What Is Uterine Morcellation? What I Wish I Had Known Before My Hysterectomy
- Deborah Ann Martin
- 1 day ago
- 12 min read
Understanding Uterine Morcellation and the Risk of Spreading an Unknown Cancer
I did not know the word morcellation before my uterine leiomyosarcoma diagnosis.
When my gynecologist told me that my previous hysterectomy had been morcellated and that the tissue had not been contained, I had no idea what she was talking about.
I had to go home and Google it.
What I learned changed the way I understood the surgery I had undergone about a year and a half earlier.
I had believed I had surgery for a benign fibroid, that my uterus and the mass had been removed, and that the pathology had settled the matter.
Then doctors found three large tumors in my abdomen - two about the size of baby heads - and another tumor on my back, along with additional growths that were benign.
My cancer was no longer something I could think about as being confined to the uterus.
It was distant disease.
And now I was learning about a word I had never been taught before: morcellation.
What I learned made me angry, frightened, and determined to make sure other patients understood the procedure before agreeing to it.
Morcellation Means Cutting Tissue Into Smaller Pieces
Morcellation is a surgical technique in which tissue is divided into smaller pieces so it can be removed through a small opening.
During some minimally invasive hysterectomies or fibroid surgeries, the uterus or fibroid may be too large to pass through the small abdominal incisions. A surgeon may reduce the tissue into pieces so it can be removed without making a larger incision.
The morcellation may be performed manually with surgical instruments or with a powered device called a laparoscopic power morcellator.
The FDA describes laparoscopic power morcellators as medical devices that cut uterine tissue into smaller pieces during certain hysterectomy and myomectomy procedures.
Morcellation and Laparoscopy Are Not the Same Thing
This distinction is extremely important.
"Laparoscopy" describes the surgical approach.
During laparoscopic surgery, a surgeon inserts a camera and instruments through small incisions instead of opening the abdomen through one large incision.
"Morcellation" describes what happens to the tissue.
A laparoscopic procedure may or may not involve morcellation.
A uterus or fibroid may sometimes be removed intact through:
The vagina
A slightly enlarged abdominal incision
A small incision similar to one used during a cesarean delivery
Another surgical approach selected for the individual patient
Therefore, the warning should not be:
“Never have laparoscopic surgery.”
The better warning is:
“Before agreeing to surgery, find out whether your uterus or fibroid will be cut into pieces and whether it can be removed intact.”
Why Surgeons Use Minimally Invasive Surgery
Laparoscopic surgery may provide meaningful benefits compared with open abdominal surgery.
Depending on the procedure and patient, those benefits may include:
Smaller incisions
Less postoperative pain
Shorter hospitalization
Lower risk of some surgical complications
Faster return to ordinary activities
Less visible scarring
These benefits matter.
A patient should not be frightened away from every minimally invasive option.
However, the benefits of smaller incisions must be weighed against the risk of disrupting an unsuspected malignancy when morcellation is proposed.
The correct choice depends on the patient’s age, symptoms, imaging, medical history, cancer risk, tumor size, surgical options, and personal priorities. What Open Abdominal Surgery Was Like for Me
My hysterectomy had been performed using minimally invasive surgery.
I did not fully understand what that meant at the time. I knew I had small incisions and that the recovery was supposed to be easier than traditional open surgery.
Later, after my cancer diagnosis, I learned what the alternative could look like.
When I needed major abdominal surgery to remove the tumors, my experience was completely different.
This time, my abdomen had to be opened.
I had drains.
I had more restrictions.
I had a much longer and harder recovery.
My body needed significant time to heal.
That experience helped me understand something I had not appreciated before my hysterectomy:
“Minimally invasive” describes the way the surgeon enters the body. It does not automatically tell you how the tissue will be removed.
A minimally invasive hysterectomy can involve different methods of removing the uterus or a fibroid. Depending on the circumstances, tissue may be removed intact or may be divided into smaller pieces.
Open abdominal surgery, sometimes called a laparotomy, uses a larger abdominal incision and may allow the uterus or mass to be removed intact.
There are advantages and disadvantages to both approaches.
