Endoscopic Bag Research Articles

Laparoscopic Living Donor Nephrectomy—Single-Center Initial Experience

(1) Background: Donor nephrectomy for living donor kidney transplantation using minimally invasive techniques is a safe procedure that has been used for more than 20 years with excellent results. The total laparoscopic approach offers decreased postoperative pain, less incisional morbidity, and a shorter recovery time. (2) Methods: We present the results of a series of 43 laparoscopic donor nephrectomies performed in a single center. The procedures were performed in a systematic approach with transperitoneal access using four ports. The main renal artery and vein were ligated using a linear stapler fixed with an alternate triple row of titanium staples. The specimen was extracted in an endoscopic bag through an additional incision. (3) Results: All procedures were performed laparoscopically without conversion to open surgery. The average warm ischemia time was 4.73 min. In all recipients, immediate kidney allograft function was observed. (4) Conclusions: Total laparoscopic living donor nephrectomy is a safe procedure. It was performed successfully in all cases with a short surgical time, low morbidity, and 0% mortality.

Adherence to guideline-based preoperative and intraoperative care during risk-reducing bilateral salpingo-oophorectomy among gynecologist-oncologists compared to general gynecologists (335)

<b>Objectives:</b> Risk-reducing Bilateral Salpingoopherectomy (rrBSO) is the only intervention proven to reduce mortality from epithelial ovarian cancer in patients with hereditary breast and ovarian cancer (HBOC)-associated gene mutations. Optimal surgical technique for rrBSO includes five steps outlined in 2005 by the Society of Gynecologic Oncology and the American College of Obstetrics and Gynecology. These five steps include: <i>1)</i> Abdominal survey; <i>2)</i> Peritoneal washings; <i>3)</i> Entering retroperitoneal space and creating pedicle 2cm from the ovary; <i>4)</i> Dividing pedicle at the uterus; and <i>5)</i> Removal in an endoscopic bag. rrBSO can be performed by both general gynecologists (GYN) and gynecologist oncologists (GO). We aimed to evaluate adherence to surgical guidelines for rrBSO when performed by GO compared to GYN and assess the utility of preoperative (preop) CA-125 and pelvic ultrasound as predictors of malignancy identified at the time of rrBSO. <b>Methods:</b> A retrospective review of patients who underwent rrBSO from October 1, 2015, to December 31, 2020, by faculty and privately employed physicians at three high volume academic sites within a healthcare system was performed. The primary outcome was compliance with all five steps of rrBSO as dictated by a surgeon. Secondary outcomes included the presence of a pre-malignant or malignant lesion at the time of rrBSO and association with preoperative imaging or CA-125. Patient demographics and clinical characteristics were collected. Descriptive statistics for continuous variables were calculated. Univariable logistic regression was used to screen variables with a p-value criterion of p < 0.05 for entry into the model selection procedure. Multivariate regression was used to identify differences in practice patterns. <b>Results:</b> A total of 236 patients were included. Among them, 122 (52%) cases were performed by a GO. Among the cases documented by GO, 27 (22%) performed all five steps of the procedure, 65 (53%) performed four steps, 26 (21%) performed three steps, four (3%) performed two steps, and none performed only one step. Among the 114 cases by GYN, four (4%) performed all five steps, 17 (15%) performed four steps, 50 (44%) performed three steps, 40 (35%) performed two steps, and three (3%) performed only one step. Univariable analysis demonstrated no association between demographic variables and procedure compliance. GO were significantly more likely to adhere to all five recommended surgical steps, (OR: 7.816, 95% CI: 2.640-23.138, p=0.0002). In total, five patients (2.12%) had pre-malignant or malignant lesions diagnosed at the time of rrBSO. None of the five patients had documented preop CA-125 or preop imaging, and all five cases occurred in patients undergoing surgery with GYN. <b>Conclusions:</b> Our results show a statistically significant difference in compliance to procedural steps of rrBSO between GYN and GO. This demonstrates a need for institution-wide education and implementation of procedural standards and standardized nomenclature for dictations to ensure provider adherence to rrBSO guidelines. Fig. 1

