Design: Randomized-Controlled Trial

Setting: Tertiary care academic medical center

Patients or Participants: All individuals over 18 years of age undergoing conventional laparoscopic (TLH) or robotic-assisted (RA-TLH) for benign indications from June 2020 to July 2022 were offered enrollment. Patients with uterine size <10 weeks and those undergoing concurrent procedures (i.e. pelvic organ prolapse procedure, bowel or hernia-related surgeries) were excluded (See exclusion criteria). A total of 46 participants were enrolled, 34 completed randomization.

Interventions: Participants were randomized between abdominal mini-laparotomy versus vaginal morcellation at time of colpotomy.

Measurements and Main Results: Participants were randomized to either abdominal or vaginal route of contained manual morcellation at the time of colpotomy creation; 18 were randomized to the vaginal route, 16 to morcellation via an abdominal mini-laparotomy incision. There were no significant differences in perioperative and patient-centered outcomes observed between groups through follow up at 6 weeks postoperatively. Perioperatively, uterine weight, total operative time and morcellation time were similar between groups as were blood loss and complications. Length of hospital stay, time in PACU, narcotic use in PACU, and total narcotic use up to 6 weeks postoperatively were not different. There was a higher rate of containment bag perforation noted in the vaginal group (56% vs 11%, p=0.015). Amongst cases that failed the containment integrity test, there were no differences in the number nor size of defects note. There were no cases of unexpected pathology.

Conclusion: Contained manual morcellation for tissue extraction during TLH through vaginal and abdominal routes are comparable, except for a higher rate of containment bag compromise during vaginal morcellation. The areas of bag breakage occurred extraperitoneally, so the clinical significance of this is unclear.