Posted by Bill Sandweg on 01 October 2018.
I have written in the past about power morcellators and the harm they have caused patients. I have links here, here and here. Despite their risks, power morcellators continue to be used by surgeons for minimally invasive gynecological surgery. In this post, I will discuss some of the pros and cons of their use and why they continue to be used despite the risks they pose.
Let’s start with the reason power morcellators were developed in the first place. In the old days, uterine surgery meant an open laparotomy. The surgeon had to cut open the uterus and operate under direct vision; there was no other way. Then came minimally invasive surgery or laparoscopy. In minimally invasive uterine surgery, a hole or holes are made in the abdomen and instruments are inserted into the uterine cavity. Gas is used to inflate the cavity. A camera is inserted as well and the surgeon manipulates the instruments in the cavity to perform the procedure. Minimally invasive surgery has a number of advantages over an open laparotomy. Among other things it is less traumatic for the patient, the recovery time is less, there is less scarring and fewer complications.
Sometimes the uterine procedure involves the removal of tissue, such as uterine fibroids. Often this tissue is too large to be removed through the small openings being used for the laparoscopy. One solution is to cut the tissue into pieces small enough to be removed through the holes. This is time consuming and often difficult. This is the problem power morcellators were designed to solve. The tip of the morcellator is inserted into one of the holes and a blade is slid out from the tip. The blade spins and chews up the tissue much the way a blender does. Then the uterus is washed out and the chewed up tissue comes out with the irrigation fluid.
Normally, all this goes well. The problem arises when the patient has unknown uterine cancer. One or more of the uterine fibroids may be cancerous, for example. The process of chewing up the cancerous tissue spreads it throughout the abdominal cavity and makes a bad situation much worse. Doctors say the cancer has been upstaged. In other words, the staging of the cancer just got worse.
Morcellators were used for many years before the problem of cancer spreading gained enough attention that the FDA took action. The FDA issued a directive that all power morcellators have a prominent warning on them about the risk of spreading cancer. The warning stated that the use of a power morcellator was contraindicated in women who had suspected uterine cancer and in older women, who were more at risk for uterine cancers. The FDA also directed that women undergoing procedures in which power morcellators were to be used be advised of the risks associated with their use. Following the FDA’s action, the use of power morcellators fell but many surgeons continued to use them. The controversy continues.
In defense of the power morcellator, the manufacturers and the surgeons who use them argue that the incidence of unknown uterine cancers in younger women of childbearing age is very low. Accordingly, the risk that cancer will be spread is very low. They also argue that just the process of entering the uterus creates a risk of spreading any cancerous cells which might be present, even if a power morcellator is not used. Lastly, they point out that returning to open laparotomies will expose women to more risks than do power morcellators. They argue that more women will be injured by the use of open laparotomies than would ever be injured through the use of a power morcellator.
A number of surgeons and companies have tried to reduce the risk of power morcellation by designing bags which can be inserted through one of the operative openings into the uterine cavity. The surgeon places the uterine tissue in the bag and introduces the morcellator into the bag to chew up the tissue. In theory, the use of the bag keeps the pieces of potentially cancerous tissue contained and the bag is then removed through one of the holes being used for the procedure. It is still not clear exactly how effective the use of these containers is in keeping any unknown cancer from spreading.
It looks as though this issue will continue to inspire discussion and attempts to prevent the spread of unknown cancers. For those of you who are undergoing a laparoscopic uterine procedure, make sure you discuss with your surgeon whether he or she intends to use power morcellation and what are the risks and benefits as they apply to your particular situation. As always, be an informed consumer and good luck.