Disseminated leiomyoma cells can be identified following conventional myomectomy.

OBJECTIVE: Uncontained morcellation of leiomyomas during laparoscopic surgery has recently been discouraged, as undetected malignant tumours, namely leiomyosarcomas, could be fragmented which may result in upstaged disease. However, enucleating leiomyomas per se may be inappropriate from an oncological perspective because complete, radical resection of malignant tumours to prevent further tumour growth or recurrence is not achieved. Thus, the aim of this study was to determine whether spillage of leiomyoma cells occurs during laparotomic myomectomy. DESIGN: Observational study. SETTING: Tertiary academic centre in the Netherlands. POPULATION: Women undergoing laparotomic myomectomy were included in the study. METHODS: Peritoneal abdominal washings were obtained on two occasions during the myomectomy procedure; the first one immediately after opening the abdomen and the second one after resection of the leiomyoma(s). Cytological evaluation of the fluids was performed. MAIN OUTCOME MEASURES: The presence of leiomyoma cells in any of the washings. RESULTS: Five patients were included in this pilot study. All first washings were negative for leiomyoma cells. However, cytology positive for the presence of leiomyoma cells was found in three of the five second, post-myomectomy washings. CONCLUSION: Tissue spillage from leiomyoma(s) occurs during conventional open myomectomy. The clinical relevance of tissue dissemination after myomectomy is unclear but it cannot be excluded that this may negatively affect the patient's outcome if there is malignant change within the enucleated leiomyoma(s). Therefore, it is questionable whether morcellation in specially designed containment bags after laparoscopic myomectomy, guarantees any additional oncological safety. TWEETABLE ABSTRACT: Even during conventional myomectomy, tissue spillage occurs during resection of leiomyoma(s).

A new approach to simplify surgical colpotomy in laparoscopic hysterectomy.

New surgical techniques and technology have simplified laparoscopic hysterectomy and have enhanced the safety of this procedure. However, the surgical colpotomy step has not been addressed. This study evaluates the surgical colpotomy step in laparoscopic hysterectomy with respect to difficulty and duration. Furthermore, it proposes an alternative route that may simplify this step in laparoscopic hysterectomy. A structured interview, a prospective cohort study, and a problem analysis were performed regarding experienced difficulty and duration of surgical colpotomy in laparoscopic hysterectomy. Sixteen experts in minimally invasive gynecologic surgery from 12 hospitals participated in the structured interview using a 5-point Likert scale. The colpotomy in LH received the highest scores for complexity (2.8 ± 1.2), compared to AH and VH. Colpotomy in LH was estimated as more difficult than in AH (2.8 vs 1.4, p < .001). In the cohort study, 107 patients undergoing LH were included. Sixteen percent of the total procedure time was spent on colpotomy (SD 7.8 %). BMI was positively correlated with colpotomy time, even after correcting for longer operation time. No relation was found between colpotomy time and blood loss or uterine weight. The surgical colpotomy step in laparoscopic hysterectomy should be simplified as this study demonstrates that it is time consuming and is considered to be more difficult than in other hysterectomy procedures. A vaginal approach to the colpotomy is proposed to achieve this simplification.

Efficacy and safety of uterine manipulators in laparoscopic surgery: a review.

PURPOSE: This review aims to objectively assess the efficacy and safety of uterine manipulators as reported in scientific literature. Furthermore, it evaluates as to which manipulator best suits which surgical procedure. METHODS: PubMed, Embase, Web of Science, COCHRANE, CINAHL, Academic Search Premier, Science Direct and the MAUDE database were searched. Technical information was retrieved from the manufacturers. RESULTS: 25 articles covering 10 uterine manipulators were found. Studies regarding implementation and use of manipulators are scarce; only two surveys were found comparing different manipulators. Moreover, clinical evidence proving the efficacy of manipulators with respect to prevention of complications, inherent to laparoscopic surgery, does not exist. CONCLUSION: The use of uterine manipulators is well established and it is clear that uterine manipulators offer the easiest way to handle the uterus during surgery. However, detailed information regarding efficacy and safety is scarce. Clinical evidence substantiating the assumed mechanism of prevention of ureter injuries was not found. Our review did not find the optimal manipulator. Some are more versatile than others and not all instruments are appropriate for all types of surgery. Therefore, gynecologists should choose the manipulator that best suits the type of surgery that is performed.