LAUSR

Study Objective Total laparoscopic hysterectomy (TLH) is the gold standard for benign indications. In recent years, there have been concerns regarding the removal of large fibroid uteri through un-contained morcellation procedures that potentially increase the risk of spread of malignancy from an undiagnosed leiomyosarcoma. We describe a technique of in-bag vaginal morcellation using the Applied Alexis CES (Contained Extraction System) and report on 113 cases. Design Prospective case study. Setting Patients underwent TLH in the lithotomy position with deep Trendelenburg. Patients or Participants Women undergoing TLH for large fibroid uterus from November 2015 - April 2019. Interventions After detaching the uterus via laparoscopic colpotomy, a 3400ml Alexis specimen retrieval bag is inserted into the abdominal cavity through the vagina. The specimen is placed into the bag. The flexible ring is pulled back through the vagina. A smaller Alexis wound retractor is placed into the vagina. The specimen is grasped and manual morcellation is performed. Measurements and Main Results From November 2015 to April 2019, 113 women underwent TLH for benign fibroid uteri. The average time for the procedure was 111 minutes. The morcellation took an average of 11 minutes. Average estimated blood loss was 56ml. The average uterus weighed 522g. Of the 113 cases, one could not be removed vaginally as the specimen did not fit into the bag (uterine weight of 2700g); the specimen was removed via a small Pfannenstiel incision. 2 cases had unexpected pathology results - one borderline mucinous ovarian tumour, one smooth muscle tumour of unknown malignant potential (STUMP). Conclusion We describe a safe and effective way of removing a large fibroid uterus through in-bag vaginal morcellation after TLH. This series demonstrates that this method is efficient, does not increase risk or adverse outcomes and minimises the risk of spread of undiagnosed malignancy.