Minimally Invasive Therapy & Allied Technologies
ISSN: 1364-5706 (Print) 1365-2931 (Online) Journal homepage: http://www.tandfonline.com/loi/imit20
Safe endobag morcellation in a single-port laparoscopy subtotal hysterectomy Stefano Angioni, Alessandro Pontis, Angelo Multinu & Gianbenedetto Melis To cite this article: Stefano Angioni, Alessandro Pontis, Angelo Multinu & Gianbenedetto Melis (2015): Safe endobag morcellation in a single-port laparoscopy subtotal hysterectomy, Minimally Invasive Therapy & Allied Technologies, DOI: 10.3109/13645706.2015.1109521 To link to this article: http://dx.doi.org/10.3109/13645706.2015.1109521
Published online: 19 Nov 2015.
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Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=imit20 Download by: [New York University]
Date: 23 November 2015, At: 14:51
MINIMALLY INVASIVE THERAPY & ALLIED TECHNOLOGIES, 2015 http://dx.doi.org/10.3109/13645706.2015.1109521
CASE REPORT
Safe endobag morcellation in a single-port laparoscopy subtotal hysterectomy Stefano Angionia, Alessandro Pontisb, Angelo Multinub and Gianbenedetto Melisa
Downloaded by [New York University] at 14:51 23 November 2015
a Department of Surgical Sciences, University of Cagliari, Monserrato, Italy; bU.O.C Obstetric and Gynecology, Ospedale San Francesco, Nuoro Italy
ABSTRACT
ARTICLE HISTORY
Recently, the American Food and Drug Administration (FDA) published an alert about the risks of uterine tissue morcellation during laparoscopic procedures. In particular, the possible risk of spreading an undiagnosed malignant tumor was emphasized. From then on, a fervent debate in the media has led major scientific societies to express their position on the matter. We present a safe endobag abdominal morcellation in a single port-access laparoscopy subtotal hysterectomy. The endobag abdominal morcellation is feasible and safe; consequently, the development of devices dedicated to intracavitary morcellation in a closed system has been encouraged.
Received 5 May 2015 Accepted 17 September 2015 Published online 18 November 2015
Introduction Minimally invasive surgery has substantially decreased both the length of hospital stays and the need for postoperative analgesia, as well as improved recovery times (1–2). Laparoscopic subtotal hysterectomy (SLH) is a minimally invasive surgical procedure that was developed during the 1990s for the treatment of abnormal uterine bleeding with or without uterine fibromas. For obvious reasons, in such cases, it is essential to fragment the uterus for complete extraction with electromedical fragmentation (morcellation) based on the use of a mechanical device characterized by a cylindrical blade that rotates at high speed. Unfortunately, electric morcellation may thus result in the micro diffusion of cells in the peritoneal cavity, with the possible implantation of fibromatous tissue in ectopic locations, even in cases of histological benignity (3). By the same kind of mechanism, such a form of dissemination and subsequent implantation is more likely to occur wherever the histological nature of the morcellated lesion corresponds to a preoperatively unexpected malignant condition (4,5). Single port-access laparoscopy subtotal hysterectomy (SPAL-SH) was first introduced in 1992, when Pelosi et al. performed a subtotal hysterectomy with a single umbilical puncture (6). This procedure did not gain wide acceptance by gynecologic surgeons right away because the available instruments were not adequate for some technical challenges. Since 2009, the development of single-access trocars and
KEYWORDS
Myoma, sarcoma, endometrial cancer, laparoscopy, morcellation, single port laparoscopy, LESS
technical improvements has increased the use of singleaccess laparoscopy in many gynecological indications (7–12). From then on, we began to perform a SPAL-SH through an intra-umbilical incision. Now, we present a safe endobag morcellation in a single-port access laparoscopy subtotal hysterectomy.
