Principles of laparoscopic organ retrieval

Advances in laparoscopic techniques have allowed detachment of almost any intra abdominal organs from their original sites.

Small specimen can be removed easily via the trocar. Any specimen larger than the diameter of the conventionally used trocar can however, prove difficult to remove and needs a special method for its removal. There are several techniques to remove specimens. Removal methods depends on the size, location and nature of specimen whether it is infected, malignant, chorionic Tissue, endometriotic or dermoid. In all these situations endobag is used for removal.

Removal of large volumes of tissue from the abdomen can be the most time consuming and frustrating part of the operation sometimes it may be more difficult than the operation itself.

Ideally the site selected for specimen removal should be along the path of least resistance that produces the least pain, prevents contamination, and provides the best cosmesis. If a specimen cannot be removed from the abdominal cavity immediately after it has been resected, it must be secured in a position that will permit ready identification and retrieval later. Ex: Ut-vesical pouch or POD is an endobag or against abdomen wall with a suture.

Several potential routes for removal of abdominal and pelvic specimens are listed in this Table and will be considered individually here

Table: Routes for removal of abdominal and pelvic specimens

Port Sites

Separate abdominal wall incisions

Transanal (if colon resection performed)

Transvaginal (via culpotomy incision)

1. Small Specimens: Can be removed directly through an appropriate cannula (Usually 10mm or larger) with or without a reducing sleeve. Use a toothed grasper to secure the specimen as it is retrieved under direct laparoscopic visualization and control. Open the valve mechanism of the cannula to allow the specimen to pass through unimpeded, if a reducting sleeve is not used.

2. Specimens at the port site by several methods:

1. Reduce the size of the specimen while it is still within the peritoneal cavity: that is, remove contents of hollow structures (fluid stones) or cut up solid structures. This technique permits removal without enlarging the incision. The major disadvantages include the risk of losing portions of the specimen and contamination of the peritoneal cavity. This method may be appropriate for the removal of specimens such as lymph node packets and benign solid tumors of moderate size.
2. Exchange the existing cannula for a larger cannula at the port site (20-40mm), by placing it over a blunt probe with a tapered introducer. This method protects the wound from direct contact with the specimen. A major disadvantage is that the specialized cannulae are not always available. This methods is sometimes used for removal of specimens such as an inflamed appendix, gallbladder, fallopian tube, and ovary.
3. Exteriorize portions of the specimen and then remove the contents so that the specimen can be pulled through the port site. This is most commonly used for removal of the gallbladder following laparoscopic cholecystectomy. Hold the specimen firmly against the end of the cannula as both are pulled our together under laparoscopic visualization. Grasp a portion of the gallbladder outside of the abdomen with clamps and open the gallbladder. Aspirate fluid, and remove stones (Fragmenting them if necessary) with stone forceps or ring forceps. This technique avoids enlarging the incision and requires. No special equipment However, it risks wound contamination and is tedious if the stones are multiple or large.
4. Enlarge the incision at a port site. This is perhaps the simplest, most commonly used method in many circumstances. It works particularly well at umbilical or other midline port sites since only a single fascial layer requires division. Either stretch the fascia or elevate it with a right-angled clamp and divide it with scissors or a scalpel. Perform this maneuver under direct laparoscopic visual control, with the specimen held in a relaxed manner (not taut against the abdominal wall) to avoid punctuating the specimen. This is frequently the best method of removing a large, stone-filled gallbladder. This is also the typical method for removing larger organs such as the colon and spleen. The length of incision necessary in these cases varies but so usually only several centimeters. When the port site incision is not midline, use a muscle spreading technique to avoid dividing abdominal wall musculature.

During colectomy the colon is often exteriorized through an extended port site incision prior to complete resection. After resection the anastomosis can be extracorporally. These are considered "laparoscopically assisted". Operations.

A disadvantage of this technique is the loss of pneumoperitoneum that occurs during specimen extraction, To reestablish the pneumoperitoneum, completely close the incision if that port site is no longer needed.

Alternatively, close or tighten the fascia around a cannula. Another disadvantage of incision enlargement for specimen retrieval is the increased discomfort that patients may have at that site. Regardless, this is often the most practical method.