A Large Parasitic Fibroid on the Mesentery

<h3>Study Objective</h3> The objective of this video is to demonstrate a rare operative finding of a parasitic fibroid attached to the mesentery and illustrate a technique for dissection. <h3>Design</h3> Case report. <h3>Setting</h3> Robot-assisted laparoscopic removal of a parasitic fibroid on the mesentery. <h3>Patients or Participants</h3> In this video, we present a 38-year-old G1P1001 with a history of a robot-assisted myomectomy with power morcellation who presented with recurrent bulk symptoms and was found to have a large parasitic fibroid to the mesentery. <h3>Interventions</h3> Parasitic fibroids are a rare clinical phenomenon in which fibroids receive their vascular supply from somewhere other than the uterus. Though they can develop de novo, the majority are thought to be iatrogenic as a result of previous uterine surgery (Kho 2009). The FDA issued a black box warning in 2014 that discouraged use of the power morcellator due to increased risk of disseminating fibroid tissue throughout the abdomen in the setting of uncontained morcellation (US FDA 2014, Seidman 2012). Though initially abandoned due to risk of increased mortality in the setting of disseminated uterine leiomyosarcoma, the most commonly reported complication of tissue dissemination is the formation of parasitic myoma (Tulandi 2016, Seidman 2012). Incidence is described between 0.12% and 1.1% after laparoscopic uterine surgery (Lete 2016). Morcellated fragments of fibroid may be left behind in the abdominal cavity and neovascularize to surrounding structures/abdominal wall. They are often multiple and can occur in a variety of locations. <h3>Measurements and Main Results</h3> Key surgical steps for the dissection of this mass are also reviewed which include: 1. Careful abdominopelvic survey 2. Identification of feeding vessels and their origin 3. Instillation of dilute vasopressin 4. Enucleation of the fibroids 5. Assure hemostasis 6. Removal with endoscopic bag 7. Contained hand morcellation <h3>Conclusion</h3> Development of parasitic fibroids after uterine surgery is a potential source of morbidity following initial treatment.

Port site metastases a year after initial laparoscopic cholecystectomy. Should the use of retrieval bags during laparoscopic cholecystectomy be the new gold standard?

Port site metastases a year after initial laparoscopic cholecystectomy. Should the use of retrieval bags during laparoscopic cholecystectomy be the new gold standard?

Inbag Morcellation Applied to the Laparoscopic Surgery of Leiomyoma: A Randomized Controlled Trial.

Objective To evaluate the efficacy and safety of an endoscopic bag during laparoscopic morcellation of leiomyoma or myomatous uterus. Materials and Methods A total of 48 patients with symptomatic leiomyoma were randomized for laparoscopic morcellation in two groups: group A with a specific endoscopic bag or group B without any bag. The primary outcome measure was the detection of smooth muscle cells from washing after power morcellation determined by peritoneal cytology and immunohistochemistry (IHC). Results Cytology and IHC from group A did not revealed any smooth muscle cells, while 29% of cases (7/24) from group B were positive (p = .009). The duration of the surgical procedure was the same in both groups. The duration of positioning the bag did not change significantly during the study. Only in one case the use of the bag was difficult due to a low pneumoperitoneum. Conclusions The use of a morcellation bag is efficient to prevent the spread of smooth muscle cells during the morcellation of leiomyoma or myomatous uterus. This study confirms the feasibility and the safety of the laparoscopic inbag morcellation versus open morcellation.

Peritoneal spillage is not an issue in patients undergoing minimally invasive surgery for colorectal cancer

BackgroundSurgery for colorectal cancer (CRC) is increasingly being performed via the minimally invasive route. However, reports of postoperative wound and port site seeding as well as peritoneal spillage have been worrisome. We investigated the risk of peritoneal spillage in patients undergoing laparoscopic surgery for CRC.MethodsCytology specimens were gained from the retrieval bag following intracorporeal resection and specimen retrieval using an endoscopic retrieval bag. Histopathologic examination of the cytology specimens was performed for the presence of malignant cells.ResultsCytology specimens of 73 (34 female and 39 male) consecutive patients with a median age of 71 years were included for analysis. Advanced CRC in stages III and IV was present in 41% of the study population. Malignant cells were not found in any specimen.ConclusionLaparoscopic oncologic resection of colorectal cancer is not a risk factor for peritoneal spillage. Minimally invasive oncologic colorectal resection is safe without the increased risk of peritoneal carcinomatosis.