For some patients, minimally invasive surgery can mean less postoperative pain, a shorter hospital stay, and a faster recovery. For others, an open approach may be recommended because of the size or location of a mass, suspected cancer, or other medical considerations.
The important question is not simply, “Will this be minimally invasive?”
The important questions are:
How will the tissue be removed? Will it be removed intact? If it will be divided, how will that be done, and will it be contained?
That is a conversation I wish I had known to have before my hysterectomy.
The Danger When the “Fibroid” Is Actually Cancer
Most uterine fibroids are benign.
The difficulty is that uterine leiomyosarcoma can sometimes resemble a fibroid before surgery. Available testing cannot reliably identify every hidden leiomyosarcoma in advance.
When a benign fibroid is divided, the tissue is still benign.
When an unsuspected uterine sarcoma is divided, cancerous tissue may be dispersed within the abdomen and pelvis.
The FDA warns that morcellating an unsuspected uterine sarcoma can spread cancer and decrease a patient’s likelihood of long-term survival.
That is the risk I did not understand before my surgery.
What Is Uncontained Morcellation?
Uncontained morcellation means the tissue is divided without being enclosed within a specially designed containment system.
When uterine tissue is cut apart inside the abdominal cavity, fragments or cells may be dispersed.
Even benign tissue can sometimes cause problems if fragments implant and grow elsewhere.
When malignant tissue is present, dissemination is much more serious because cancer cells may be spread to additional areas.
The FDA’s 2020 guidance recommends that laparoscopic power morcellation be performed only with a legally marketed tissue-containment system and only when the procedure is appropriate for a carefully selected patient.
What Uncontained Morcellation Means in My Story
This is where the medical explanation becomes personal for me.
My hysterectomy involved uncontained morcellation.
At the time, I did not know what morcellation meant. I did not understand that my uterus and the mass believed to be a fibroid had been cut into pieces. I did not know that the tissue had not been placed inside a containment system.
I learned all of this only after I was diagnosed with uterine leiomyosarcoma.
About a year and a half after my hysterectomy, doctors found three large tumors in my abdomen, including two that were approximately the size of baby heads, another tumor on my back, and additional growths that were benign.
By then, my cancer had reached distant sites.
I was no longer dealing with a cancer that was confined to my uterus.
I had to face the possibility that cancer cells had been dispersed beyond where the original tumor had been.
Did Morcellation Cause My Cancer to Spread?
This is the part of my story where I have to be very careful about what I know and what I cannot prove.
I believe the uncontained morcellation of my cancerous uterine tissue contributed to the spread of my cancer.
But I cannot prove that morcellation was responsible for every tumor that developed afterward.
Uterine leiomyosarcoma can spread through the bloodstream and lymphatic system, and cancer may already have spread before the original surgery. The FDA specifically acknowledges that cancer can spread through those routes independently of what happens during morcellation.
What I do know is this:
My uterine tissue was morcellated without containment.
That tissue later turned out to contain cancer.
My cancer was subsequently found at distant sites, including a tumor on my back.
And the FDA warns that morcellating an unsuspected uterine sarcoma can spread cancerous tissue within the abdomen and pelvis and can decrease the likelihood of long-term survival.
Those facts are enough for me to take morcellation very seriously.
Why I Still Have to Think About Recurrence
Reaching my five-year milestone was something I once wondered if I would ever experience.
But reaching five years did not erase what happened to me.
Because my cancer had spread to distant sites, I continue to live with the possibility of recurrence.
That is one reason my doctors continue to monitor me and why my treatment plan has included maintenance medication based on information from genetic or molecular testing of my cancer.
My doctors are using what they learned about the biology of my cancer to help guide treatment decisions.
I think of it in a very simple way.
The testing helped identify characteristics of my cancer that could potentially make certain treatments useful. My maintenance treatment is part of an effort to make my body less favorable to the cancer's growth and to reduce the chance of the cancer finding the right environment to grow again.
I am not saying that my treatment will guarantee that my cancer never returns.
No treatment can make that promise.
But after everything I have been through, I am willing to use every medically appropriate tool available to me.
