroscopic myomectomy. A total of 695 studies were reviewed, with 185 studies included for analysis. Tabulation, Integration, and Results The following variables were extracted: patient demographics, study type, Morcellation technique, and adverse outcome category. Adverse outcomes included prolonged operative time, Morcellation time, blood loss, direct injury from a morcellator, dissemination of tissue (benign or malignant), and disruption of the pathologic specimen. Conclusion Complications related to Morcellation are rare; however, there is a great need for higher quality studies to evaluate associated adverse outcomes.

  • 2538 current methods of tissue extraction in minimally invasive surgical treatment of uterine fibroids
    Journal of Minimally Invasive Gynecology, 2019
    Co-Authors: R Kim, Jon I Einarsson, Monalisa Dmello, Nisse V Clark, M O Ajao, Sarah L Cohen
    Abstract:

    Study Objective Since the 2014 Food and Drug Administration warnings regarding the use of power Morcellation, gynecologists have adopted multiple alternative tissue extraction strategies. The objective of this study is to investigate the current techniques used by minimally invasive gynecologic surgeons for tissue extraction following minimally invasive hysterectomy for fibroids. Design Web-based survey. Setting N/a Patients or Participants Current AAGL members were sent a link to access the survey, which was available from March 26, 2019 to April 17, 2019. Interventions N/a. Measurements and Main Results 420 respondents completed the survey. The most common methods of tissue extraction were manual Morcellation through the colpotomy (72.4%) and mini-laparotomy (66.9%). 31.7% of all participants endorsed the use of power Morcellation. Intact specimen removal through a laparotomy was reported by 10% of respondents. Other methods of tissue extraction, such as intra-abdominal manual Morcellation with a laparoscopic scalpel, were reported by 1.4%. Use of containment bags was reported by 43.4% during vaginal Morcellation, 83.6% during mini-laparotomy, and 56.8% during power Morcellation. Mini-laparotomies were on average 3.5cm and most commonly located at the umbilicus. Geographic differences were seen with respect to power Morcellation, with 18.4% of US-based surgeons reporting its use compared to 56.9% of non-US-based surgeons. Conclusion Minimally invasive gynecologic surgeons are currently employing a variety of tissue extraction strategies for hysterectomy for fibroids. A large majority of practitioners are performing manual Morcellation through the colpotomy and/or mini-laparotomy; use of containment bags is more common with during mini-laparotomy than via colpotomy. Power Morcellation is still in use, less commonly in the United States than in other countries, and usually within a containment system.

  • tissue extraction techniques during laparoscopic uterine surgery
    Journal of Minimally Invasive Gynecology, 2017
    Co-Authors: Nisse V Clark, Sarah L Cohen
    Abstract:

    Morcellation allows minimally invasive approaches to surgery even in the presence of large uteri or myomas. Recent restrictions in the use of power Morcellation, as well as concerns regarding the potential for Morcellation to disseminate malignant tissue, have initiated investigation and innovation to find safer methods. This review examines current techniques for tissue extraction during uterine surgery, with a focus on contained power Morcellation and contained manual Morcellation via mini-laparotomy or colpotomy. Videos are included to demonstrate these methods.

  • comparison of Morcellation techniques at the time of laparoscopic hysterectomy and myomectomy
    Journal of Minimally Invasive Gynecology, 2017
    Co-Authors: Elsemieke A I M Meurs, Jon I Einarsson, M O Ajao, Allison F Vitonis, Luiz Gustavo Oliveira Brito, Emily R Goggins, Sarah L Cohen
    Abstract:

