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Retained myoma after laparoscopic supracervical hysterectomy with morcellation
August 1998, Vol. 5, No. 3
The JournaL of the American Association of Gynecologic Laparoscopists
Retained Myoma after Laparoscopic Supracervical Hysterectomy with Morcellation Francis L. Hutchins, Jr., M.D., and Elizabeth M. Reinoehl, D.O.
Abstract
Laparoscopic myomectomy and, more recently, laparoscopic supracervical hysterectomy are practical alternatives to traditional surgical management of uterine fibroids. With the advent of mechanical morcellation these procedures are now much more feasible. A 6-cm fibroid was lost at the time of laparoscopic-assisted supracervical hysterectomy and caused persistent, severe abdominal pain over the next 3 weeks. The fibroid was lodged in the region of the liver and gallbladder and required removal by laparotomy. Although retention of fibroids after operative laparoscopy has been reported, it has not been associated with complications. Technical alternatives at the time of operative laparoscopy involving morcellation should be considered to prevent this event. (J Am Assoc Gynecol Laparosc 5(3):293-295, 1998)
As advanced laparoscopic procedures become more common, surgeons encounter new challenges. One of these is complete removal of surgical specimens. Improved techniques for morcellation were developed to meet this challenge. But as morcellation is performed more frequently, identifying and removing all tissue fragments become more complex.
supracervical hysterectomy with intraabdominal morcellation of the uterus. The morcellated specimen had an aggregate weight of 512 g. The patient had an unremarkable postoperative course and was discharged within 24 hours. She was readmitted 2 days later for increasing abdominal pain. Pelvic ultrasound and complete blood cell count were negative, and urine culture and sensitivities were positive. The patient's condition was improved after 3 days, and she was discharged taking antibiotics. She was readmitted 1 month after surgery with increasing pain in the upper right quadrant. Ultrasound and computerized tomographic scans revealed an abdominal mass in the right upper quadrant approximately
Case Report A 42-year-old, para 2 0 0 2, 140-1b woman experienced intermittent pelvic pain and heavy periods. Ultrasound revealed 14.2 x 7.8 x 8.5-cm uterus with a fundal fibroid measuring 9.3 x 6.4 x 8.2 cm. After informed consent, the patient underwent laparoscopic-assisted
From Thomas Jefferson University and Division of Gynecologic Endoscopy, Allegheny University of the Health Sciences (Dr. Hutchins); and the Department of Obstetrics and Gynecology, Philadelphia College of Osteopathic Medicine (Dr. Reinoehl), Philadelphia, Pennsylvania. Address reprint requests to Francis L. Hutchins, Jr., M.D., One Bala Avenue, Suite 120, Bala Cynwyd, PA 19004; fax 610 668 1482. Presented at the 26th annual meeting of the American Association of Gynecologic Laparoscopists, Seattle, Washington, September 23-28, 1997. Accepted for publication May 4, 1998.
293
Retained Myoma after Supracervical Hysterectomy Hutchins and Reinoehl
5 x 7 x 3 cm (Figures 1 and 2). Attempts to drain the mass failed. Exploratory laparotomy revealed a 5.0 x 4.7 x 3.0-cm abdominal mass connected to the gallbladder, ascending colon, omentum, and small bowel. Pathology confirmed infarcted leiomyoma weighing 54 g and measuring 5 x 4.7 x 4.1 cm (Figure 3). The patient had an unremarkable course and was discharged on postoperative day 4 with lessening of pain. Discussion
Until recently, lost surgical specimens at time of laparoscopy were addressed only by anecdotal discussions, and usually these occurred at national or regional meetings such as those sponsored by the AAGL. The first published report on the topic appeared in the February 1997 issue of this journal. 1 In that series of 12 lost tissue specimens, 3 involved retained myomas, the largest of which was 4 x 4 cm. None of the patients experienced significant postoperative sequelae with follow-up over 1 to 2 years. Our case is unusual in several aspects. First, it involved electromechanical morcellation of a large fibroid uterus at the time of laparoscopic hysterectomy. Because of the large quantity of tissue of such a uterus, it would be anticipated that numerous fragments would be generated during morcellation. This is more likely because of the presence of encapsulated fibroids. Once the capsule is invaded, the tumor tends to be freed from uterine myometrium and may drop away from the dominant specimen. The bulk of tissue makes it more difficult for the operator to be fully aware that this has
occurred. This is further complicated by the large size of the overall specimen, which generally requires morcellation to be carried out relatively high in the lower abdomen, adding to the possibility that fragments might be concealed in loops of bowel. Second, our patient developed substantial postoperative symptomatology that required laparotomy to remove the retained specimen. Third, the retained fragment was much larger than lost myomas reported in the earlier article. It is our opinion that the combination of large tissue fragment plus necessity to carry out morcellation relatively high in the pelvis made it more likely not only that a larger fragment could be
FIGURE 2. Computerized tomographic scan of the upper abdominal mass.
