Morcellation

Morcellation is a surgical technique that uses a morcellator to cut larger pieces of tissue into smaller fragments so they can be removed through small laparoscopic incisions. It is commonly applied in minimally invasive gynecologic surgery to remove uterine fibroids (myomectomy) or the uterus (hysterectomy). Morcellation can be performed with powered devices that shred tissue or with manual methods such as scissors, and increasingly within protective containment systems to limit tissue dispersion.

Context and methods: In laparoscopic procedures, tissue is fragmented into pieces small enough to extract through trocars or small incisions. Power morcellators involve rapidly rotating blades or blades with suction, while manual morcellation relies on precise cutting under visualization. Contained or in-bag morcellation encloses tissue within a retrieval bag to reduce the spread of fragments into the peritoneal cavity.

Risks and regulatory history: A major safety concern is the potential dissemination of occult malignant or premalignant tissue, particularly leiomyosarcoma, when morcellating presumed benign uterine fibroids. Fragments can seed peritoneal surfaces or lead to upstaging of undiagnosed cancer. Other risks include fragmentation of tissue that complicates complete removal and injury to surrounding organs. In 2014 the U.S. Food and Drug Administration advised against the use of power morcellation for most women undergoing fibroid or uterine surgery due to cancer risk, with later guidance emphasizing careful patient selection and consideration of containment strategies and alternative surgical approaches.

Alternatives and current practice: Alternatives include open surgery or mini-laparotomy for complete removal, removal without morcellation, and contained morcellation within a bag to reduce tissue spread. Decisions are guided by patient age, cancer risk, fibroid size and number, and surgeon experience.