Original Research
Innovative Technique for Enclosed Morcellation Using a Surgical Glove Ali Akdemir, MD, Enes Taylan, MD, Burak Zeybek, MD, Ahmet Mete Ergenoglu, MD, and Fatih Sendag, MD OBJECTIVE: To describe an innovative approach for enclosed morcellation using a surgical glove in multiport laparoscopic surgery. METHODS: Power morcellation was performed within an insufflated surgical glove in a completely enclosed manner between January and May 2014. The specimen was placed into the glove within the abdomen. The glove opening and thumb were exteriorized through the umbilical and left lower abdominal trocar incisions, respectively. The optical trocar and optic were inserted into the glove, which was then insufflated. The thumb tip was cut, and a power morcellator was inserted through this finger. The morcellation was accomplished within the completely enclosed glove. The thumb tip was closed, and the glove, containing residual specimens and bloody fluid, was removed from the abdomen through the umbilical incision. Thus, the risks of bag piercing and leakage during contained power morcellation were eliminated. Demographic and operative data were collected and analyzed for all cases. RESULTS: Thirty multiport laparoscopic myomectomy and morcellation procedures were performed during the study period. The median operative time was 85 minutes (range 60–140 minutes). The median morcellation preparation time, total morcellation time, and withdrawal time were 6 (range 4.5–14), 32 (range 15– 55), and 1.2 (range 1–1.5) minutes, respectively. No intraoperative complications or bag ruptures were recorded. CONCLUSION: With our innovative technique, a disposable latex glove can be used for an enclosed morcellation that avoids piercing the enclosure container within the abdominal cavity, thereby offering decreased risks From the Department of Obstetrics and Gynecology, Ege University School of Medicine, Izmir, Turkey. Corresponding author: Ali Akdemir, MD, Ege University School of Medicine, Department of Obstetrics and Gynecology, Bornova TR-35100, Izmir, Turkey; e-mail: [email protected]. Financial Disclosure The authors did not report any potential conflicts of interest. © 2015 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0029-7844/15
VOL. 125, NO. 5, MAY 2015
related to bag perforation and leakage compared with previous contained power morcellation techniques. (Obstet Gynecol 2015;125:1145–9) DOI: 10.1097/AOG.0000000000000823
LEVEL OF EVIDENCE: III
E
lectromechanical morcellation is a very important procedure that enables minimally invasive surgery for many gynecologic conditions. During the use of this technology since 1993, hundreds of women have undergone laparoscopy without requiring a laparotomy. However, electromechanical morcellation has long been performed inside the abdomen without any containment.1 Therefore, this practice has recently undergone increased scrutiny because of very important concerns related to tissue dissemination during intracorporeal power morcellation.2–4 Although the incidence is unknown, in some cases, authors have reported many complications related to retained tissue fragments. In addition to the increased risks of postoperative pain, infection, and the necessity of reoperation, the most hazardous concern is likely to be the unintended seeding of occult malignancies, which results in an upstaging of the disease and a worse prognosis.5,6 In April 2014, the U.S. Food and Drug Administration released a safety communication discouraging power morcellation in laparoscopic hysterectomy and myomectomy procedures.7 As a response to these serious concerns, researchers have developed various tissue extraction and containment techniques.8,9 In these techniques, the surgical specimen is placed into a bag, and the opening of the bag is exteriorized from one of the trocar incisions. The bag is then insufflated, and the optic system is inserted into the bag. Under indirect vision, one of the trocars is then inserted into the bag by piercing the bag. A laparoscopic power morcellator is then inserted into the bag through this trocar. However, these techniques pose potential problems resulting from piercing the bag inside the abdominal cavity. Piercing or penetrating the bag inside the abdominal
OBSTETRICS & GYNECOLOGY
Copyright ª by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
1145
cavity jeopardizes the bag integrity and may cause leakage during morcellation. Consequently, in this study, we aimed to describe an innovative technique using a surgical glove without piercing or penetrating the bag for enclosed or contained morcellation, which may provide a solution to the risks of leakage and tissue dissemination.
