Reducing Peritoneal Cell Dissemination in Laparoscopic Uterine Surgery: A Comparative Pilot Study on Morcellation Techniques and Peritoneal Irrigation

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Following the U.S. Food and Drug Administration’s warning against power morcellators due to potential cell dissemination of occult malignancy, there has been a shift away from minimally invasive approaches. This concern also overshadows the well-documented advantages of minimally invasive surgery in benign gynecology. Objectives: To evaluate whether intraperitoneal cell dissemination during laparoscopic surgery for uterine fibroids can be reduced by (i) the choice of morcellation method and/or (ii) copious irrigation after the procedure. Methods: This prospective multicenter comparative pilot study included 72 women undergoing laparoscopic myomectomy (LM) or total laparoscopic hysterectomy (TLH) for benign conditions. Women were divided into four groups in order to compare different types of morcellation, including a reference group without morcellation: (i) LM with power morcellation (n = 21, Group A), (ii) TLH with en-bloc transvaginal tissue removal without morcellation (n = 17, Group B), (iii) TLH with manual vaginal morcellation (n = 19, Group C), and (iv) TLH with contained manual vaginal morcellation (n = 15, Group D). Patients receiving cold knife morcellation were randomized into Groups C or D. In order to assess cell spread before surgery, after surgery but before morcellation, after morcellation, and after abdominal irrigation with a total of 3000 mL saline solution, peritoneal washings were collected at six timepoints. Results: After specimen removal (TP3), cell spread was significantly higher in cases with power morcellation [13/19 (68%) in Group A] compared to transvaginal cold knife morcellation, both contained and uncontained [Group C 1/14 (7%) and Group D 1/19 (9%)] (p < 0.001), or to TLH with en bloc removal [Group B 1/17 (6%)]. Saline irrigation reduced the positive cytologies. After 3000 mL (TP6), the difference between Group A and the TLH groups was not significant [4/18 (22%) vs. 3/45 (7%), p = 0.079]. Conclusions: Our study shows that (i) transvaginal cold knife morcellation results in significantly less peritoneal cell dissemination than power morcellation, and (ii) peritoneal irrigation with 3000 mL of saline significantly reduces residual cell presence. These findings could support maintaining minimally invasive approaches while addressing safety concerns.

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