A morcellator is a surgical instrument used for division and removal of large masses of tissues during laparoscopic surgery.
During the laparoscopic hysterectomy the uterus is minced up (morcellated), into smaller pieces to extract it from the abdomen.
The morcellator may consist of a hollow cylinder that penetrates the abdominal wall, ending with sharp edges or cutting jaws.
The cylinder may be entered by a grasper can be inserted to pull the mass into the cylinder to cut out an extractable tissue.
Laparoscopic morcellation is commonly performed to remove bulky specimens from the abdomen using minimally invasive techniques.
Process may cause injury to surrounding organs including bowel, bladder, ureters, pancreas, spleen and major vascular structures.
Potential damage issues include: parasitic growth of retained tissue with the potential to cause adhesions, bowel dysfunction and dissemination unrecognized cancer.
Associated with spreading of cellular material of the morcellated tissue.
For hysterectomy for benign pathologies there is approximately a 0.09~0.1% risk of an unexpected leiomyosarcoma.
In such cased 64% may develop disseminated disease.
With the much more frequent benign leiomyoma variants, morcellation, may cause disseminated disease, which is more difficult to manage than the original disease.
Today powered uterine morcellation devices are used.
Since April 2014 the Food and Drug Administration (FDA) has discouraged its use for uterine procedures, issuing a warning that morcellators may spread occult cancer in the course of fibroid removal.
The dissemination of disease may also be the result of predisposition, reduced paracrine feedback, or metastasis independent of surgery, making the process difficult to understand fully.
Whenever tissue is morcellated,there is a risk of incomplete removal of the tissue.
Residual fragments of tissue can result in parasitic myomas, endometriosis, or dissemination of cancer.
Parasitic leiomyomas can occur in up to 1% of morcellated laparoscopic procedures.
Process of morcellation disrupts the anatomic landmarks of the uterus making staging more difficult and its ability to disrupt pathologic specimens increases the chance of missing occult malignancies.
Uterine morcellation leads to iatrogenic spread of cancer, and the risk of dissemination with electromechanical techniques is potentially heightened by increased intra-abdominal pressure required to maintain the pneumoperitoneum during laparoscopic surgical procedures, and the velocity that the rotary blades spin.
The presence of known uterine malignancy is an absolute contraindication to morcellation.
The procedure in the presence of premalignant conditions or during risk reducing surgery is is also relatively contraindicated.
Uncontained power morcellation at the time of hysterectomy or myomectomy is related to increased mortality risk in patients with occult uterine cancer.
The FDA has issued safety warnings about uterine power morcellation performed at the time of hysterectomy and myomectomy.
Concern that the rapidly rotating cylindrical blade during the process of morcellation may spread cancer cells to the abdominopelvic cavity if a patient has undiagnosed uterine cancer.
Among women with unexpected uterine sarcoma, especially leiomyosarcoma, power morcellation was associated with a higher risk of death.
Patients with unexpected leiomyosarcoma who had a hysterectomy or myomectomy with power morcellation were more than three times as likely to die from uterine cancer than patients who did not undergo power morcellation.
For women with a high risk of having uterine cancer, choosing a surgical approach that avoids power morcellation would be beneficial.
There is not a statistically significant association between power morcellation and disease-specific mortality risk among patients with unexpected endometrial carcinoma.