MATERIALS AND METHODS After approval was given by the university ethics committee, this investigation was designed as a cohort study of 30 patients who underwent enclosed power morcellation during multiport laparoscopic myomectomy from January 2014 to May 2014 at Ege University Hospital. The patients were informed by the researchers, and informed consent was obtained from each participant. Patients with known or suspected malignancies were excluded from the study. All of the patients were evaluated for demographic and perioperative information. The demographic information included age, parity, body mass index, surgical indication, and obstetric and surgical history. The perioperative information included the procedure type, operative time (from incision to closure), bag preparation (from bag insertion into the abdomen to the beginning of morcellation), total morcellation time, time required for bag withdrawal (from the end of morcellation to bag export), bag integrity (by a methylene blue dye test), estimated blood loss, specimen weight, intraoperative complications, length of hospital stay, and readmission. The demographic and perioperative data were analyzed using the Statistical Package for the Social Sciences 15.0, and the results were reported as the median (range) and number (proportion). In our practice, the standard trocar configuration is as follows: a 10-mm trocar in the umbilicus for the optic system, a 5-mm trocar in the left upper quadrant, and two 5-mm trocars in the lower right and left quadrants. When the specimen is ready for extraction and before beginning the morcellation procedure, the left lower trocar is upsized from 5 to 12 mm. Subsequently, a surgical latex glove (size 8.5) is introduced through the left lower trocar into the abdomen. Before inserting the glove into the abdomen, the surgical glove is lubricated with normal saline to remove the talcum powder. The specimen is then placed inside the glove under direct visualization. Next, the thumb of the glove is grasped and removed from the abdominal cavity through the left lower quadrant port. The lips of the glove with the specimen inside are grasped with the instrument through the upper left port. By manipulating the laparoscopic instrument from the left upper port, the lips of the surgical glove are pushed into the 10-mm umbilical port inside the abdominal cavity, and the optic
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Video 1. Laparoscopic enclosed power morcellation using a surgical glove. The specimen is placed into the glove within the abdomen. Glove opening and thumb are exteriorized through the umbilical and left lower incisions, respectively. The trocar and optic are inserted into the glove, which is then insufflated. The thumb tip is cut, and a power morcellator is inserted through this finger. The morcellation is accomplished within the glove. The thumb tip is closed, and the glove, containing residuals, is removed through the umbilical incision. Thus, the risks of bag piercing and leakage during contained power morcellation are eliminated. The video was created by Ali Akdemir, MD. Used with permission.
system and the umbilical trocar are removed until the tip of the laparoscopic instrument is observed from the skin. The mouth of the glove is withdrawn by the surgeon. Subsequently, the mouth of the glove is exteriorized around the umbilicus. The umbilical trocar and the optic system are gently inserted into the glove. After desufflation of the abdominal cavity, the glove is insufflated and the pressure is set at 14–20 mm Hg. Outside, the tip of the thumb of the glove is cut, and the morcellator is introduced into the glove through the thumb; morcellation is performed under direct visualization. After the extraction of the specimen, the morcellator is removed and the thumb of the glove is tied safely to prevent tissue or liquid leakage before glove removal from the abdomen (Video 1, available online at http://links.lww.com/ AOG/A629). The glove with the tissue fragments is removed from the umbilical port under visualization with the optic system and tested for rupture or leakage with methylene blue dye. Figure 1 depicts the surgical steps. To test for leakage, in all cases, the glove is filled with water mixed with methylene blue dye and placed in a clean water container (Fig. 2).
Innovative Approach to Enclosed Morcellation
Scan this image to view Video 1 on your smartphone.
OBSTETRICS & GYNECOLOGY
Copyright ª by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Fig. 1. A. A surgical latex glove is introduced through the left lower trocar into the abdomen. B. The specimen is then placed inside the glove under direct visualization. C. The thumb of the glove is grasped and removed from the abdominal cavity through the left lower quadrant port. D. The lips of the glove with the specimen inside are grasped by manipulating the laparoscopic instrument from the left upper port. The lips of the glove are pushed into the 10-mm umbilical port inside the abdomen, and the optic system and trocar are removed until the tip of the laparoscopic instrument is observed from the skin. Subsequently, the mouth of the glove is exteriorized around the umbilicus. E. The umbilical trocar and the optic system are gently inserted into the glove and the glove is insufflated. The tip of the thumb of the glove is cut, and the morcellator is introduced into the glove through the thumb; morcellation is performed under direct visualization. F. After extraction of the specimen, the morcellator is removed and the thumb of the glove is tied safely to prevent tissue or liquid leakage before removal of the glove from the abdomen. G. The glove with the tissue fragments is removed from the umbilical port under visualization with the optic system. Akdemir. Innovative Approach to Enclosed Morcellation. Obstet Gynecol 2015.
