In-Bag Manual Extraction of Excised Myomas by Surgical Scalpel through Suprapubic Mini-Laparotomic Incision in Laparoscopic-Assisted Myomectomy

Abstract

Study objective: To evaluate the safety and feasibility of in-bag manual extraction for the retrieval of excised myomas through a suprapubic mini-laparotomic incision in 2-port laparoscopic-assisted myomectomy.

Design: Retrospective comparative study (Canadian Task Force classification II-2).

Setting: Departments of obstetrics and gynecology and diagnostic pathology at a general hospital.

Patients: Twenty-six patients undergoing open manual extraction and 26 patients undergoing in-bag manual extraction by surgical scalpel for the retrieval of excised myomas through a suprapubic mini-laparotomic incision in 2-port laparoscopic-assisted myomectomy.

Interventions: In patients with open manual extraction, myoma tissues were directly morcellated in an uncontained setting, whereas in patients managed by in-bag manual extraction, enucleated myomas were put into a retriever bag and then were morcellated by a surgical scalpel while monitoring bag damage by the leakage of indigo carmine dye filled in a bag. The patient demographics and surgical outcome measures were compared between the 2 groups. In the initial 15 patients with in-bag manual extraction, the macroscopic myoma fragments retained in the bag were collected and removed after completion of myoma extraction. Then, the bag contents were washed with normal saline and spilled microscopic tissues salvaged by centrifugation. A histologic examination was performed for collected tissue materials to identify the microscopic myoma fragments.

Measurements and main results: In patient demographics and surgical outcomes, which include excised tissue weight, surgical duration, and estimated intraoperative blood loss, no significant differences could be identified between the 2 groups. Bag rupture as monitored by the leakage of indigo carmine dye in vivo and ex vivo was not observed. In all patients managed by in-bag manual extraction, spilled macroscopic myoma fragments were identified in the bag. Furthermore, histologic examinations of collected bag contents detected microscopic myoma tissues in 53.3% of patients. These results suggest that without closed conditions, these microscopic myoma particles, which could be difficult to completely remove even by rigorous washing of the peritoneal cavity under laparoscopic vision, might be dispersed in the peritoneal cavity and potentially form iatrogenic peritoneal parasitic myomas if they survive and grow.

Conclusion: In-bag manual extraction of myoma tissues through a suprapubic mini-laparotomic incision by a surgical scalpel is a feasible alternative to prevent the dispersion of microscopic myoma fragments and to avoid the potential risk of spreading occult malignancy in 2-port laparoscopic-assisted myomectomy.

Keywords: In-bag manual extraction; Laparoscopic-assisted myomectomy; Myoma extraction; Retriever bag; Surgical scalpel; Wound retractor.