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    Product reviews: Pro-Nox and Alexis CES




    In the last 2 years, contained tissue extraction (CTE) has dominated professional discourse in minimally invasive gynecologic surgery from both philosophical and technical perspectives. For a surgical discipline focused over the last 40-odd years on get bigger out through smaller incisions, the sudden move away from open morcellation has left many eyes seeking the next technical edge to help get the MIGS train back onto a safer track. To that end, seemingly every quarter, a new bag in which to place to-be-extracted tissues appears on the market to address this latest challenge. This review will focus on Applied Medical’s Alexis Contained Extraction System.


    The Alexis Contained Extraction System is a clever extension of Applied’s well-established Alexis retractor technology. With the same semi-rigid rim attached to a heavyweight PVC bag, the Alexis Contained Extraction System has a comfortable feel for anyone who has previously used Alexis retractors. The 6500-cc bag is big enough to accommodate almost all pathology that is typically removed, while rolling the rim over the bag allows it to shrink as needed. The bag comes with a tag on a string attached to the rim, which is strong enough that is can be used to pull the bag out through the incision once the specimen is inside. In addition to the bag, the “system” comes with a 12-mm Hassan-style Kii balloon fixation trocar as well as a flexible neck guard to protect the lining from tears from the knife used for morcellation.

    In use in the operating room, the Alexis Contained Extraction System worked much as expected. The bag’s sturdy rim nicely facilitated insertion of the bag through a 3-cm skin incision and, once inside the body, the rim kept the bag opened, which again made getting the specimen into it easier. The polymer membrane was hefty enough to endure a lot of tugging and to resist tearing. The only caveat is that the bag’s size (6500 cc) coupled with the rim’s large mouth fill most of the pelvis and lower abdomen and can limit visibility when large specimens are involved. But large specimen cases are always challenging and, overall, this bag did make it easier. Separate from the bag itself, I was less impressed with the neck guard. Conceptually, it seems like a great idea, but in practice, it just added bulk to the already narrow incision and hindered rather than helped the tissue extraction process. Finally, the addition of the trocar was completely superfluous for me. I never used it in any of my cases and would prefer to see it removed from the system to help lower the cost of the device.


    I generally liked the Alexis Contained Extraction System and think is a clever adaption of the company’s standard Alexis technology, especially considering the short timeline in which it was developed and brought to market. I love the way Applied tweaked what they had to give us what we needed.


    James Greenberg, MD
    Dr. Greenberg is Chief, Division of Gynecology, Brigham & Women’s Faulkner Hospital, and Associate Professor, Harvard Medical School, ...


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