RESULTS Thirty enclosed morcellation procedures were performed during multiport laparoscopic myomectomy with the same, previously described surgical technique.
Fig. 2. The surgical glove was filled with water mixed with methylene blue dye and placed in a clean water container to test for leakage. Akdemir. Innovative Approach to Enclosed Morcellation. Obstet Gynecol 2015.
VOL. 125, NO. 5, MAY 2015
The demographic data of the patients are presented in Table 1, and the perioperative data are provided in Table 2. The most common indication for surgery was leiomyoma, particularly in infertile patients. In two cases, morcellation of a 10-cm myoma (weighing approximately 275 g) was performed using our containment technique, and the recorded morcellation time was a maximum of 55 minutes. The glove preparation for morcellation and the total morcellation time were found to increase in proportion to the myoma size. No complications or bag ruptures were recorded in the study. All of the patients were discharged from the hospital in good condition, and no readmissions or reoperations were required.
DISCUSSION Enclosed morcellation is a feasible, promising, and practical technique with the potential of eliminating the risks related to open power morcellation during laparoscopy. Our innovative technical approach can
Akdemir et al
Innovative Approach to Enclosed Morcellation
Copyright ª by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
1147
Table 1. Demographic Patient Information (N530) Characteristic
Value
Age (y) BMI (kg/m2) Surgical indication Leiomyoma Abnormal uterine bleeding Pelvic pain Previous surgery Laparotomy (including cesarean delivery) Laparoscopy None Obstetric history Gravida Parity
33 (28–44) 29 (20–39) 30 (100) 24 (80) 6 (20) 6 (20) 5 (16.6) 19 (63.4) 2 (0–10) 2 (0–6)
BMI, body mass index. Data are median (range) or n (%).
decrease the risks related to bag piercing and leakage associated with the contained power morcellation techniques described by various authors. In an attempt to reduce the risks of tissue dissemination during power morcellation, researchers have developed new techniques to modify intracorporeal morcellation by contained or enclosed morcellation. Einarsson et al8 demonstrated an inbag morcellation technique and reported the preliminary results of 15 cases in which the technique was used with traditional multiport laparoscopic surgery. After establishing their standard four-trocar configuration, they described two options for contained morcellation conducted in a 15-mm Endobag and with the Anchor Tissue Retrieval System. Although the authors did not investigate the exact time parameters (such as the times required for bag preparation and specimen securement inside the bag and the duration of the morcellation), they reported no intraoperative complications Table 2. Perioperative Patient Information (N530) Characteristic
Value
Type of procedure (multiport laparoscopic myomectomy) Operative time (min) Preparation for morcellation (min) Morcellation time (min) Withdrawing bag (min) Integrity of bag Intraoperative complications Estimated blood loss (mL) Specimen weight (g) Length of hospital stay (d) Readmission or reoperation Data are n (%) or median (range).
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Akdemir et al
30 (100) 85 6 32 1.2 30 0 50 155 1 0
(60–140) (4.5–14) (15–55) (1–1.5) (100) (0) (10–450) (80–275) (0–2) (0)
and no bag ruptures during morcellation or bag insertion (like in our study). Recently, Cohen et al9,10 published two articles regarding contained power morcellation. In one study, titled “Contained Power Morcellation Within an Insufflated Isolation Bag,” they describe two discrete techniques for single-port laparoscopic surgery and multiport laparoscopic surgery. In both techniques, they used a 50350-cm isolation bag for morcellation with a containment technique. In the other study, titled “Risk of Leakage and Tissue Dissemination With Various Contained Tissue Extraction (CTE) Techniques: An In Vitro Pilot Study,” they investigated the risk of leakage and tissue dissemination with various enclosed morcellation techniques and compared the risks with those of open morcellation using a box trainer. The researchers conclude that, compared with traditional open morcellation, contained morcellation could effectively decrease or potentially eradicate tissue spillage. In these three studies, there is a significant common problem associated with the described techniques (except in the single-port laparoscopic approach), namely, the risk of penetrating or piercing the bag by one or more trocars or instruments. This procedure involves the risks of disrupting the bag integrity, leakage, and difficulty in piercing the bag under indirect optic visualization. The philosophy and aim of contained morcellation is to perform morcellation in a space isolated from the abdominal cavity. The process of bag penetration or piercing should be eliminated to prevent any direct connection of the bag surface to the intraabdominal space. In our unique technique for multiport laparoscopic surgery, this goal has been realized. The innovation in our technique is the insertion of the morcellator into the closed space of the bag outside the abdomen through a protrusion (with the glove fingertip outside the abdomen). Consequently, the risks of bag puncture-related leakage inherent in other techniques have been eliminated. With this technique, the tissue extraction procedure during multiport laparoscopic surgery can be performed in a completely contained manner without any risk of bag perforation or leakage. This technique presents a markedly crucial advantage that enables this procedure to also be applied in oncologic cases. In addition, this method is a highly practical and efficient approach that decreases the total morcellation time. One of the advantageous features of our technique is related to the material we use. Because the elastic structure of the glove enables its expansion, we can easily use a standard-sized glove for variously sized specimens.