    Abstract Study Objective To compare perioperative outcomes associated with the use of 3 techniques for tissue removal at the time of laparoscopic hysterectomy and myomectomy. Design A retrospective cohort study (Canadian Task Force classification II-2). Setting An academic hospital in Boston, MA. Patients Women who underwent a laparoscopic or robot-assisted laparoscopic hysterectomy or myomectomy involving tissue Morcellation in 2014. Interventions One of 3 Morcellation techniques: electronic power Morcellation (PM), manual vaginal Morcellation via the vagina (VM), or manual Morcellation via minilaparotomy (ML). Measurements and Main Results Of the 297 cases included in this study (137 myomectomies, 62 total laparoscopic hysterectomies, and 98 laparoscopic supracervical hysterectomies), 96% of the cases were performed by fellowship-trained surgeons using conventional laparoscopy. Containment bags were used at the time of tissue extraction in 77% of the cases. Baseline characteristics and perioperative outcomes were similar in all groups. In hysterectomy cases, the average specimen size was largest in the ML group (591 ± 419 g in the ML group compared with 368 ± 293 g in the PM group and 449 ± 175 g in the VM group, p = .0009). After multivariate regression, no significant difference was found in blood loss, length of stay, or complications. The operative time was shorter in the PM group compared with the ML group by 16 minutes (mean = 140 minutes [95% confidence interval, 130–149 minutes] compared with 156 [95% confidence interval, 146–167], p = .02); this association remained significant once additionally adjusting for the use or nonuse of containment bags (p = .05). Conclusion We did not detect a significant difference between the 3 Morcellation techniques when comparing the perioperative complications although the longest operative times were noted for the minilaparotomy approach. All 3 Morcellation techniques represent viable options for tissue extraction at the time of minimally invasive surgery.

  • updates in uterine fibroid tissue extraction
    Current Opinion in Obstetrics & Gynecology, 2016
    Co-Authors: Sarah L Cohen, Eduardo Hariton, Yalda Afshar, M T Siedhoff
    Abstract:

    Purpose of review Safety concerns regarding Morcellation of presumed benign fibroid disease have led to an increase in recent research activity on this topic, as well as advances in surgical technique. Recent findings The prevalence of occult leiomyosarcoma is debated; however, estimates from a robust meta-analysis suggest it may be in the range of 1 case per 1960-8300 fibroid surgeries. Advancing age is an important clinical risk factor for occult malignancy. The impact of tumor Morcellation may vary by mode of tissue removal, though tissue fragmentation is consistently associated with poorer outcomes. Decision and cost analyses continue to support laparoscopic hysterectomy as a low-morbidity and cost-effective approach. The increased scrutiny on fibroid procedures in the past few years may lead to changes in surgical approach; however, alternative tissue extraction options are evolving, including incorporation of contained Morcellation. Summary Although the incidence of occult leiomyosarcoma is low, outcomes are poor and may be worsened by Morcellation. By addressing risk factors for malignancy and incorporating evolving surgical techniques into practice, gynecologists can continue to offer patients a minimally invasive approach for fibroid management.

Roberta Venturella - One of the best experts on this subject based on the ideXlab platform.

  • in bag manual versus uncontained power Morcellation for laparoscopic myomectomy
    Cochrane Database of Systematic Reviews, 2019
    Co-Authors: Fulvio Zullo, Roberta Venturella, Antonio Raffone, Gabriele Saccone
    Abstract:

