Specimen Extraction Technique Research Articles

465. INNOVATION TO STANDARDIZATION OF THORACOLAPAROSCOPIC ESOPHAGECTOMY: CULMINATION OF THREE DECADES OF EXPERIENCE

Abstract Minimally invasive esophagectomy has seen a great deal of evolution over the last three decades. As one of the earliest adopters of minimally invasive approach for esophagectomy, we present our experience and the lessons we have learnt in over 1300 cases. We adopted the prone position and later modified to mid prone position for the thoracic phase of esophagectomy. This position has several advantages of better exposure due to gravity aided retraction of the lungs, clear operating field as blood trickles away as well as feasibility of rapid conversion to open thoracotomy in emergencies. A major transformation in our surgery was the technical modifications and the extent of mediastinal lymphadenectomy. With refinements in technique and greater understanding of the lymphatic spread, we evolved from standard to extended and even total mediastinal lymphadenectomy improving the oncological outcomes without increasing the operative morbidity. The mean total lymph node yield is over 35. Recurrent laryngeal nerve injury was noted in 7% of cases. The technique of anastomosis was also extensively modified from hand sewn to circular stapler to semi mechanical and finally fully mechanical side to side anastomosis using triangulation technique. The triangulation technique has led to significant reduction in leak rates to less than 5% and stricture formation (<1%). Finally, our innovative railroading technique for specimen extraction through the neck is oncologically safe that avoids large incisions in the chest or abdomen. The 30 day mortality rate is less than 1%

Tips and tricks for transluminal specimen extraction and extra-abdominal sigmoid colon resection.

The purpose of this video is to demonstrate how to achieve adequate length and blood supply of the proximal colon for a perineal pull-through procedure, without splenic flexure mobilization during natural orifice specimen extraction. Key steps of the procedure include lateral mobilization of the colon, D3 lymph node dissection, preservation of the left colic artery, low ligation of the inferior mesenteric vein, ligation and washout of the distal bowel lumen, extra-abdominally proximal resection of sigmoid colon, purse-string sutures on the distal sigmoid colon, and an air leak test. Transluminal specimen extraction with extra-abdominal resection was found to be a cost-effective procedure with good cosmetic effects. Tension-free anastomosis was achieved by preservation of the left colic artery and low ligation of the inferior mesenteric vein. The purse-string sutures were placed on the proximal and distal bowel to avoid crossing the staples line. Transluminal specimen extraction with extra-abdominal resection required minimal manipulation intra-abdominally in comparison with other natural orifice specimen extraction techniques.

Specimen extraction techniques utilized in minimally invasive surgery for women with uterine cancer and an enlarged Uterus: A quality assurance study (1108)

Specimen extraction techniques utilized in minimally invasive surgery for women with uterine cancer and an enlarged Uterus: A quality assurance study (1108)

Comparative short-term and survival outcomes of three specimen extraction techniques in laparoscopic low rectal cancer surgery: does it affect ileostomy closure?

IntroductionThis study aimed to compare the short-term and survival outcomes in laparoscopic low rectal cancer surgery with three different specimen extraction techniques, and whether it affects loop ileostomy closure.Materials and methodsA consecutive series of patients with low rectal cancer who underwent laparoscopic low anterior resection plus protective loop ileostomy (LAR-PLI) were enrolled. Three main techniques, namely specimen extraction through auxiliary incision (EXAI), specimen extraction through stoma incision (EXSI), and specimen eversion and extra-abdominal resection (EVER), were employed. The postoperative short-term and survival outcomes of the three techniques and the impact on loop ileostomy closure were compared.ResultsIn all, 254 patients were enrolled in this study: 104 (40.9%) in the EXAI group, 104 (40.9%) in the EXSI group, and 46 (18.1%) in the EVER group. For primary surgery, EXAI group had significantly longer operative time (P < 0.001), more intraoperative bleeding (P < 0.001), longer length of abdominal incision (P<0.001), longer time to first flatus (P < 0.001), longer time to first defecation (P < 0.001), longer time to first eat (P < 0.001), and longer postoperative hospital stays (P = 0.005) than the EXSI and EVER groups. The primary postoperative complication rate in the EXAI and EVER group was significantly higher than in the EXSI group (P = 0.005). In loop ileostomy closure, EXAI group had significantly longer operative time (P = 0.001), more bleeding volume, and longer postoperative hospital stays (P < 0.001) than the EXSI and EVER groups. For survival outcomes, the 3-year local recurrence-free survival (LRFS) is 92.6% for all patients. The 3-year LRFS for patients in EXAI, EXSI, and EVER were 90.1%, 95.4%, and 92.7%, with P = 0.476.ConclusionsOur single-center results found that in LAR-PLI surgery for low rectal cancer, the short-term outcomes of specimen extraction through the stoma incision or anus were better than that through the auxiliary incision, but the 3-year LRFS was no statistically different.

