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Safe vaginal uterine morcellation following total laparoscopichysterectomy
TO THE EDITORS We read with great interest the articlepublished by Guumlnthert et al1 who reported a simple and
safe method to wrap the uterus in a contained environmentwith 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 thatenhancement of minimally invasive specimen retrieval tech-
niques 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 lapa-roscopic guidance has been reported as a safe and effectiv e
option for specimen retrieval after laparoscopic splenectomy 2
and nephrectomy3 Recently Montella et al4 described a
safe sealed vaginal morcellation technique that allows the
surgeon to morcellate a bulky uterus in cases of endometrialcancer and reduces the chance of neoplastic cell spillag e
during debulking at TLH Data reported by Guumlnthert et al1
along with the breadth of procedures performed supportsthe generalizability of morcellation within an isolation bag
Given that the morcellation is in a wrapped uterus withina 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 havedocumented some instance of bag perforation when using a
coring morcellator within a laparoscopic specimen retrieval
bag5 A study of bag integrity after contained morcellation isan important next step however Microscopic tears and
leakage were not assessed in this studyThere are many additional aspects of tissue dissemination
in the setting of occult malignancy that also require further
attention and future investigation For example microscopiccellular dissemination may occur during a myomectomy or
TLH even when performed through laparotomy Further-
more efforts should be made to implement contained mor-cellation even when not using power morcellation devicesprobably coring morcellation through the vagina may also
result in dissemination
Although this study is a multicenter one with participationof 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 majorconcern Additionally the intact status of the bag and lack
of tissue dissemination were identi1047297ed by the surgeonrsquosvisual inspection and as such may introduce ascertainment
bias
This is an evolving interesting technique that is in the early stages of development and will bene1047297t from further testing
and re1047297nement before implementing this procedure in daily
routine -
Tarek Shokeir MD
Department of Obstetrics and Gynecology
Mansoura University HospitalMansoura Faculty of Medicine
Mansoura Egypt
tarekshokeirgmailcom
The author reports no con1047298ict of interest
REFERENCES
1 Guumlnthert AR Christmann C Kostov P Mueller MD Safe vaginal
uterine morcellation following total laparoscopic hysterectomy Am J
Obstet Gynecol 2015212546e1-4
2 Greene AK Hodin RA Laparoscopic splenectomy for massive
splenomegaly using a Lahey bag Am J Surg 2001181543-6
3 Wu SD Lesani OA Zhao LC et al A multi-institutional study on the
safety and ef 1047297cacy of specimen morcellation after laparoscopic radicalnephrectomy for clinical stage T1 or T2 renal cell carcinoma J Endourol
2009231513-8
4 Montella F Riboni F Cosma S et al A safe method of vaginal longi-
tudinal morcellation of bulky uterus with endometrial cancer in a bag at
laparoscopy Surg Endosc 2014281949-53
5 Urban DA Kerbl K McDougall EM Stone AM Fadden PT
Clayman RV Organ entrapment and renal morcellation permeability
studies Urology 19931501792-4
ordf 2015 Elsevier Inc All rights reserved httpdxdoiorg101016jajog
201412024
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 cancerWe share these concerns but as demonstrated in our
video we observe vaginal morcellation by simultaneous lap-aroscopy The coring morcellation procedure always produces
some 1047298uid as residue which accumulates in the bag After
extraction we always test the bag for leakage by controlling thetightness of the bag But we admit that a very low risk of
microscopic leakage can not entirely be excludedAs stated in our manuscript and in contrast to some recent
reports we strictly exclude vaginal in-bag morcellation inpatients at high risk for cancer or with already con1047297rmed
malignancy12 We recommend it as a risk-reducing procedure
in patients with uncertain uterine mass and in these cases ourdata seem strong enough to recommend it as clinical routine
to avoid laparotomy Since incidental morcellated uterine
malignancies are rare3 we appreciate any independent reportin the future about the experience of our described method-
Andreas R Guumlnthert
Department of Gynecology and Obstetrics
Cantonal Hospital of Lucerne
Lucerne Switzerland
MAY 2015 American Journal of Obstetrics amp Gynecology 689
ajogorg Letters to the Editors