Morcellation of Morcellation of specimen : Fact specimen : Fact
or fiction? or fiction? Gustavo Plasencia Gustavo Plasencia
MD, FACS, FASCRSMD, FACS, FASCRS
Historical TechniqueHistorical Technique Sufficient mobilization so that distal and Sufficient mobilization so that distal and
proximal bowel reach point of extraction proximal bowel reach point of extraction at abdominal wallat abdominal wall
Intracorporeal devascularization requires Intracorporeal devascularization requires smaller incisionssmaller incisions
Transecting bowel intracorporeally, may Transecting bowel intracorporeally, may require smaller incision, vs loop require smaller incision, vs loop extractionextraction
Incisions should be muscle splitting; Incisions should be muscle splitting; bulky pathology may require cutting bulky pathology may require cutting musclesmuscles
Historical TechniqueHistorical Technique
Incision size should be as small as Incision size should be as small as technically feasibletechnically feasible
Wound protectors necessary in Wound protectors necessary in malignant pathologymalignant pathology
Inject local long acting anesthetic at Inject local long acting anesthetic at incisionsincisions
Incision
Transverse/Longitudinal
Muscle Splitting/Sparing
Wound Protector- helps prevent wound
recurrence/infection
Current Steps of Current Steps of ColectomyColectomy
Anastomosis and Extraction Anastomosis and Extraction independentindependent of each other of each other
Devascularization Devascularization should should be done be done intracorporeally to facilitate intracorporeally to facilitate extractionextraction
Intact Intact or Morcellated specimen or Morcellated specimen Extraction through incision of Extraction through incision of anterior abdominal wall, anterior abdominal wall, through through trochar, through natural orificetrochar, through natural orifice
Intracorporeal Intracorporeal AnastomosisAnastomosis
Totally intracorporeal colectomyTotally intracorporeal colectomy Transrectal extraction (NOTES)Transrectal extraction (NOTES) 19901990
IntroductionIntroductionTissue MorcelationTissue Morcelation
Common for spleen, uterus,kidney, Common for spleen, uterus,kidney, in benign diseases in benign diseases
Piecemeal extraction of tissuesPiecemeal extraction of tissues Avoid extraction incisions. Use only Avoid extraction incisions. Use only
trochar sites; may be slightly trochar sites; may be slightly enlarged, dilatedenlarged, dilated
Principles for morcellationPrinciples for morcellation
Only performed for benign diseaseOnly performed for benign disease Requires impermeable entrapment Requires impermeable entrapment
bagbag Check bag for perforationCheck bag for perforation Maintenance of pneumoperitoneumMaintenance of pneumoperitoneum Avoid overflow in the bag by Avoid overflow in the bag by
frequent suction of fluid and tissuesfrequent suction of fluid and tissues
Principles for morcellationPrinciples for morcellation cont.cont.
Change gloves after tissue Change gloves after tissue extractionextraction
Any manipulation should be done Any manipulation should be done with atraumatic instrumentswith atraumatic instruments
Perform under laparoscopic Perform under laparoscopic visualizationvisualization
AdvantagesAdvantages
Less post-operative painLess post-operative pain Improved cosmesisImproved cosmesis Potential advantagesPotential advantages
Reduced risk of incisional hernias Reduced risk of incisional hernias Decreased risk of wound infectionDecreased risk of wound infection Quicker return to activitiesQuicker return to activities
DisadvantagesDisadvantages
Injury to adjacent tissues when Injury to adjacent tissues when morcellatingmorcellating
Extra cost if using morcellating Extra cost if using morcellating devicedevice
Longer OR timesLonger OR times Not recommended for malignant Not recommended for malignant
diseasedisease
Malignancy?Malignancy?
Cannot obtain adequate staging of Cannot obtain adequate staging of cancer, due to destruction of cancer, due to destruction of primary as well as lymph nodesprimary as well as lymph nodes
How we do itHow we do it
Cook endo bag usedCook endo bag used Tissues morcellated without any Tissues morcellated without any
extra equipment.extra equipment.