Laparoscopic Low Anterior Resection for Severe Deep Pelvic Endometriosis (Stage IV) With Hybrid Notes Technique for Specimen Extraction and Anvil Insertion.

Saeidi, Sara M.D.1,2; Meroni, Paola M.D.3; Di Saverio, Salomone M.D.2,4,5 Author Information

Application of transanal total mesorectal excision in natural orifice specimen extraction technique in rectum cancer surgery.

Application of transanal total mesorectal excision in natural orifice specimen extraction technique in rectum cancer surgery.

Transanal total mesorectal excision as a natural orifice specimen extraction technique

Transanal total mesorectal excision as a natural orifice specimen extraction technique

Natural orifice specimen extraction surgery in laparoscopic pancreaticoduodenectomy: A single-center case series.

Laparoscopic pancreaticoduodenectomy is an appealing and minimally invasive method for pancreaticoduodenal tumors. However, an abdominal incision is still required to extract the specimen. We used the natural orifice specimen extraction technique in laparoscopic pancreaticoduodenectomy to accomplish specimen retraction in 8 female patients and summarized the clinical results. A total of 8 female patients with periampullary carcinoma or duodenal cancer who underwent laparoscopic pancreaticoduodenectomy were enrolled in our study between April 2018 and October 2019. A 4-cm transverse incision was made in the posterior vaginal wall, and the specimen was extracted via the vagina. Age, operative time, intraoperative hemorrhage, pathological data of the tumor, postoperative hospital stay, and postoperative complications were recorded and analyzed. All operations were performed laparoscopically, by the same team of surgeons. The mean age of the patients was 67.5±7.7 years. Mean BMI was 23.7±1.7kg/m2. The operative time ranged between 312 and 460min. The intraoperative blood loss ranged from 100 to 600ml. The average hospital stay of all patients was 9.9±2.2 days; 5 out of 8 patients (62.5%) had postoperative complications, including postoperative pancreatic fistula, delayed gastric emptying, and postpancreatectomy hemorrhage. No patient developed short-term complications due to vaginal extraction of specimens. All patients underwent R0 resection. Transvaginal specimen extraction is a practicable method for laparoscopic pancreaticoduodenectomy. By adhering to correct operation specifications and selecting patients with appropriate indications for natural orifice specimen extraction, this technique was safe and beneficial to selected female patients with pancreaticoduodenal tumors.

Site of extraction for laparoscopic colectomy: review and technique

Laparoscopic colon resection has shown many beneficial outcomes including reduced pain, earlier recovery and shorter length of stay at hospital. A minilaparotomy after colon resection is necessary for the creation of intestinal anastomosis and specimen extraction. This incision can cause complications including incisional hernia (IH) and wound infection. To retain maximum advantage of minimally invasive surgery, different incisions and specimen retrieval techniques have been practiced. In this review article, we include and discuss alternative incision and specimen extraction techniques including periumbilical incision, transverse incision, Pfannenstiel incision, natural orifice specimen extraction (NOSE) and stoma site extraction (SSE) after colectomy and recommends the use of the Pfannenstiel incision as the ideal extraction site after laparoscopic colectomy due to significantly reduced incidence of IH.

Alternative specimen extraction techniques complimenting enhanced recovery after surgery protocol in gastrointestinal malignancies: An early experience

Background Minimally invasive surgery is being increasingly implemented for Gastrointestinal (GI) malignancies. Site of specimen extraction after surgery influence the postoperative course by adding up-to the parietal wound morbidity. We studied the effect of alternative specimen extraction techniques on postoperative recovery and ease of implementation of ERAS protocol. Results A single center prospective data of 32 patients were compiled and the alternative specimen extraction sites studied were Natural Orifice Specimen Extraction-Vagina (n=8), Proposed Stoma Site Specimen Extraction (n=19), Trans Anal Specimen Extraction (n=5). All the patients had ease in the implementation of ERAS protocol and showed enhance recovery after the surgery with minimal wound related morbidity. The average duration of stay in the hospital was 5.8 days (SD=1.4) and the time to start adjuvant therapy when needed was an average of 21.7 days (SD= 5.46). Conclusion Alternative Specimen extraction techniques other than routine laparotomy compliment ERAS protocol initiation and implementation in patients undergoing Minimally invasive GI Oncological Surgery.