Case A 44-year-old woman presented herself at our clinic with a one-year history of metrorrhagia and symptomatic leiomyoma resistant to medical therapy. She reported a cesarean section in 2006 and no history of previous systemic disease pathology. Transvaginal ultrasonography showed a retroverted uterus with a longitudinal diameter of 125 mm, anterioposterior diameter of 50 mm, and transverse diameter of 55 mm; a left ovary increased in size due to the presence of an anechoic cyst of 50 x 40 mm, with an internal baffle not vascularized and regular right ovary. Cervical cytology and an office diagnostic hysteroscopy with endometrial biopsy revealed no evidence of malignancy. After counseling, the patient decided to undergo a single-port subtotal hysterectomy with a left salpingo-oophorectomy, right salpingectomy, and preservation of the right ovary. In the written consent, the patient accepted the choice to morcellate the uterus inside a bag in order to avoid spillage into the abdominal cavity. The procedure time was 90 minutes, and the estimated blood loss was540 cc.
CONTACT S. Angioni [email protected] Department of Surgical Sciences, Section of Obstetrics & Gynecology, University of Cagliari, Azienda Ospedaliero Universitaria, Blocco Q, 09124 Monserrato, Italy ß 2015 Taylor & Francis
2
S. ANGIONI ET AL.
The abdominal endobag morcellation was performed in this patient without difficulty. There was no intraabdominal spill during the morcellation procedure. She was discharged home on postoperative day two. Her pain (VAS score) measured immediately after surgery in the recovery unit was 5.5; postoperative pain scores after six, 24, and 48 hours were 4, 4, and 3, respectively. Pathology revealed a 450-g uterus with no evidence of malignancy. In the next section, we will describe, step by step, the endo-bag morcellation procedure during a single-port subtotal hysterectomy with left salpingo-oophorectomy, right salpingectomy, and preservation of the right ovary.
Downloaded by [New York University] at 14:51 23 November 2015
Surgical procedure A 2-cm intra-umbilical vertical skin incision and a 2.5-cm rectus fasciotomy were perfomed to enter the peritoneal cavity. The single-port trocar (S-Portal X-Cone; Karl Storz, Tuttlingen, Germany) was inserted into the abdominal cavity, and the abdomen was insufflated to 12 mmHg. This single-port trocar device allows the simultaneous passage of various laparoscopic instruments through one small opening and has the added advantage of being reusable. Following the placement of the X-Cone, the surgeon stood behind the patient’s left shoulder, the assistant at the level of the patient’s right shoulder, and the monitor was positioned between the patient’s legs. A rigid, 30 , 5 mm-diameter, 50 cm-long, Hopkins high-definition 3-chip camera (Karl Storz, Tuttlingen, Germany) was used. For the surgical procedure, a rigid, single, curved forceps or scissors (Karl Storz, Tuttlingen, Germany) and a rotating and curveable multifunctional device (ENSEALÕ G2 Curved and Straight Tissue Sealers, Ethicon, Cincinnati, OH, USA) were used simultaneously. Cervical detachment was performed using a monopolar loop (Brucker/ Messroghli SupraLoop, Karl Storz, Tuttlingen, Germany). To prevent adhesions on the cervical stump, a site-specific adhesion prevention gel was used (Hyalobarrier Gel Endo, Anika Therapeutics Inc., Abano Terme, Italy). Suture of the umbilicus was performed as usual (7).
Figure 1. Specimen inserted inside the endobag.
Figure 2. Positioning the endoscope inside the cervix.
The X-Cone was removed, and the endo bag was lifted, exposing its edge outside the abdomen. The CO2 insufflation of the abdomen was continued, with the tube inserted in the umbilicus and kept in place by the assistant-lifted endo-bag (Endo CatchTM Specimen Pouch 15-mm, Covidien, Mansfield, MA, USA) (Figure 3); With a continued view of the endobag, the uterus was morcellated with the bipolar morcellator (PKS PlasmaSORD, Olympus Medical System Europa, Hamburg, Germany), and once the specimen was reduced enough, the sac was extracted (Figure 4).