How we do itHow we do it
Three 3mm or 5mm trochars for Three 3mm or 5mm trochars for graspers and cameragraspers and camera 5mm thirty degree scope gives better 5mm thirty degree scope gives better
visualizationvisualization One 15mm port for placement of One 15mm port for placement of
stapler, through which well lubricated stapler, through which well lubricated head of circular stapler is passed, and head of circular stapler is passed, and tissue extractedtissue extracted May have to enlarged by blunt dilatation May have to enlarged by blunt dilatation
(opened Kelly clamp)(opened Kelly clamp)
How we do itHow we do it
Take mesentery either at base or Take mesentery either at base or close to bowel. Divide bowel at close to bowel. Divide bowel at rectosigmoid jctrectosigmoid jct
Introduce into abdomen, head of Introduce into abdomen, head of circular stapler with spear and loop circular stapler with spear and loop of 1-0 prolene attached of 1-0 prolene attached
Choose proximal margin of Choose proximal margin of resection, a few cm distally make an resection, a few cm distally make an incision on antimesenteric borderincision on antimesenteric border
How we do itHow we do it Pass the head with attached spear and Pass the head with attached spear and
prolene proximally into bowel. Let prolene prolene proximally into bowel. Let prolene stick outstick out
Transect bowel at proximal margin of Transect bowel at proximal margin of resection with endostapler. Place no resection with endostapler. Place no tension on prolene suture. tension on prolene suture. Stapler will Stapler will not cut suturenot cut suture
Pull on suture until tip of spear pushes Pull on suture until tip of spear pushes staple line and apply countertraction until staple line and apply countertraction until spear perforates staple line. Pull on suture spear perforates staple line. Pull on suture until head is flat on staple line.until head is flat on staple line.
Place an endoloop around circular head for Place an endoloop around circular head for security. Remove spearsecurity. Remove spear
How we do itHow we do it
Perform transrectal anastomosis.Perform transrectal anastomosis. Place specimen in bagPlace specimen in bag Exteriorize bag through 15mm Exteriorize bag through 15mm
trochar.trochar. Extract specimen piecemeal or with Extract specimen piecemeal or with
morcelator morcelator
ResultsResults
10 pts10 pts Avg age 66y (range 52 – 81)Avg age 66y (range 52 – 81) 4 males, 6 females4 males, 6 females Length of stay 2.4 days (range 1-4)Length of stay 2.4 days (range 1-4) Time to flatus 1.4 days (range 1-3)Time to flatus 1.4 days (range 1-3)
Pain ControlPain Control KETOROLAC iv started intraop, KETOROLAC iv started intraop,
continued as needed for first 24 hrs. on continued as needed for first 24 hrs. on all pts, then switched to propoxyphene, all pts, then switched to propoxyphene, ibuprofen or acetaminophenibuprofen or acetaminophen
one pt required ketorolac for 48 hrsone pt required ketorolac for 48 hrs Three pts required ketorolac and Three pts required ketorolac and
narcotics (HYDROMORPHONE) for first narcotics (HYDROMORPHONE) for first 48 hrs48 hrs
Three pts used propoxyphene after being Three pts used propoxyphene after being discharged, the rest used ibuprofen or discharged, the rest used ibuprofen or acetaminophenacetaminophen
ComplicationsComplications
One pt (male with acute and chronic One pt (male with acute and chronic diverticulitis) converted to normal diverticulitis) converted to normal laparoscopic colectomy, due to laparoscopic colectomy, due to incomplete anastomosisincomplete anastomosis
No leaksNo leaks 1 mild cellulitis at extraction site, 1 mild cellulitis at extraction site,
treated with oral antibioticstreated with oral antibiotics 1 pt travelling from South America 1 pt travelling from South America
discharged post op day 1, readmitted discharged post op day 1, readmitted and treated for severe diarrheaand treated for severe diarrhea