In-bag manual versus uncontained power morcellation for laparoscopic myomectomy.

Uterine leiomyomas, also referred to as myomas or fibroids, are benign tumours arising from the smooth muscle cells of the myometrium. They are the most common pelvic tumour in women. The estimated rate of leiomyosarcoma, found during surgery for presumed benign leiomyomas, is about 0.51 per 1000 procedures, or approximately 1 in 2000. Treatment options for symptomatic uterine leiomyomas include medical, surgical, and radiologically-guided interventions. Laparoscopic myomectomy is the gold standard surgical approach for women who want offspring, or otherwise wish to retain their uterus. A limitation of laparoscopy is the inability to remove large specimens from the abdominal cavity through the laparoscope. To overcome this challenge, the morcellation approach was developed, during which larger specimens are broken into smaller pieces in order to remove them from the abdominal cavity via the port site. However, intracorporeal power morcellation may lead to scattering of benign tissues, with the risk of spreading leiomyoma or endometriosis. In cases of unsuspected malignancy, power morcellation can cause unintentional dissemination of malignant cells, and lead to a poorer prognosis by upstaging the occult cancer. A strategy to optimise women's safety is to morcellate the specimens inside a bag. In-bag morcellation may avoid the dissemination of tissue fragments. To evaluate the effectiveness and safety of protected in-bag extracorporeal manual morcellation during laparoscopic myomectomy compared to intra-abdominal uncontained power morcellation. On 1 July 2019, we searched; the Cochrane Gynaecology and Fertility Group Specialized Register of Controlled Trials, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL, LILACS, PubMed, Google Scholar, and two trials registers. We reviewed the reference lists of all retrieved full-text articles, and contacted experts in the field for additional and ongoing trials. We included all randomised controlled trials comparing in-bag extracorporeal manual morcellation versus intracorporeal uncontained power morcellation during laparoscopic myomectomy in premenopausal women. We followed standard Cochrane methods. Two review authors independently reviewed the eligibility of trials, extracted data, and evaluated the risk of bias. Data were checked for accuracy. The summary measures were reported as risk ratios (RR) or mean differences (MD) with 95% confidence interval (CI). The outcomes of interest were a composite of intraoperative and postoperative complications, operative times, ease of morcellation, length of hospital stay, postoperative pain, conversion to laparotomy, and postoperative diagnosis of leiomyosarcoma. Results for the five main outcomes follow. We included two trials, enrolling 176 premenopausal women with fibroids, who underwent laparoscopic myomectomy. The experimental group received in-bag manual morcellation, during which each enucleated myoma was placed into a specimen retrieval bag, and manually morcellated with scalpel or scissors. In the control group, intracorporeal uncontained power morcellation was used to reduce the size of the myomas. No intraoperative complications, including accidental morcellation of the liver, conversion to laparotomy, endoscopic bag disruption, bowel injury, bleeding, accidental injury to any viscus or vessel, were reported in either group in either trial. We found very low-quality evidence of inconclusive results for total operative time (MD 9.93 minutes, 95% CI -1.35 to 21.20; 2 studies, 176 participants; I² = 35%), and ease of morcellation (MD -0.73 points, 95% CI -1.64 to 0.18; 1 study, 104 participants). The morcellation operative time was a little longer for the in-bag manual morcellation group, however the quality of the evidence was very low (MD 2.59 minutes, 95% CI 0.45 to 4.72; 2 studies, 176 participants; I² = 0%). There were no postoperative diagnoses of leiomyosarcoma made in either group in either trial. We are very uncertain of any of these results. We downgraded the quality of the evidence due to indirectness and imprecision, because of limited sites in high-income settings and countries, small sample sizes, wide confidence intervals, and few events. There are limited data on the effectiveness and safety of in-bag morcellation at the time of laparoscopic myomectomy compared to uncontained power morcellation. We were unable to determine the effects of in-bag morcellation on intraoperative complications as no events were reported in either group. We are uncertain if in-bag morcellation improves total operative time or ease of morcellation compared to control. Regarding morcellation operative time, the quality of the evidence was also very low and we cannot be certain of the effect of in-bag morcellation compared to uncontained morcellation. No cases of postoperative diagnosis of leiomyosarcoma occurred in either group. We found only two trials comparing in-bag extracorporeal manual morcellation to intracorporeal uncontained power morcellation at the time of laparoscopic myomectomy. Both trials had morcellation operative time as primary outcome and were not powered for uncommon outcomes such as intraoperative complications, and postoperative diagnosis of leiomyosarcoma. Large, well-planned and executed trials are needed.

