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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

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morcellation of specimen fact or fiction

Morcellation of specimen : Fact or fiction?

Gustavo Plasencia MD, FACS, FASCRS

historical technique
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

historical technique1
Historical Technique

Incision size should be as small as technically feasible

Wound protectors necessary in malignant pathology

Inject local long acting anesthetic at incisions

incision
Incision
  • Transverse/Longitudinal
  • Muscle Splitting/Sparing
  • Wound Protector- helps prevent wound

recurrence/infection

current steps of colectomy
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

intracorporeal anastomosis
IntracorporealAnastomosis

Totally intracorporealcolectomy

Transrectal extraction (NOTES)

1990

introduction tissue morcelation
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

principles for morcellation
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
principles for morcellation cont
Principles for morcellationcont.
  • Change gloves after tissue extraction
  • Any manipulation should be done with atraumatic instruments
  • Perform under laparoscopic visualization
advantages
Advantages
  • Less post-operative pain
  • Improved cosmesis
  • Potential advantages
    • Reduced risk of incisional hernias
    • Decreased risk of wound infection
    • Quicker return to activities
disadvantages
Disadvantages
  • Injury to adjacent tissues when morcellating
  • Extra cost if using morcellating device
  • Longer OR times
  • Not recommended for malignant disease
malignancy
Malignancy?
  • Cannot obtain adequate staging of cancer, due to destruction of primary as well as lymph nodes
how we do it
How we do it
  • Cook endo bag used
  • Tissues morcellated without any extra equipment.
how we do it1
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)
how we do it2
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

how we do it3
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

how we do it4
How we do it

Perform transrectalanastomosis.

Place specimen in bag

Exteriorize bag through 15mm trochar.

Extract specimen piecemeal or with morcelator

r esults
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)

pain control
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

complications
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

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