Objective: To review the current evidence, controversies and implications for future practice pertaining to contained intracorporeal morcellation during minimally invasive benign gynaecological surgery.

Background: Electromechanical morcellation (EMM) has been around for two decades and has enabled surgeons to offer patients a minimally invasive approach to hysterectomy and myomectomy. ¹ Minimally invasive surgery (MIS) has been well established to be associated with quicker recovery, less postoperative pain, less blood loss and overall less morbidity and mortality.

Recently the U.S. Food and Drug Administration (FDA) released a statement discouraging the use of EMM for women with uterine myoma citing safety concerns and recommended that morcellation be contraindicated in cases where the patient is peri/post-menopausal and for cases where they are candidates for en bloc removal of tissue.² The FDA also suggested that 1 in 350 women undergoing surgery for fibroids is found to have an unsuspected uterine sarcoma and that this perceived risk is more common than previously assumed.²

Recent events have put the use of EMM under scrutiny especially highlighting important drawbacks associated with open EMM including risk of trauma to surrounding structures, tissue disruption and dispersion within the abdominal cavity and more importantly the potential for the dissemination of occult malignancy. In addition such dissemination of occult malignancy can potentially upstage the disease, necessitate further surgical interventions and may be associated with worse prognosis. EMM should be reserved for cases where preoperative assessment is suggestive of benign pathology after careful counselling as recommended by governing bodies.¹ This proves to be challenging as the ability to preoperatively diagnose and screen certain types of uterine malignancy such as uterine sarcoma is limited.

Given the recommendation of caution with the use of EMM, the availability and the use of EMM has been variable across different health care institutions thereby limiting the extent of MIS that can be offered to patients with uterine fibroids.

Moving forward we must advance in two main aspects. Firstly improving preoperative detection and screening of uterine malignancy especially uterine sarcoma. Secondly, surgical innovation targeting different ways to morcellate uterine tissue in appropriate cases with ongoing safety evaluation.¹

We will review the current evidence, controversies and recommendations surrounding the risks of EMM. We will review the potential alternative contained ways to morcellate tissue as described in the literature and a related video presentation.