REFERENCES 1. Van Mieghem T, De Heus R, Lewi L, Klaritsch P, Kollmann M, Baud D, et al. Prenatal management of monoamniotic twin pregnancies. Obstet Gynecol 2014; 124:498–506. 2. Robinson BK, Grobman WA. Effectiveness of timing strategies for delivery of individuals with vasa previa. Obstet Gynecol 2011;117:542–9. 3. Tita AT, Landon MB, Spong CY, Lai Y, Leveno KJ, Varner MW, et al. Timing of elective repeat cesarean delivery at term and neonatal outcomes. N Engl J Med 2009;360:111–20. 4. Morikawa M, Yamada T, Yamada T, Sato S, Minakami H. Prospective risk of intrauterine fetal death in monoamniotic twin pregnancies. Twin Res Hum Genet 2012;15:522–6. 5. Demaria F, Goffinet F, Kayem G, Tsatsaris V, Hessabi M, Cabrol D. Monoamniotic twin pregnancies: antenatal management and perinatal results of 19 consecutive cases. BJOG 2004; 111:22–6.
Unfortunately, only a small fraction ofminimally invasive surgeons have chosen to transition to single-port surgery. Using this bag for multiport endoscopy appears to be defeating the purpose. Why are we looking so far to teach safe removal of a large uterus without power morcellation? Could vaginal morcellation be the answer? Before any other minimally invasive approach, there was vaginal surgery, which allows for removal of large uteri from a truly single incision. In the hands of the average surgeon, this bag will have more holes than those intentionally created when used for multiport laparoscopy. Let’s spend our valuable time and resources teaching vaginal morcellation to our junior colleagues, not this technically complex method, difficult to duplicate. With a concerted effort, acquiring vaginal morcellation skills may be easier than learning how to set up this bag. Financial Disclosure: The author did not report any potential conflicts of interest.
Contained Power Morcellation Within an Insufflated Isolation Bag To the Editor: I read the article about contained power morcellation in a large “isolation bag” with curiosity.1 It reminded me of how I felt when I watched surgical videos performed by talented surgeons, which I wish had a disclaimer: “This was performed by an exceptional team under specific conditions. Do not try this in your own operating room.” Widespread adaptation to a new surgical approach is possible only if it can be duplicated by the average surgeon. It is hard to imagine placing this bag in the hands of lessexperienced gynecologists. The manufacturer and approved indication of the bag were unclear. I wonder whether the same product was used at all four institutions. I doubt if the use of an “isolation bag,” not approved for this purpose, would be allowed at my institution. I am certain that a study that presents testing of such a tool would not have found space in Obstetrics & Gynecology had it not been for the ban on power morcellation, one of the hottest current debates in gynecology. Additionally, this concept is clearly more suitable for single-port laparoscopy.
VOL. 125, NO. 1, JANUARY 2015
Oz Harmanli, MD Urogynecology and Pelvic Surgery, Baystate Medical Center, Springfield, Massachusetts and Department of Obstetrics and Gynecology, Tufts University School of Medicine, Boston, Massachusetts
REFERENCE 1. Cohen SL, Einarsson JI, Wang KC, Brown D, Boruta D, Scheib SA, et al. Contained power morcellation within an insufflated isolation bag. Obstet Gynecol 2014;124:491–7.
In Reply: The authors thank Dr. Harmanli for his thoughts regarding the technique of contained power morcellation within an insufflated isolation bag.1 Regarding the comments about vaginal morcellation being the answer, we would instead like to suggest that the route of morcellation is less important than the fact that tissue be contained during this process. In the article by Park et al,2 which describes the adverse effects of tumor morcellation on prognosis for uterine leiomyosarcoma, the majority of patients underwent tissue morcellation through the vagina or mini-laparotomy. In addition, a study by Perri et al3 demon-
strates that any primary surgery involving tumor injury was associated with a worse prognosis in cases of occult early-stage leiomyosarcoma. To mitigate risk of tissue morcellation during surgery for uterine leiomyomas, any process that involves disruption and possible dissemination of tissue should be performed in a contained fashion. The route of contained morcellation then becomes a decision based on surgeon and patient preference and should not be viewed as a one-size-fitsall scenario. The technique we describe is simply one of many that may be employed for a laparoscopic approach to contained morcellation. For example, in cases of laparoscopic myomectomy or supracervical hysterectomy, contained vaginal morcellation, which would require a colpotomy to perform, may not be as appealing a technique as contained morcellation through either mini-laparotomy or laparoscopic approach. We also acknowledge the concern about intentional puncture into the isolation bag with the multiport approach to contained power morcellation. Although the risk of spillage or tissue dissemination from this site is theoretically low owing to the placement in the nondependent portion of the bag and obstruction of this site by a trocar throughout the time of bag insufflation, it is a topic that deserves further study. An in vitro pilot study of this technique4 did not find any evidence of fluid, tissue, or cytologic leakage when employing a multiportcontained tissue extraction with the isolation bag. We are also involved in an ongoing prospective multicenter study that aims to assess this issue further by looking for evidence of dye spillage outside of the isolation bag after multiport contained power morcellation. The comment about a need for training holds true not only for contained laparoscopic power morcellation, but also for contained vaginal and mini-laparotomy tissue morcellation. This should become a major focus as surgeons strive to provide patients with the benefits of minimally invasive surgery while minimizing risk of tissue dissemination. The technique we describe represents an interim stage in contained tissue extraction methods. We look forward to further advances as new techniques and containment systems are
Letters
229
Unfortunately, only a small fraction ofminimally invasive surgeons have chosen to transition to single-port surgery. Using this bag for multiport endoscopy appears to be defeating the purpose. Why are we looking so far to teach safe removal of a large uterus without power morcellation? Could vaginal morcellation be the answer? Before any other minimally invasive approach, there was vaginal surgery, which allows for removal of large uteri from a truly single incision. In the hands of the average surgeon, this bag will have more holes than those intentionally created when used for multiport laparoscopy. Let’s spend our valuable time and resources teaching vaginal morcellation to our junior colleagues, not this technically complex method, difficult to duplicate. With a concerted effort, acquiring vaginal morcellation skills may be easier than learning how to set up this bag. Financial Disclosure: The author did not report any potential conflicts of interest.
