We read with great interest the article published by Günthert et al, 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 splenectomy and nephrectomy. Recently, Montella et al 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, 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. 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.