Giant Parasitic Fibroid Mimicking Gist: A Clinical Dilemma

ABSTRACTBackgroundParasitic fibroids are a rare type of fibroids without direct uterine attachment. They pose a diagnostic dilemma and often present atypically.Case descriptionWe report a rare case of large secondary parasitic fibroid in a 24 year unmarried female who presented with history of lump abdomen for 6 months. She had history of laparoscopic myomectomy done 2.5 years back for the same complaint with histopathology report suggestive of leiomyoma. On examination, it was found to be subserosal pedunculated fibroid. All the tumor markers were negative except CA 125 which was 225 IU/mL. Exploratory laparotomy was done. Uterus was normal size and seen separately. Bilateral tubes and ovaries were normal. A mass of size 30 × 22 × 15 cm, firm in consistency occupying all the quadrants of abdomen, was observed. It had no attachment to the uterus or to the bowel. Mass weighing 6.5 kg was removed completely and sent for histopathology. HPE report confirmed leiomyoma. Her postoperative period was uneventful.ConclusionIf the patient had prior history of myomectomy and mass is separate from the uterus with its blood supply away from uterus, diagnosis of parasitic leiomyoma should be considered.Clinical significanceDuring morcellation procedures, a thorough inspection and washing of peritoneal cavity must be carried out, and endoscopic bag should be used to prevent secondary parasitic leiomyoma.How to cite this articleKurude VN, Gitte V, Raheja A,et al. Giant Parasitic Fibroid Mimicking Gist: A Clinical Dilemma. J South Asian Feder Menopause Soc 2020;8(1):49–51.

Fast prostate retrieval in robot-assisted laparoscopic prostatectomy for next-generation biobanking.

Robotic-assisted laparoscopic radical prostatectomy (RALP) has become the most widespread treatment for organ-confined prostate cancer. Here, we describe a fast specimen retrieval technique for RALP to obtain high-quality tissue specimen with minimal warm ischemia time for next-generation biobanking. Here, we show that using fast retrieval technique, short warm ischemia times can be achieved while not increasing the surgical time. Patients undergoing RALP with written informed consent participated in Helsinki Urological Bank study. Previously operated RALP patients and those, who were not willing to participate in the study, served as a control group. The study consisted of 1685 patients, 684 in fast retrieval and 1001 in control group. We developed a novel fast retrieval technique in which fascia is opened for camera port according to the prostate size and a running suture is placed and tightened against the camera port in the beginning of the operation. Immediately after prostate is freed from attachments, suture is loosened and the prostate is extirpated inside the endoscopic bag through the camera port fascial opening, then the fascial suture is again tightened against the camera port and the RALP procedure is completed. The mean warm ischemia times in fast retrieval group were 20min 18s and 22min 30s, respectively, in patients without and with lymphadenectomy. The mean console and surgery times with and without lymphadenectomy were similar in both groups. There were no technique-related complications associated with Fast Retrieval procedure. Tissue integrity test results for the RNA and DNA quality showed good quality for the specimen. Fast retrieval technique can easily and safely be utilized to maximize usefulness of RALP tissue specimen in downstream biobank applications.