This Is Why I Want Women to Understand Morcellation
I am not writing this because I believe every woman who has a fibroid should be afraid of surgery.
I am not writing it to say that every laparoscopic hysterectomy is dangerous.
And I am not writing it to tell a woman what surgical procedure she should choose.
I am writing because I did not know what morcellation was until after it became part of my cancer story.
I wish I had known before my hysterectomy.
I wish I had understood the difference between laparoscopic surgery and morcellation.
I wish I had asked whether my uterus and the presumed fibroid could be removed intact.
I wish I had understood whether the tissue would be contained.
And I wish I had known that an apparently benign fibroid can, in rare cases, contain an unsuspected uterine sarcoma.
You cannot make an informed decision about something you do not know to ask about.
That is why I am telling you what I wish someone had told me.
What Is Contained Morcellation?
Contained morcellation involves placing the tissue inside a specially designed bag before using the power morcellator.
The intention is to keep the pieces and fluids within the bag while the tissue is divided and removed.
Containment may reduce the risk of tissue escaping during the procedure.
It does not eliminate every risk.
The FDA has explained that a containment system cannot prevent cancer spread that:
Occurred before surgery
Occurs through the blood or lymphatic system
Results from handling the tissue before it enters the bag
Results from leakage, damage, or technical failure
Occurs through another route not controlled by the bag
When the FDA permitted marketing of an early containment system in 2016, the required labeling stated that the device had not been clinically proven to reduce the risk of cancer spread.
Contained morcellation is therefore a risk-reduction method, not a guarantee.
What Is Manual Morcellation?
Manual morcellation means dividing tissue with a scalpel or another hand-operated instrument rather than an electric morcellator.
It may be performed:
Inside the abdomen
Inside a containment bag
Through the vagina
Through a small abdominal incision
The absence of a power device does not automatically remove the cancer concern.
The basic issue remains whether potentially malignant tissue is being cut apart and whether fragments or cells could escape.
Patients should ask about "all forms of tissue fragmentation", not only power morcellation.
What Is Intact Removal?
Intact removal means removing the uterus or fibroid without dividing the mass into smaller pieces inside the body.
Depending on the patient and procedure, this may require:
Vaginal removal
A larger laparoscopic incision
A small open abdominal incision
A full abdominal hysterectomy
Another surgical technique
Intact removal may require a larger incision and a longer recovery in some situations.
However, when cancer is known or strongly suspected, avoiding tumor disruption may be medically important.
The choice must be discussed with a qualified surgeon who understands both minimally invasive surgery and gynecologic cancer risk.
What Does the FDA Recommend?
The FDA does not recommend laparoscopic power morcellation for every patient undergoing surgery for presumed fibroids.
Its current guidance says power morcellation should be used only with a legally marketed containment system and only in appropriately selected patients.
The FDA advises against using laparoscopic power morcellators when:
Uterine cancer is known or suspected
The patient is postmenopausal
The patient is older than 50
The tissue can be removed intact through the vagina
The tissue can be removed through a small abdominal incision without morcellation
The FDA also says patients should be told that:
Hidden cancer may be present
Morcellation can spread cancer and reduce long-term survival
The risk of hidden uterine cancer increases with age
Benign uterine tissue can also spread and later require treatment
These are informed-consent issues, not small technical details.
How Often Is an Unexpected Cancer Found?
Estimates vary according to the studies, patient groups, years, and definitions used.
The FDA has estimated that an unsuspected uterine sarcoma may be present in approximately 1 in 225 to 1 in 580 women undergoing surgery for presumed uterine fibroids. It has estimated that leiomyosarcoma may be present in approximately 1 in 495 to 1 in 1,100 such patients.
Those estimates do not mean every uterine mass is likely to be cancer.
They mean the risk is uncommon but real.
When the possible consequence is spreading an aggressive cancer, even a rare risk deserves a clear conversation.
Why Age Matters
The risk of an unsuspected uterine malignancy generally increases with age.
That is why current FDA recommendations specifically advise against laparoscopic power morcellation in women who are postmenopausal or older than 50.
Age alone cannot diagnose cancer.
