Specimen Removal After Laparoscopic Myomectomy
The safest and most effective method for removing fibroid specimens after laparoscopic myomectomy is in-bag contained extraction to prevent tissue dissemination, with manual morcellation preferred over power morcellation when possible. 1
Extraction Techniques
In-Bag Extraction (Preferred Method)
- Place the enucleated fibroid into a specimen retrieval bag before extraction
- Extract through one of the following methods:
- Manual morcellation with scalpel or scissors within the bag
- Contained fragmentation through minilaparotomy incision
- Posterior colpotomy for larger specimens
Technique Selection Based on Fibroid Size
Small fibroids (<3-4 cm):
- Direct removal through slightly enlarged port site
- Removal through posterior colpotomy
Medium fibroids (4-8 cm):
- In-bag manual morcellation
- Contained fragmentation through minilaparotomy
Large fibroids (>8 cm):
- In-bag manual morcellation through extended umbilical incision
- Posterior colpotomy with in-bag extraction
Risks of Uncontained Morcellation
Uncontained power morcellation has fallen out of favor due to significant risks:
- Dissemination of occult malignancies (leiomyosarcoma risk ~1 in 2000 procedures) 2
- Parasitic myomas from retained tissue fragments 3
- Iatrogenic endometriosis
- Retained tissue causing persistent pain 4
Evidence-Based Considerations
- In-bag morcellation may take slightly longer than uncontained power morcellation (approximately 2.6 minutes longer) but provides critical safety benefits 2
- Even exceptionally large fibroids (up to 4 kg) can be successfully removed laparoscopically using contained tissue fragmentation techniques 5
- All tissue pieces must be diligently removed, as even small fragments can develop into parasitic fibroids if they find a blood supply 3
Technical Pearls
- Ensure complete bag integrity throughout the extraction process
- Maintain pneumoperitoneum during in-bag morcellation
- Consider posterior colpotomy for large specimens when appropriate
- Document complete removal of all tissue fragments
- Thoroughly irrigate the abdominal cavity after specimen removal
Complications to Monitor
- Accidental bag disruption during extraction
- Incomplete tissue removal
- Bleeding from extraction site
- Infection at extraction site
By following these principles, surgeons can minimize the risks associated with specimen removal after laparoscopic myomectomy while maintaining the benefits of minimally invasive surgery, including shorter hospital stays and faster recovery compared to open procedures 6.