Transvaginal in-bag specimen extraction of surgical specimens after laparoscopic myomectomy: a feasible and safe alternative to in-bag intra-abdominal morcellation?

Background We aimed to evaluate the rate of intraoperative and postoperative complications in women undergoing transvaginal in bag specimen extraction of surgical specimens after laparoscopic myomectomy. Methods Retrospective analysis of prospectively collected data, between January 2004 and December 2018. The laparoscopic myomectomy was performed in a standard fashion. After the myoma(s) enucleation, a posterior 1–2 cm transverse colpotomy was performed laparoscopically, precisely in the midline of the posterior fornix. We introduced a 10- or 15- mm polyurethane specimen pouch through the colpotomy incision, opening it into the abdominal cavity. Once the fibroid was placed into the bag using a laparoscopic grasper, the specimen bag was tightened and pulled out for transvaginal removal. In case the fibroid was too large to fit through the colpotomy, we performed in-bag manual morcellation to take the specimen out, until the fibroid pieces were small enough to remove them along with the bag. A careful gross inspection of bag integrity was always performed, filling the bag with saline solution. Subsequently, the colpotomy was closed transvaginally using a running 1-0 polyglactin suture. For each patient, we recorded age, Body Mass Index (BMI), parity, indication for myomectomy, largest myoma size, number of fibroids removed, myoma(s) total weight, operative time, intraoperative blood loss, hospital stay, intraoperative and perioperative complications, as well as complications found at the 30-days follow-up. Results During the study period, we collected 440 consecutive women who underwent transvaginal in-bag specimen extraction of surgical specimens after laparoscopic myomectomy. The study design was approved by an independent institutional review board and each patient signed informed consent to allow data collection for research purpose. The median age was 36 (19–65) years, median BMI was 22 (17–32) and 193 women (61.5%) were nulliparous. Indication for myomectomy was abnormal uterine bleeding in 243 (55.2%) cases, pain in 43 (9.8%) cases and subfertility/infertility in 154 (35%) cases. The median largest myoma size was 7 (3–15) cm, median number of fibroids removed was one (1–5), median myoma(s) weight was 150 (30–800) grams, median operative time was 80 (20–320) minutes, median blood loss was 125 (20–1000) ml. Median hospital stay was 2 (1–7) days. We did not observe any intraoperative complication. In the early post-operative period, we had 21 (4.8%) cases of fever, treated with antibiotics and antipyretics, and 3 (0.7%) cases of minimal haemoperitoneum, which resolved spontaneously after expectant management. We did not observe any complication at the 30-days follow-up, including dyspareunia, vaginal dehiscence/bleeding, need for readmission/reoperation. We did find any case of misdiagnosed malignancy (leiomyosarcoma) or uncertain malignant potential. Conclusions Transvaginal in-bag specimen extraction of surgical specimens after laparoscopic myomectomy could be considered a feasible, not expensive and safe alternative to in-bag intra-abdominal morcellation.