title: Assessing basic "physiology" of the morcellation process and tissue spread: a time-action analysis.
abstract: OBJECTIVE
  To assess the basic morcellation process in laparoscopic supracervical hysterectomy (LSH). Proper understanding of this process may help enhance future efficacy of morcellation regarding the prevention of tissue scatter.
  
  
  METHODS
  Time-action analysis was performed based on video imaging of the procedures (Canadian Task Force classification II-2).
  
  
  METHODS
  Procedures were performed at Leiden University Medical Centre and St Lucas Andreas Hospital, Amsterdam, the Netherlands.
  
  
  METHODS
  Women undergoing LSH for benign conditions.
  
  
  METHODS
  Power morcellation of uterine tissue.
  
  
  RESULTS
  The morcellation process was divided into 4 stages: tissue manipulation, tissue cutting, tissue depositing, and cleaning. Stages were timed, and perioperative data were gathered. Data were analyzed as a whole and after subdivision into 3 groups according to uterine weight: <350 g, 350 to 750 g, and >750 g. A cutoff point was found at a uterine weight of 350 g, after which an increase in uterine weight did not affect the cleaning stage. The tissue strip cutting time was used as a measure for tissue strip length. With progression of the morcellation process, the tissue strip cutting time decreases. The majority of cutting time is of short duration (i.e., 60% of the cutting lasts 5 seconds or less), and these occur later on in the morcellation process.
  
  
  CONCLUSIONS
  With the current power morcellators, the amount of tissue spread peaks and is independent of uterine weight after a certain cutoff point (in this study 350 g). There is a relative inefficiency in the rotational mechanism because mostly small tissue strips are created. These small tissue strips occur increasingly later on in the procedure. Because small tissue strips are inherently more prone to scatter by the rotational mechanism of the morcellator, the risk of tissue spread is highest at the end of the morcellation procedure. This means that LSH and laparoscopic hysterectomy procedures may be at higher risk for tissue scatter than total laparoscopic hysterectomy. Finally, engineers should evaluate how to create only large tissue strips or assess alternatives to the rotational mechanism.
authors.affiliation: Department of BioMechanical Engineering, Delft University of Technology, Delft, The Netherlands.
authors.forename: Ewout A
authors.initials: EA
authors.lastname: Arkenbout
authors.affiliation: Department of Gynecology, Leiden University Medical Center, Leiden, The Netherlands.
authors.forename: Lukas
authors.initials: L
authors.lastname: van den Haak
authors.affiliation: Department of Gynecology, Leiden University Medical Center, Leiden, The Netherlands.
authors.forename: Sara R C
authors.initials: SR
authors.lastname: Driessen
authors.affiliation: Department of Gynecology, Sint Lucas Andreas Ziekenhuis, Amsterdam, The Netherlands.
authors.forename: Andreas L
authors.initials: AL
authors.lastname: Thurkow
authors.affiliation: Department of BioMechanical Engineering, Delft University of Technology, Delft, The Netherlands; Department of Gynecology, Leiden University Medical Center, Leiden, The Netherlands. Electronic address: f.w.jansen@lumc.nl.
authors.forename: Frank-Willem
authors.initials: FW
authors.lastname: Jansen
mesh_terms: D000328:Adult; D005260:Female; D006801:Humans; D007044:Hysterectomy / Q000295:instrumentation / Q000379:methods*; D010535:Laparoscopy; D008875:Middle Aged; D019060:Minimally Invasive Surgical Procedures; D009426:Netherlands; D009929:Organ Size; D017410:Practice Guidelines as Topic; D011446:Prospective Studies; D013647:Task Performance and Analysis; D016896:Treatment Outcome; D063186:Uterine Myomectomy / Q000295:instrumentation*; D014599:Uterus / Q000473:pathology*
keywords: Laparoscopy; Morcellation; Morcellator; Scatter; Spread; Tissue