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A Simple, Inexpensive Method of Specimen Removal at Laparoscopy
A Simple Method of Specimen Removal Mashiach et al
A Simple, Inexpensive Method of Specimen Removal at Laparoscopy Roy Mashiach, M.D., Shlomo Mashiach, M.D., Amir Szold, M.D., and Joseph B. Lessing, M.D.
Abstract After completing operative laparoscopy, it is often necessary to enlarge a 5-mm port to 10 or 12 mm for tissue removal. This may increase the risk of vessel injury and herniation, and has obvious cosmetic drawbacks. A simple, cost-effective technique for tissue removal does not require enlarging the 5-mm port. A long, firm thread is sutured to a sterile plastic bag. When tissue removal is required, the optic telescope is removed and the bag is blindly introduced through the available optical 11- or 12-mm cannula. The telescope is reintroduced, keeping the end of the thread outside the cannula sleeve. The specimen is placed in the bag and the bag is removed by pulling the suture through the optical cannula after removing the telescope. This technique was performed successfully in over 300 patients, with no difficulty or complication either during or after surgery. The device is inexpensive and takes 2 minutes to assemble. (J Am Assoc Gynecol Laparosc 9(2):214–216, 2002)
Laparoscopic procedures such as oophorectomy and myomectomy frequently end in the frustrating need to enlarge a 5-mm port to 10 mm or more just to remove tissue, even though surgery itself does not require more than 5 mm. Use of large cannulas increases the risk of injury to abdominal wall vessels,1 and resultant satellite defects in the rectus abdominis fascia increase the risk of incisional herniation, even when the defects are sutured closed.2 Many devices and techniques are available to dilate small initial punctures to the diameter necessary to accommodate 10- or 12-mm ports.3,4 We developed a simple technique that eliminates the need for port enlargement. Its benefits in reducing complications, cost, and aesthetic shortcomings are obvious.
Technique After operative laparoscopy is completed, the optic telescope is removed and a plastic bag is tied to a long thread (Figure 1). Almost all commercially available bags may be introduced. The bag is rolled, grasped with an atraumatic grasper, and introduced through the optical cannula. The optic telescope is then reintroduced alongside the suture, which is held from the proximal end of the cannula outside the abdomen. The specimen is placed into the bag and the two lips of the bag are approximated. The optic telescope is withdrawn and the thread pulled. The endobag follows the suture and is removed as described
From the Department of Obstetrics and Gynecology, Lis Maternity Hospital (Drs. R. Mashiach and Lessing) and Endoscopic Surgery (Dr. Szold), Tel Aviv Sourasky Medical Center; Department of Obstetrics and Gynecology, Sheba Medical Center Ramat-Gan (Dr. S. Mashiach); and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (all authors). Address reprint requests to Roy Mashiach, M.D., Department of Obstetrics and Gynecology, Lis Medical Center, 64044 Tel-Aviv, Israel; fax 972 3 609 4848. Presented at the 30th annual meeting of the American Association of Gynecologic Laparoscopists, San Francisco, California, November 16–19, 2001. First prize Daniel F. Kott award for best new instrumentation. Accepted for publication October 30, 2001.
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May 2002, Vol. 9, No. 2
The Journal of the American Association of Gynecologic Laparoscopists
elsewhere.5–7 The cannula sleeve is removed and reintroduced after the endobag is removed. When visualization of the specimen retrieval and morcellation are required, a 5-mm endoscope can be inserted through one of the 5-mm cannulas. The umbilical cannula site can be enlarged, when necessary, with less risk of future herniation than with lateral abdominal cannula site enlargement. In cases that involve large solid masses, especially malignant tumors, or when a minilaparotomy incision would facilitate performance of the laparoscopic procedure itself (myomectomy), one should consider minilaparotomy incision.
cannulas are often placed lateral to the relatively avascular midline,8 but also because of the larger area at risk for vessel injury when using these cannulas rather than 5-mm ones.9 The risk of postoperative herniation is also higher, even if fascia is sutured closed4; this was attributed to the size of the defect.2 It is commonly believed that an umbilical opening carries less risk of herniation than a lateral opening of the same size, and can be repaired with a better cosmetic outcome. Methods to increase the safety of lateral abdominal cannula port enlargement include disposable radially expanding system3 and blunt-tipped conical cannula with fascial threads integrated into the port sleeve.4 The advantage of our approach is that it usually eliminates the need for cannula site enlargement. Using the umbilical port has safety and cosmetic advantages even in cases in which enlargement is necessary. The method requires common, inexpensive instrumentation, which itself has economic implications. We did not encounter any complications, but when blind specimen morcellation is performed, the risk of bowl injury and bag disruption with spillage of contents must be considered. We therefore recommend morcellization under vision with a 5-mm endoscope when the specimen is large or bulky.
