Morcellation

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IlDestriero

IlDestriero

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It's an unfortunate situation but not entirely unheard of.

I have a few issues with this case and some of the comments in the article.

A leiomyosarcoma is a fairly rare situation. A vast majority of the time, a fibroid uterus is just a fibroid uterus. It's sad, but the patient in this case just got dealt a bad hand and the odds did not work in her favor. Since the article isn't going into any details, it's hard to say what the clinical situation. If this is a woman who never had any issues and is suddenly presenting with an enlarged uterus, then my concern for malignancy would be higher and potentially change my recommendation from a minimally invasive approach to an open approach.

Regarding the case in the article. You need to morcellate for a supracervical hysterectomy or if the uterus is too large to remove through the vagina. They don't mention what the situation was in this case. Performing a laparoscopic hysterectomy does not mean you need to morcellate so I'm not sure why they are focusing on that portion. What I am going to guess in this case was that the uterus was too large to remove vaginally and that they needed to morcellate to get it out.

I feel for her husband and his situation but I resent his implication that morcellation is a money issue and allows a case to be done faster. A total laparoscopic hysterectomy will on average always take longer than an open hysterectomy. If he really believes that, then why aren't more surgeons performing abdominal hysterectomies?

And I'm not sure what a vaginal hysterectomy has to do with this from the comment in the article. Mayo has a history of vaginal surgery which they are very proud of. What Dr. Gostout conveniently fails to mention is that if you are performing a vaginal hysterectomy for a large uterus that cannot be removed through the vagina, you have to debulk/morcellate it using a scalpel or a pair of heavy Mayo scissors to remove it. This is a technique that they even teach and is fairly standard across the country.
 
It is possible to morcellate vaginally after a TLH for a large uterus but man is it a pain. It takes forever, and the only bowel injury I've had was doing vaginal morcellation (fortunately only a serosal injury and recognized).

I think it is faster and better for the patients to use a morcellator.

If I have a straight forward TLH for fibroids I typically don't do an endometrial biopsy ahead of time. However, because of all this publicity I've started doing them if I am planning on morcellating. I don't think it is worth doing laparotomies on everyone to prevent the rare case of morcellating a leiomyosarcoma. And honestly, if the patient does have an undiagnosed leiomyosarcoma what are the chances of survival morcellating or not?
 
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Morcellation is an incorrect surgical practice. No tumors or tissues with malignant potential should be disrupted inside a patient's body cavities. In fact, in the fields of general and thoracic surgery this practice is considered a serious error-at best, when it occurs, it is considered a suboptimal operation. Yet in gynecological surgery morcellation is practiced routinely using devices specifically designed and marketed to gynecologists for the purpose. This is done for technical ease, speed and in the interest of not having to make larger incisions. Simply, it is a technically and scientifically crude and erroneous practice that places many women in danger and has devastated many families for over a decade now.

There are several significant issues to consider with respect to the oncological sequelae of morcellation:
1) In the case of sarcomas of the uterus, preoperative diagnostics are of extremely limited utility in identifying the patients with the cancer. These occult sacromas occur at a frequency somewhere in the 1 in 400-1000 range and are not identifiable.
2) When a contained stage 1 uterine sarcoma is disrupted using morcellation, a loco-regionally spread stage 4 sarcoma is caused. The notion that the prognosis of stage 1 and stage 4 sarcomas are similar is incorrect and unscientific. The oncological literature is very clear on a very wide disparity in survival between the two group.
3) The notion that "informed consent" on the part of the patient makes this practice acceptable is ethically negligent. Specifically, because in this case "informed consent" does nothing to protect the patient but does place medico-legal protection in place for the doctor doing the morcellating. Therefore, it is a systemic act of negligence on the part of the gynecological community to claim that by informing the patient, the gynecologist is justified in exposing 1 in 400-1000 women to the possibility of developing a stage 4 cancer.
4) The fact that this practice has made it into gynecological surgery as a standard of care, speaks to a major deficit in surgical training in gynecological surgery in immediate need of correction. It is a truth that gynecological surgeons train in a "silo" far away from other surgeons. Unfortunately, patients are the ones who end up paying for this training deficit. This is likely to be the reason why a practice, such as morcellation, that is so clearly seen as perilous by all other branches of surgery has been widely accepted by gynecologists.
5) The notion that it is acceptable for 1 in 400-1000 women to be exposed to the hazards of morcellation for the benefit of the other 399-999 undergoing minimally invasive hysterectomy or myomectomy is also ethically negligent. Specifically, because morcellation poses an Avoidable and specific hazard to the women it is practiced on. If an avoidable drug posed that level of mortality hazard to patients, the medical establishment would immediately cease its use for this reason. Unlike other societies, in the United States our ethical foundation is based on the intrinsic value, dignity and worth of every individual patient. Thus, to accept that an avoidable and deadly complication affecting 1 in 400-1000 should remain a standard of care speaks to an entire specialty's disconnection from the ethical foundation of our profession and society.