A younger patient can still develop uterine leiomyosarcoma, and an older patient’s uterine mass can still be benign.
Age is one factor in the larger risk assessment.
Questions to Ask When the Surgeon Says “Minimally Invasive”
Some questions to ask:
Does this procedure involve morcellation?
Will any tissue be cut apart inside my abdomen or pelvis?
Will the uterus or fibroid be removed intact?
Will you use a power morcellator?
Will you use manual morcellation?
Will the tissue be enclosed in a containment system?
What happens if the bag leaks or tears?
What alternatives would allow intact removal?
How would those alternatives change recovery?
Why do you believe morcellation is appropriate for me?
Do I fall within an FDA group for whom power morcellation is not recommended?
What is my individual risk of an unsuspected cancer?
Can I obtain a second opinion?
Do not settle for:
“It is just a routine procedure.”
Routine does not mean risk-free.
Obtain the Actual Procedure Name
Patients may remember being told they are having:
Fibroid surgery
Robotic surgery
Laparoscopic surgery
A partial hysterectomy
A complete hysterectomy
Minimally invasive surgery
Those descriptions may not explain how the tissue will be extracted.
Ask the surgeon to write down:
The complete procedure name
The planned surgical route
Whether the cervix, ovaries, or tubes will be removed
Whether morcellation is planned
The type of morcellation
Whether a containment system will be used
The alternatives available
Take the written information home and read it before signing final consent.
What I Wish I Had Known
I wish I had known that small incisions did not necessarily mean my uterus would be removed whole.
I wish I had understood that tissue might be cut into pieces inside me.
I wish I had known the difference between laparoscopy and morcellation.
I wish I had asked whether my fibroid could be removed intact.
I wish someone had explained that uterine leiomyosarcoma could not always be ruled out before surgery.
I cannot change the surgery I already had.
I can help another patient ask better questions before hers.
Hope for Today
Most fibroid surgeries do not uncover cancer.
Most women with fibroids do not have uterine leiomyosarcoma.
The purpose of learning about morcellation is not to create panic.
It is to create informed decisions.
You deserve to understand what will happen inside your body.
You deserve to know whether tissue will be removed intact or cut into pieces.
You deserve to hear the benefits, alternatives, and worst-case risks before surgery rather than after a cancer diagnosis.
Ask the question:
“How are you going to remove the tissue from my body?”
That one question can reveal far more than the phrase “minimally invasive surgery”.
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References
U.S. Food and Drug Administration (FDA) — UPDATE: Perform Only Contained Morcellation When Laparoscopic Power Morcellation Is Appropriate: FDA Safety Communication — https://www.fda.gov/medical-devices/safety-communications/update-perform-only-contained-morcellation-when-laparoscopic-power-morcellation-appropriate-fda
U.S. Food and Drug Administration (FDA) — Laparoscopic Power Morcellators — https://www.fda.gov/medical-devices/surgery-devices/laparoscopic-power-morcellators
American College of Obstetricians and Gynecologists (ACOG) — Uterine Morcellation for Presumed Leiomyomas — https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2021/03/uterine-morcellation-for-presumed-leiomyomas
U.S. Food and Drug Administration (FDA) — Non-Clinical Performance Assessment of Tissue Containment Systems Used During Power Morcellation Procedures — https://www.fda.gov/regulatory-information/search-fda-guidance-documents/non-clinical-performance-assessment-tissue-containment-systems-used-during-power-morcellation
National Cancer Institute (NCI) — Uterine Sarcoma Treatment (PDQ®) — https://www.cancer.gov/types/uterine/patient/uterine-sarcoma-treatment-pdq
American Cancer Society — Survival Rates for Uterine Sarcoma — https://www.cancer.org/cancer/types/uterine-sarcoma/detection-diagnosis-staging/survival-rates.html
Mayo Clinic — Uterine Fibroids: Symptoms and Causes — https://www.mayoclinic.org/diseases-conditions/uterine-fibroids/symptoms-causes/syc-20354288
National Leiomyosarcoma Foundation. "National Leiomyosarcoma Foundation." National Leiomyosarcoma Foundation.https://nlmsf.org/
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