The Best Way Out: Outcomes of Vaginal vs Abdominal Morcellation in Hysterectomies

INTRODUCTION: Laparoscopic hysterectomies often require manual morcellation of the uterus to allow for extraction abdominally or vaginally. While surgeon preference often drives this intraoperative decision, limited studies have compared perioperative and patient-centered outcomes across the two modes of morcellation. OBJECTIVE: To investigate the association between morcellation in laparoscopic hysterectomy (LH) and patient-reported and objective surgical outcomes. METHODS: 73 patients undergoing LH for benign indications from 4/2023 to 2/2024 were recruited. Surveys assessing patient-reported outcomes including satisfaction with cosmesis (Likert scale 1–5; 1 = not satisfied, 5 = satisfied), incisional and deep pelvic pain (scale 0–10; 0 = no pain, 10 = excruciating pain), and return to baseline activity level (yes/no) were administered 2 and 6 weeks postoperatively. Chart review was conducted to capture operative outcomes of interest. Appropriate statistical analyses were used to compare outcomes between patients who underwent morcellation vs those who did not and a sub-analysis was performed by type of morcellation (vaginal vs abdominal). RESULTS: Of the 73 patients, 45 (61.6%) did not undergo uterine morcellation and 28 (38.3%) did. Of the 28 patients, 9 (32.1%) underwent abdominal morcellation and 19 (67.8%) vaginal. Baseline group characteristics (e.g. average age, race, BMI, prior surgeries, medical co-morbidities, and lysis of adhesions) did not differ significantly. Comparison of surgical outcomes between the morcellation and no morcellation groups revealed longer procedure average time with morcellation compared to those without (247.2 min vs 194.6 min, p<0.001) but no significant differences in estimated blood loss (p=0.356), length of stay (p=0.417), or postoperative complications (p>0.999). No significant differences in EBL, length of procedure, length of stay, or post-op complications were noted when comparing vaginal vs abdominal morcellation (p>0.05). Patient-centered outcomes did not significantly vary between morcellation and no morcellation groups at 2 and 6 weeks: cosmetic satisfaction (p=0.283 and 0.563, respectively), surgical site pain (p=0.429 and 0.09), deep pelvic pain (p=0.724 and 0.727), and return to daily activities (p=0.326 and 0.384). No significant differences were observed when comparing the same outcomes by morcellation site at 2 and 6 weeks: cosmetic satisfaction (p=0.669 and 0.353, respectively), surgical site pain (p=0.538 and >0.999), deep pelvic pain (p=0.790 and >0.999), and return to daily activities (p=0.407 and >0.999). CONCLUSIONS: Morcellation increases operative time; however, no differences in other objective or patient-centered outcomes were observed. This encourages surgeons to continue using this extraction method via their preferred route.