    Background Uterine leiomyomas, also referred to as myomas or fibroids, are benign tumours arising from the smooth muscle cells of the myometrium. They are the most common pelvic tumour in women. The estimated rate of leiomyosarcoma, found during surgery for presumed benign leiomyomas, is about 0.51 per 1000 procedures, or approximately 1 in 2000. Treatment options for symptomatic uterine leiomyomas include medical, surgical, and radiologically-guided interventions. Laparoscopic myomectomy is the gold standard surgical approach for women who want offspring, or otherwise wish to retain their uterus. A limitation of laparoscopy is the inability to remove large specimens from the abdominal cavity through the laparoscope. To overcome this challenge, the Morcellation approach was developed, during which larger specimens are broken into smaller pieces in order to remove them from the abdominal cavity via the port site. However, intracorporeal power Morcellation may lead to scattering of benign tissues, with the risk of spreading leiomyoma or endometriosis. In cases of unsuspected malignancy, power Morcellation can cause unintentional dissemination of malignant cells, and lead to a poorer prognosis by upstaging the occult cancer. A strategy to optimise women's safety is to morcellate the specimens inside a bag. In-bag Morcellation may avoid the dissemination of tissue fragments. Objectives To evaluate the effectiveness and safety of protected in-bag extracorporeal manual Morcellation during laparoscopic myomectomy compared to intra-abdominal uncontained power Morcellation. Search methods On 1 July 2019, we searched; the Cochrane Gynaecology and Fertility Group Specialized Register of Controlled Trials, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, LILACS, PubMed, Google Scholar, and two trials registers. We reviewed the reference lists of all retrieved full-text articles, and contacted experts in the field for additional and ongoing trials. Selection criteria We included all randomised controlled trials comparing in-bag extracorporeal manual Morcellation versus intracorporeal uncontained power Morcellation during laparoscopic myomectomy in premenopausal women. Data collection and analysis We followed standard Cochrane methods. Two review authors independently reviewed the eligibility of trials, extracted data, and evaluated the risk of bias. Data were checked for accuracy. The summary measures were reported as risk ratios (RR) or mean differences (MD) with 95% confidence interval (CI). The outcomes of interest were a composite of intraoperative and postoperative complications, operative times, ease of Morcellation, length of hospital stay, postoperative pain, conversion to laparotomy, and postoperative diagnosis of leiomyosarcoma. Results for the five main outcomes follow. Main results We included two trials, enrolling 176 premenopausal women with fibroids, who underwent laparoscopic myomectomy. The experimental group received in-bag manual Morcellation, during which each enucleated myoma was placed into a specimen retrieval bag, and manually morcellated with scalpel or scissors. In the control group, intracorporeal uncontained power Morcellation was used to reduce the size of the myomas. No intraoperative complications, including accidental Morcellation of the liver, conversion to laparotomy, endoscopic bag disruption, bowel injury, bleeding, accidental injury to any viscus or vessel, were reported in either group in either trial. We found very low-quality evidence of inconclusive results for total operative time (MD 9.93 minutes, 95% CI -1.35 to 21.20; 2 studies, 176 participants; I² = 35%), and ease of Morcellation (MD -0.73 points, 95% CI -1.64 to 0.18; 1 study, 104 participants). The Morcellation operative time was a little longer for the in-bag manual Morcellation group, however the quality of the evidence was very low (MD 2.59 minutes, 95% CI 0.45 to 4.72; 2 studies, 176 participants; I² = 0%). There were no postoperative diagnoses of leiomyosarcoma made in either group in either trial. We are very uncertain of any of these results. We downgraded the quality of the evidence due to indirectness and imprecision, because of limited sites in high-income settings and countries, small sample sizes, wide confidence intervals, and few events. Authors' conclusions There are limited data on the effectiveness and safety of in-bag Morcellation at the time of laparoscopic myomectomy compared to uncontained power Morcellation. We were unable to determine the effects of in-bag Morcellation on intraoperative complications as no events were reported in either group. We are uncertain if in-bag Morcellation improves total operative time or ease of Morcellation compared to control. Regarding Morcellation operative time, the quality of the evidence was also very low and we cannot be certain of the effect of in-bag Morcellation compared to uncontained Morcellation. No cases of postoperative diagnosis of leiomyosarcoma occurred in either group. We found only two trials comparing in-bag extracorporeal manual Morcellation to intracorporeal uncontained power Morcellation at the time of laparoscopic myomectomy. Both trials had Morcellation operative time as primary outcome and were not powered for uncommon outcomes such as intraoperative complications, and postoperative diagnosis of leiomyosarcoma. Large, well-planned and executed trials are needed.

  • in bag manual versus uncontained power Morcellation for laparoscopic myomectomy randomized controlled trial
    Fertility and Sterility, 2016
    Co-Authors: Roberta Venturella, Morena Rocca, Daniela Lico, Nicolo La Ferrera, Roberto Cirillo, Salvatore Gizzo, Michele Morelli, E Zupi, Fulvio Zullo
    Abstract:

    Objective To evaluate whether manualin-bag Morcellation could be efficiently proposed as alternative to the uncontained power technique. Design Randomized controlled trial. Setting Academic hospital. Patient(s) One hundred fifty-two premenopausal women eligible for myomectomy were screened, and 104 were randomized. Intervention(s) Patients were randomized into two groups. In the experimental group, "in-bag" protected Morcellation was performed. In the control group, patients were treated by uncontained power myoma removal. Main Outcome Measure(s) The primary endpoint was the comparison of Morcellation operative time (MOT). The secondary endpoints were the comparisons of total operative time (TOT), simplicity of Morcellation (as defined by the surgeon using a visual analogue scale scale), intraoperative blood loss, rate of complications, and postoperative outcomes. Result(s) A sample size of 51 per group (n = 102) was planned. Between March 2014 and January 2015, patients were randomized as follows: 53 to the experimental group and 51 to the control group. Most demographic characteristics were similar across groups. MOT was observed to be similar in both study groups (16.18 ± 8.1 vs. 14.35 ± 7.8 minutes, in the experimental and control groups, respectively). Fibroid size was identified as the principal factor influencing Morcellation time (Pearson coefficient 0.484 vs. 0.581, in the experimental and control groups, respectively). No significant difference in TOT, simplicity of Morcellation, delta Hb, postoperative pain, and postoperative outcomes were observed between groups. Conclusion(s) The protected manual in-bag Morcellation technique represents a time-efficient and feasible alternative, which does not interfere with surgical outcomes in women undergoing laparoscopic myomectomy. Clinical Trial Registration NCT02086435.

Gabriele Saccone - One of the best experts on this subject based on the ideXlab platform.

  • in bag manual versus uncontained power Morcellation for laparoscopic myomectomy
    Cochrane Database of Systematic Reviews, 2019
    Co-Authors: Fulvio Zullo, Roberta Venturella, Antonio Raffone, Gabriele Saccone
    Abstract:

    Background Uterine leiomyomas, also referred to as myomas or fibroids, are benign tumours arising from the smooth muscle cells of the myometrium. They are the most common pelvic tumour in women. The estimated rate of leiomyosarcoma, found during surgery for presumed benign leiomyomas, is about 0.51 per 1000 procedures, or approximately 1 in 2000. Treatment options for symptomatic uterine leiomyomas include medical, surgical, and radiologically-guided interventions. Laparoscopic myomectomy is the gold standard surgical approach for women who want offspring, or otherwise wish to retain their uterus. A limitation of laparoscopy is the inability to remove large specimens from the abdominal cavity through the laparoscope. To overcome this challenge, the Morcellation approach was developed, during which larger specimens are broken into smaller pieces in order to remove them from the abdominal cavity via the port site. However, intracorporeal power Morcellation may lead to scattering of benign tissues, with the risk of spreading leiomyoma or endometriosis. In cases of unsuspected malignancy, power Morcellation can cause unintentional dissemination of malignant cells, and lead to a poorer prognosis by upstaging the occult cancer. A strategy to optimise women's safety is to morcellate the specimens inside a bag. In-bag Morcellation may avoid the dissemination of tissue fragments. Objectives To evaluate the effectiveness and safety of protected in-bag extracorporeal manual Morcellation during laparoscopic myomectomy compared to intra-abdominal uncontained power Morcellation. Search methods On 1 July 2019, we searched; the Cochrane Gynaecology and Fertility Group Specialized Register of Controlled Trials, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, LILACS, PubMed, Google Scholar, and two trials registers. We reviewed the reference lists of all retrieved full-text articles, and contacted experts in the field for additional and ongoing trials. Selection criteria We included all randomised controlled trials comparing in-bag extracorporeal manual Morcellation versus intracorporeal uncontained power Morcellation during laparoscopic myomectomy in premenopausal women. Data collection and analysis We followed standard Cochrane methods. Two review authors independently reviewed the eligibility of trials, extracted data, and evaluated the risk of bias. Data were checked for accuracy. The summary measures were reported as risk ratios (RR) or mean differences (MD) with 95% confidence interval (CI). The outcomes of interest were a composite of intraoperative and postoperative complications, operative times, ease of Morcellation, length of hospital stay, postoperative pain, conversion to laparotomy, and postoperative diagnosis of leiomyosarcoma. Results for the five main outcomes follow. Main results We included two trials, enrolling 176 premenopausal women with fibroids, who underwent laparoscopic myomectomy. The experimental group received in-bag manual Morcellation, during which each enucleated myoma was placed into a specimen retrieval bag, and manually morcellated with scalpel or scissors. In the control group, intracorporeal uncontained power Morcellation was used to reduce the size of the myomas. No intraoperative complications, including accidental Morcellation of the liver, conversion to laparotomy, endoscopic bag disruption, bowel injury, bleeding, accidental injury to any viscus or vessel, were reported in either group in either trial. We found very low-quality evidence of inconclusive results for total operative time (MD 9.93 minutes, 95% CI -1.35 to 21.20; 2 studies, 176 participants; I² = 35%), and ease of Morcellation (MD -0.73 points, 95% CI -1.64 to 0.18; 1 study, 104 participants). The Morcellation operative time was a little longer for the in-bag manual Morcellation group, however the quality of the evidence was very low (MD 2.59 minutes, 95% CI 0.45 to 4.72; 2 studies, 176 participants; I² = 0%). There were no postoperative diagnoses of leiomyosarcoma made in either group in either trial. We are very uncertain of any of these results. We downgraded the quality of the evidence due to indirectness and imprecision, because of limited sites in high-income settings and countries, small sample sizes, wide confidence intervals, and few events. Authors' conclusions There are limited data on the effectiveness and safety of in-bag Morcellation at the time of laparoscopic myomectomy compared to uncontained power Morcellation. We were unable to determine the effects of in-bag Morcellation on intraoperative complications as no events were reported in either group. We are uncertain if in-bag Morcellation improves total operative time or ease of Morcellation compared to control. Regarding Morcellation operative time, the quality of the evidence was also very low and we cannot be certain of the effect of in-bag Morcellation compared to uncontained Morcellation. No cases of postoperative diagnosis of leiomyosarcoma occurred in either group. We found only two trials comparing in-bag extracorporeal manual Morcellation to intracorporeal uncontained power Morcellation at the time of laparoscopic myomectomy. Both trials had Morcellation operative time as primary outcome and were not powered for uncommon outcomes such as intraoperative complications, and postoperative diagnosis of leiomyosarcoma. Large, well-planned and executed trials are needed.