Innovative Approach to Enclosed Morcellation
OBSTETRICS & GYNECOLOGY
Copyright ª by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
The limitations in our study were predominantly related to the size of the glove used for the enclosed morcellation. Because of the limited volume of the glove, we were restricted in the containment procedure to morcellating myomas with a maximum diameter of 10 cm. We rarely perform subtotal hysterectomies in our clinic, and we included only myomectomy cases in our study. Another possible limitation may be related to tying the fingertip of the glove at the end of the procedure. It is obvious that tying the fingertip prevents the spillage of macroscopic tissue fragments, but it is uncertain whether it prevents microscopic tissue dissemination. In conclusion, we have described an innovative technique as a possible solution for completely enclosed power morcellation. However, further studies are necessary to demonstrate the safety of our technique. In addition, manufacturing a glove-shaped bag specifically for laparoscopic power morcellation may facilitate overcoming the limitations experienced in our study and accelerate the progress on eliminating the dissemination problem during morcellation. REFERENCES 1. Steiner RA, Wight E, Tadir Y, Haller U. Electrical cutting device for laparoscopic removal of tissue from the abdominal cavity. Obstet Gynecol 1993;81:471–4.
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2. Kho KA, Nezhat CH. Evaluating the risks of electric uterine morcellation. JAMA 2014;311:905–6. 3. Takeda A, Mori M, Sakai K, Misui T, Nakamura H. Parasitic peritoneal leiomyomatosis diagnosed 6 years after laparoscopic myomectomy with electric tissue morcellation: report of a case and review of the literature. J Minim Invasive Gynecol 2007;14: 770–5. 4. Milad MP, Milad EA. Laparoscopic morcellator-related complications. J Minim Invasive Gynecol 2014;21:486–91. 5. Park JY, Park SK, Kim DY, Kim JH, Kim YM, Kim YT, et al. The impact of tumor morcellation during surgery on the prognosis of patients with apparently early uterine leiomyosarcoma. Gynecol Oncol 2011;122:255–9. 6. Einstein MH, Barakat RR, Chi DS, Sonoda Y, Alektiar KM, Hensley ML, et al. Management of uterine malignancy found incidentally after supracervical hysterectomy or uterine morcellation for presumed benign disease. Int J Gynecol Cancer 2008; 18:1065–70. 7. U.S. Food and Drug Administration. Laparoscopic uterine power morcellation in hysterectomy and myomectomy: FDA safety communication. Available at: http://www.fda.gov/MedicalDevices/ Safety/AlertsandNotices/ucm393576.htm. Retrieved May 12, 2014. 8. Einarsson JI, Cohen SL, Fuchs N, Wang KC. In bag morcellation. J Minim Invasive Gynecol 2014;21:951–3. 9. Cohen SL, Einarsson JI, Wang KC, Brown D, Boruta D, Scheib SA, et al. Contained power morcellation within an insufflated isolation bag. Obstet Gynecol 2014;124:491–7. 10. Cohen SL, Greenberg JA, Wang KC, Srouji SS, Gargiulo AR, Pozner CN, et al. Risk of leakage and tissue dissemination with various contained tissue extraction (CTE) techniques: an in vitro pilot study. J Minim Invasive Gynecol 2014;21:935–9.
