Hysteroscopic Morcellation

Hysteroscopic Morcellation

  • Hysteroscopic Morcellator is the most recent innovation in hysteroscopic treatment, delivering several advantages over conventional techniques for the removal of submucosal myomas and endometrial polyps.
  • It is quicker, simpler, safer lesion removal
  • In hysteroscopic morcellation, tissue delivered into a trap, or collecting pouch. This allows for complete capture and histopathologic assessment of all fragments extracted.
  • Introduction of uterine endoscopy by D.Commando. Pantaleoni in 1869
  • Neuwirth & Amin used a urological resectoscope to perform and report the first hysteroscopic resection of submucousmyoma in 1976
  • Using a modified prototype based on an orthopaedic arthroscopic tissue shaver, Dr Mark Hans Emanuel of Netherland was able to create a first generation device that used mechanical energy rather than electrical energy to resect intrauterine tissue.
Morcellators available….
  • In 2005, the US Food and Drug Administration (FDA) approved the TRUCLEAR™ hysteroscopic morcellator (Smith & Nephew, Andover, MA) as the first motorized morcellator for intrauterine pathology.
  • In 2009, the FDA approved another hysteroscopic morcellation device—the MyoSure® Tissue Removal System (Hologic, Bedford, MA).
  • G Bigatti in conjunction with KARLSTORZ have developed a new morcellation system called Integrated Bigatti Shaver (IBS) system. This shaver system is inserted through the working channel of a wideangle telescope with parallel view and permits most operative procedures in hysteroscopy such as polypectomies or myomectomies. The IBS consists of 6o angled telescope with an integrated sheath and working  channel within a rigid shaver system. The outer diameter of the sheath is 8mm.
Hysteroscopic MorcellatorsTRUCLEAR 5.0 – Smith & Nephew
  • Offset Lens Hysteroscope
  • Outer Blade TRUCLEAR INCISOR PLUS -2.9 mm OD
  • Scope 5.0 mm, 0°
  • Hysteroscopic Sheath 5.6 mm OD
Hysteroscopic resectoscopy utilizing a radiofrequency (RF) energy device

Requires Skilled Surgeon Risk of:

  • Fluid overload (non-electrolyte fluid)
  • Multiple instrumentations of the uterus
  • Uterine perforation, air embolus, false passageway
  • Injury related to electrical energy source(monopolar or bipolar energy source)
  • Generates Visually Obscuring Tissue Pieces
Hysteroscopic Morcellators TRUCLEAR 8.0 – Smith & Nephew
  • FDA Approved 2005
  • Dedicated Fluid Management
  • Tissue Removed with Suction
  • Offset Lens Hysteroscope
  • Outer Blade 4.0 mm OD
  • Scope 8 mm, 0°
  • Hysteroscopic Sheath 9 mm OD
  • Tissue Trap
Reusable Hand-Piece
Rotary Morcellator
  1. Polyps
  2. Oscillates back and forth
  3. Serrated
  4. 7 mm cutting window
Reciprocating Morcellator (ultra plus)
  1. Myomas
  2. Rotates and reciprocates
  3. 10 mm cutting window

357 bites per minute at 2,500 rpm

Hysteroscopic Morcellators Advantages
  • Operate in Saline
  • Decreased risk of fluid overload
  • Mechanical
  • No thermal injury no risk of generation of stray currents
  • Remove Tissue Pieces
  • Clear visual field
  • Decreases risks of multiple instrument placement,Uterine perforation, false passage way and air embolus
  • Are Easy to Use
  • Facilitate Removal Type 0 and I Myomas
  • Decreased operative time and Fluid deficit
  • Small Diameter Can Be Used in the Office: They allow for the use of smaller-diameter hysteroscopes, which in turn requires less cervical dilation.
  • The learning curve is quicker.
  • No risk of spreading or upstaging the unsuspected leiomyosarcoma

 

Hysteroscopic Morcellators Disadvantages
  • No electrosurgery for hemostasis
  • Type 2 myomas are difficult
  • Fundal pathology is difficult
  • Potential for significant fluid use
  • Cost of fluid management system
  • In case of larger myomas the use of morcellator becomes time consuming.
  • The cost of disposables needed to perform the hysteroscopic morcellation procedure is high
Conclusion:

Hysteroscopic  tissue removal have risks as well as benefits which must be balanced and tailed according to the patients’ profile. Correct evaluation and proper pre-operative workup which includes the type of pathology and the degree of extent into the myometrium needs to be carefully done.

Informed consent is of prime priority. Training and education of surgeons in safe and appropriate use of all methods of tissue resection should be done.

 

Dr. Ira Biswas

 

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