Scalpel Morcellation During Laparoscopic Hysterectomy for Large Uterine Fibroids. Is It a Safe Alternative to Power-Morcellation?

This case series was done in the Department of Surgical Oncology, Oncology Center, Mansoura University (OCMU), Egypt. Between April 2016 and May 2021, fifty-two lady patients underwent laparoscopic hysterectomy and manual scalpel morcellation of the uterus for easy vaginal extraction of specimens. An Institutional Research Board (IRB) approval of the Faculty of Medicine, Mansoura University code (R.21.07.1387) was obtained. All patients with benign uterine diseases such as leiomyoma, adenomyosis, and dysfunctional uterine bleeding were enrolled in this study. Patients excluded from this study were those with pathologically confirmed uterine malignancy, a history of ≥ 2 years of tamoxifen therapy, a history of pelvic irradiation, patients with radiological suspicious uterine mass, and those unfit for general anesthesia or laparoscopic surgeries. The procedure was explained to the patients and written informed consent was obtained from all the patients before surgery. Demographic and clinical features were collected from the patients’ database registry in OCMU. Preoperative preparations included pelviabdominal ultrasonography (US), measurement of the uterine size (by bimanual examination according to the appropriate pregnancy week), dilatation, and curettage (D&C) for any patient with a thick endometrial plate to exclude endometrial carcinoma and pelvic MRI for any suspicious uterine mass with guided needle biopsy to exclude sarcomatous changes.

All surgical procedures were performed under general anesthesia by the same surgical team. The procedures started with pneumoperitoneum, then 3 laparoscopy ports were placed; one port sized 10 mm in the umbilicus for the 30-degree rigid camera, and two working 5 mm ports were placed following the baseball diamond concept. Careful examination of the peritoneum was done for adhesions, implantation and to rule out uterine leiomyosarcoma. A uterine manipulator was applied at the start of the procedure to facilitate manipulation of the uterus for easier dissection and visualization of the pelvic structures.

Laparoscopic hysterectomy started with transection of the round ligaments lateral to the uterus using the Ligasure (by Covidien™) then the broad ligaments were dissected on both sides into anterior and posterior leaflets. An incision in the anterior leaflet was done toward the bladder for bladder flap formation, and the bladder was dissected away from the uterus utilizing either the harmonic scalpel (by Ethicon™) or Ligasure (by Covidien™). Transection of the infundibulopelvic ligaments was done using the 5 mm LigaSure (by Covidien™) in cases associated with salpingo-oophorectomy or the ovarian ligaments when ovaries were preserved. The uterine manipulator was then pushed cranially to ensure that the uterine arteries were away from the ureters. The ascending uterine vessels were skeletonized, sealed, and divided using the 5 mm Ligasure, then the uterus was separated from the vagina.

For the specimen delivery, No.24 scalpel was inserted through the abdominal wall (Fig. 1a) in the suprapubic region or through the previous Pfannenstiel incision in patients with a history of Cesarean section (CS). The uterus is grasped from two opposing points and approximated to the anterior abdominal wall (Fig. 1b). The scalpel morcellation was started in the craniocaudal direction from the fundus of the uterus (Fig. 2) till the complete separation of the uterus into two halves with the preservation of its gross architecture (Fig. 3). Each half is then delivered easily from the vagina using artery forceps. The vagina is closed with intracorporeal sutures and the scalpel entrance site in the anterior abdominal wall was assessed for any bleeding. A pelvic drain was placed for postoperative drainage and monitoring.

Analysis of data was performed using Statistical Package for Scientific Studies (SPSS) v.26 for macOS v11.3. Numerical data were expressed as means ± standard deviation (SD).

The patients’ mean age was 47.71 years, and the mean BMI was 35.19 kg/m². Most of the patients (67.3%) had ASA (American Society of Anesthesiology) score I. Hypertension was the common comorbidity in 10 patients, combined hypertension, and diabetes in four patients, two patients had hypothyroidism and one patient had rheumatic heart disease. Eleven patients had previous abdominal surgeries, previous Cesarean section (CS) was reported in 49 patients and normal/vaginal delivery was reported in 20 patients. All patients were multipara except one postmenopausal patient who did not conceive. The median preoperative uterine size was 12 weeks (range 8–20 weeks) (Table 1).

Leiomyoma was the main indication of laparoscopic hysterectomy in most of the patients (86.5%) enrolled in this study (Table 2). Half of the patients (51.9%) had a total abdominal hysterectomy and bilateral salpingo-oophorectomy. The mean operative time was 140 SD37 minutes, while the mean scalping time was 17.21 SD6.4 minutes. The mean estimated blood loss was 105.29 ml and nine patients needed an intraoperative blood transfusion. Extensive intraoperative adhesions were noted in 67.3% of patients. Four patients had intraoperative complications during laparoscopic hysterectomy; three had iatrogenic bladder injury and one patient had a rectal serosal tear.

Postoperative data were reported in (Table 3). Two patients had grade II postoperative complications (according to Clavien and Dindo classification); one patient required blood transfusion, and the other one had a small pelvic collection that was treated conservatively. One patient had grade III postoperative complication and was reoperated for an evident urinary bladder leak. The median hospital stay was 2 days (range 1–12 days), and the median follow-up duration was 3 months (range 1–12 months). Postoperative uterine weight had a median of 450 g (range 320–740 g). The median uterine length was 14 cm (range 9–23 cm), while its width was 9 cm (range 6–18 cm). Leiomyoma was the common postoperative pathology in (96.15%) with a median size of 8 cm (range 5–12 cm).