Step-by-step morcellation
After completing the subtotal hysterectomy, a large bag was inserted inside the abdominal cavity, opened in the pelvis and the specimen was introduced inside it (Figure 1). The endoscope was inserted inside the cervix, and it was positioned in order to see the anterior abdominal wall (Figure 2).
Discussion A subtotal hysterectomy is a minimally invasive surgical option that we can propose to patients with symptomatic adenomyosis or dysfunctional uterine bleeding not responsive to medical treatment. Once surgery is decided upon, the presurgical evaluation should exclude any
ENDOBAG MORCELLATION IN SINGLE-PORT SUBTOTAL HYSTERECTOMY
Downloaded by [New York University] at 14:51 23 November 2015
Figure 3. View of the lifted endobag and of the CO2 insufflation tube.
3
continuous control of the 5-mm endoscope through the cervical canal. Another element of safety is related to the type of morcellation we have used. The PKS PlasmaSORD is a bipolar morcellator that is completely bladeless and allows tissue removal without the risk of inadvertent sac rupture. It does not rotate the tissue, facilitating the extraction inside the endobag. It is not necessary to fill the bag with CO2, as the tissue is cut inside the device. The procedure is very simple and quick and could be proposed even in multiport laparoscopy enlarging an ancillary port to 15–20 mm. SPAL surgery seems to have advantages for patients in terms of postoperative pain and cosmesis and has enlarged its gynecological indications (16–20). SPAL subtotal hysterectomy is a safe and feasible procedure that could be proposed to patients with benign uterine disease (20). Beside the possible advantage related to this minimally invasive procedure, the safe extraction of the specimen could enlarge its role in the future. The authors have no commercial, proprietary, or financial interest in the products or companies described Morcellation of the corpus uteri inside the endobag in this article.
References
Figure 4. Morcellation of the corpus uteri inside the endobag.
suspicion of malignant disease to minimize the possible risk related to morcellation, as recently recommended by many scientific societies (10). In these patients, it is mandatory to perform an office hysteroscopy and an endometrial biopsy to rule out endometrial carcinoma (11,12). Unfortunately, at the moment, a presurgical exclusion diagnosis of uterine sarcoma is still not absolutely available. Moreover, according to the case studies in the available literature, the possibility of postoperative histological diagnosis of these types of lesions not previously identified is in the range of 0.08% to 0.13%. This can worsen the prognosis of the patient, with a decrease of 73% to 46% in the five-year survival rate, depending on whether the lesion has been extracted intact or after morcellation (13–15). Systems of closed morcellation to minimize any possible risk are advisable (13). The presented case underscores that single-port access allows the possibility of a safe morcellation in a subtotal hysterectomy. In fact this approach is simple. The 2.5 umbilical access allows the morcellation inside the plastic sac at the level of the abdominal wall under
1. Angioni S, Pontis A, Dessole M, Surico D, De Cicco Nardone C, Melis I. Pain control and quality of life after laparoscopic en-block resection of deep infiltrating endometriosis (DIE) vs. incomplete surgical treatment with or without GnRHa administration after surgery. Arch Gynecol Obstet. 2015;291:363–70. 2. Pluchino N, Litta P, Freschi L, Russo M, Simi G, Santoro AN et al. Comparison of the initial surgical experience with robotic and laparoscopic myomectomy. Int J Med Robot. 2014 Jun;10:208–12. 3. Senapati S, Tu FF, Magrina JF. Power morcellators: a review of current practice and assessment of risk. Am J Obstet Gynecol.2015,212:18–23. 4. Theben JU, Schellong ARM, Altgassen C, Kelling K, Schneider S, Grobe-Drieling. Unexpected malignancies after laparoscopic-assisted supracervical hysterectomies (LASH): An analysis of 1,584 LASH cases. Arch Gynecol Obstet. 2013;287:455–62. 5. Parker WH, Fu YS, Berek JS. Uterine sarcoma in patients operated on for presumed leiomyoma and rapidly growing leiomyoma. Obstet Gynecol. 1994;83:414–8. 6. Pelosi MA, Pelosi MA Laparoscopic supracervical hysterectomy using a single-umbilical puncture (minilaparoscopy). J Reprod Med. 1992;37:777–84. 7. Mereu L, Angioni S, Melis GB, Mencaglia L. Single access laparoscopy for adnexal pathologies using a novel reusable port and curved instruments. Int J Gynaecol Obstet. 2010;109:78–80. 8. Angioni S, Pontis A, Cela V, Sedda F, Gennazzani A, Nappi L. Surgical technique of endometrioma excision impacts on the ovarian reserve. Single-port access