Akdemir et al
Innovative Approach to Enclosed Morcellation
Copyright ª by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
1149
Innovative Technique for Enclosed Morcellation Using a Surgical Glove Ali Akdemir, MD, Enes Taylan, MD, Burak Zeybek, MD, Ahmet Mete Ergenoglu, MD, and Fatih Sendag, MD OBJECTIVE: To describe an innovative approach for enclosed morcellation using a surgical glove in multiport laparoscopic surgery. METHODS: Power morcellation was performed within an insufflated surgical glove in a completely enclosed manner between January and May 2014. The specimen was placed into the glove within the abdomen. The glove opening and thumb were exteriorized through the umbilical and left lower abdominal trocar incisions, respectively. The optical trocar and optic were inserted into the glove, which was then insufflated. The thumb tip was cut, and a power morcellator was inserted through this finger. The morcellation was accomplished within the completely enclosed glove. The thumb tip was closed, and the glove, containing residual specimens and bloody fluid, was removed from the abdomen through the umbilical incision. Thus, the risks of bag piercing and leakage during contained power morcellation were eliminated. Demographic and operative data were collected and analyzed for all cases. RESULTS: Thirty multiport laparoscopic myomectomy and morcellation procedures were performed during the study period. The median operative time was 85 minutes (range 60–140 minutes). The median morcellation preparation time, total morcellation time, and withdrawal time were 6 (range 4.5–14), 32 (range 15– 55), and 1.2 (range 1–1.5) minutes, respectively. No intraoperative complications or bag ruptures were recorded. CONCLUSION: With our innovative technique, a disposable latex glove can be used for an enclosed morcellation that avoids piercing the enclosure container within the abdominal cavity, thereby offering decreased risks From the Department of Obstetrics and Gynecology, Ege University School of Medicine, Izmir, Turkey. Corresponding author: Ali Akdemir, MD, Ege University School of Medicine, Department of Obstetrics and Gynecology, Bornova TR-35100, Izmir, Turkey; e-mail: [email protected]. Financial Disclosure The authors did not report any potential conflicts of interest. © 2015 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0029-7844/15
VOL. 125, NO. 5, MAY 2015
related to bag perforation and leakage compared with previous contained power morcellation techniques. (Obstet Gynecol 2015;125:1145–9) DOI: 10.1097/AOG.0000000000000823
LEVEL OF EVIDENCE: III
E
lectromechanical morcellation is a very important procedure that enables minimally invasive surgery for many gynecologic conditions. During the use of this technology since 1993, hundreds of women have undergone laparoscopy without requiring a laparotomy. However, electromechanical morcellation has long been performed inside the abdomen without any containment.1 Therefore, this practice has recently undergone increased scrutiny because of very important concerns related to tissue dissemination during intracorporeal power morcellation.2–4 Although the incidence is unknown, in some cases, authors have reported many complications related to retained tissue fragments. In addition to the increased risks of postoperative pain, infection, and the necessity of reoperation, the most hazardous concern is likely to be the unintended seeding of occult malignancies, which results in an upstaging of the disease and a worse prognosis.5,6 In April 2014, the U.S. Food and Drug Administration released a safety communication discouraging power morcellation in laparoscopic hysterectomy and myomectomy procedures.7 As a response to these serious concerns, researchers have developed various tissue extraction and containment techniques.8,9 In these techniques, the surgical specimen is placed into a bag, and the opening of the bag is exteriorized from one of the trocar incisions. The bag is then insufflated, and the optic system is inserted into the bag. Under indirect vision, one of the trocars is then inserted into the bag by piercing the bag. A laparoscopic power morcellator is then inserted into the bag through this trocar. However, these techniques pose potential problems resulting from piercing the bag inside the abdominal cavity. Piercing or penetrating the bag inside the abdominal
OBSTETRICS & GYNECOLOGY
Copyright ª by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
1145
cavity jeopardizes the bag integrity and may cause leakage during morcellation. Consequently, in this study, we aimed to describe an innovative technique using a surgical glove without piercing or penetrating the bag for enclosed or contained morcellation, which may provide a solution to the risks of leakage and tissue dissemination.
