Vaginal morcellation techniques: uncontained and contained

Highlight the various techniques of vaginal morcellation and considerations surrounding contained and uncontained morcellation. Uncontained morcellation at the time of vaginal hysterectomy for benign indications has no significant associated risks. However, limited data exists regarding potential spread of occult malignancy. Although uncontained morcellation is not contraindicated, contained morcellation should be employed when feasible. Shared decision making is critical to ensure informed consent regarding risks, including potential dissemination of disease. Morcellation during vaginal hysterectomy begins by securing the uterine vasculature bilaterally and bivalving the cervix. Multiple morcellation techniques, including intramyometrial coring, wedge resection, and myomectomy can then be used to decrease uterine size and facilitate completion of the vaginal hysterectomy. Similar methods and surgical principles can be utilized at the time of total laparoscopic or robotic hysterectomy to facilitate contained vaginal morcellation within a bag. Adequate retraction of the vaginal walls, visualization of the uterine serosa, and directing the scalpel into the specimen throughout vaginal morcellation ensures safety without risk of injury to the vaginal canal, pelvic sidewalls or surrounding viscera. Uncontained vaginal morcellation during vaginal hysterectomy and contained morcellation during total laparoscopic or robotic hysterectomy can facilitate removal of enlarged uterine specimens. Techniques include intramyometrial coring, wedge resection, and myomectomy. Shared decision making is critical, and this technique should be avoided if there is concern for underlying malignancy.