Cell Spillage after Contained Electromechanical Morcellation Using a Specially Designed In-Bag System for Laparoscopic Myomectomy: Prospective Cohort Pilot Study

Study ObjectiveFew reports have investigated the use of endoscopic retrieval bags in the context of laparoscopic myomectomy with electromechanical morcellation. We performed a leak test of a specially designed endoscopic bag system in women undergoing laparoscopic myomectomy with contained electromechanical morcellation. Design ClassificationProspective study. SettingUniversity hospital. PatientsThirty-one women undergoing laparoscopic myomectomy with contained electromechanical morcellation. InterventionsElectromechanical morcellation was introduced for large specimen extraction during laparoscopic procedures. Complications such as retained/disseminated parasitic tissue were documented. Measurements and Main ResultsSystematic peritoneal washings were performed at 3 specific times: at baseline, T1, once the peritoneal cavity was accessed laparoscopically; T2, when the myometrial incision was closed after myomectomy; and T3, after contained electromechanical morcellation. After retrieval of the endoscopic bag from the abdominal cavity, visual inspection and water test on the bag with NaCl infiltration were performed to detect leaks attributed to intraoperative perforations. A pathologist performed cytologic analyses on the 3 washings. The mean endoscopic bag procedure duration was 9 minutes. The use of a specially designed endoscopic bag system was found to be easy in 45% of cases, and no complications were reported. Cytologic washings were positive for smooth muscle cell detection in 8 cases (25.8%) at T2 and 3 cases (9.7%) at T3. All positive cases at T3 already had detectable smooth muscle cells at T2. After retrieval from the abdominal cavity, perforations on the optic access of the endoscopic bag were observed in 3 cases. ConclusionThe results from this pilot study are encouraging. The use of a specially designed endoscopic bag system could be an adjuvant to reduce the risk of disseminating cells during myomectomy.

Could leiomyosarcoma be a real concern for the gynecologist performing minimally-invasive surgery for uterine myoma?

Uterine leiomyosarcoma is a rare malignant tumor with a poor prognosis. The diagnosis of uterine sarcoma is often made after myomectomy or hysterectomy at the histologic examination. The differential diagnosis between leiomyosarcoma and uterine fibroids is difficult to establish preoperatively. Most cases of uterine fibroids can be treated minimally invasively, but extracting lar­ger specimens is an impediment to choosing this surgical method. The risks of morcellation (vascular or bowel injury, intraabdominal tissue dissemination) must be balanced against comorbidities related to laparatomy. In 2014, FDA warned that the prevalence of occult leiomyosarcoma in patients undergoing hysterectomy or myomectomy for presumed benign leiomyoma is 1 in 498 and discouraged the morcellation of uterine fibroids during laparoscopy. In order not to give up minimally-invasive surgery and to reduce the risks of morcellation, the use of endoscopic bags has been considered to avoid the spread of potentially malignant tissue. However, it is advisable not to use morcellator, even with the endoscopic bag, if there is a high suspicion of malignancy. We need to take into account the disadvantages of the method. In conclusion, uterine leiomyosarcoma continues to be a concern for gynecologists, given that until now there are no investigations to detect it preoperatively. The selection of patients with uterine fibroids for laparoscopy using the morcellation of the specimens should be rigorous.