MATERIALS AND METHODS After approval was given by the university ethics committee, this investigation was designed as a cohort study of 30 patients who underwent enclosed power morcellation during multiport laparoscopic myomectomy from January 2014 to May 2014 at Ege University Hospital. The patients were informed by the researchers, and informed consent was obtained from each participant. Patients with known or suspected malignancies were excluded from the study. All of the patients were evaluated for demographic and perioperative information. The demographic information included age, parity, body mass index, surgical indication, and obstetric and surgical history. The perioperative information included the procedure type, operative time (from incision to closure), bag preparation (from bag insertion into the abdomen to the beginning of morcellation), total morcellation time, time required for bag withdrawal (from the end of morcellation to bag export), bag integrity (by a methylene blue dye test), estimated blood loss, specimen weight, intraoperative complications, length of hospital stay, and readmission. The demographic and perioperative data were analyzed using the Statistical Package for the Social Sciences 15.0, and the results were reported as the median (range) and number (proportion). In our practice, the standard trocar configuration is as follows: a 10-mm trocar in the umbilicus for the optic system, a 5-mm trocar in the left upper quadrant, and two 5-mm trocars in the lower right and left quadrants. When the specimen is ready for extraction and before beginning the morcellation procedure, the left lower trocar is upsized from 5 to 12 mm. Subsequently, a surgical latex glove (size 8.5) is introduced through the left lower trocar into the abdomen. Before inserting the glove into the abdomen, the surgical glove is lubricated with normal saline to remove the talcum powder. The specimen is then placed inside the glove under direct visualization. Next, the thumb of the glove is grasped and removed from the abdominal cavity through the left lower quadrant port. The lips of the glove with the specimen inside are grasped with the instrument through the upper left port. By manipulating the laparoscopic instrument from the left upper port, the lips of the surgical glove are pushed into the 10-mm umbilical port inside the abdominal cavity, and the optic
1146
Akdemir et al
Video 1. Laparoscopic enclosed power morcellation using a surgical glove. The specimen is placed into the glove within the abdomen. Glove opening and thumb are exteriorized through the umbilical and left lower incisions, respectively. The trocar and optic are inserted into the glove, which is then insufflated. The thumb tip is cut, and a power morcellator is inserted through this finger. The morcellation is accomplished within the glove. The thumb tip is closed, and the glove, containing residuals, is removed through the umbilical incision. Thus, the risks of bag piercing and leakage during contained power morcellation are eliminated. The video was created by Ali Akdemir, MD. Used with permission.
system and the umbilical trocar are removed until the tip of the laparoscopic instrument is observed from the skin. The mouth of the glove is withdrawn by the surgeon. Subsequently, the mouth of the glove is exteriorized around the umbilicus. The umbilical trocar and the optic system are gently inserted into the glove. After desufflation of the abdominal cavity, the glove is insufflated and the pressure is set at 14–20 mm Hg. Outside, the tip of the thumb of the glove is cut, and the morcellator is introduced into the glove through the thumb; morcellation is performed under direct visualization. After the extraction of the specimen, the morcellator is removed and the thumb of the glove is tied safely to prevent tissue or liquid leakage before glove removal from the abdomen (Video 1, available online at http://links.lww.com/ AOG/A629). The glove with the tissue fragments is removed from the umbilical port under visualization with the optic system and tested for rupture or leakage with methylene blue dye. Figure 1 depicts the surgical steps. To test for leakage, in all cases, the glove is filled with water mixed with methylene blue dye and placed in a clean water container (Fig. 2).
Innovative Approach to Enclosed Morcellation
Scan this image to view Video 1 on your smartphone.
OBSTETRICS & GYNECOLOGY
Copyright ª by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Fig. 1. A. A surgical latex glove is introduced through the left lower trocar into the abdomen. B. The specimen is then placed inside the glove under direct visualization. C. The thumb of the glove is grasped and removed from the abdominal cavity through the left lower quadrant port. D. The lips of the glove with the specimen inside are grasped by manipulating the laparoscopic instrument from the left upper port. The lips of the glove are pushed into the 10-mm umbilical port inside the abdomen, and the optic system and trocar are removed until the tip of the laparoscopic instrument is observed from the skin. Subsequently, the mouth of the glove is exteriorized around the umbilicus. E. The umbilical trocar and the optic system are gently inserted into the glove and the glove is insufflated. The tip of the thumb of the glove is cut, and the morcellator is introduced into the glove through the thumb; morcellation is performed under direct visualization. F. After extraction of the specimen, the morcellator is removed and the thumb of the glove is tied safely to prevent tissue or liquid leakage before removal of the glove from the abdomen. G. The glove with the tissue fragments is removed from the umbilical port under visualization with the optic system. Akdemir. Innovative Approach to Enclosed Morcellation. Obstet Gynecol 2015.
