A morcellator is a

surgical instrument A surgical instrument is a tool or device for performing specific actions or carrying out desired effects during a surgery or operation, such as modifying biological tissue, or to provide access for viewing it. Over time, many different kinds of ...

used for division and removal of large masses of tissues during

laparoscopic surgery Laparoscopy () is an operation performed in the abdomen or pelvis using small incisions (usually 0.5–1.5 cm) with the aid of a camera. The laparoscope aids diagnosis or therapeutic interventions with a few small cuts in the abdomen.Medl ...

. In laparoscopic hysterectomy the uterus is cut up in strips, or morcellated, into smaller pieces inside the patient's abdominal cavity in order to extract from the abdomen. It can consist of a hollow cylinder that penetrates the abdominal wall, ending with sharp edges or cutting jaws, through which a grasper can be inserted to pull the mass into the cylinder to cut out an extractable piece.

Surgery

Laparoscopic morcellation is commonly used at surgery to remove bulky specimens from the abdomen using minimally invasive techniques. Historically, morcellation was performed using a device that required the surgeon or assistant to manually 'squeeze' the handle. Other reports describe using a scalpel directly through the abdomen to create small specimens that can be drawn out of the abdominal cavity. In 1993, the first electric morcellator was introduced in the US market. It was initially used for uterine extraction, but later applied to other organs. The use of morcellators at surgery has now become commonplace, with at least 5 devices currently on the US market. Despite decades of experience, there remains limited understanding of the short-term and long-term

sequelae A sequela (, ; usually used in the plural, sequelae ) is a pathological condition resulting from a disease, injury, therapy, or other trauma. Derived from the Latin word, meaning “sequel”, it is used in the medical field to mean a complication ...

of morcellation. Concerns have been raised about injury to surrounding organs including bowel, bladder,

ureter The ureters are tubes made of smooth muscle that propel urine from the kidneys to the urinary bladder. In a human adult, the ureters are usually long and around in diameter. The ureter is lined by urothelial cells, a type of transitional epit ...

pancreas The pancreas is an organ of the digestive system and endocrine system of vertebrates. In humans, it is located in the abdomen behind the stomach and functions as a gland. The pancreas is a mixed or heterocrine gland, i.e. it has both an end ...

spleen The spleen is an organ found in almost all vertebrates. Similar in structure to a large lymph node, it acts primarily as a blood filter. The word spleen comes .

and major vascular structures. Long-term issues may include parasitic growth of retained tissue with the potential to cause

adhesions Adhesions are fibrous bands that form between tissues and organs, often as a result of injury during surgery. They may be thought of as internal scar tissue that connects tissues not normally connected. Pathophysiology Adhesions form as a natural ...

, cause bowel dysfunction and potentially

disseminate To disseminate (from lat. ''disseminare'' "scattering seeds"), in the field of communication, is to broadcast a message to the public without direct feedback from the audience. Meaning Dissemination takes on the theory of the traditional view ...

unrecognized cancer.

Safety concerns

Morcellation is associated with spreading of cellular material of the morcellated tissue. In gynecologic surgery for

benign Malignancy () is the tendency of a medical condition to become progressively worse. Malignancy is most familiar as a characterization of cancer. A ''malignant'' tumor contrasts with a non-cancerous benign tumor, ''benign'' tumor in that a malign ...

pathologies there is approximately a 0.1% risk of an unexpected

leiomyosarcoma Leiomyosarcoma is a malignant (cancerous) smooth muscle tumor. A benign tumor originating from the same tissue is termed leiomyoma. While leiomyosarcomas are not thought to arise from leiomyomas, some leiomyoma variants' classification is evolvi ...

. After morcellation 64% of such cases may develop

disseminated disease Disseminated disease refers to a diffuse disease-process, generally either infectious or neoplastic. The term may sometimes also characterize connective tissue disease. A disseminated infection, for example, has extended beyond its origin or nidus ...

which is of particular concern because of the considerable

mortality Mortality is the state of being mortal, or susceptible to death; the opposite of immortality. Mortality may also refer to: * Fish mortality, a parameter used in fisheries population dynamics to account for the loss of fish in a fish stock throug ...

of leiomyosarcoma. Morcellation of the more frequent benign leiomyoma variants may also cause disseminated disease, which while not associated with increased mortality is frequently inoperable and therefore much more difficult to manage than the original disease. Since April 2014 the

Food and Drug Administration The United States Food and Drug Administration (FDA or US FDA) is a List of United States federal agencies, federal agency of the United States Department of Health and Human Services, Department of Health and Human Services. The FDA is respon ...

(FDA) has discouraged its use for uterine procedures, issuing a warning that morcellators may spread occult cancer in the course of fibroid removal. A second warning was followed in November of the same year.

Johnson & Johnson Johnson & Johnson (J&J) is an American multinational corporation founded in 1886 that develops medical devices, pharmaceuticals, and consumer packaged goods. Its common stock is a component of the Dow Jones Industrial Average and the company i ...

subsequently suspended sale of its morcellators until the role of morcellation "is redefined by the FDA and the medical community," and later pulled its morcellators from the market. Critics of this device have mounted a high-profile campaign to have the devices recalled. At least one device maker has threatened legal action against what it calls "unfounded and unproven allegations." In the same statement the FDA discouraged the use of power morcellators in patients seeking

hysterectomy Hysterectomy is the surgical removal of the uterus. It may also involve removal of the cervix, ovaries (oophorectomy), Fallopian tubes (salpingectomy), and other surrounding structures. Usually performed by a gynecologist, a hysterectomy may b ...