FIGURE 1. Ultrasound of the upper abdomen shows the FIGURE 3. Excised fibroid fragment.
mass.
294
August 1998, Vd. 5, No. 3
The journal of the American Association of Gynecologic Laparoscopists
lost, but that this fragment might migrate to the upper abdomen and cause symptoms. The choice of operation in this woman was based on our success performing laparoscopic supracervical hysterectomy. We routinely discharge women within 24 hours after operating on fibroid uteri 14 to 18 weeks in size. The second author practiced subtotal hysterectomy for many years when cervical neoplasia or other contraindications were absent. In recent years this practice was extended to laparoscopic hysterectomy. Simple methods to prevent retained tissue, we believe, do not currently exist. Of course, diligence in keeping track of tissue fragments during morcellation will help to decrease the frequency of losing them.
295
Morcellation techniques that facilitate removal of largest possible tissue pieces should also be helpful. However, it is likely that, for the present, being aware of this complication is most useful. Thus, when a patient complains of localized, persistent, severe pain after an advanced laparoscopic procedure with morcellation, early imaging studies to localize retained fragments, plus a high index of suspicion, may facilitate management by minimally invasive surgery. Reference
1. Hill DJ, Maher PJ, Wood EC: Lost surgical specimens. J Am Assoc Gynecol Laparosc 4(2):277-279, 1997
The JournaL of the American Association of Gynecologic Laparoscopists
Retained Myoma after Laparoscopic Supracervical Hysterectomy with Morcellation Francis L. Hutchins, Jr., M.D., and Elizabeth M. Reinoehl, D.O.
Abstract
Laparoscopic myomectomy and, more recently, laparoscopic supracervical hysterectomy are practical alternatives to traditional surgical management of uterine fibroids. With the advent of mechanical morcellation these procedures are now much more feasible. A 6-cm fibroid was lost at the time of laparoscopic-assisted supracervical hysterectomy and caused persistent, severe abdominal pain over the next 3 weeks. The fibroid was lodged in the region of the liver and gallbladder and required removal by laparotomy. Although retention of fibroids after operative laparoscopy has been reported, it has not been associated with complications. Technical alternatives at the time of operative laparoscopy involving morcellation should be considered to prevent this event. (J Am Assoc Gynecol Laparosc 5(3):293-295, 1998)
As advanced laparoscopic procedures become more common, surgeons encounter new challenges. One of these is complete removal of surgical specimens. Improved techniques for morcellation were developed to meet this challenge. But as morcellation is performed more frequently, identifying and removing all tissue fragments become more complex.
supracervical hysterectomy with intraabdominal morcellation of the uterus. The morcellated specimen had an aggregate weight of 512 g. The patient had an unremarkable postoperative course and was discharged within 24 hours. She was readmitted 2 days later for increasing abdominal pain. Pelvic ultrasound and complete blood cell count were negative, and urine culture and sensitivities were positive. The patient's condition was improved after 3 days, and she was discharged taking antibiotics. She was readmitted 1 month after surgery with increasing pain in the upper right quadrant. Ultrasound and computerized tomographic scans revealed an abdominal mass in the right upper quadrant approximately
Case Report A 42-year-old, para 2 0 0 2, 140-1b woman experienced intermittent pelvic pain and heavy periods. Ultrasound revealed 14.2 x 7.8 x 8.5-cm uterus with a fundal fibroid measuring 9.3 x 6.4 x 8.2 cm. After informed consent, the patient underwent laparoscopic-assisted
From Thomas Jefferson University and Division of Gynecologic Endoscopy, Allegheny University of the Health Sciences (Dr. Hutchins); and the Department of Obstetrics and Gynecology, Philadelphia College of Osteopathic Medicine (Dr. Reinoehl), Philadelphia, Pennsylvania. Address reprint requests to Francis L. Hutchins, Jr., M.D., One Bala Avenue, Suite 120, Bala Cynwyd, PA 19004; fax 610 668 1482. Presented at the 26th annual meeting of the American Association of Gynecologic Laparoscopists, Seattle, Washington, September 23-28, 1997. Accepted for publication May 4, 1998.
