Case Report
Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Cases. Jul 16, 2021; 9(20): 5655-5660
Published online Jul 16, 2021. doi: 10.12998/wjcc.v9.i20.5655
Novel technique of extracorporeal intrauterine morcellation after total laparoscopic hysterectomy: Three emblematic case reports
Antonio Macciò, Elisabetta Sanna, Fabrizio Lavra, Piergiorgio Calò, Clelia Madeddu
Antonio Macciò, Elisabetta Sanna, Fabrizio Lavra, Department of Gynecologic Oncology, Businco Hospital, ARNAS G. Brotzu, Cagliari 09100, Italy
Piergiorgio Calò, Department of Surgical Sciences, University of Cagliari, Cagliari 09100, Italy
Clelia Madeddu, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari 09100, Italy
Author contributions: Macciò A was responsible for manuscript intellectual content; Macciò A and Madeddu C contributed to manuscript drafting, data analysis, interpretation, reviewed the literature and were responsible for the revision of the manuscript; Macciò A, Sanna E and Lavra F were the gynecological surgeons, performed the data analysis and interpretation and contributed to manuscript drafting; Calò PG contributed to manuscript drafting, data interpretation, review of the literature, manuscript revision; all authors issued final approval for the version to be submitted.
Informed consent statement: Informed consent was obtained from all subjects involved in the study.
Conflict-of-interest statement: The authors declare no conflict of interest.
CARE Checklist (2016) statement: The authors have read the CARE Checklist (2016), and the manuscript was prepared and revised according to the CARE Checklist (2016).
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Antonio Macciò, MD, Chief Doctor, Department of Gynecologic Oncology, Businco Hospital, ARNAS G. Brotzu, Via Jenner, Cagliari 09100, Italy. clelia.madeddu@tiscali.it
Received: February 28, 2021
Peer-review started: February 28, 2021
First decision: April 29, 2021
Revised: May 10, 2021
Accepted: May 24, 2021
Article in press: May 24, 2021
Published online: July 16, 2021
Processing time: 128 Days and 12.7 Hours
Abstract
BACKGROUND

In the presence of a large uterus, total laparoscopic hysterectomy (TLH), always requires morcellation to allow removal of the tissues from the abdominal cavity. However, uncontained morcellation has been scrutinized because of the possible spread of occult leiomyosarcoma. Therefore, in-bag extracorporeal morcellation has been developed. However, tissue containment and extraction are extremely challenging, especially when considering the increasing uterine size to be removed through minimally invasive surgery.

CASE SUMMARY

Herein, we describe a novel technique for extracorporeal intrauterine morcellation using the uterus outermost layer as a bag to achieve tissue extraction of very large uteri with suspected occult leiomyosarcoma after TLH. The study enrolled patients who were planned for TLH for large uteri (weight > 500 g). TLH was performed following the procedure reported in our previous studies. The novel technique has been described step-by-step in a video, which representatively describes the preoperative imaging and morcellation procedure of three very large uteri weighing 1500 g, 1700 g, and 3700 g, respectively. The procedures were performed without any complications. The patients had an uneventful postoperative course, and in all cases, the pathology was benign leiomyoma.

CONCLUSION

Extracorporeal intrauterine morcellation using the uterus outmost layer as a bag was found to be a feasible technique that allows a careful diagnosis and safe removal of suspected occult malignancies. The technique herein presented may be adopted in surgical practice, by adding it to the other available techniques of contained morcellation. It may represent a valid and feasible alternative, especially useful in cases of very large uteri exceeding the capacity of specimen retrieval bags.

Keywords: Laparoscopy; Minimally invasive surgery; Morcellation; myomas; Large uterus; Total laparoscopic hysterectomy; Case report

Core Tip: In presence of large uteri, to preserve minimally invasive surgery morcellation is required to allow removal of the specimens from the abdominal cavity. However, uncontained morcellation has been banned because of the possible spread of occult leiomyosarcoma. Therefore, a variety of tissue containment systems have been developed; in particular, in case of very large specimen the practice of in-bag extracorporeal morcellation has been tested. Herein, we describe a novel technique for extracorporeal intrauterine morcellation using the uterus outermost layer as a bag to achieve tissue extraction of very large uteri after total laparoscopic hysterectomy. Such technique showed to be feasible and safe; it may be adopted in surgical practice, as an additional alternative to the currently available techniques of contained morcellation.