Since the first use of autologous blood transfusion by the renowned obstetrician gynecologist James Blundell of Guy’s Hospital (London, UK) in 1825, debate has surrounded its role in contemporary practice. It is therefore with interest that we read the assessment of the usefulness of intraoperative cell salvage in abdominal myomectomy by Son et al. We are heartened to see that no complications were reported from cell salvage use, reaffirming the technique as safe.

Without guidelines for use in abdominal myomectomy, our institution has followed a pattern of cell salvage use similar to that reported by the authors. Use is at the discretion of the operating surgeon (with consideration given to the availability of equipment, personnel skills, and subjective assessment of bleeding risk).

Interrogation of institutional operative records, which was aimed at better targeting cell salvage use, revealed that only the very largest uteri (>30 weeks’ gestation) reliably predicted the need for transfusion and that most of the women who underwent operation and required transfusion had smaller uteri. A factor not reported by the authors is the importance of the incision, and we wonder what impact this variable would have on the analysis. We found that midline incision was associated with a substantial chance of the need of transfusion and that this increased risk was not accounted for by size of the uterus alone. Overall though, we agree that only marginal improvements can be made through risk stratification, given its poor predictive power.

As acknowledged by the limitations of this study, costs are highly institution specific. We do not recognize the use of a perfusionist as routine practice; because anesthetist colleagues possess the skills to set up and run cell salvage, we avoid this substantial cost. Further, the costs of consumables in the analysis have not been separated between cases of collection only and collection, processing, and reinfusion. “Standby” collection whereby blood is collected in a separate reservoir with heparin is well reported and substantially reduces the cost, relative to processing and reinfusion. Processing and reinfusion can then be initiated only if blood products are required clinically. This technique is most appropriate for surgery, such as myomectomy, during which there is a small risk of large blood loss.

We therefore believe that it is not possible to conclude that the routine use of cell salvage in myomectomy cannot be justified until all attempts at cost reduction have been made.