Jon I Einarsson - One of the best experts on this subject based on the ideXlab platform.

  • safety of minimally invasive tissue extraction in myoma management a systematic review
    Journal of Minimally Invasive Gynecology, 2021
    Co-Authors: Kristen Pepin, Jon I Einarsson, Adela G Cope, Jacqueline Cellini, Sarah L Cohen
    Abstract:

    ABSTRACT Objective This review seeks to establish the incidence of adverse outcomes associated with minimally invasive tissue extraction at the time of surgical procedures for myomas. Data Sources Articles published in the following databases without date restrictions: PubMed, EMBASE, Web of Science, Cochrane Database of Systematic Reviews and Trials. Search was conducted on March 25, 2020. Methods of Study Selection Included studies evaluated minimally invasive surgical procedures for uterine myomas involving Morcellation. This review did not consider studies of nonuterine tissue Morcellation, studies involving uterine procedures other than hysterectomy or myomectomy, studies involving Morcellation of known malignancies, nor studies concerning hysteroscopic myomectomy. A total of 695 studies were reviewed, with 185 studies included for analysis. Tabulation, Integration, and Results The following variables were extracted: patient demographics, study type, Morcellation technique, and adverse outcome category. Adverse outcomes included prolonged operative time, Morcellation time, blood loss, direct injury from a morcellator, dissemination of tissue (benign or malignant), and disruption of the pathologic specimen. Conclusion Complications related to Morcellation are rare; however, there is a great need for higher quality studies to evaluate associated adverse outcomes.

  • 2538 current methods of tissue extraction in minimally invasive surgical treatment of uterine fibroids
    Journal of Minimally Invasive Gynecology, 2019
    Co-Authors: R Kim, Jon I Einarsson, Monalisa Dmello, Nisse V Clark, M O Ajao, Sarah L Cohen
    Abstract:

    Study Objective Since the 2014 Food and Drug Administration warnings regarding the use of power Morcellation, gynecologists have adopted multiple alternative tissue extraction strategies. The objective of this study is to investigate the current techniques used by minimally invasive gynecologic surgeons for tissue extraction following minimally invasive hysterectomy for fibroids. Design Web-based survey. Setting N/a Patients or Participants Current AAGL members were sent a link to access the survey, which was available from March 26, 2019 to April 17, 2019. Interventions N/a. Measurements and Main Results 420 respondents completed the survey. The most common methods of tissue extraction were manual Morcellation through the colpotomy (72.4%) and mini-laparotomy (66.9%). 31.7% of all participants endorsed the use of power Morcellation. Intact specimen removal through a laparotomy was reported by 10% of respondents. Other methods of tissue extraction, such as intra-abdominal manual Morcellation with a laparoscopic scalpel, were reported by 1.4%. Use of containment bags was reported by 43.4% during vaginal Morcellation, 83.6% during mini-laparotomy, and 56.8% during power Morcellation. Mini-laparotomies were on average 3.5cm and most commonly located at the umbilicus. Geographic differences were seen with respect to power Morcellation, with 18.4% of US-based surgeons reporting its use compared to 56.9% of non-US-based surgeons. Conclusion Minimally invasive gynecologic surgeons are currently employing a variety of tissue extraction strategies for hysterectomy for fibroids. A large majority of practitioners are performing manual Morcellation through the colpotomy and/or mini-laparotomy; use of containment bags is more common with during mini-laparotomy than via colpotomy. Power Morcellation is still in use, less commonly in the United States than in other countries, and usually within a containment system.

  • comparison of Morcellation techniques at the time of laparoscopic hysterectomy and myomectomy
    Journal of Minimally Invasive Gynecology, 2017
    Co-Authors: Elsemieke A I M Meurs, Jon I Einarsson, M O Ajao, Allison F Vitonis, Luiz Gustavo Oliveira Brito, Emily R Goggins, Sarah L Cohen
    Abstract:

    Abstract Study Objective To compare perioperative outcomes associated with the use of 3 techniques for tissue removal at the time of laparoscopic hysterectomy and myomectomy. Design A retrospective cohort study (Canadian Task Force classification II-2). Setting An academic hospital in Boston, MA. Patients Women who underwent a laparoscopic or robot-assisted laparoscopic hysterectomy or myomectomy involving tissue Morcellation in 2014. Interventions One of 3 Morcellation techniques: electronic power Morcellation (PM), manual vaginal Morcellation via the vagina (VM), or manual Morcellation via minilaparotomy (ML). Measurements and Main Results Of the 297 cases included in this study (137 myomectomies, 62 total laparoscopic hysterectomies, and 98 laparoscopic supracervical hysterectomies), 96% of the cases were performed by fellowship-trained surgeons using conventional laparoscopy. Containment bags were used at the time of tissue extraction in 77% of the cases. Baseline characteristics and perioperative outcomes were similar in all groups. In hysterectomy cases, the average specimen size was largest in the ML group (591 ± 419 g in the ML group compared with 368 ± 293 g in the PM group and 449 ± 175 g in the VM group, p = .0009). After multivariate regression, no significant difference was found in blood loss, length of stay, or complications. The operative time was shorter in the PM group compared with the ML group by 16 minutes (mean = 140 minutes [95% confidence interval, 130–149 minutes] compared with 156 [95% confidence interval, 146–167], p = .02); this association remained significant once additionally adjusting for the use or nonuse of containment bags (p = .05). Conclusion We did not detect a significant difference between the 3 Morcellation techniques when comparing the perioperative complications although the longest operative times were noted for the minilaparotomy approach. All 3 Morcellation techniques represent viable options for tissue extraction at the time of minimally invasive surgery.

  • open power Morcellation versus contained power Morcellation within an insufflated isolation bag comparison of perioperative outcomes
    Journal of Minimally Invasive Gynecology, 2015
    Co-Authors: M V Vargas, Sarah L Cohen, Noga Fuchsweizman, K C Wang, E Manoucheri, Allison F Vitonis, Jon I Einarsson
    Abstract:

    Abstract 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.

  • contained power Morcellation within an insufflated isolation bag
    Obstetrics & Gynecology, 2014
    Co-Authors: Sarah L Cohen, Jon I Einarsson, K C Wang, David M Boruta, Douglas L Brown, Stacey A Scheib, Amanda N Fader, Tony Shibley
    Abstract:

    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