KEYPOINTS
- In appropriately selected patients, the ability to easily and skillfully remove tissue during laparoscopy facilitates patient recovery and healing and limits hospitalization time.
- Even dense tissues such as partially calcified leiomyomata are readily removed with automatic morcellators, and the size of masses is less significant than with “manual” approaches.
Novel surgical devices and techniques have transformed operative laparoscopy by improving the inefficiencies in tissue extraction that limited early acceptance.
In the beginning, it was relatively easy to isolate a myoma and dissect it from the underlying myometrium, but it took hours to extract the tissue using a hand-held morcellator. This article focuses on the 4 techniques commonly used today, as well as the products that make them possible.
In appropriately selected patients, the ability to remove tissue through any of these methods facilitates patient recovery and healing and limits hospitalization time.
Posterior colpotomy
In the 1980s and early 1990s, it was common for tissue to be extracted through a posterior colpotomy. This is not surprising given that gynecologists were trained to perform transvaginal tubal ligation and to use colpotomies when incising and draining tubo-ovarian abscesses—not to mention our ease in entering the posterior cul-de-sac during vaginal surgery.
The elasticity of the vagina facilitates removal of fairly sizeable masses. Large ovarian cysts or masses can be brought to the cul-de-sac and incised and drained in a manner that markedly reduces the risk of intraperitoneal spillage.
There are disadvantages, however. For example, if the surgeon wants to maintain laparoscopic visualization once the colpotomy has been made, the tissue to be removed must be grasped and brought toward the opening to plug the defect and maintain pneumoperitoneum.
This may not be particularly problematic if there is only 1 mass to be removed, but it can be troublesome if there are several. An option is to place the masses in the posterior cul-de-sac so they can be readily grasped once the posterior colpotomy has been made.
One conceptual concern is the issue of subsequent adhesion formation, especially in patients desiring fertility. Unfortunately, no substantive trials exist to better answer this question.
Removal through the trocar or trocar site
Although some physicians still remove tissue through a posterior colpotomy, most have abandoned that approach in favor of extraction through a primary or lateral laparoscopic port. Indeed, this is the simplest technique for extracting tissue. I often change from a 10-mm laparoscope to a 5-mm instrument, placing the smaller endoscope in one of the lower ports and removing tissue under direct visualization through the 10- or 11-mm infraumbilical port.
If a cystic mass placed in a laparoscopic bag is too large to be removed, carefully aspirate it with a large-gauge needle.
Trapped tissue. One potential problem is the trapping of tissue in trocars that contain a flap valve. If this occurs, remove the trocar, clear the tissue, and replace the trocar in the original site using a blunt instrument such as the 10-mm laparoscope. Do not use the sharp inner blade to replace this port, as it is unduly risky.
For large masses, remove the port to create extra space. It also may be necessary to enlarge the skin or the fascial incision using a blunt instrument such as forceps.
Before the widespread availability of laparoscopic bags, tissue extraction was generally performed in this manner.
Risks include spillage of cyst contents during extraction and development of a hernia secondary to the wider disruption of fascia. This risk is particularly high in the infraumbilical area, which is inherently weak to begin with. It is thus critical—in any methodology—that the fascia be appropriately closed.
Laparoscopic bags
Many of the laparoscopic bags now widely available are easily opened once they have been placed in the abdomen, though some must be opened with graspers after the bag is positioned in the peritoneal cavity. Laparoscopic bags have greater utility when the extracted tissue is soft, such as with a dermoid cyst or ovary. Dense tissue is more difficult to manage.
Some surgeons fashion their own bags using sterile gloves or baggies.
Durability. The bags vary in their ability to withstand manipulation and puncture. For example, one type of nylon bag has a polyurethane inner coating and drawstring closure, making it quite durable. It also comes in a range of sizes, allowing the surgeon to choose the bag most suitable for the mass being removed.
To use a laparoscopic bag, insert it through the infraumbilical trocar and place the mass inside it. Then remove the trocar to provide maximal room for the mass to be extracted.