Single-port Robotic Pelvic Bulky Lymph Node Resection: A Case Report

Study ObjectiveTo report the feasibility of bulky pelvic lymph node resection with robotic-assisted single-port laparoscopy in a patient with cervical cancer before chemoradiation therapy. DesignResection of pelvic bulky lymph nodes with a narrated video of da Vinci single-port platform surgery (Intuitive Surgical, Sunnyvale, CA) (Canadian Task Force classification III). SettingAlthough not enough evidence exists to reveal that single-site surgery is better than traditional endoscopic surgery, several studies have suggested that single-site robotic surgery has certain advantages such as less postoperative analgesic use, shorter hospital stay, and quicker recovery. Furthermore, robotic single-site surgery has evolved single-site procedures. Compared with the single-port laparoendoscopic procedure, the robotic-assisted single-port laparoscopic procedure offers some advantages to minimally invasive surgery such as greater dexterity, 3-dimensional visualization, and fewer instrument clashes. These advantages make robotic single-port surgery more preferable; nevertheless, the lack of articulating instruments and the low quality of optical exposure are still challenges. Robotic single-port pelvic lymphadenectomy was first described by Tateo et al [1] in an endometrial carcinoma patient. We present a robotic single-port pelvic bulky lymph node resection in an advanced cervical cancer patient. Even though current data are controversial about removing bulky lymph nodes in patients with advanced cervical cancer, some studies have recommended that debulking of tumor-involved lymph nodes before chemoradiation may be benefical for these patients (Leblanc et al [2], Marnitz et al [3]). In our case, the patient underwent robotic-assisted single-port laparoscopy using the da Vinci Single-Site platform. The abdominal cavity was insufflated from a 3-cm umblical incision, and a 5-lumen single port was inserted. Then, an 8.5-mm 3-dimensional camera was inserted through the port, and for dissection and resection 5-mm bipolar fenestrated forceps and a monopolar hook were used. After resection, the bulky lymph nodes were taken out with an endoscopic bag through the assistant port lumen. Additionally, it is important to remember that single-site procedures are not approved by the Food and Drug Administration for lymphadenectomy. PatientsA 46-year-old patient diagnosed with advanced-stage cervical cancer (Fédération Internationale de Gynécologie et d'Obstétrique stage IIIB) presented with bilateral pelvic lymph node metastasis revealed by pelvic magnetic resonance imaging. The patient had no history of prior surgery or comorbidity. We decided to perform resection of the pelvic lymph nodes with a robotic-assisted single-site laparoscopic procedure before chemoradiation threapy. InterventionsExcision of pelvic bulky lymph nodes using robotic-assisted single-port laparoscopy. Measurements and Main ResultsThe total operating time was 170 minutes (from docking to the end of the extubation), the estimated blood loss was 30 mL, and no complications occurred. The patient was discharged the day after surgery. The histopathologic examination revealed squamous cell carcinoma metastasis. ConclusionRobotic-assisted single-port surgery seems to be an applicable and alternative technique to perform the resection of bulky pelvic lymph nodes in patients with advanced cervical cancer before chemoradiation therapy.

Extracorporeal Manual Morcellation of Very Large Uteri Within an Enclosed Endoscopic Bag: Our 5-Year Experience

Study ObjectivesTo describe a technique to manually morcellate large uteri within a polyurethane endoscopic bag at the time of laparoscopic hysterectomy, and report perioperative outcomes from our 5 years of experience. Study DesignRetrospective review of all consecutive hysterectomies with uterine weight >500 g performed between January 2010 and December 2014 in which the uterus was manually morcellated within an endoscopic bag by either an abdominal or vaginal approach (Canadian Task Force Classification Level III). SettingTertiary care academic medical center. PatientsA total of 104 women with a uterine weight >500 g who underwent laparoscopic hysterectomy using a manual morcellation technique. InterventionManual morcellation was done extracorporeally, within a partially exteriorized specimen bag, using a scalpel under direct visualization by the operating surgeon. Measurements and Main ResultsA total of 104 laparoscopic hysterectomies were performed in women with a uterus weighing >500 g using a manual morcellation technique for specimen extraction. The median patient age was 48.1 years (range, 34–69 years), and the median body mass index was 31.0 kg/m2 (range, 19.1–56.7 kg/m2). The median blood loss and specimen weight were 200 mL (range, 20–1200 mL) and 741.5 g (range, 500–1930 g), respectively. Morcellation was performed through an abdominal approach in 58.7% of the patients and through a vaginal approach in 41.3%. The median duration of morcellation was 14.8 minutes (range, 4.5–21.6 minutes) for the abdominal route and 11.7 minutes (range, 5.2–16.8 minutes) for the vaginal route. Occult malignancy was identified in 2 patients. There were no complications related to the morcellation technique or gross bag rupture. ConclusionManual morcellation within an endoscopic bag allows for the extraction of large uteri without the use of a power morcellator. In our 5 years of experience, we have not experienced any incidence of gross spillage, visually noted bag rupture, or complications associated with our morcellation technique.