Please consider these issues and do not participate in this dangerous practice. The women it has devastated and their families deserve your full attention and every effort to prevent any other family from being devastated by this practice. Please see below link:
http://www.change.org/petitions/wom...ally-invasive-and-robot-assisted-hysterectomy
 
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I figure you're the husband of the patient described in the Boston case.

Please don't come into an OB GYN forum and talk trash as though the whole speciality is being negligent and that morcellation is a major deficit.

Whether you like it or not, morcellation is essentially considered standard of care in BENIGN cases. The incidence of uterine sarcomas is very low and the vast majority of the time, a fibroid is just a fibroid. Should uterine artery embolization and myomectomies go by the wayside as well then since we can't confirm a fibroid isn't a sarcoma pre operatively? I know your family member got burned and I feel bad but you don't know what you're talking about.

What you're advocating will cause more laparotomies which are the associated with more complications including infection risk, embolic risk, etc which increases morbidity and mortality.
 
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Sorry Im not an obgyn expert by any means. But I think at the very least, obgyns should be about providing better informed consent to patients. While it is not fair to the 399 patients to receive an open approach to prevent the 1 in 400 risk of morcellating a cancer, pts need to be aware of this scary risk before undergoing the procedure.

Also cant you just convert from a laparoscopic approach to an open approach if the uterus is too large to get through the vagina? This way you can avoid morcellation but still give people a shot at a lap approach?
 
A simple reminder to refrain from personal attacks and to maintain a degree of professionalism! Topics in this forum can often generate a lot if emotion (e.g. Males in OB thread), and it's always advised that you keep the discussion constructive regardless of the opposing view.
 
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Where does the 1/400-1/1000 come from?

Please cite, otherwise I assume this came from a tabloid.
 
JoBreeze said:
Where does the 1/400-1/1000 come from?

Please cite, otherwise I assume this came from a tabloid.
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Agreed. Those numbers seem awfully high for incidence of uterine sarcoma.

With regards to morcellation, there must be a way to design a device that morcellates a uterus within an enclosed capture bag to prevent spread of tissues.

. . . I mean . . . just kidding, its impossible. Patent pending.
 
I'm annoyed at the statement because it is a knee jerk reaction to a poor outcome from a loud mouthed physician.

What I find interesting is that they really don't address the use of morcellation during a vaginal hysterectomy. I was just at a conference where Mickey Karram stated that proceeding vaginally with a uterus up to 16 weeks in size is reasonable. In a lot of these types of situations, a surgeon will be morcellating/debulking the specimen vaginally. How is that not any different from the use of a power morcellator?

If the use of power morcellators is going by the wayside, are these large fibroids going to have to be taken out with laparotomies now? What additional morbidity and potential mortality are we exposing patients to for a very small risk? Wound infections, increased pain, increased hospital stay, longer time off from work are all very real consequences from abandoning a minimally invasive technique that has been proven to be very safe and effective.

SGO hasn't come out with a very strong stance and I don't believe ACOG has either.
 
anonperson said:
I'm annoyed at the statement because it is a knee jerk reaction to a poor outcome from a loud mouthed physician.
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By loud mouthed physician are you referring to the faculty anesthesiologist who is now suffering from stage 4 sarcoma and is likely to die in her early 40s? The same one who didn't get a reasonable informed consent? Or do you mean her cardiothoracic surgeon husband who will be left a single dad to 6 young kids?
Professional colleagues who want to make sure that this doesn't happen to other people unnecessarily, or without true informed consent.
Which loud mouth are you referring to exactly?

Your comments are appalling.
Absolutely Appalling. I wonder if you would have the same attitude if it was your wife picking out a headstone while trying to keep it together for their kids.

Are you an OB? If so, you should be an expert on the risks of catastrophic outcomes from the surgeries you perform. So you tell us what the literature says the risk is.

Loud mouth physician... Un F'ing believable.
 
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IlDestriero said:
By loud mouthed physician are you referring to the faculty anesthesiologist who is now suffering from stage 4 sarcoma and is likely to die in her early 40s? The same one who didn't get a reasonable informed consent? Or do you mean her cardiothoracic surgeon husband who will be left a single dad to 6 young kids?
Professional colleagues who want to make sure that this doesn't happen to other people unnecessarily, or without true informed consent.
Which loud mouth are you referring to exactly?

Your comments are appalling.
Absolutely Appalling. I wonder if you would have the same attitude if it was your wife picking out a headstone while trying to keep it together for their kids.

Are you an OB? If so, you should be an expert on the risks of catastrophic outcomes from the surgeries you perform. So you tell us what the literature says the risk is.

Loud mouth physician... Un F'ing believable.
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Please save your self righteous BS for the anesthesia forum. You have no idea what the F you're talking about.

