Comparison Between the In-Bag Morcellation Techniques During Laparoscopic Myomectomy or Hysterectomy: A Systematic Review and Network Meta-analysis.

OBJECTIVE

To compare the safety and perioperative outcomes of the 3 currently available in-bag morcellation techniques-intra-abdominal, extra-abdominal, and intra-vaginal-during laparoscopic myomectomy or hysterectomy using a systematic review and network meta-analysis.

DATA SOURCES: Searches were conducted in Cochrane Library, Embase, and PubMed, covering studies from inception up to January 31, 2024.

METHODS OF STUDY SELECTION: Comparative studies evaluating 2 or more in-bag morcellation techniques during laparoscopic myomectomy and/or hysterectomy and reporting at least 1 predefined outcome were eligible. The co-primary outcomes were endoscopic bag disruption and intraoperative complications, defined as a composite of conversion to laparotomy, bowel injury, or accidental visceral or vascular injury.

TABULATION, INTEGRATION AND

RESULTS

Independent random-effect frequentist network meta-analyses (NMA) were carried out on each outcome, to estimate odds ratios (OR) or differences in means with corresponding 95% confidence intervals. Overall, 6 out of 1970 published studies were included in the NMAs. No significant impact of morcellation techniques was shown on intraoperative complications (in-bag manual vs intra-abdominal in-bag: OR = 0.46 [0.05; 3.98], in-bag manual vs intra-vaginal in-bag: OR = 0.63 [0.11; 3.61], intra-vaginal in-bag vs intra-abdominal in-bag: OR = 0.73 [0.14; 3.84] with moderate heterogeneity or inconsistency (τ² = 0.9, I² = 36% [0%; 76%]). The intra-vaginal in-bag technique was statistically significantly faster than intra-abdominal in-bag procedure (-36.6 minutes [-68.5; -4.8]). The subgroup analyses on the surgery type (hysterectomy or myomectomy) did not show any statistical difference between morcellation techniques for intraoperative complications; however, among patients undergoing myomectomy, total operative time was significantly longer with the intra-abdominal in-bag technique compared with the other 2 techniques. Other sensitivity analyses led to the same conclusions.

CONCLUSIONS

Current comparative data do not demonstrate significant differences in perioperative safety among available in-bag morcellation techniques during laparoscopic myomectomy or hysterectomy. Although intra-vaginal in-bag morcellation may shorten operative time compared with intra-abdominal in-bag morcellation, these findings should be interpreted cautiously given the limited quantity and precision of the available evidence. Until higher-quality comparative data become available, selection of the in-bag morcellation technique should be individualized according to patient characteristics, specimen features, available equipment, and surgeon expertise. Future adequately powered multicenter comparative studies evaluating standardized surgical techniques, different tissue containment systems, clinically relevant outcomes, and cost-effectiveness are warranted.