Laparoscopic port closure with a simple, inexpensive, effective and easy procedure to prevent port-site hernia

BackgroundIn this modern era of surgery, laparoscopy is more popular than before and widely practised. Although the surgeons focus more on the laparoscopic technique of specimen extraction, less attention is given for port-site sheath and peritoneum closure, resulting in port-site hernia (PSH). Various methods and use of number of instruments have been described for closure of port-site defects. We are reporting a simple, inexpensive, but effective, technique for closure of port-site sheath as well as peritoneum to prevent PSH. Materials and methodsWe have used a looped spinal needle and another thread introducing spinal needle for closure of port-site sheath along with peritoneum under camera vision in 84 patients and compared with conventional open blind port closure in another 70 patients. ResultsThis procedure was used to close port-site defects in 84 patients (66 female and 18 male) after laparoscopic procedures during April 2016 to August 2018. Neither PSH nor other post operative complications was reported over a mean follow-up of 18 months with our described port-site closure method using spinal needles. But, we recorded 2 cases (2.85%) of PSH and one case (1.43%) of omental incorporation, resulting in persistent postoperative pain in the abdomen in the group of patients in whom conventional blind fascial closure was performed. ConclusionOur described procedure using spinal needles is an easy, safe and inexpensive port-site defect closure method to prevent PSH.

Left colon resection with transrectal specimen extraction: current status.

Full laparoscopic left colectomy with transrectal specimen extraction is proposed as an improvement of the minimally invasive surgical technique. This paper reviews in detail the current status of left-sided colectomy and upper rectum resection with transrectal specimen extraction. A systematic review was performed of all types of publications on colorectal resection with natural orifice specimen extraction (NOSE). We only included studies reporting on left colectomy, sigmoidectomy, and high anterior resection with transrectal specimen extraction (TRSE), excluding transanal (TASE), transvaginal, or transcolonic specimen extraction. Surgical techniques, patient characteristics, and outcomes were reviewed in detail. Thirty-five papers reported on TRSE (2 randomized clinical trials, 7 case-matched series, 19 case series, 5 case reports, and 2 articles on surgical technique). We found a wide variety of innovative anastomotic and specimen extraction techniques. After excluding duplicates and papers reporting mixed TRSE and TASE results, outcomes in patients undergoing TRSE from 23 publications showed a conversion rate to conventional laparoscopy of 3.7% (21/559), overall morbidity 9.5% (53/559) [major in 2.9% (16/559), intra-abdominal infection in 2.1% (12/559)]. No mortality was reported. Postoperative anal incontinence was rarely reported. Several studies showed a decrease in postoperative pain and some in length of hospital stay. Colectomy with TRSE is feasible and seems safe in selected patients. Reported outcomes seem in general similar to conventional laparoscopic colectomy with a possible benefit in postoperative pain and length of hospital stay. Obvious selection bias and lack of high quality trials do not allow firm conclusions to be drawn.

"Hand-Over-Hand Grasping Technique": A Fast and Safe Procedure for Specimen Extraction in Laparoscopic Sleeve Gastrectomy.

Laparoscopic sleeve gastrectomy (LSG) has become one of the most popular bariatric surgeries worldwide, given good result concerning weight loss and long-term morbidity. While surgical technique is well standardized, specimen extraction is still a matter of controversy between surgeons. In this video, we present a simple, fast, safe, and reproducible technique of specimen extraction after laparoscopic sleeve gastrectomy. After the sleeve gastrectomy is completed with hemostasis, the specimen is introduced in a retrieval bag. Stomach specimen orientation is very important, such as the largest specimen part is removed firstly. The 2cm of the held fundus is introduced under direct vision in the 12-mm trocar. Traction is applied to simultaneously remove the trocar, the cord of the bag, and the grasper. The stomach is held by a Kocher once it is outside the peritoneal cavity. The bag is opened and everted to protect the wound. The pneumoperitoneum is deflated to relax the abdominal wall. The specimen is removed from the abdominal cavity by traction hand-over-hand grasping with gauze. We have applied this technique in 200 consecutive patients with an average body mass index of 42.5. At the first postoperative visit (1month), none of the patients experienced wound infection. Clinical incisional hernia was detected in one patient (0.5%). This hand-over-hand grasping with gauze technique is simple, safe, reproducible, and time saving.

Unlimited-Length Proctocolectomy Utilizing Sequential Intussusception and Pull-Through: Novel Clean Endolumenal NOTE-Assisted Technique With Transanal Natural Orifice Specimen Extraction Without Rectal Stump Opening in a Porcine Model.

