Power Morcellation in the Bag: Surgical Technique and Clinical Applications

Abstract

Introduction: Morcellation refers to the division of specimens into smaller pieces or fragments to facilitate the removal of tissue through small incisions during minimally invasive procedures. Most commonly it may be performed after laparoscopic hysterectomy (for enlarged uteri) or myomectomy. Recently, the use of power morcellation has been discouraged because of the risk of spreading an unsuspected uterine malignancy. In this video (run time 9:51), the authors demonstrate the surgical technique for laparoscopic power morcellation in the bag and some clinical applications of it. Patients and Methods: In our department, laparoscopic gynecologic procedures are performed using four trocars: one 10-mm umbilical trocar for the zero degree laparoscope and three 5-mm trocars for the instruments, one at the right iliac fossa, 2 cm medial to the right anterior superior iliac spine, another one at the left iliac fossa, 2 cm medial to the left anterior superior iliac spine, and the third one in the midline, 8 to 10 cm below the umbilical trocar. Whenever power morcellation is needed, the 5-mm trocar at the left iliac fossa is replaced by a 15-mm trocar for the morcellator at the end of the procedure, specifically for the step of morcellation. To perform the power morcellation within a bag, the authors use a large tissue retrieval bag (3100 mL). The bag is placed inside the abdominal cavity through the 15-mm trocar. The mouth of the bag is opened and the specimen to be morcellated is put inside the bag. The bag is closed pulling the draw string and it is retrieved from the abdominal cavity through the 15-mm trocar. This allowed for the externalization of the mouth of the bag through the skin incision. Then, the 15-mm trocar is replaced through the mouth of the bag. Pneumoperitoneum is insufflated through the 10-mm umbilical trocar. The assistant grabs the deeper part of the bag and pulls it out through the skin at the right iliac fossa. Finally, the surgeon grabs the closest portion of the bag to the umbilicus and externalizes it through the umbilical trocar. In this way, we have three different sites of the bag outside the abdominal cavity. The trocars are reinserted inside the bag. The insufflation pressure is increased from 12 mm Hg to 15 mm Hg and the insufflation is performed within the specimen bag. In this way, the specimen can be enclosed morcellated under direct visualization. Results: The procedure was effectively performed in four patients with different pathologies: (1) a 40-year-old woman with a 400 g uterus requiring total laparoscopic hysterectomy due to leiomyomas and abnormal uterine bleeding, (2) a 35-year-old woman undergoing laparoscopic myomectomy, (3) a 45-year-old woman undergoing subtotal laparoscopic hysterectomy for a 900 g uterus, and (4) a 49-year-old woman with a 65 mm solid ovarian mass (serous cystadenofibroma). In all patients, power morcellation could be performed safely within the bag. Conclusions: Power morcellation within a bag is a feasible technique. It may be an alternative way to preserve the benefits of minimally invasive surgery while mitigating the risks whenever specimen morcellation is necessary. No competing financial interests exist. Runtime of video: 9 mins 51 secs