You and I have no idea what the informed consent process was during this surgical procedure for this particular patient. All we know is that there was a poor outcome. I've got news for you. A sarcoma has a poor outcome regardless of the situation. She was never correctly staged as far as I know so who exactly knows what her appropriate stage was.

I'm pissed because this is having a ripple effect across many many hospitals. At my hospital, the knee jerk reaction is now at banning the use of morcellators for ALL hysterectomies. So know you've effectively increased the rate of laparotomies and the associated morbidity that goes along with it. How about the risk of DVT/PE, wound infections, increased pain, increaed adhesion formation. Will this CT surgeon take responsibility for a patient that drops dead from a PE because they were bed bound for a longer period of time because of a large incision? You ever take that into account before you started spouting off on something you don't know about? What about a large wound infection that results in long term morbidity? Is he going to come and walk them through everything?

How about the fact that people morcellate a uterus manually during a vaginal hysterectomy. The party line has been that even a 16 week sized uterus can be operated on vaginally. Once you get control of the uterine arteries, the general procedure has been to core/debulk the uterus. How is that any different then? Huh? ACOG has made a big stink from the president down to increase the amount of vaginal surgery and minimally invasive surgery to benefit the patient. How exactly is this going to help?

We had a morbidly obese women (BMI 55) with a 17 cm pelvic mass-likely benign based on imaging and lab work. Approached it laparoscopically, morcellated in a bag etc. Guess what, she went home the same day with minimal issuess and is up on her feet. You know what kind of disservice we would have done to her giving her a midline vertical incision? I know as anesthesia you don't really care what happens outside of the OR or PACU. But guess what, patient's have to be rounded on and then seen as outpatients and their complications have to be dealt with.

The original situation in question is very unfortunate but this is setting off a domino effect and patients will pay the price because of one loud mouthed surgeon who isn't willing to accept that sometimes even in the best of circumstances a bad outcome will happen.
 
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So I guess you don't know what the literature says. I'm not surprised. Perhaps no one knows. It seems like you should know that before your leadership pushes for more minimally invasive surgery. I hope more loud mouth physicians stand up against questionable practice and encourage appropriate research and truly informed consent. I know what she says her informed consent was and they actually did address the risk. They said it was along the lines of extremely rare chance of the spread of cancer if you have an undiagnosed uterine tumor. I've provided anesthesia for thousands of minimally invasive procedures over my career. Nobody outside of OB seems to be breaking up tissues to pull them out of smaller holes. I wonder why? I guess everyone else is doing it wrong. It would be nice to know what the real risk is.
The FDA did not ban the use of the device BTW. Any decision to stop its use on all patients was an internal decision made by your local leadership. If you believe that it is a safe practice, you should use it on appropriately selected patients.

It's amusing that you think anesthesiologists don't care about what happens to patients outside the OR. I've certainly seen that attitude before, but fortunately very rarely since residency.
 
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IlDestriero said:
So I guess you don't know what the literature says. I'm not surprised. Perhaps no one knows. It seems like you should know that before your leadership pushes for more minimally invasive surgery. I hope more loud mouth physicians stand up against questionable practice and encourage appropriate research and truly informed consent. I know what she says her informed consent was and they actually did address the risk. They said it was along the lines of extremely rare chance of the spread of cancer if you have an undiagnosed uterine tumor. I've provided anesthesia for thousands of minimally invasive procedures over my career. Nobody outside of OB seems to be breaking up tissues to pull them out of smaller holes. I wonder why? I guess everyone else is doing it wrong. It would be nice to know what the real risk is.
The FDA did not ban the use of the device BTW. Any decision to stop its use on all patients was an internal decision made by your local leadership. If you believe that it is a safe practice, you should use it on appropriately selected patients.

It's amusing that you think anesthesiologists don't care about what happens to patients outside the OR. I've certainly seen that attitude before, but fortunately very rarely since residency.
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So the possibility of this exact situation was covered in the informed consent? Is there any evidence that this ISN'T an extremely rare event?
 
VA Hopeful Dr said:
So the possibility of this exact situation was covered in the informed consent? Is there any evidence that this ISN'T an extremely rare event?
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That's my understanding. It was mentioned in a vague comment by the consenting surgeon along with risk of bowel perforation, etc. I suppose it could also be covered in the "you might die" part of the "informed" consent as well. As to the rate of uterine sarcoma by age group, rate of uterine sarcoma in a patient with large fibroids, rate of mets with morcellation vs cutting the uterus up into a few pieces vs removal intact, etc. I would think that the OB surgeons performing the procedure and complaining about its discontinuation should be able to answer that question. As far as I know, they are the only ones using the device, so they are the ones who should be the subject matter experts. As this forum seems very quiet, I'm not sure you'll find the answer here. If they really don't know these statistics, how can they give informed consent for the procedure? How can they risk stratify patients? These are questions that should have been explored and answered a couple decades ago. This isn't a new practice.
 