293
Retained Myoma after Supracervical Hysterectomy Hutchins and Reinoehl
5 x 7 x 3 cm (Figures 1 and 2). Attempts to drain the mass failed. Exploratory laparotomy revealed a 5.0 x 4.7 x 3.0-cm abdominal mass connected to the gallbladder, ascending colon, omentum, and small bowel. Pathology confirmed infarcted leiomyoma weighing 54 g and measuring 5 x 4.7 x 4.1 cm (Figure 3). The patient had an unremarkable course and was discharged on postoperative day 4 with lessening of pain. Discussion
Until recently, lost surgical specimens at time of laparoscopy were addressed only by anecdotal discussions, and usually these occurred at national or regional meetings such as those sponsored by the AAGL. The first published report on the topic appeared in the February 1997 issue of this journal. 1 In that series of 12 lost tissue specimens, 3 involved retained myomas, the largest of which was 4 x 4 cm. None of the patients experienced significant postoperative sequelae with follow-up over 1 to 2 years. Our case is unusual in several aspects. First, it involved electromechanical morcellation of a large fibroid uterus at the time of laparoscopic hysterectomy. Because of the large quantity of tissue of such a uterus, it would be anticipated that numerous fragments would be generated during morcellation. This is more likely because of the presence of encapsulated fibroids. Once the capsule is invaded, the tumor tends to be freed from uterine myometrium and may drop away from the dominant specimen. The bulk of tissue makes it more difficult for the operator to be fully aware that this has
occurred. This is further complicated by the large size of the overall specimen, which generally requires morcellation to be carried out relatively high in the lower abdomen, adding to the possibility that fragments might be concealed in loops of bowel. Second, our patient developed substantial postoperative symptomatology that required laparotomy to remove the retained specimen. Third, the retained fragment was much larger than lost myomas reported in the earlier article. It is our opinion that the combination of large tissue fragment plus necessity to carry out morcellation relatively high in the pelvis made it more likely not only that a larger fragment could be
FIGURE 2. Computerized tomographic scan of the upper abdominal mass.
FIGURE 1. Ultrasound of the upper abdomen shows the FIGURE 3. Excised fibroid fragment.
mass.
294
August 1998, Vd. 5, No. 3
The journal of the American Association of Gynecologic Laparoscopists
lost, but that this fragment might migrate to the upper abdomen and cause symptoms. The choice of operation in this woman was based on our success performing laparoscopic supracervical hysterectomy. We routinely discharge women within 24 hours after operating on fibroid uteri 14 to 18 weeks in size. The second author practiced subtotal hysterectomy for many years when cervical neoplasia or other contraindications were absent. In recent years this practice was extended to laparoscopic hysterectomy. Simple methods to prevent retained tissue, we believe, do not currently exist. Of course, diligence in keeping track of tissue fragments during morcellation will help to decrease the frequency of losing them.
295
Morcellation techniques that facilitate removal of largest possible tissue pieces should also be helpful. However, it is likely that, for the present, being aware of this complication is most useful. Thus, when a patient complains of localized, persistent, severe pain after an advanced laparoscopic procedure with morcellation, early imaging studies to localize retained fragments, plus a high index of suspicion, may facilitate management by minimally invasive surgery. Reference
1. Hill DJ, Maher PJ, Wood EC: Lost surgical specimens. J Am Assoc Gynecol Laparosc 4(2):277-279, 1997