Experience
References
We have performed this technique in over 300 patients with excellent results. Procedures were a mix of gynecologic and surgical surgeries, and the technique was effective in removing solid and cystic ovarian masses, gallbladders, spleens, and adrenal glands. We did not use this method for large, malignant, solid masses, and therefore did not have to enlarge the umbilical incision more than a few millimeters. There were no complications or bag disruptions, either intraoperatively or postoperatively. In the few cases in which the umbilical cannula site was enlarged, no bleeding or herniation was noted as the umbilical port site is easy to suture well compared with a lateral incision. The technique is very simple and inexpensive (cost of one endobag ~$15.00).
1. Bateman BG, Kolp LA, Hoeger K: Complications of laparoscopy—Operative and diagnostic. Fertil Steril 66:30–35, 1996
FIGURE 1. Endobag with thread.
2. Boike GM, Miller CE, Spirtos NM, et al: Incisional bowel herniations after operative laparoscopy: A series of nineteen cases and review of the literature. Am J Obstet Gynecol 172:1726–1733, 1995 3. Turner DJ: A new, radially expanding access system for laparoscopic procedures versus conventional cannulas. J Am Assoc Gynecol Laparosc 3:609–615, 1996 4. Davis DR, Schilder JM, Hurd WW: Laparoscopic secondary port conversion using a reusable blunt conical trocar. Obstet Gynecol;96:634–635, 2000
Discussion
5. Kuhn T, Hock S, Zippel HH: Endoscopic therapy of adnexa tumors using endobag extraction. Geburtshilfe Frauenheilkd 55:684–686, 1995
Enlarging the lateral lower abdominal cannula port for tissue removal increases the risk of abdominal wall vessel injury, not only because these larger
6. Campo S, Garcea N: Laparoscopic conservative excision of ovarian dermoid cysts with and without an endobag. J Am Assoc Gynecol Laparosc 5:165–170, 1998
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A Simple Method of Specimen Removal Mashiach et al
7. Nezhat CR, Kalyoncu S, Nezhat CH, et al: Laparoscopic management of ovarian dermoid cysts: Ten years’ experience. J Soc Laparosc Surg 3:179–184, 1999
9. Hurd WW, Wang L, Schemmel MT: A comparison of the relative risk of vessel injury with conical versus pyramidal laparoscopic trocars in a rabbit model. Am J Obstet Gynecol 173:1731–1733, 1995
8. Hurd WW, Bude RO, DeLancey JO, et al: The location of abdominal wall blood vessels in relationship to abdominal landmarks apparent at laparoscopy. Am J Obstet Gynecol 171:642–646, 1994
216
A Simple, Inexpensive Method of Specimen Removal at Laparoscopy Roy Mashiach, M.D., Shlomo Mashiach, M.D., Amir Szold, M.D., and Joseph B. Lessing, M.D.
Abstract After completing operative laparoscopy, it is often necessary to enlarge a 5-mm port to 10 or 12 mm for tissue removal. This may increase the risk of vessel injury and herniation, and has obvious cosmetic drawbacks. A simple, cost-effective technique for tissue removal does not require enlarging the 5-mm port. A long, firm thread is sutured to a sterile plastic bag. When tissue removal is required, the optic telescope is removed and the bag is blindly introduced through the available optical 11- or 12-mm cannula. The telescope is reintroduced, keeping the end of the thread outside the cannula sleeve. The specimen is placed in the bag and the bag is removed by pulling the suture through the optical cannula after removing the telescope. This technique was performed successfully in over 300 patients, with no difficulty or complication either during or after surgery. The device is inexpensive and takes 2 minutes to assemble. (J Am Assoc Gynecol Laparosc 9(2):214–216, 2002)
Laparoscopic procedures such as oophorectomy and myomectomy frequently end in the frustrating need to enlarge a 5-mm port to 10 mm or more just to remove tissue, even though surgery itself does not require more than 5 mm. Use of large cannulas increases the risk of injury to abdominal wall vessels,1 and resultant satellite defects in the rectus abdominis fascia increase the risk of incisional herniation, even when the defects are sutured closed.2 Many devices and techniques are available to dilate small initial punctures to the diameter necessary to accommodate 10- or 12-mm ports.3,4 We developed a simple technique that eliminates the need for port enlargement. Its benefits in reducing complications, cost, and aesthetic shortcomings are obvious.
Technique After operative laparoscopy is completed, the optic telescope is removed and a plastic bag is tied to a long thread (Figure 1). Almost all commercially available bags may be introduced. The bag is rolled, grasped with an atraumatic grasper, and introduced through the optical cannula. The optic telescope is then reintroduced alongside the suture, which is held from the proximal end of the cannula outside the abdomen. The specimen is placed into the bag and the two lips of the bag are approximated. The optic telescope is withdrawn and the thread pulled. The endobag follows the suture and is removed as described
From the Department of Obstetrics and Gynecology, Lis Maternity Hospital (Drs. R. Mashiach and Lessing) and Endoscopic Surgery (Dr. Szold), Tel Aviv Sourasky Medical Center; Department of Obstetrics and Gynecology, Sheba Medical Center Ramat-Gan (Dr. S. Mashiach); and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel (all authors). Address reprint requests to Roy Mashiach, M.D., Department of Obstetrics and Gynecology, Lis Medical Center, 64044 Tel-Aviv, Israel; fax 972 3 609 4848. Presented at the 30th annual meeting of the American Association of Gynecologic Laparoscopists, San Francisco, California, November 16–19, 2001. First prize Daniel F. Kott award for best new instrumentation. Accepted for publication October 30, 2001.
