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 Günthert 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 Günthert 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 identified by the surgeon’s 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 benefit from further testing and refinement before implementing this procedure in daily routine. -
Tarek Shokeir, MD Department of Obstetrics and Gynecology Mansoura University Hospital Mansoura Faculty of Medicine Mansoura, Egypt [email protected] The author reports no conflict of interest.
REFERENCES 1. Günthert 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 efficacy 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. ª 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 fluid 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 confirmed 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. Günthert Department of Gynecology and Obstetrics Cantonal Hospital of Lucerne Lucerne, Switzerland
MAY 2015 American Journal of Obstetrics & Gynecology
689
Letters to the Editors
Safe vaginal uterine morcellation following total laparoscopic hysterectomy TO THE EDITORS: We read with great interest the article published by Günthert 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 Günthert 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 identified by the surgeon’s 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 benefit from further testing and refinement before implementing this procedure in daily routine. -
Tarek Shokeir, MD Department of Obstetrics and Gynecology Mansoura University Hospital Mansoura Faculty of Medicine Mansoura, Egypt [email protected] The author reports no conflict of interest.
REFERENCES 1. Günthert 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 efficacy 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. ª 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 fluid 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 confirmed 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. Günthert Department of Gynecology and Obstetrics Cantonal Hospital of Lucerne Lucerne, Switzerland
MAY 2015 American Journal of Obstetrics & Gynecology
689