IlDestriero said:
That's my understanding. It was mentioned in a vague comment by the consenting surgeon along with risk of bowel perforation, etc. I suppose it could also be covered in the "you might die" part of the "informed" consent as well. As to the rate of uterine sarcoma by age group, rate of uterine sarcoma in a patient with large fibroids, rate of mets with morcellation vs cutting the uterus up into a few pieces vs removal intact, etc. I would think that the OB surgeons performing the procedure and complaining about its discontinuation should be able to answer that question. As far as I know, they are the only ones using the device, so they are the ones who should be the subject matter experts. As this forum seems very quiet, I'm not sure you'll find the answer here. If they really don't know these statistics, how can they give informed consent for the procedure? How can they risk stratify patients? These are questions that should have been explored and answered a couple decades ago. This isn't a new practice.
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So I just UpToDated this, and it looks like around 0.31% of uterine masses turn out to be sarcomas. If my math is right, we're talking just shy of 3 cases per thousand hysterectomies or roughly 1 case per 310 hysterectomies. I wouldn't call that extremely rare, but nor do I think its common enough to force OBs to start doing more and more open hysterectomies.

I don't have any idea, nor, as a family doctor, do I care enough to look up the specifics about surgical technique and just how likely "seeding" is from chopping up a sarcoma. Likely some of that will become more well known because of this somewhat high profile case.
 
Exactly, that is the point of the loud mouth surgeon and his wife's efforts. Raise awareness of the real problem, force investigation if necessary, and require accurate informed consent and real risk/benefit decision making.
When I'm getting consent for anesthesia, I specifically comment on and quantify catastrophic risks on the order of 1 in 50k to 250k, it is particularly
 
IlDestriero said:
That's my understanding. It was mentioned in a vague comment by the consenting surgeon along with risk of bowel perforation, etc. I suppose it could also be covered in the "you might die" part of the "informed" consent as well. As to the rate of uterine sarcoma by age group, rate of uterine sarcoma in a patient with large fibroids, rate of mets with morcellation vs cutting the uterus up into a few pieces vs removal intact, etc. I would think that the OB surgeons performing the procedure and complaining about its discontinuation should be able to answer that question. As far as I know, they are the only ones using the device, so they are the ones who should be the subject matter experts. As this forum seems very quiet, I'm not sure you'll find the answer here. If they really don't know these statistics, how can they give informed consent for the procedure? How can they risk stratify patients? These are questions that should have been explored and answered a couple decades ago. This isn't a new practice.
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I'm just shaking my head at your myopic view of this situation. The issue is not just power morcellators. The FDA statement is ******ed because it is essentially extending into the arena of morcellating in general, which can be done manually like in my example above with a vaginal hysterectomy. The CT surgeon who has taken up this crusade is pissed off at any type of morcellation. What if his wife had a vaginal hysterectomy and the surgeon debulked the uterus from down below? You can bet that some of the tissue would have seeded. Then what would he be able to complain about? Vaginal surgery? Even though it is one of the safest/cheapest forms of surgery?

How about myomectomies? Should those go by the wayside now because we cannot be certain they are not sarcomas or some other obscure malignancy?

This is why I said you have no idea what you are talking about. Save your smug BS. Like I said before, the rates of uterine sarcomas are very very low. I can pull any random retrospective study out of my ass and show it:
http://www.sciencedirect.com/science/article/pii/0090825885902173
http://www.sciencedirect.com/science/article/pii/S0959804997000403
http://journals.lww.com/greenjourna...e_sarcoma_in_patients_operated_on_for.17.aspx

See what I did, showed that it's very very rare.

Even using the criteria of rapidly enlarging fibroid to stratify a patient is a soft call and will not yield a great number of positive findings. So yeah, how are you going to risk stratify that then. If you are looking to absolutely minimize the risk of a uterine sarcoma seeding a patient, then EVERY SINGLE hysterectomy should be done abdominally for full evaluation of the pelvis with complete removal of the cervix and fallopian tubes and ovaries. Yeah, your risk of seeding a uterine sarcoma will be low as hell, but now you've got a huge number of wound infections, thrombo embolic events, pneumonias, etc to deal with which I can guarantee you will harm more patient's and cost more lives.

Please also don't act so dense as to think that an FDA statement won't have an effect. You and I know that medicine is incredibly defensive and the bean counters at hospitals see these sensational headlines and say "Hmm, we should ban morcellators because of this" because they are *****s who have no clinical insight. So when I see this and having some experience think to myself, "How is using a power morcellator any different than debulking a uterus abdominally or vaginally" which is something I have seen done and done myself numerous times. How is that any different than using a damn scalpel to "morcellate" a uterus?
 
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