ajog.

org

Letters to the Editors

Safe vaginal uterine morcellation following total laparoscopic

hysterectomy
TO THE EDITORS: We read with great interest the article
published by Gnthert et al,1 who reported a simple and
safe method to wrap the uterus in a contained environment
with a plastic bag through the posterior vaginal fornix prior
to conventional coring morcellation for vaginal extraction in
total laparoscopic hysterectomy (TLH). It is well known that
enhancement of minimally invasive specimen retrieval techniques is critical to enhance and optimize perioperative
outcomes for women with gynecologic conditions requiring
myomectomy or hysterectomy.
Morcellation of tissue within a specimen bag under laparoscopic guidance has been reported as a safe and effective
option for specimen retrieval after laparoscopic splenectomy2
and nephrectomy.3 Recently, Montella et al4 described a
safe sealed vaginal morcellation technique that allows the
surgeon to morcellate a bulky uterus in cases of endometrial
cancer and reduces the chance of neoplastic cell spillage
during debulking at TLH. Data reported by Gnthert et al,1
along with the breadth of procedures performed, supports
the generalizability of morcellation within an isolation bag.
Given that the morcellation is in a wrapped uterus within
a contained environment with a plastic isolation bag, the
authors believe it is unlikely for tissue to escape from this
site. In vitro studies of porcine renal morcellation have
documented some instance of bag perforation when using a
coring morcellator within a laparoscopic specimen retrieval
bag.5 A study of bag integrity after contained morcellation is
an important next step, however. Microscopic tears and
leakage were not assessed in this study.
There are many additional aspects of tissue dissemination
in the setting of occult malignancy that also require further
attention and future investigation. For example, microscopic
cellular dissemination may occur during a myomectomy or
TLH even when performed through laparotomy. Furthermore, efforts should be made to implement contained morcellation even when not using power morcellation devices;
probably coring morcellation through the vagina may also
result in dissemination.
Although this study is a multicenter one with participation
of surgeons with varying gynecologic disciplines, the overall
small sample size, lack of a control group, inclusion of only
high-volume surgeons, and lack of a cost analysis are of major
concern. Additionally, the intact status of the bag and lack
of tissue dissemination were identied by the surgeons
visual inspection and as such may introduce ascertainment
bias.
This is an evolving interesting technique that is in the early
stages of development and will benet from further testing
and renement before implementing this procedure in daily
routine.
-

Tarek Shokeir, MD
Department of Obstetrics and Gynecology
Mansoura University Hospital
Mansoura Faculty of Medicine
Mansoura, Egypt
tarek.shokeir@gmail.com
The author reports no conict of interest.

REFERENCES
1. Gnthert AR, Christmann C, Kostov P, Mueller MD. Safe vaginal
uterine morcellation following total laparoscopic hysterectomy. Am J
Obstet Gynecol 2015;212:546.e1-4.
2. Greene AK, Hodin RA. Laparoscopic splenectomy for massive
splenomegaly using a Lahey bag. Am J Surg 2001;181:543-6.
3. Wu SD, Lesani OA, Zhao LC, et al. A multi-institutional study on the
safety and efcacy of specimen morcellation after laparoscopic radical
nephrectomy for clinical stage T1 or T2 renal cell carcinoma. J Endourol
2009;23:1513-8.
4. Montella F, Riboni F, Cosma S, et al. A safe method of vaginal longitudinal morcellation of bulky uterus with endometrial cancer in a bag at
laparoscopy. Surg Endosc 2014;28:1949-53.
5. Urban DA, Kerbl K, McDougall EM, Stone AM, Fadden PT,
Clayman RV. Organ entrapment and renal morcellation: permeability
studies. Urology 1993;150:1792-4.
2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajog.
2014.12.024

REPLY
The major concerns of the author are microscopic leakage
of the plastic bag, that we indeed have not excluded, and
the morcellation of tissue with a high probability of cancer.
We share these concerns, but as demonstrated in our
video, we observe vaginal morcellation by simultaneous laparoscopy. The coring morcellation procedure always produces
some uid as residue, which accumulates in the bag. After
extraction we always test the bag for leakage by controlling the
tightness of the bag. But we admit that a very low risk of
microscopic leakage can not entirely be excluded.
As stated in our manuscript and in contrast to some recent
reports, we strictly exclude vaginal in-bag morcellation in
patients at high risk for cancer or with already conrmed
malignancy.1,2 We recommend it as a risk-reducing procedure
in patients with uncertain uterine mass, and in these cases our
data seem strong enough to recommend it as clinical routine
to avoid laparotomy. Since incidental morcellated uterine
malignancies are rare,3 we appreciate any independent report
in the future about the experience of our described method.Andreas R. Gnthert
Department of Gynecology and Obstetrics
Cantonal Hospital of Lucerne
Lucerne, Switzerland

MAY 2015 American Journal of Obstetrics & Gynecology

689