4
S. ANGIONI ET AL.
9.
10.
11.
Downloaded by [New York University] at 14:51 23 November 2015
12.
13. 14.
laparoscopy versus multiport access laparoscopy: a case control study. Gynecol Endocrinol. 2015;31:454–7. Angioni S, Pontis A, Sorrentino F, Nappi L. Bilateral salpingo-oophorectomy and adhesiolysis with single port access laparoscopy and use of diode laser in a BRCA carrier. Eur J Gynaecol Oncol. 2015;36:479–81. Angioni S, Malzoni M, Schettini S. Recommendations for laparoscopic morcellation of uterus and leiomyomas. Position paper of the SEGi (Societa` Italiana di Endoscopia Ginecologica). Giorn It Gin Ost. 2015;37:61–5. Di Spiezio Sardo A, Bettocchi S, Spinelli M, Guida M, Nappi L, Angioni S, et al. Review of new office-base hysteroscopic procedure 2003-2009. J of Minim Invas Gynecol. 2010;17:436–48. Angioni S, Loddo A, Milano F, Piras B, Minerba L, Melis GB. Detection of benign intracavitary lesions in postmenopausal women with abnormal uterine bleeding: a prospective comparative study on outpatient hysteroscopy and blind biopsy. J Minim Invasive Gynecol. 2008;15:87–91. http://www.fda.gov/MedicalDevices/Safety/Alertsand Notices/ucm393576.htm Brooks SE, Zhan M, Cote T, Baquet CR. Surveillance, epidemiology, and end results analysis of 2677 cases of uterine sarcoma 1989 to 1999. Gyn Oncol. 2004;93:204–8.
15. Park JY, Park SK, Kim DY, et al. The impact of tumor morcellation during surgery on the prognosis of patients with apparently early uterine leiomyosarcoma. Gynecol Oncol. 2011;122:255–9. 16. Einstein MH, Barakat RR, Chi DS, et al. Management of uterine malignancy found incidentally after supracervical hysterectomy or uterine morcellation for presumed benign disease. IntJ Gynecol Cancer 2008;18:1065–70. 17. Kujansuu S, Salari BW, Galloway M, Findley A, Yaklis JL, Massengill JC et al. Contained morcellation using the GelPOINT advance access platforms and 3M SteriDrape endobag. Fertil Steril 2015. doi:10.1016/j.fernstert. 2015.02.017. 18. Mencaglia L, Mereu L, Carri G, Arena I, Khalifa H, Tateo S, et al. Single port entry-are there any advantages? Best Pract Res Clin Obstet Gynaecol. 2013;27:441–55. 19. Angioni S, Pontis A, Sedda F, Zampetoglou T, Cela V, Mereu L et al. Single-port vs conventional multi-port access prophylactic laparoscopic bilateral salpingooophorectomy (SO) in high risk patients for ovarian cancer. Comparison of surgical outcomes. Onco Targets Ther. 2015;8:1575–80. 20. Angioni S, Pontis A, Pisanu A, Mereu L, Roman H. Single port access subtotal laparoscopic hysterectomy: a prospective case-control study. J Minim Invasive Gynecol. 2015 Jul–Aug;22:807–12. doi:10.1016/j.jmig. 2015.03.011
ISSN: 1364-5706 (Print) 1365-2931 (Online) Journal homepage: http://www.tandfonline.com/loi/imit20
Safe endobag morcellation in a single-port laparoscopy subtotal hysterectomy Stefano Angioni, Alessandro Pontis, Angelo Multinu & Gianbenedetto Melis To cite this article: Stefano Angioni, Alessandro Pontis, Angelo Multinu & Gianbenedetto Melis (2015): Safe endobag morcellation in a single-port laparoscopy subtotal hysterectomy, Minimally Invasive Therapy & Allied Technologies, DOI: 10.3109/13645706.2015.1109521 To link to this article: http://dx.doi.org/10.3109/13645706.2015.1109521
Published online: 19 Nov 2015.
