Power morcellation is a surgical technique designed to break down tissue for removal. It gained widespread use for procedures like hysterectomy and myomectomy, offering benefits of minimally invasive surgery. However, its application raised concerns about patient safety and surgical practices. This article clarifies what morcellation involves, the concerns around its use, and how current surgical approaches have adapted.
Understanding Morcellation
Power morcellation involves using a specialized surgical device, a morcellator, to fragment large masses of tissue into smaller pieces. This instrument features rapidly spinning blades that reduce the size of tissue, such as the uterus or uterine fibroids. By breaking tissue into smaller components, surgeons can remove them through small incisions during minimally invasive procedures like laparoscopic hysterectomy or myomectomy.
This technique was appealing because it facilitated keyhole surgery, or laparoscopy, offering advantages over traditional open surgery. Patients undergoing minimally invasive procedures often experience less pain, shorter hospital stays, and a reduced risk of infection and blood clots. The ability to remove large fibroids or uteri through small abdominal incisions contributed to its adoption.
The Controversy and Regulatory Actions
The controversy surrounding power morcellation stems from the risk of spreading undetected cancerous tissue during procedures for presumed benign conditions. The primary concern is the potential dissemination of leiomyosarcoma, a rare but aggressive uterine cancer, difficult to distinguish from benign fibroids before surgery. If a morcellator is used when such an unsuspected malignancy is present, it can inadvertently spread cancer cells throughout the abdominal and pelvic cavities. This can worsen the patient’s prognosis and decrease long-term survival rates.
This patient safety concern prompted regulatory action from the U.S. Food and Drug Administration (FDA). In April 2014, the FDA warned against using laparoscopic power morcellators in most women undergoing hysterectomy or myomectomy for uterine fibroids. The agency estimated a hidden uterine sarcoma might be present in 1 in 225 to 1 in 580 women undergoing surgery for uterine fibroids, a higher risk than previously understood. This led to recommendations that the devices be contraindicated for most women, particularly those post-menopausal or over 50, where uterine cancer risk increases.
Further FDA actions included a 2020 update to their safety communication. It recommended power morcellation only with a tissue containment system. These systems isolate and contain the tissue being morcellated, reducing the risk of spreading cells into the abdominal cavity. The FDA also recommended that product labels for power morcellators include a boxed warning highlighting these risks and specifying conditions for their use.
Current Surgical Practice
Due to safety concerns and FDA warnings, the use of power morcellation in gynecological surgery has declined. Many hospitals and healthcare systems implemented restrictions or outright bans on these devices. This reflects a cautious approach to prioritize patient safety and minimize cancer dissemination risk.
While its use has become restricted, power morcellation might still be considered under specific circumstances. One scenario involves the mandatory use of a tissue containment system, often called “contained morcellation.” This technique aims to isolate tissue within a bag before morcellation, preventing spread. However, even with containment, its application is limited to carefully selected patients where malignancy risk is very low, and other surgical alternatives are not feasible or would pose greater risks.
Patient counseling and informed consent are now essential when considering any procedure involving morcellation. Healthcare providers must discuss potential risks, particularly the rare but serious risk of spreading undetected cancer, with patients before proceeding. Emphasis has shifted towards alternative tissue removal methods that avoid these risks.
Alternatives to Morcellation
For procedures like hysterectomy and myomectomy, several surgical alternatives avoid power morcellation. One traditional approach is mini-laparotomy or open abdominal surgery, involving a larger abdominal incision to remove the uterus or fibroids intact. This method allows direct visualization and tissue removal without fragmentation. While effective, it typically involves a longer recovery and greater post-operative pain compared to minimally invasive techniques.
Another option is vaginal hysterectomy, where the uterus is removed through the vagina, eliminating abdominal incisions. This approach is minimally invasive and offers quicker recovery. However, its suitability depends on factors like uterus or fibroid size and the patient’s specific anatomy.
If a minimally invasive approach is desired, surgeons can perform laparoscopic or robotic-assisted hysterectomy or myomectomy with tissue removal through a larger incision or the vagina. This involves detaching the uterus or fibroids laparoscopically, then removing them intact, or after manual morcellation (without power), through an enlarged abdominal incision or the vagina. This method maintains many benefits of minimally invasive surgery while avoiding power morcellator risks. Robotic-assisted surgery offers enhanced precision and visualization for the surgeon, similar to traditional laparoscopic techniques.