Contained Power Morcellation Within an Insufflated Isolation Bag To the Editor: I read the article about contained power morcellation in a large “isolation bag” with curiosity.1 It reminded me of how I felt when I watched surgical videos performed by talented surgeons, which I wish had a disclaimer: “This was performed by an exceptional team under specific conditions. Do not try this in your own operating room.” Widespread adaptation to a new surgical approach is possible only if it can be duplicated by the average surgeon. It is hard to imagine placing this bag in the hands of lessexperienced gynecologists. The manufacturer and approved indication of the bag were unclear. I wonder whether the same product was used at all four institutions. I doubt if the use of an “isolation bag,” not approved for this purpose, would be allowed at my institution. I am certain that a study that presents testing of such a tool would not have found space in Obstetrics & Gynecology had it not been for the ban on power morcellation, one of the hottest current debates in gynecology. Additionally, this concept is clearly more suitable for single-port laparoscopy.
VOL. 125, NO. 1, JANUARY 2015
Oz Harmanli, MD Urogynecology and Pelvic Surgery, Baystate Medical Center, Springfield, Massachusetts and Department of Obstetrics and Gynecology, Tufts University School of Medicine, Boston, Massachusetts
REFERENCE 1. Cohen SL, Einarsson JI, Wang KC, Brown D, Boruta D, Scheib SA, et al. Contained power morcellation within an insufflated isolation bag. Obstet Gynecol 2014;124:491–7.
In Reply: The authors thank Dr. Harmanli for his thoughts regarding the technique of contained power morcellation within an insufflated isolation bag.1 Regarding the comments about vaginal morcellation being the answer, we would instead like to suggest that the route of morcellation is less important than the fact that tissue be contained during this process. In the article by Park et al,2 which describes the adverse effects of tumor morcellation on prognosis for uterine leiomyosarcoma, the majority of patients underwent tissue morcellation through the vagina or mini-laparotomy. In addition, a study by Perri et al3 demon-
strates that any primary surgery involving tumor injury was associated with a worse prognosis in cases of occult early-stage leiomyosarcoma. To mitigate risk of tissue morcellation during surgery for uterine leiomyomas, any process that involves disruption and possible dissemination of tissue should be performed in a contained fashion. The route of contained morcellation then becomes a decision based on surgeon and patient preference and should not be viewed as a one-size-fitsall scenario. The technique we describe is simply one of many that may be employed for a laparoscopic approach to contained morcellation. For example, in cases of laparoscopic myomectomy or supracervical hysterectomy, contained vaginal morcellation, which would require a colpotomy to perform, may not be as appealing a technique as contained morcellation through either mini-laparotomy or laparoscopic approach. We also acknowledge the concern about intentional puncture into the isolation bag with the multiport approach to contained power morcellation. Although the risk of spillage or tissue dissemination from this site is theoretically low owing to the placement in the nondependent portion of the bag and obstruction of this site by a trocar throughout the time of bag insufflation, it is a topic that deserves further study. An in vitro pilot study of this technique4 did not find any evidence of fluid, tissue, or cytologic leakage when employing a multiportcontained tissue extraction with the isolation bag. We are also involved in an ongoing prospective multicenter study that aims to assess this issue further by looking for evidence of dye spillage outside of the isolation bag after multiport contained power morcellation. The comment about a need for training holds true not only for contained laparoscopic power morcellation, but also for contained vaginal and mini-laparotomy tissue morcellation. This should become a major focus as surgeons strive to provide patients with the benefits of minimally invasive surgery while minimizing risk of tissue dissemination. The technique we describe represents an interim stage in contained tissue extraction methods. We look forward to further advances as new techniques and containment systems are
Letters
229