RESULTS Thirty enclosed morcellation procedures were performed during multiport laparoscopic myomectomy with the same, previously described surgical technique.
Fig. 2. The surgical glove was filled with water mixed with methylene blue dye and placed in a clean water container to test for leakage. Akdemir. Innovative Approach to Enclosed Morcellation. Obstet Gynecol 2015.
VOL. 125, NO. 5, MAY 2015
The demographic data of the patients are presented in Table 1, and the perioperative data are provided in Table 2. The most common indication for surgery was leiomyoma, particularly in infertile patients. In two cases, morcellation of a 10-cm myoma (weighing approximately 275 g) was performed using our containment technique, and the recorded morcellation time was a maximum of 55 minutes. The glove preparation for morcellation and the total morcellation time were found to increase in proportion to the myoma size. No complications or bag ruptures were recorded in the study. All of the patients were discharged from the hospital in good condition, and no readmissions or reoperations were required.
DISCUSSION Enclosed morcellation is a feasible, promising, and practical technique with the potential of eliminating the risks related to open power morcellation during laparoscopy. Our innovative technical approach can
Akdemir et al
Innovative Approach to Enclosed Morcellation
Copyright ª by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
1147
Table 1. Demographic Patient Information (N530) Characteristic
Value
Age (y) BMI (kg/m2) Surgical indication Leiomyoma Abnormal uterine bleeding Pelvic pain Previous surgery Laparotomy (including cesarean delivery) Laparoscopy None Obstetric history Gravida Parity
33 (28–44) 29 (20–39) 30 (100) 24 (80) 6 (20) 6 (20) 5 (16.6) 19 (63.4) 2 (0–10) 2 (0–6)
BMI, body mass index. Data are median (range) or n (%).
decrease the risks related to bag piercing and leakage associated with the contained power morcellation techniques described by various authors. In an attempt to reduce the risks of tissue dissemination during power morcellation, researchers have developed new techniques to modify intracorporeal morcellation by contained or enclosed morcellation. Einarsson et al8 demonstrated an inbag morcellation technique and reported the preliminary results of 15 cases in which the technique was used with traditional multiport laparoscopic surgery. After establishing their standard four-trocar configuration, they described two options for contained morcellation conducted in a 15-mm Endobag and with the Anchor Tissue Retrieval System. Although the authors did not investigate the exact time parameters (such as the times required for bag preparation and specimen securement inside the bag and the duration of the morcellation), they reported no intraoperative complications Table 2. Perioperative Patient Information (N530) Characteristic
Value
Type of procedure (multiport laparoscopic myomectomy) Operative time (min) Preparation for morcellation (min) Morcellation time (min) Withdrawing bag (min) Integrity of bag Intraoperative complications Estimated blood loss (mL) Specimen weight (g) Length of hospital stay (d) Readmission or reoperation Data are n (%) or median (range).
1148
Akdemir et al
30 (100) 85 6 32 1.2 30 0 50 155 1 0
(60–140) (4.5–14) (15–55) (1–1.5) (100) (0) (10–450) (80–275) (0–2) (0)
and no bag ruptures during morcellation or bag insertion (like in our study). Recently, Cohen et al9,10 published two articles regarding contained power morcellation. In one study, titled “Contained Power Morcellation Within an Insufflated Isolation Bag,” they describe two discrete techniques for single-port laparoscopic surgery and multiport laparoscopic surgery. In both techniques, they used a 50350-cm isolation bag for morcellation with a containment technique. In the other study, titled “Risk of Leakage and Tissue Dissemination With Various Contained Tissue Extraction (CTE) Techniques: An In Vitro Pilot Study,” they investigated the risk of leakage and tissue dissemination with various enclosed morcellation techniques and compared the risks with those of open morcellation using a box trainer. The researchers conclude that, compared with traditional open morcellation, contained morcellation could effectively decrease or potentially eradicate tissue spillage. In these three studies, there is a significant common problem associated with the described techniques (except in the single-port laparoscopic approach), namely, the risk of penetrating or piercing the bag by one or more trocars or instruments. This procedure involves the risks of disrupting the bag integrity, leakage, and difficulty in piercing the bag under indirect optic visualization. The philosophy and aim of contained morcellation is to perform morcellation in a space isolated from the abdominal cavity. The process of bag penetration or piercing should be eliminated to prevent any direct connection of the bag surface to the intraabdominal space. In our unique technique for multiport laparoscopic surgery, this goal has been realized. The innovation in our technique is the insertion of the morcellator into the closed space of the bag outside the abdomen through a protrusion (with the glove fingertip outside the abdomen). Consequently, the risks of bag puncture-related leakage inherent in other techniques have been eliminated. With this technique, the tissue extraction procedure during multiport laparoscopic surgery can be performed in a completely contained manner without any risk of bag perforation or leakage. This technique presents a markedly crucial advantage that enables this procedure to also be applied in oncologic cases. In addition, this method is a highly practical and efficient approach that decreases the total morcellation time. One of the advantageous features of our technique is related to the material we use. Because the elastic structure of the glove enables its expansion, we can easily use a standard-sized glove for variously sized specimens.
