Morcellation is a technique used during minimally invasive surgeries to cut a large mass of tissue into smaller fragments. This allows surgeons to remove large, solid structures through small incisions without resorting to an open wound, as the pieces can be extracted through narrow surgical ports.
The Morcellation Procedure in Surgery
Two common gynecological procedures where morcellation is used are hysterectomy, the removal of the uterus, and myomectomy, the removal of uterine fibroids. Fibroids are noncancerous growths that can cause pain and bleeding, often necessitating their removal while preserving the uterus.
Using morcellation provides the benefits of minimally invasive surgery. Patients experience shorter hospital stays, a quicker overall recovery period, and less postoperative pain compared to traditional open surgery. The cosmetic outcome is also a consideration, as laparoscopy results in much smaller scars than the large incision required for an open abdominal procedure.
Surgeons use a medical device called a power morcellator. This tool is a rapidly rotating blade within a protective sheath that shaves or shreds the targeted tissue. The resulting small pieces are then suctioned out of the body through one of the surgical ports.
Associated Cancer Dispersal Risk
A primary concern with morcellation is the potential for spreading undetected cancer. Uterine fibroids are common and almost always benign, but in some cases, a presumed fibroid is actually a cancerous tumor called a sarcoma. A specific type of cancer, leiomyosarcoma, can mimic the appearance of a benign fibroid, and there is no consistently reliable way to diagnose it before surgical removal.
The mechanical action of a power morcellator can disseminate these cancerous cells throughout the abdominal and pelvic cavities. If an undiagnosed sarcoma is morcellated, malignant cells are scattered, seeding new tumor growth in surrounding tissues. This action can worsen a patient’s prognosis by spreading a localized cancer, a process known as up-staging.
Data from the U.S. Food and Drug Administration (FDA) highlights this risk. The agency estimated that an unsuspected uterine sarcoma is present in approximately 1 in 225 to 1 in 580 women undergoing surgery for presumed fibroids. For leiomyosarcoma, the estimated prevalence is between 1 in 495 and 1 in 1,100 women. The risk increases with age, particularly in women over 50.
In response to these findings, the FDA issued a safety communication in 2014 and later mandated a “black box warning” for power morcellators. This is the agency’s most stringent warning, highlighting that the use of these devices during fibroid surgery may spread cancer and decrease long-term survival. The agency cautioned against using power morcellators in most women undergoing hysterectomy or myomectomy for fibroids.
Mitigation and Surgical Alternatives
To make morcellation safer, containment systems were developed. This technique, called “contained morcellation,” involves performing the procedure inside a specially designed surgical bag. The uterus or fibroid is placed inside the bag within the abdominal cavity, and the morcellator is then used to shred the tissue inside this enclosed space. The bag is designed to trap the tissue fragments, preventing them from spreading.
While these containment systems are intended to reduce the risk of cell dispersal, the FDA requires their labeling to state that they have not been clinically proven to reduce the risk of spreading cancer. Therefore, it is a risk-reduction strategy, not a complete solution.
Several surgical alternatives that do not involve morcellation are available. A traditional abdominal hysterectomy or myomectomy is performed through a larger incision, allowing the surgeon to remove the uterus or fibroids intact. Another option is a vaginal hysterectomy, where the uterus is removed through the vaginal canal.
A compromise between traditional open surgery and laparoscopy is the mini-laparotomy. This procedure uses an incision that is smaller than a full abdominal one but still large enough to remove the tissue mass whole. These alternatives eliminate the cancer-spreading risk associated with morcellation, providing different options for patients to discuss with their doctors.