Laparoscopic Cystectomy In-a-Bag of an Intact Cyst: Is It Feasible and Spillage-Free After All?

This prospective study was conducted to assess the feasibility of laparoscopic cystectomy of an intact adnexal cyst performed inside a water proof endoscopic bag, aiming to avoid intraperitoneal spillage in case of cyst rupture. 102 patients were recruited. Two of them were pregnant. In 8 of the patients the lesions were bilateral, adding up to a total of 110 cysts involved in our study. The endoscopic sac did not rupture in any case. Mean diameter of the cysts was 5.7 cm (range: 2.3–10.5 cm). In 75/110 (68.2%) cases, cystectomy was completed without rupture, whereas in the remaining 35/110 (31.8%) cases the cyst ruptured. Minimal small spillage occurred despite every effort only in 8/110 (7.2%) cases with large (>8 cm) cystic teratomas. There were no intraoperative or postoperative complications. We concluded that laparoscopic cystectomy in-a-bag of an intact cyst is feasible and oncologically safe for cystic tumors with a diameter < 8 cm. Manipulation of larger tumors with the adnexa into the sac may be more difficult, and in such cases previous puncture and evacuation of the cyst contents should be considered.

Vaginal Uterine Morcellation Within a Specimen Containment System: A Study of Bag Integrity.

To evaluate the integrity of the endoscopic bag after transvaginal in-bag morcellation of uteri that need to be removed by vaginal morcellation during total laparoscopic hysterectomy (TLH). Prospective pilot study (Canadian Task Force classification II-2). University hospital. Twelve patients with uteri that needed to be removed and who required vaginal morcellation underwent TLH from September 2014 to February 2015, without suspected or confirmed malignancy. After transvaginal in-bag morcellation of uteri at the end of TLH, careful visual inspection of the endoscopic pouch, using diluted methylene blue, was carried out, highlighting any minimal bag damage. No gross rupture was encountered after morcellation; however, 4 minimal ruptures were recognized (33%) after filling up the bag with diluted methylene blue. Minimal lesions of the bag may occur after transvaginal morcellation of uteri that need to be removed by vaginal morcellation; this may potentially affect the spread of cancer cells into the abdominal cavity.

An Efficient Technique to Manually Morcellate Very Large Uteri Within an Enclosed Endoscopic Bag: Our Five-Year Experience

An Efficient Technique to Manually Morcellate Very Large Uteri Within an Enclosed Endoscopic Bag: Our Five-Year Experience

Vaginal Uterine Morcellation Within a Specimen Containment System: A Study of Bag Integrity

To evaluate the integrity of the endoscopic bag after transvaginal morcellation of large uteri during total laparoscopic hysterectomy (TLH).

A new concept of minimally invasive laparoscopic surgery utilizing the vaginal route to prevent iatrogenic spillage of dermoid cysts: The bathtub method

Abstract Objective Surgical management of dermoid cysts remains controversial, and some surgeons prefer to approach these cysts via laparotomy due to the high risk of intraperitoneal cyst rupture in laparoscopic surgery and the related risks of chemical peritonitis. In our hospital, laparoscopic-assisted cystectomy (LAC) has been performed as a gasless laparoscopic surgery using an abdominal wall lifting method with a 3–5-cm transverse suprapubic incision that enables the dermoid cyst to be approached directly, as in laparotomy. Although LAC is safe and effective, it is performed in only specific areas and limited institutes. Therefore, we developed the method, a modified laparoscopic method that uses an endoscopic bag inserted through the vagina. The cyst is enucleated within the bag to catch cyst spillage. We compared results of the bathtub method with those of LAC. Methods We evaluated 37 patients scheduled for laparoscopic cystectomy with the bathtub method and 37 patients scheduled for LAC. Results Intraoperative cyst rupture occurred in 22 patients treated with the bathtub method; the majority of the cyst contents spilled into the endoscopic bag. White blood cell count and C-reactive protein level on postoperative Day 1 were 7708.3±1920.0/μL and 0.91±1.0 mg/dL, respectively, for the bathtub method versus 9913.9±2644.9/μL and 2.7±1.9 mg/dL for LAC ( p Conclusion The bathtub method is less invasive than is LAC, with unremarkable scarring and minimum spillage. It is considered safe and useful.