Submit your article to this journal
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=imit20 Download by: [New York University]
Date: 23 November 2015, At: 14:51
MINIMALLY INVASIVE THERAPY & ALLIED TECHNOLOGIES, 2015 http://dx.doi.org/10.3109/13645706.2015.1109521
CASE REPORT
Safe endobag morcellation in a single-port laparoscopy subtotal hysterectomy Stefano Angionia, Alessandro Pontisb, Angelo Multinub and Gianbenedetto Melisa
Downloaded by [New York University] at 14:51 23 November 2015
a Department of Surgical Sciences, University of Cagliari, Monserrato, Italy; bU.O.C Obstetric and Gynecology, Ospedale San Francesco, Nuoro Italy
ABSTRACT
ARTICLE HISTORY
Recently, the American Food and Drug Administration (FDA) published an alert about the risks of uterine tissue morcellation during laparoscopic procedures. In particular, the possible risk of spreading an undiagnosed malignant tumor was emphasized. From then on, a fervent debate in the media has led major scientific societies to express their position on the matter. We present a safe endobag abdominal morcellation in a single port-access laparoscopy subtotal hysterectomy. The endobag abdominal morcellation is feasible and safe; consequently, the development of devices dedicated to intracavitary morcellation in a closed system has been encouraged.
Received 5 May 2015 Accepted 17 September 2015 Published online 18 November 2015
Introduction Minimally invasive surgery has substantially decreased both the length of hospital stays and the need for postoperative analgesia, as well as improved recovery times (1–2). Laparoscopic subtotal hysterectomy (SLH) is a minimally invasive surgical procedure that was developed during the 1990s for the treatment of abnormal uterine bleeding with or without uterine fibromas. For obvious reasons, in such cases, it is essential to fragment the uterus for complete extraction with electromedical fragmentation (morcellation) based on the use of a mechanical device characterized by a cylindrical blade that rotates at high speed. Unfortunately, electric morcellation may thus result in the micro diffusion of cells in the peritoneal cavity, with the possible implantation of fibromatous tissue in ectopic locations, even in cases of histological benignity (3). By the same kind of mechanism, such a form of dissemination and subsequent implantation is more likely to occur wherever the histological nature of the morcellated lesion corresponds to a preoperatively unexpected malignant condition (4,5). Single port-access laparoscopy subtotal hysterectomy (SPAL-SH) was first introduced in 1992, when Pelosi et al. performed a subtotal hysterectomy with a single umbilical puncture (6). This procedure did not gain wide acceptance by gynecologic surgeons right away because the available instruments were not adequate for some technical challenges. Since 2009, the development of single-access trocars and
KEYWORDS
Myoma, sarcoma, endometrial cancer, laparoscopy, morcellation, single port laparoscopy, LESS
technical improvements has increased the use of singleaccess laparoscopy in many gynecological indications (7–12). From then on, we began to perform a SPAL-SH through an intra-umbilical incision. Now, we present a safe endobag morcellation in a single-port access laparoscopy subtotal hysterectomy.
