1 / 22

Morcellation of specimen : Fact or fiction?

Morcellation of specimen : Fact or fiction?. Gustavo Plasencia MD, FACS, FASCRS. Historical Technique. Sufficient mobilization so that distal and proximal bowel reach point of extraction at abdominal wall Intracorporeal devascularization requires smaller incisions

jaquelyn-young
Download Presentation

Morcellation of specimen : Fact or fiction?

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Morcellation of specimen : Fact or fiction? Gustavo Plasencia MD, FACS, FASCRS

  2. Historical Technique Sufficient mobilization so that distal and proximal bowel reach point of extraction at abdominal wall Intracorporealdevascularization requires smaller incisions Transecting bowel intracorporeally, may require smaller incision, vs loop extraction Incisions should be muscle splitting; bulky pathology may require cutting muscles

  3. Historical Technique Incision size should be as small as technically feasible Wound protectors necessary in malignant pathology Inject local long acting anesthetic at incisions

  4. Incision • Transverse/Longitudinal • Muscle Splitting/Sparing • Wound Protector- helps prevent wound recurrence/infection

  5. Current Steps of Colectomy Anastomosis and Extraction independent of each other Devascularizationshould be done intracorporeally to facilitate extraction Intact or Morcellated specimen Extraction through incision of anterior abdominal wall, through trochar, through natural orifice

  6. IntracorporealAnastomosis Totally intracorporealcolectomy Transrectal extraction (NOTES) 1990

  7. IntroductionTissue Morcelation Common for spleen, uterus,kidney, in benign diseases Piecemeal extraction of tissues Avoid extraction incisions. Use only trochar sites; may be slightly enlarged, dilated

  8. Principles for morcellation • Only performed for benign disease • Requires impermeable entrapment bag • Check bag for perforation • Maintenance of pneumoperitoneum • Avoid overflow in the bag by frequent suction of fluid and tissues

  9. Principles for morcellationcont. • Change gloves after tissue extraction • Any manipulation should be done with atraumatic instruments • Perform under laparoscopic visualization

  10. Advantages • Less post-operative pain • Improved cosmesis • Potential advantages • Reduced risk of incisional hernias • Decreased risk of wound infection • Quicker return to activities

  11. Disadvantages • Injury to adjacent tissues when morcellating • Extra cost if using morcellating device • Longer OR times • Not recommended for malignant disease

  12. Malignancy? • Cannot obtain adequate staging of cancer, due to destruction of primary as well as lymph nodes

  13. How we do it • Cook endo bag used • Tissues morcellated without any extra equipment.

  14. How we do it • Three 3mm or 5mm trochars for graspers and camera • 5mm thirty degree scope gives better visualization • One 15mm port for placement of stapler, through which well lubricated head of circular stapler is passed, and tissue extracted • May have to enlarged by blunt dilatation (opened Kelly clamp)

  15. How we do it Take mesentery either at base or close to bowel. Divide bowel at rectosigmoidjct Introduce into abdomen, head of circular stapler with spear and loop of 1-0 prolene attached Choose proximal margin of resection, a few cm distally make an incision on antimesenteric border

  16. How we do it Pass the head with attached spear and prolene proximally into bowel. Let prolene stick out Transect bowel at proximal margin of resection with endostapler. Place no tension on prolene suture. Stapler will not cut suture Pull on suture until tip of spear pushes staple line and apply countertraction until spear perforates staple line. Pull on suture until head is flat on staple line. Place an endoloop around circular head for security. Remove spear

  17. How we do it Perform transrectalanastomosis. Place specimen in bag Exteriorize bag through 15mm trochar. Extract specimen piecemeal or with morcelator

  18. Results 10 pts Avg age 66y (range 52 – 81) 4 males, 6 females Length of stay 2.4 days (range 1-4) Time to flatus 1.4 days (range 1-3)

  19. Pain Control KETOROLAC iv started intraop, continued as needed for first 24 hrs. on all pts, then switched to propoxyphene, ibuprofen or acetaminophen one pt required ketorolac for 48 hrs Three pts required ketorolac and narcotics (HYDROMORPHONE) for first 48 hrs Three pts used propoxyphene after being discharged, the rest used ibuprofen or acetaminophen

  20. Complications One pt (male with acute and chronic diverticulitis) converted to normal laparoscopic colectomy, due to incomplete anastomosis No leaks 1 mild cellulitis at extraction site, treated with oral antibiotics 1 pt travelling from South America discharged post op day 1, readmitted and treated for severe diarrhea

  21. Future? • Incisionless • Natural Orifice • Hybrid (Laparoscopic+Morcelation+NOTES)

  22. Sigmoid MorcelizationVideo

More Related