Transanal, hybrid natural orifice translumenal endoscopic surgery (NOTES) and NOTES-assisted natural orifice specimen extraction techniques hold promise as leaders in the field of natural orifice surgery. We report the feasibility of a novel NOTES assisted technique for unlimited length, clean, endolumenal proctocolectomy in a porcine model. This technique is a modification of a transanal intussusception and pull-through procedure recently published by our group. Rectal mobilization was achieved laparoscopically; this was followed by a transanal recto-rectal intussusception and pull-through (IPT). IPT was established in a stepwise fashion. First, the proximal margin of resection was attached laparoscopically to the shaft of the anvil of an end-to-end circular stapler with a ligature around the rectum. Second, this complex was pulled transanally to produce IPT. To achieve an unlimited-length proctocolectomy, the IPT step was repeated several times prior to bowel resection. This was facilitated by removing the ligature applied in the first step of this procedure. Once sequential IPT established the desired length of bowel to be resected, a second ligature was placed around the rectum approximating the proximal and distal resection margins. The specimen was resected and extracted by making a full-thickness incision through the 2 bowel walls. The anastomosis was achieved by deploying the stapler. The technique was found to be feasible. Peritoneal samples, collected after transanal specimen extraction, did not demonstrate bacterial growth. The minimally invasive nature of this evolving technique as well as its aseptic bowel manipulation has the potential to limit the complications associated with abdominal wall incision and surgical site infection.

Abdominal Approaches to Tissue Containment and Extraction in Minimally Invasive Gynecologic Surgery

Study ObjectiveTo show different abdominal methods of tissue containment and specimen extraction techniques as an alternative to electromechanical morcellation (EMM). DesignA stepwise surgical tutorial using a narrated video (Canadian Task Force classification III). SettingAn academic tertiary care hospital. InterventionsMinimally invasive gynecologic surgery requires the extraction of large tissue specimens through small incisions. EMM was largely used until recently when the Food and Drug Administration issued a statement on its safety. In this video, we present alternative techniques to EMM as well as different methods of tissue containment. Uteri specimens are contained using a 3M Steri-Drape isolation bag (3M Healthcare, Maplewood, MN) and, alternatively, the Alexis Containment Extraction System (Applied Medical, Rancho Santa Margarita, CA). The contained specimen is manually extracted through the 2.5-cm umbilical port incision using the paper roll technique described here. ConclusionThese techniques for tissue containment and extraction provide an alternative to EMM. They allow the minimally invasive surgeon to contain and retrieve large specimens. When used appropriately, these techniques can decrease conversion rates to open abdominal surgery. They are easily reproducible with a minimal learning curve.

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.

Erratum to: Letter to the Editor: Minimizing the Access Trauma of Laparoscopic Sleeve Gastrectomy: the Transoral Specimen Extraction Technique

Erratum to: Letter to the Editor: Minimizing the Access Trauma of Laparoscopic Sleeve Gastrectomy: the Transoral Specimen Extraction Technique

Simple, Safe, and Cost-Effective Technique for Resected Stomach Extraction in Laparoscopic Sleeve Gastrectomy.

Background. Laparoscopic sleeve gastrectomy (LSG) has become a popular operation during the recent years. This procedure requires resection of 80–90% of the stomach. Extraction of gastric specimen is known to be a challenging and costly stage of the operation. In this paper, we report results of a simple and cost-effective specimen extraction technique which was applied to 137 consecutive LSG patients. Methods. Between October 2013 and October 2015, 137 laparoscopic sleeve gastrectomy surgeries were performed at Dokuz Eylul University General Surgery Department, Upper Gastrointestinal Surgery Unit. All specimens were extracted through a 15 mm trocar site without using any special device. Results. We noticed one superficial incisional surgical site infection and treated this patient with oral antibiotics. No cases of trocar site hernia were observed. Conclusion. Different techniques have been described for specimen extraction. This simple technique allows extraction of specimen safely in a short time and does not require any special device.

Transanal specimen extraction in laparoscopic colorectal resection

To investigate the feasibility and efficacy of transanal specimen extraction in laparoscopic colorectal resection. From January 2009 to December 2010, transanal specimen extraction technique was performed in 12 patients undergoing laparoscopic colorectal resection. The clinical data were retrospectively analyzed. There were 8 males and 4 females. The age ranged from 41 to 67 (mean, 58) years old. The mean operative time was (240±45) min, mean blood loss was (70±40) ml. There was no anastomotic leakage or stenosis. One patient with constipation suffered from intractable right lower abdominal pain and was managed with antispasmodic agents. The frequency of bowel movements was 3-7/d in the 5 patients with constipation and 1-2/d in patients with colorectal carcinoma at six months postoperatively. No local recurrence and metastasis in patients with colorectal cancer after follow-up of 1-20 months. Transanal specimen extraction in laparoscopic colorectal resection is feasible, safe, and reliable.

A useful technique for specimen extraction from the thorax: the vacuum-packing method

Most thoracic surgeons have encountered a number of situations in which a specimen was too large to fit through a small intercostal incision. This report highlights a useful technique for specimen extraction from the thorax using a vinyl bag and a sucker. The sucker creates negative pressure, and the liquid and air components from the specimen are removed. The specimen can be deflated and removed from the thoracic cavity through the access incision. We call this method the 'vacuum-packing method'.