(removal of uterus through lower abdomen) and

myomectomy Myomectomy, sometimes also called fibroidectomy, refers to the surgical removal of uterine leiomyomas, also known as fibroids. In contrast to a hysterectomy, the uterus remains preserved and the woman retains her reproductive potential. Indicati ...

(surgery to remove uterine fibroids – also called leiomyomas) procedures, estimating that approximately 1 in 350 such patients is found to have an unsuspected uterine sarcoma, a type of uterine cancer that includes leiomyosarcoma. The FDA says that it has known for some time that the morcellators could spread uterine cancer, but the recent attention given to the subject because of the death of Barbara Leary leading them to reopen the investigation, and they discovered a higher risk than was initially reported. Magdy Milad, chief of gynecology and gynecologic surgery at

Northwestern Memorial Hospital Northwestern Memorial Hospital (NMH) is a nationally ranked academic medical center located on Northwestern University’s Chicago campus in Streeterville, Chicago, Illinois. It is the flagship campus for Northwestern Medicine and the primary ...

reported that “there were times connections were made but not reported." The problem of secondary

and parasitic

leiomyoma A leiomyoma, also known as a fibroid, is a benign smooth muscle tumor that very rarely becomes cancer (0.1%). They can occur in any organ, but the most common forms occur in the uterus, small bowel, and the esophagus. Polycythemia may occur due to ...

after gynaecological surgeries is not new and such problems have been reported independently of the methods of surgery. The surgery may not be the only or main culprit: the disseminated disease may also be the result of predisposition, reduced

paracrine Paracrine signaling is a form of cell signaling, a type of cellular communication in which a cell produces a signal to induce changes in nearby cells, altering the behaviour of those cells. Signaling molecules known as paracrine factors diffuse ove ...

feedback, or

metastasis Metastasis is a pathogenic agent's spread from an initial or primary site to a different or secondary site within the host's body; the term is typically used when referring to metastasis by a cancerous tumor. The newly pathological sites, then, ...

independent of surgery. According to some studies, there was no difference in the overall survival of women with unsuspected uterine malignancy with or without endometrial cancer between laparotomic myomectomy group and laparoscopic myomectomy group.

References

{{reflist, 2, refs= Disposable laparoscopic morcellator
GM Savage, JJ Christian, DC Dillow - US Patent 6,039,748, 2000 Morcellator
Jude S. Sauer, Roger J. Greenwald, Mark A. Bovard, John F. Hammond - US Patent 5562694. Issue date: Oct 8, 1996. {{Cite journal , last1 = Seidman , first1 = M. A. , last2 = Oduyebo , first2 = T. , last3 = Muto , first3 = M. G. , last4 = Crum , first4 = C. P. , last5 = Nucci , first5 = M. R. , last6 = Quade , first6 = B. J. , editor1-last = Sullivan , editor1-first = David J , title = Peritoneal Dissemination Complicating Morcellation of Uterine Mesenchymal Neoplasms , doi = 10.1371/journal.pone.0050058 , journal = PLOS ONE , volume = 7 , issue = 11 , pages = e50058 , year = 2012 , pmid = 23189178 , pmc =3506532 , bibcode = 2012PLoSO...750058S , doi-access = free {{Cite journal , pmid = 26577118, year = 2015, last1 = Yuk, first1 = J. S., title = Comparison of Survival Outcomes in Women with Unsuspected Uterine Malignancy Diagnosed After Laparotomic Versus Laparoscopic Myomectomy: A National, Population-Based Study., journal = Annals of Surgical Oncology, volume = 23, issue = 4, pages = 1287–1293, last2 = Ji, first2 = H. Y., last3 = Shin, first3 = J.Y., last4 = Kim, first4 = L.Y., last5 = Kim, first5 = S.Y., last6 = Lee, first6 = J. H., doi = 10.1245/s10434-015-4976-3, s2cid = 19615919, url = https://www.semanticscholar.org/paper/8958ccb3a0eb2aeac7bfe4ff0bf0634f228f4b24 {{Cite journal , pmid = 30146112 , year = 2018, last1 = Yuk, first1 = J. S., title = Six-year survival of patients with unsuspected uterine malignancy after laparoscopic versus laparotomic myomectomy: An 11-year national retrospective cohort study , journal = Gynecologic Oncology, volume = 151, issue = 1, pages = 91–95, last2 = Lee, first2 = J.H., doi = 10.1016/j.ygyno.2018.08.026, s2cid = 52092926 {{cite web , url=http://www.medscape.com/viewarticle/824371?src=wnl_edit_newsal&uac=28013DZ, title=J&J Suspends Power Morcellator Sales Over Cancer Risk, author=Robert Lowes , publisher=

Medscape Medscape is a website providing access to medical information for clinicians; the organization also provides continuing education for physicians and health professionals. It references medical journal articles, Continuing Medical Education (CM ...

, date=April 30, 2014, access-date=April 30, 2014 {{cite web , url=https://finance.yahoo.com/news/fda-strengthens-warning-device-linked-163440402.html , title=FDA strengthens warning on device linked to cancer , author=Linda a. Johnson , publisher=AP Business Writer, date=November 24, 2014, access-date=November 24, 2014 , quote=FDA strengthens warning on gynecologic surgical device linked to spreading cancer inside women Surgical instruments

Surgery

Safety concerns

See also

References