Case A 44-year-old woman presented herself at our clinic with a one-year history of metrorrhagia and symptomatic leiomyoma resistant to medical therapy. She reported a cesarean section in 2006 and no history of previous systemic disease pathology. Transvaginal ultrasonography showed a retroverted uterus with a longitudinal diameter of 125 mm, anterioposterior diameter of 50 mm, and transverse diameter of 55 mm; a left ovary increased in size due to the presence of an anechoic cyst of 50 x 40 mm, with an internal baffle not vascularized and regular right ovary. Cervical cytology and an office diagnostic hysteroscopy with endometrial biopsy revealed no evidence of malignancy. After counseling, the patient decided to undergo a single-port subtotal hysterectomy with a left salpingo-oophorectomy, right salpingectomy, and preservation of the right ovary. In the written consent, the patient accepted the choice to morcellate the uterus inside a bag in order to avoid spillage into the abdominal cavity. The procedure time was 90 minutes, and the estimated blood loss was540 cc.
CONTACT S. Angioni [email protected] Department of Surgical Sciences, Section of Obstetrics & Gynecology, University of Cagliari, Azienda Ospedaliero Universitaria, Blocco Q, 09124 Monserrato, Italy ß 2015 Taylor & Francis
2
S. ANGIONI ET AL.
The abdominal endobag morcellation was performed in this patient without difficulty. There was no intraabdominal spill during the morcellation procedure. She was discharged home on postoperative day two. Her pain (VAS score) measured immediately after surgery in the recovery unit was 5.5; postoperative pain scores after six, 24, and 48 hours were 4, 4, and 3, respectively. Pathology revealed a 450-g uterus with no evidence of malignancy. In the next section, we will describe, step by step, the endo-bag morcellation procedure during a single-port subtotal hysterectomy with left salpingo-oophorectomy, right salpingectomy, and preservation of the right ovary.
Downloaded by [New York University] at 14:51 23 November 2015
Surgical procedure A 2-cm intra-umbilical vertical skin incision and a 2.5-cm rectus fasciotomy were perfomed to enter the peritoneal cavity. The single-port trocar (S-Portal X-Cone; Karl Storz, Tuttlingen, Germany) was inserted into the abdominal cavity, and the abdomen was insufflated to 12 mmHg. This single-port trocar device allows the simultaneous passage of various laparoscopic instruments through one small opening and has the added advantage of being reusable. Following the placement of the X-Cone, the surgeon stood behind the patient’s left shoulder, the assistant at the level of the patient’s right shoulder, and the monitor was positioned between the patient’s legs. A rigid, 30 , 5 mm-diameter, 50 cm-long, Hopkins high-definition 3-chip camera (Karl Storz, Tuttlingen, Germany) was used. For the surgical procedure, a rigid, single, curved forceps or scissors (Karl Storz, Tuttlingen, Germany) and a rotating and curveable multifunctional device (ENSEALÕ G2 Curved and Straight Tissue Sealers, Ethicon, Cincinnati, OH, USA) were used simultaneously. Cervical detachment was performed using a monopolar loop (Brucker/ Messroghli SupraLoop, Karl Storz, Tuttlingen, Germany). To prevent adhesions on the cervical stump, a site-specific adhesion prevention gel was used (Hyalobarrier Gel Endo, Anika Therapeutics Inc., Abano Terme, Italy). Suture of the umbilicus was performed as usual (7).
Figure 1. Specimen inserted inside the endobag.
Figure 2. Positioning the endoscope inside the cervix.
The X-Cone was removed, and the endo bag was lifted, exposing its edge outside the abdomen. The CO2 insufflation of the abdomen was continued, with the tube inserted in the umbilicus and kept in place by the assistant-lifted endo-bag (Endo CatchTM Specimen Pouch 15-mm, Covidien, Mansfield, MA, USA) (Figure 3); With a continued view of the endobag, the uterus was morcellated with the bipolar morcellator (PKS PlasmaSORD, Olympus Medical System Europa, Hamburg, Germany), and once the specimen was reduced enough, the sac was extracted (Figure 4).
