If the mass is cystic and too large to be removed, carefully aspirate it with a largegauge needle, taking care not to puncture the bag. Otherwise, morcellate the mass in the sac and remove it piecemeal, allowing no spillage of contents.
This may be performed under laparoscopic visualization through the lower ancillary trocars or trocar site. If a larger port has been placed—or there is a clinical need for one—tissue extraction also could be performed through the lower port.
Risks include bag breakage and potential spillage. In addition, it sometimes is necessary to change to a larger bag.
Morcellators
Early morcellators were hand-held, requiring the operator to continuously bite into the tissue and remove the small fragments. While this approach was effective for soft tissues and small myomas, it was ineffective for larger or more solid masses.
“Orange peel” technique. Scissors have been used to achieve the same effect as the handheld morcellator. Harrith Hasson described the “orange peel” technique, in which the surgeon uses scissors to peel away the tissue as one would peel an orange.1 The long, thin strips of tissue then can be extracted through the trocar. Unfortunately, laparoscopic scissors are often too small or dull to adequately incise larger fibroids.
Automatic morcellators have markedly enhanced our ability to perform laparoscopic myomectomy and similar procedures. They also have had a strong impact on nongynecologic procedures such as splenectomy or nephrectomy, in which large amounts of tissue must be removed. Although these devices are costly, the time savings associated with their use are significant. Current devices range from disposable to semidisposable and are available in a wide variety of sizes.
Even dense tissues such as partially calcified leiomyomata are readily removed with automatic morcellators.
Hasson’s orange-peel technique also can be employed with automatic morcellators. This allows long, thin strips of tissue to be removed while facilitating constant visualization of anatomy surrounding the tissue being extracted.
An alternative is making multiple “through-passes” into the myoma using the morcellator. In this method, the strips of tissue obtained will be smaller and the myoma will develop a Swiss-cheese appearance. Note that this approach takes longer and may increase the number of myoma fragments that fall into the pelvis and need to be removed.
Effective for a range of masses. Not surprisingly, 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. Nevertheless, it is critical that the surgeon maintain constant visualization and that tissue be brought toward the morcellator and away from underlying structures (FIGURE).
Do not move the morcellator toward the tissue. Because of its sharpness, the automatic morcellator will cut through vital structures as easily as it penetrates fibroids.
FIGURE Automatic morcellation: Move excised tissue toward device
To prevent injury, tissue should be brought toward the morcellator and away from underlying structures. Do not move the morcellator toward the tissue or vital structures may be cut.
Spillage
An early and continuing concern regarding ovarian cystectomy or oophorectomy is spillage of the mass’s contents into the peritoneal cavity. This is more of an issue in the case of borderline or malignant ovarian lesions or mucinous or dermoid ovarian cysts. In fact, nowhere is there more contention than over the clinical ramifications of spillage in the case of malignancy.
Mixed data on impact of spillage. Clinical data suggest that the impact of spillage is inconsequential, whereas other evidence suggests a worsening prognosis.2-5 In the event of spillage, most gynecologic oncologists would convert an ovarian cancer patient with a 1A or 1B staged lesion to stage 1C and would likely administer chemotherapy.
Concern about spillage of a mucinous or dermoid cyst centers on the theoretical risk of pseudomyxoma peritonei or, in the case of a teratoma, chemical peritonitis. Some surgeons routinely enter dermoids and intentionally spill the contents.6,7 Of note, we lack significant case series of ensuing infections or problems with this technique. Still, removing an intact cyst negates this issue and expedites surgery, eliminating the need to irrigate the abdomen and pelvis with large quantities of fluid.
Ectopic pregnancy has also been a concern, as there have been reports of chorionic tissue being disseminated in the abdomen and pelvis during laparoscopic procedures.8
Nowhere is there more contention than over the clinical ramifications of spillage in the case of malignancy.
Patient selection
Preoperative evaluation is a critical component of patient selection. A thorough ultrasound examination can help determine who is and who is not an appropriate candidate for laparoscopic management.