Enclosed Transvaginal Uterus Morcellation of an 18 Week-Sized Uterus after Total Laparoscopic Hysterectomy and Bilateral Salpingo-Oophorectomy

To describe the technique of transvaginal morcellation for large uteri and specimens within an enclosed endoscopic bag.

Robotic Duodenal Polypectomy and Pyloroplasty

Introduction: Sporadic duodenal adenomas are precancerous lesions and warrant resection due to malignant potential. The majority of duodenal adenomas are resected endoscopically. Endoscopic mucosal resection includes employing techniques, such as snare resection, submucosal injection of normal saline solution, or controlling a difficult lesion using a suction cap.1–3 The recurrence rate after resection approaches 8.3% to 45%.4,5 Lesions unamenable to endoscopic interventions require surgical resection. Open and laparoscopic techniques have been described.6–8 Although rare, robotic duodenal polypectomy has been described with successful outcomes.1,9 We demonstrate a novel technique of robotic duodenal polypectomy utilizing a pyloromyotomy to identify and resect an anatomically difficult-to-reach lesion, which was recalcitrant to multiple endoscopic resections. Materials and Methods: An 86-year-old male patient was referred for surgical excision of a duodenal polyp. The patient experienced recurrent upper and lower gastrointestinal bleeding for the past 5 years secondary to a 2 cm biopsy-confirmed duodenal adenomatous polyp. The lesion was recalcitrant to multiple endoscopic resections. On esophagogastroduodenoscopy, the location of the lesion was in the proximal duodenal bulb. The patient subsequently underwent a robotic duodenal polypectomy via a pyloromyotomy and Heineke–Mikulicz pyloroplasty. The patient was placed in supine positioning and the abdomen was entered using the Hasson technique in the right upper quadrant with a 5-mm nonbladed trocar. Under direct vision, a 5-mm port was placed in the right lateral abdominal wall, a 12-mm port in the supraumbilical position, and 8-mm ports in the right and left mid-abdomen were inserted to achieve appropriate geometry for approach to the pylorus. A combination of blunt and sharp dissection was used to mobilize the second portion of duodenum (Video). The anterior surface of the pylorus was opened in a longitudinal manner with the harmonic scalpel and extended approximately 1 cm to the first portion of the duodenum. The polyp was identified, everted into the operative bed through the pyloromyotomy, and a single PDS Endoloop® (Ethicon Endo-Surgery, Inc., Cincinnati, OH) was used to grasp the neck of the lesion. A combination of electrocautery and sharp dissection was used to excise the lesion as it was friable and prone to hemorrhage. The specimen was removed from the lumen and placed onto the extraluminal mesentary for eventual retrieval. The pyloromyotomy was then closed in a transverse manner with interrupted 0 silk sutures. Insufflations of the stomach ensured the absence of a leak, and the specimen was then retrieved with an endoscopic bag. Results and Conclusions: The patient tolerated enteric feeds on postoperative day 3 and was discharged on postoperative day 4. Upon 1-month postoperatively, his recovery remained uncomplicated. Histological findings revealed a completely resected duodenal tubular adenoma without signs of dysplasia or malignancy. Robotic resection of duodenal polyps may serve as a plausible approach in resection of duodenal lesions that are unable to be completely removed using traditional endoscopic techniques, especially lesions in the first portion of the duodenum, and in the elderly population less suitable for tolerating an exploratory laparotomy. No financial support was provided for this article. Dr. Sosin and Ms. Guevara do not have any conflict of interest nor financial ties to disclose. Dr. Gillian is a consultant and surgeon trainer for Davol and Ethicon and a proctor for Intuit Surgical. Runtime of video: 2 mins 28 secs This was presented as a poster presentation at the SAGES Annual Meeting in Baltimore, Maryland, in April 2013.