Step-by-step morcellation
After completing the subtotal hysterectomy, a large bag was inserted inside the abdominal cavity, opened in the pelvis and the specimen was introduced inside it (Figure 1). The endoscope was inserted inside the cervix, and it was positioned in order to see the anterior abdominal wall (Figure 2).
Discussion A subtotal hysterectomy is a minimally invasive surgical option that we can propose to patients with symptomatic adenomyosis or dysfunctional uterine bleeding not responsive to medical treatment. Once surgery is decided upon, the presurgical evaluation should exclude any
ENDOBAG MORCELLATION IN SINGLE-PORT SUBTOTAL HYSTERECTOMY
Downloaded by [New York University] at 14:51 23 November 2015
Figure 3. View of the lifted endobag and of the CO2 insufflation tube.
3
continuous control of the 5-mm endoscope through the cervical canal. Another element of safety is related to the type of morcellation we have used. The PKS PlasmaSORD is a bipolar morcellator that is completely bladeless and allows tissue removal without the risk of inadvertent sac rupture. It does not rotate the tissue, facilitating the extraction inside the endobag. It is not necessary to fill the bag with CO2, as the tissue is cut inside the device. The procedure is very simple and quick and could be proposed even in multiport laparoscopy enlarging an ancillary port to 15–20 mm. SPAL surgery seems to have advantages for patients in terms of postoperative pain and cosmesis and has enlarged its gynecological indications (16–20). SPAL subtotal hysterectomy is a safe and feasible procedure that could be proposed to patients with benign uterine disease (20). Beside the possible advantage related to this minimally invasive procedure, the safe extraction of the specimen could enlarge its role in the future. The authors have no commercial, proprietary, or financial interest in the products or companies described Morcellation of the corpus uteri inside the endobag in this article.
References
Figure 4. Morcellation of the corpus uteri inside the endobag.
suspicion of malignant disease to minimize the possible risk related to morcellation, as recently recommended by many scientific societies (10). In these patients, it is mandatory to perform an office hysteroscopy and an endometrial biopsy to rule out endometrial carcinoma (11,12). Unfortunately, at the moment, a presurgical exclusion diagnosis of uterine sarcoma is still not absolutely available. Moreover, according to the case studies in the available literature, the possibility of postoperative histological diagnosis of these types of lesions not previously identified is in the range of 0.08% to 0.13%. This can worsen the prognosis of the patient, with a decrease of 73% to 46% in the five-year survival rate, depending on whether the lesion has been extracted intact or after morcellation (13–15). Systems of closed morcellation to minimize any possible risk are advisable (13). The presented case underscores that single-port access allows the possibility of a safe morcellation in a subtotal hysterectomy. In fact this approach is simple. The 2.5 umbilical access allows the morcellation inside the plastic sac at the level of the abdominal wall under
1. Angioni S, Pontis A, Dessole M, Surico D, De Cicco Nardone C, Melis I. Pain control and quality of life after laparoscopic en-block resection of deep infiltrating endometriosis (DIE) vs. incomplete surgical treatment with or without GnRHa administration after surgery. Arch Gynecol Obstet. 2015;291:363–70. 2. Pluchino N, Litta P, Freschi L, Russo M, Simi G, Santoro AN et al. Comparison of the initial surgical experience with robotic and laparoscopic myomectomy. Int J Med Robot. 2014 Jun;10:208–12. 3. Senapati S, Tu FF, Magrina JF. Power morcellators: a review of current practice and assessment of risk. Am J Obstet Gynecol.2015,212:18–23. 4. Theben JU, Schellong ARM, Altgassen C, Kelling K, Schneider S, Grobe-Drieling. Unexpected malignancies after laparoscopic-assisted supracervical hysterectomies (LASH): An analysis of 1,584 LASH cases. Arch Gynecol Obstet. 2013;287:455–62. 5. Parker WH, Fu YS, Berek JS. Uterine sarcoma in patients operated on for presumed leiomyoma and rapidly growing leiomyoma. Obstet Gynecol. 1994;83:414–8. 6. Pelosi MA, Pelosi MA Laparoscopic supracervical hysterectomy using a single-umbilical puncture (minilaparoscopy). J Reprod Med. 1992;37:777–84. 7. Mereu L, Angioni S, Melis GB, Mencaglia L. Single access laparoscopy for adnexal pathologies using a novel reusable port and curved instruments. Int J Gynaecol Obstet. 2010;109:78–80. 8. Angioni S, Pontis A, Cela V, Sedda F, Gennazzani A, Nappi L. Surgical technique of endometrioma excision impacts on the ovarian reserve. Single-port access