Innovative Approach to Enclosed Morcellation
OBSTETRICS & GYNECOLOGY
Copyright ª by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
The limitations in our study were predominantly related to the size of the glove used for the enclosed morcellation. Because of the limited volume of the glove, we were restricted in the containment procedure to morcellating myomas with a maximum diameter of 10 cm. We rarely perform subtotal hysterectomies in our clinic, and we included only myomectomy cases in our study. Another possible limitation may be related to tying the fingertip of the glove at the end of the procedure. It is obvious that tying the fingertip prevents the spillage of macroscopic tissue fragments, but it is uncertain whether it prevents microscopic tissue dissemination. In conclusion, we have described an innovative technique as a possible solution for completely enclosed power morcellation. However, further studies are necessary to demonstrate the safety of our technique. In addition, manufacturing a glove-shaped bag specifically for laparoscopic power morcellation may facilitate overcoming the limitations experienced in our study and accelerate the progress on eliminating the dissemination problem during morcellation. REFERENCES 1. Steiner RA, Wight E, Tadir Y, Haller U. Electrical cutting device for laparoscopic removal of tissue from the abdominal cavity. Obstet Gynecol 1993;81:471–4.
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2. Kho KA, Nezhat CH. Evaluating the risks of electric uterine morcellation. JAMA 2014;311:905–6. 3. Takeda A, Mori M, Sakai K, Misui T, Nakamura H. Parasitic peritoneal leiomyomatosis diagnosed 6 years after laparoscopic myomectomy with electric tissue morcellation: report of a case and review of the literature. J Minim Invasive Gynecol 2007;14: 770–5. 4. Milad MP, Milad EA. Laparoscopic morcellator-related complications. J Minim Invasive Gynecol 2014;21:486–91. 5. Park JY, Park SK, Kim DY, Kim JH, Kim YM, Kim YT, et al. The impact of tumor morcellation during surgery on the prognosis of patients with apparently early uterine leiomyosarcoma. Gynecol Oncol 2011;122:255–9. 6. Einstein MH, Barakat RR, Chi DS, Sonoda Y, Alektiar KM, Hensley ML, et al. Management of uterine malignancy found incidentally after supracervical hysterectomy or uterine morcellation for presumed benign disease. Int J Gynecol Cancer 2008; 18:1065–70. 7. U.S. Food and Drug Administration. Laparoscopic uterine power morcellation in hysterectomy and myomectomy: FDA safety communication. Available at: http://www.fda.gov/MedicalDevices/ Safety/AlertsandNotices/ucm393576.htm. Retrieved May 12, 2014. 8. Einarsson JI, Cohen SL, Fuchs N, Wang KC. In bag morcellation. J Minim Invasive Gynecol 2014;21:951–3. 9. Cohen SL, Einarsson JI, Wang KC, Brown D, Boruta D, Scheib SA, et al. Contained power morcellation within an insufflated isolation bag. Obstet Gynecol 2014;124:491–7. 10. Cohen SL, Greenberg JA, Wang KC, Srouji SS, Gargiulo AR, Pozner CN, et al. Risk of leakage and tissue dissemination with various contained tissue extraction (CTE) techniques: an in vitro pilot study. J Minim Invasive Gynecol 2014;21:935–9.
Akdemir et al
Innovative Approach to Enclosed Morcellation
Copyright ª by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
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