214
May 2002, Vol. 9, No. 2
The Journal of the American Association of Gynecologic Laparoscopists
elsewhere.5–7 The cannula sleeve is removed and reintroduced after the endobag is removed. When visualization of the specimen retrieval and morcellation are required, a 5-mm endoscope can be inserted through one of the 5-mm cannulas. The umbilical cannula site can be enlarged, when necessary, with less risk of future herniation than with lateral abdominal cannula site enlargement. In cases that involve large solid masses, especially malignant tumors, or when a minilaparotomy incision would facilitate performance of the laparoscopic procedure itself (myomectomy), one should consider minilaparotomy incision.
cannulas are often placed lateral to the relatively avascular midline,8 but also because of the larger area at risk for vessel injury when using these cannulas rather than 5-mm ones.9 The risk of postoperative herniation is also higher, even if fascia is sutured closed4; this was attributed to the size of the defect.2 It is commonly believed that an umbilical opening carries less risk of herniation than a lateral opening of the same size, and can be repaired with a better cosmetic outcome. Methods to increase the safety of lateral abdominal cannula port enlargement include disposable radially expanding system3 and blunt-tipped conical cannula with fascial threads integrated into the port sleeve.4 The advantage of our approach is that it usually eliminates the need for cannula site enlargement. Using the umbilical port has safety and cosmetic advantages even in cases in which enlargement is necessary. The method requires common, inexpensive instrumentation, which itself has economic implications. We did not encounter any complications, but when blind specimen morcellation is performed, the risk of bowl injury and bag disruption with spillage of contents must be considered. We therefore recommend morcellization under vision with a 5-mm endoscope when the specimen is large or bulky.
Experience
References
We have performed this technique in over 300 patients with excellent results. Procedures were a mix of gynecologic and surgical surgeries, and the technique was effective in removing solid and cystic ovarian masses, gallbladders, spleens, and adrenal glands. We did not use this method for large, malignant, solid masses, and therefore did not have to enlarge the umbilical incision more than a few millimeters. There were no complications or bag disruptions, either intraoperatively or postoperatively. In the few cases in which the umbilical cannula site was enlarged, no bleeding or herniation was noted as the umbilical port site is easy to suture well compared with a lateral incision. The technique is very simple and inexpensive (cost of one endobag ~$15.00).
1. Bateman BG, Kolp LA, Hoeger K: Complications of laparoscopy—Operative and diagnostic. Fertil Steril 66:30–35, 1996
FIGURE 1. Endobag with thread.
2. Boike GM, Miller CE, Spirtos NM, et al: Incisional bowel herniations after operative laparoscopy: A series of nineteen cases and review of the literature. Am J Obstet Gynecol 172:1726–1733, 1995 3. Turner DJ: A new, radially expanding access system for laparoscopic procedures versus conventional cannulas. J Am Assoc Gynecol Laparosc 3:609–615, 1996 4. Davis DR, Schilder JM, Hurd WW: Laparoscopic secondary port conversion using a reusable blunt conical trocar. Obstet Gynecol;96:634–635, 2000
Discussion
5. Kuhn T, Hock S, Zippel HH: Endoscopic therapy of adnexa tumors using endobag extraction. Geburtshilfe Frauenheilkd 55:684–686, 1995
Enlarging the lateral lower abdominal cannula port for tissue removal increases the risk of abdominal wall vessel injury, not only because these larger
6. Campo S, Garcea N: Laparoscopic conservative excision of ovarian dermoid cysts with and without an endobag. J Am Assoc Gynecol Laparosc 5:165–170, 1998
215
A Simple Method of Specimen Removal Mashiach et al
7. Nezhat CR, Kalyoncu S, Nezhat CH, et al: Laparoscopic management of ovarian dermoid cysts: Ten years’ experience. J Soc Laparosc Surg 3:179–184, 1999
9. Hurd WW, Wang L, Schemmel MT: A comparison of the relative risk of vessel injury with conical versus pyramidal laparoscopic trocars in a rabbit model. Am J Obstet Gynecol 173:1731–1733, 1995
8. Hurd WW, Bude RO, DeLancey JO, et al: The location of abdominal wall blood vessels in relationship to abdominal landmarks apparent at laparoscopy. Am J Obstet Gynecol 171:642–646, 1994
216