4
S. ANGIONI ET AL.
9.
10.
11.
Downloaded by [New York University] at 14:51 23 November 2015
12.
13. 14.
laparoscopy versus multiport access laparoscopy: a case control study. Gynecol Endocrinol. 2015;31:454–7. Angioni S, Pontis A, Sorrentino F, Nappi L. Bilateral salpingo-oophorectomy and adhesiolysis with single port access laparoscopy and use of diode laser in a BRCA carrier. Eur J Gynaecol Oncol. 2015;36:479–81. Angioni S, Malzoni M, Schettini S. Recommendations for laparoscopic morcellation of uterus and leiomyomas. Position paper of the SEGi (Societa` Italiana di Endoscopia Ginecologica). Giorn It Gin Ost. 2015;37:61–5. Di Spiezio Sardo A, Bettocchi S, Spinelli M, Guida M, Nappi L, Angioni S, et al. Review of new office-base hysteroscopic procedure 2003-2009. J of Minim Invas Gynecol. 2010;17:436–48. Angioni S, Loddo A, Milano F, Piras B, Minerba L, Melis GB. Detection of benign intracavitary lesions in postmenopausal women with abnormal uterine bleeding: a prospective comparative study on outpatient hysteroscopy and blind biopsy. J Minim Invasive Gynecol. 2008;15:87–91. http://www.fda.gov/MedicalDevices/Safety/Alertsand Notices/ucm393576.htm Brooks SE, Zhan M, Cote T, Baquet CR. Surveillance, epidemiology, and end results analysis of 2677 cases of uterine sarcoma 1989 to 1999. Gyn Oncol. 2004;93:204–8.
15. Park JY, Park SK, Kim DY, et al. The impact of tumor morcellation during surgery on the prognosis of patients with apparently early uterine leiomyosarcoma. Gynecol Oncol. 2011;122:255–9. 16. Einstein MH, Barakat RR, Chi DS, et al. Management of uterine malignancy found incidentally after supracervical hysterectomy or uterine morcellation for presumed benign disease. IntJ Gynecol Cancer 2008;18:1065–70. 17. Kujansuu S, Salari BW, Galloway M, Findley A, Yaklis JL, Massengill JC et al. Contained morcellation using the GelPOINT advance access platforms and 3M SteriDrape endobag. Fertil Steril 2015. doi:10.1016/j.fernstert. 2015.02.017. 18. Mencaglia L, Mereu L, Carri G, Arena I, Khalifa H, Tateo S, et al. Single port entry-are there any advantages? Best Pract Res Clin Obstet Gynaecol. 2013;27:441–55. 19. Angioni S, Pontis A, Sedda F, Zampetoglou T, Cela V, Mereu L et al. Single-port vs conventional multi-port access prophylactic laparoscopic bilateral salpingooophorectomy (SO) in high risk patients for ovarian cancer. Comparison of surgical outcomes. Onco Targets Ther. 2015;8:1575–80. 20. Angioni S, Pontis A, Pisanu A, Mereu L, Roman H. Single port access subtotal laparoscopic hysterectomy: a prospective case-control study. J Minim Invasive Gynecol. 2015 Jul–Aug;22:807–12. doi:10.1016/j.jmig. 2015.03.011
