Safety of in-bag morcellation during laparoscopic myomectomy and hysterectomy: a systematic review and meta-analysis.

Abstract

Objective: To systematically evaluate the outcomes of in-bag versus no-bag morcellation during laparoscopic myomectomy and hysterectomy, focusing on safety.

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

Methods of study selection: Inclusion of studies on females undergoing laparoscopic myomectomy and/or hysterectomy with in-bag morcellation, excluding series with fewer than 10 patients.

Tabulation, integration and results: Data were synthesized using meta-analysis techniques, with sensitivity analyses for rare events, focusing on intraoperative complications (i.e. a composite outcome including conversion to laparotomy, bowel injury or, accidental injury to any viscus injury or vessel). The secondary outcomes include presence of parasitic fibroma, fragment of myometrium/uterus, blood transfusion, bleeding > 500mL, total operative time, postoperative length of stay, postoperative pain, conversion to laparotomy, postoperative complications and cost. From 1,970 published studies, we included 20 trials, enrolling 5,505 women in the in-bag and 37,283 women in the no-bag group. We included 9 trials in each subgroup: myomectomy and hysterectomy, enrolling 767 and 4678 women in the in-bag; 830 and 36380 women in the no-bag groups, respectively. We observed increased intraoperative complications compared to no-bag morcellation (OR 1.45, 95% CI 1.11;1.89) with a null heterogeneity (I²= 0%). The hysterectomy subgroup analysis showed a significant association between bag and intraoperative complications (OR 1.47, 95% CI 1.12;1.93) but not myomectomy (OR 1.00, 95% CI 0.29;3.43). We did not have enough information to conclude about the presence of parasitic fibroma, fragment of myometrium and costs. No statistical differences were observed concerning the other secondary outcomes.

Conclusions: The use of containment bags in morcellation may increase the risk of intra-operative complications, particularly in case of hysterectomy. However, these events might not be directly related to bag use and could represent confounding factors. Further studies are needed to investigate in-bag morcellation.

Registration: CRD42023478908 on the International Prospective Register of Systematic reviews. Registered November 19, 2024.