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

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

Future?

Incisionless

Natural Orifice

Hybrid (Laparoscopic+Morcelation+NOTES)

Sigmoid MorcelizationSigmoid MorcelizationVideoVideo