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    Product Review: Technologies for laparoscopic contained tissue extraction

     

     

     

    Morcellation technologies were developed to facilitate the removal of large amounts of tissue through small laparoscopic incisions. These techniques have been notably useful in surgeries involving the uterus with a particular focus on procedures for fibroids (leiomyomas). The advantages of using laparoscopic approaches compared to laparotomy to treat uterine fibroids include a lower risk of infection, less blood loss, less postoperative pain, and more rapid return to full activities.1 However, recent data have demonstrated that intracorporeal morcellation of tumor tissue without the use of a containment system may have a greater potential to spread tumor tissue throughout the peritoneal cavity than previously recognized.2

    While the absolute risk of encountering an unanticipated uterine malignancy is small (1:350 to 1:1000),3-5 newer surgical techniques to facilitate the extraction of uterine tumors in a containment system (contained tissue extraction or CTE) have sufficiently advanced to make this small risk even lower.

    Here we focus on a few of the newer techniques and technologies in this niche. This is a rapidly evolving space that may be dramatically different in a short period of time.

    Insufflated contained tissue extraction

    The core of the techniques discussed here was first described by Shibley et al in 2012.6 Common features include the following steps:

    --Introduction of a specimen bag into the abdomen
    --Placement of the surgical specimen inside the bag
    --Exteriorization of the neck of the bag through one of the incisions
    --Intracorporeal insufflation of the bag with concomitant desufflation of the surrounding abdomen.
    --Introduction of a laparoscopic camera and power tissue morcellator into the insufflated bag
    --Power tissue extraction of the specimen entirely within the confines of the bag
    --Removal of the bag from the abdomen

    In general terms, the most significant variation with insufflated contained tissue extraction (iCTE) methods is single-site incision versus a multiport technique. With the single-site technique, the single-site port is uncapped, the specimen bag is introduced through the single site port, and the port is recapped. Next the specimen is placed into the bag using traditional laparoscopic single-site techniques. The port is then uncapped and the neck of the bag is exteriorized through the port. The port is recapped with the bag’s edges enclosed within its rim and the bag is insufflated intracorporeally while the abdomen outside of the bag is desufflated. A power morcellator and a laparoscope can then be introduced through the single-site port and the specimen can be extracted, with the entire process fully contained. With the specimen extracted, the bag is removed and the procedure is completed as per routine.

    With the multi-port technique, the specimen bag is introduced through a 12- or 15-mm port or directly through the largest incision already in the abdomen. The specimen is then placed into the bag and the neck of the bag is exteriorized through the largest incision. The 12- or 15-mm trocar is introduced into the bag through the neck and the bag is insufflated intracorporeally while the abdomen outside of the bag is desufflated. With the bag insufflated inside the abdomen, a 5-mm trocar is used to puncture the bag near the top to provide an access port for visualization and insufflation. Once the secondary port in secured inside the bag, the trocar in the neck is removed and replaced with a power morcellator and the specimen can be extracted. The entire process is contained. With the specimen extracted, the bag is removed and the procedure is completed as per routine.

     

    James Greenberg, MD
    Dr. Greenberg is Chief, Division of Gynecology, Brigham & Women’s Faulkner Hospital, and Associate Professor, Harvard Medical School, ...
    Mobolaji Oluwaseun Ajao, MD
    Dr. Ajao is a Fellow in Minimally Invasive Gynecologic Surgery, Brigham & Women’s Hospital, Harvard Medical School, Boston, Massachusetts.

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