Safety of In-Bag Morcellation During Laparoscopic Myomectomy and Hysterectomy: A Systematic Review and Meta-Analysis

To systematically evaluate the outcomes of in-bag versus no-bag morcellation during laparoscopic myomectomy and hysterectomy, focusing on safety.

Searches were conducted in Cochrane Library, Embase, and PubMed, covering studies from inception up to January 31, 2024.

Inclusion of studies on females undergoing laparoscopic myomectomy and/or hysterectomy with in-bag morcellation, excluding series with fewer than 10 patients.

Data were synthesized using meta-analysis techniques, with sensitivity analyses for rare events, focusing on intraoperative complications (i.e., a composite outcome including conversion to laparotomy, bowel injury, or accidental injury to any viscus injury or vessel). The secondary outcomes include presence of parasitic fibroma, fragment of myometrium/uterus, blood transfusion, bleeding > 500 mL, total operative time, postoperative length of stay, postoperative pain, conversion to laparotomy, postoperative complications, and cost. From 1970 published studies, we included 20 trials, enrolling 5505 women in the in-bag group and 37 283 women in the no-bag group. We included 9 trials in each subgroup, myomectomy and hysterectomy, enrolling 767 and 4678 women in the in-bag group and 830 and 36 380 women in the no-bag groups, respectively. We observed increased intraoperative complications compared to no-bag morcellation (Odds ratio [OR] 1.45, 95% confidence interval [CI] 1.11;1.89) with a null heterogeneity (I² = 0%). The hysterectomy subgroup analysis showed a significant association between bag and intraoperative complications (OR 1.47, 95% CI 1.12;1.93) but not myomectomy (OR 1.00, 95% CI 0.29;3.43). We did not have enough information to conclude about the presence of parasitic fibroma, a fragment of myometrium, and costs. No statistical differences were observed concerning the other secondary outcomes.

The use of containment bags in morcellation may increase the risk of intraoperative complications, particularly in the case of hysterectomy. However, these events may not directly link to bag use and could potentially represent confounding factors. Further studies are needed to investigate in-bag morcellation.