Short- and Long-Term Complications of Intraoperative Benign Ovarian Cyst Spillage: A Systematic Review and Meta-analysis.

OBJECTIVE: To review short- and long-term complications associated with intraoperative rupture of benign ovarian cysts. DATA SOURCES: The Cochrane Central Register of Controlled Trials, BIOSIS, Medline (Ovid), Web of Science, ClinicalTrials.gov, and Google Scholar were searched using the following terms and their combinations: "spillage," "rupture," "leakage," "ovarian cyst," "teratoma," "dermoid," "operative," "surgery," "outcome." METHODS OF STUDY SELECTION: Randomized controlled and observational studies evaluating the operative outcomes of surgical treatment of ovarian cysts with intraoperative spillage compared with those of surgical treatment of ovarian cysts without spillage were included. A systematic review and meta-analysis following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed. TABULATION, INTEGRATION, AND RESULTS: A total of 28 studies were included in the qualitative analysis and 12 in the quantitative analysis. Ovarian cyst diameter was not found to be associated with the risk for spillage (relative risk [RR] 0.75; 95% confidence interval [CI], -0.33 to 1.82). Intraoperative benign ovarian cyst rupture was not associated with adverse short- and long-term outcomes such as reoperation (RR 1.16; 95% CI, 0.39-3.48), infertility (RR 0.73; 95% CI, 0.15-3.63), transient fever (RR 3.22; 95% CI, 0.83-12.51), and readmission (RR 1.00; 95% CI, 0.33-2.98). However, intraoperative spillage was found to be associated with increased risk for benign recurrence (RR 3.1; 95% CI, 1.05-9.14). A subgroup analysis of the studies that included only dermoid cysts showed an association between intraoperative cyst rupture and postoperative chemical peritonitis (RR 9.36; 95% CI, 1.20-73.28). CONCLUSION: Intraoperative ovarian cyst spillage of a benign cyst is associated with limited adverse clinical outcomes. Although the surgical approach (minimally invasive vs open) should not be affected by the concern regarding an intraoperative cyst rupture, maximal efforts should be made to prevent intra-abdominal spillage.

Contained Morcellation of Very Large Uterus.

A 38-year-old woman was referred to our centre for symptomatic leiomyoma. The patient had a large uterus, heavy menstrual bleeding, and compressive symptoms refractory to medical treatments. The patient was then scheduled for total laparoscopic hysterectomy with contained morcellation. After circular colpotomy completion, a strong, folded, 4-L bag with an additional sleeve for the optics was inserted into the abdominal cavity through the vagina. The colored tabs on the edge of the bag mouth served as landmarks during bag deployment. After ensuring optimal positioning, the entire bag was fully deployed, and the specimen was placed inside. Thereafter, the coloured tabs were joined together, and a monofilament drawstring was cinched to close the bag and pulled out through the suprapubic trocar. Next, the small extra sleeve was brought up through the umbilical incision. The bag was then insufflated, and the power morcellator was inserted through the suprapubic incision. After completing the morcellation, the pneumo bag was evacuated, and knots were made in both openings of the bag to avoid spillage. The closed bag was finally removed through the vagina, with final laparoscopic closure of the vaginal vault.

Morcellation During Total Laparoscopic Hysterectomies: Implications of the Use of a Contained Bag System.

OBJECTIVE: This study sought to report the feasibility and clinical implications of in-bag morcellation for total laparoscopic hysterectomy (TLH). METHODS: Women who required uterine morcellation during TLH from January 2017 to December 2018 (at the Centre Hospitalier Universitaire de Québec - CHUL, Québec, QC) were included. Women with a preoperative suspicion of malignancy were excluded (Canadian Task Force classification II-2). RESULTS: During the 2-year study period, uterine morcellation was required in 42% (106 of 252) of women undergoing TLH. Mean uterine weight of morcellated uterus was 541 ± 291 g, with 11 of 106 uteri weighing >1000 g. In-bag morcellation was attempted in 84 of 106 (79%) and successfully performed in 79 of 84 (94%) women. Failures resulted from inability to insert the specimen into the bag or apparent perforation. Uncontained morcellation was chosen for 22 of 106 (21%) women, most of whom underwent vaginal morcellation of the uterus. Total operative time was 40 minutes longer for the in-bag morcellation group (170 ± 48 vs. 130 ± 43 min; P < 0.001), although this difference can be partly explained by the higher mean uterine size compared with the uncontained morcellation group (580 ± 309 vs. 391 ± 122 g; P = 0.01). In a subgroup analysis of 16 women, the mean times of installation and extraction of the bag were estimated to be 17 ± 9 and 4 ± 3 minutes, respectively. Complications were infrequent (2 of 106) and occurred in the in-bag morcellation group. CONCLUSION: In-bag morcellation is feasible in a high proportion of women undergoing laparoscopic hysterectomy and is associated with an increase in operative time. Larger studies will be required in order to better assess the risk of complications with in-bag morcellation and the potential benefits of this technique, namely, reducing the spread of tissue.