Member Update: Disseminated Leiomyosarcoma with Power Morcellation (Update #2)
Since its inception, the AAGL has striven to continually innovate and educate physicians worldwide so that women will always have the least invasive surgical options available without compromise to the most optimal outcomes in gynecologic surgery. Recently, much attention has been turned towards the clinical practice of power-driven (battery & electrical) mechanical morcellation for the intra-corporeal removal of tissue, typically uteri and leiomyomata. The basis for this attention has been the rare, yet very real risk of uterine leiomyosarcoma which, if inadvertently morcellated, carries potentially serious implications, depending on the clinical scenario.
Although this particular uterine malignancy is rare, statistics about just how many women may be at risk vary widely (1 in 1,000 to 1 in 400) depending on the source and interpretation of the current literature. Further compounding the situation is the difficulty in pre-surgical diagnosis of this malignancy, when compared to other gynecologic malignancies such as endometrial cancer.
Given these concerns, there has been much discussion lately within medical and public forums regarding the possible placement of a ban or moratorium on the clinical practice of power-driven mechanical morcellation. Such a decision would have obvious clinical impact to both patients and physicians as it pertains to the spectrum of minimally invasive gynecologic surgery. As a result, the AAGL Board of Trustees, along with key opinion leaders and subject matter experts, has developed and implemented the following 3 core initiatives to address the aforementioned concerns and to educate not only its membership, but also patients worldwide.
Education has always been core to the mission of the AAGL. The AAGL also recognizes that learning is not episodic and occurs in a life-long continuum. As a result, the following resources and venues will be immediately accessible to the membership as they become available throughout the year, in order to address optimal tissue extraction techniques in minimally invasive gynecologic surgery. Safe implementation of currently available power-driven (battery & electrical) mechanical morcellation techniques will be discussed, along with appropriate alternatives, including the use of contained or “bagged” intra-corporeal tissue extraction methods.
- Scheduled SurgeryU webinars & video-based surgical tutorials
- Establishment of a repository for shared tissue extraction techniques by AAGL members at TissueExtraction@aagl.org
- Didactics & hands-on instruction at AAGL sponsored or endorsed postgraduate courses including:
- The 16th Annual Advanced Workshop on Gynecologic Laparoscopic Anatomy & MIS including Pelvic Floor Reconstruction – May 16-17, 2014 at the University of Louisville, Louisville, KY
- 43rd AAGL Global Congress on MIG, November 17-21, 2014 in Vancouver, BC, Canada
- Establishment of a pertinent reference library on tissue extraction literature to be published on the AAGL website as well as the society journal, JMIG
Innovation is woven throughout the history of the AAGL and this pillar of the organization represents the second initiative. Through the creation of a Tissue Extraction Task Force, comprised of key opinion leaders and subject matter experts, this focused group of individuals will review and consider all aspects of tissue extraction in minimally invasive gynecologic surgery. Subsequently, guidelines and algorithms will be developed after thorough analysis of risks and interpretation of the available scientific data. Additionally, this task force will serve as an appropriate conduit to establish innovative collaboration with surgical device companies, and to create a dialogue with our governmental representatives and regulatory agencies, such as the FDA.
Research comprises the third initiative of the AAGL. Physicians constantly make adjustments to their practice based on new developments in research. As questions remain unanswered, the ability to perform large scale, multi-center research studies will continue to be of paramount importance in order to guide practicing surgeons. Through ACAR (the AAGL Consortium of Advanced Research), clinical questions related to issues such as disease incidence and pre-operative diagnosis can be addressed. Furthermore, the most appropriate tissue extraction techniques can also be determined. Our COEMIG sites and the BOLD database will certainly play a critical role in this process. At this time, the AAGL welcomes proposals for potential studies that can be realistically implemented and funded through private, institutional, or governmental sources.
Despite all of the incredible advancements in surgery and the best intentions of physicians, there will still be a small percentage of procedures that have a negative outcome. Surgical decisions carry both benefits and risks even for common, seemingly harmless procedures. As issues surrounding tissue extraction and malignancy are addressed, the importance of informed consent cannot be overlooked. Patients must be supported throughout this process with the best medical information and surgical options available to them. Second opinions and referrals to specialized consultants should be considered. Patients and physicians must maintain a healthy dialogue in order to successfully navigate concerns regarding tissue extraction methods in minimally invasive gynecologic surgery. The initiatives outlined by the AAGL will serve to facilitate that dialogue so the most optimal outcomes can be achieved.
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