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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