3.Separate abdominal wall incision. In some situations it may be most practical to remove the specimen through a separate abdominal wall incision that does nor incorporate any of the existing port sites. These incisions can generally be limited to a few centimeters in length, and a muscle-splitting technique can be used for nonmidline sites. Examples of this technique include removal of the right or left colon through transverse incisions lateral to the rectus in the right or left abdomen, respectively, removal of colon through a suprapubic or lower abdominal incision, and removal of an intact spleen through a low midline or Pfannenstiel incision. During colon resection the site of incision can gauged by holding the mobilized specimen up to the abdominal wall; this location may or may not correspond to an existing cannula site.

4.Transanal route. Transanal extraction has been used for some laparoscopic low anterior colon resections. This route can be considered when the lower limited of transection is near or below the pelvic brim and the specimen is not too bulky. Place the specimen is a bag. Slowly dilate the anus and pass a ring forceps or similar instrument transanally. Grasp the bag and gently pull it through the rectal stump and anus. During laparoscopic abdominperineal resection the specimen is readily delivered through the perineal incision in a similar manner.

5.Transvaginal route. Another alternative to abdominal incision for intact removal of larger specimens is an incision in the posterior vaginal fornix (cul de sac), which is termed coldotomy or posterior colptomy. This has most frequently been used for removal of ovarian masses, fibroids or the uterus during laparoscopic-assisted vaginal hysterectomy and occasionally for other solid organs.

RETRIEVAL BAGS

Retrieval Bags are - Commercially manufactured bags and retrieval devices are Disposable, Expensive, Not freely available.

Devices:

        Olympus keymed- 5 mm, 15mm, 20mm tubes.   

        Extraction bags-storz-germany

        Lap Sac-cook uk

        Endo catch-Autosuture

Use of a specimen retrieval bag minimizes the risk of contamination and specimen loss.

This is particularly important when the specimen may be infected, malignant friable or leaking or chorionic tissue or endometriotic tissue.

The important features to consider in selecting a retrieval bag are its strength, size, aperture, maneuverability, ease of deployment and retrieval, and porosity. Bags are typically made of polyuretherine and are preferred for removing larger specimens that must be fragmented in the bag, such as the spleen or kidney.

There are several common principles

Bag insertion:

Tightly roll the bag and insert it through the cannula.

Bag deployment:

Pull the bag gently our of the cannula site to unroll it. Grasp the edges of the bag and open the month by pulling in opposite directions. Third instrument may be necessary to help open the bag.

Specimen entrapment:

This is the most difficult step particularly for large organs.

Hold the mouth of the bag open with graspers, advance the grasper holding the specimen all the way to the depth of the bag. The specimen should enter the bag and the entire specimen must fit within the bag prior to closure.

Bag closure:

Commercial bags are equipped with a draw string that must be tightened. Close the small plastic bags with a preformed endoscopic ligature.

Bag extraction:

Under constant visual control with draw the bag and cannula through the abdomen wall as a unit.

Small bags comes our through 10 to 12mm port.

The Big bag and the contained specimen are removed by wither enlarging the port or by reducing the specimen size by removing portions or fragment org.

Resist the temptation to pull hand and use care to avoid punching or tearing the bag.

In Our institution we use condoms, Sterile plastic bags as endobags. These endobags are-

Economical

    Easily avaiable

    Electronically tested

    Easy to introduce through the 10mm port

    Easy to put the specimens

    Easy extraction

MORCELLATOR

Devices exist for both manual and mechanical morcellation. The hand operated Tissue punch (Storz, Tuttlingen, Germany), first described by semm in 1978 takes bites of tissue, which are pushed up the 11mm diameter shaft of the instrument. It is said to beinadequate for large tissue volumes and unable to deal with firm or calcified specimens (Steiner et al.,1993).

Two devices are currently available that will mechanically morcellate large volumes of tissue. The cook Tissue Morcellator (Cook UK) Letchworth, UK), was first described for the laparoscopic removal of a 190g tumor-bearing kidney through an 11mm port by Clayman et al. in 1991. The disposable morcellator is connected to a reusable power unit and a suction supply.

The tissue for removal needs to be placed in an isolating bag, the mouth of which pulled through the abdominal wall. The cutting cannula is then placed into the bag. Using the foot switch the specimen is then morcellated and aspirated from within the bag.

The Steiner electromechanical Morcellator (Storz, Turrlingen, Germany) is shown in 1993, this reusable device allows morcellation inside the abdomen under laparoscopic observation. The instrument has a motor driven cutting tube that is 13mm in diameter. After inserting the tube, claw forceps are passed down the shaft to grasp the specimen. Using a foot switch the tube is then rotated while pulling the specimen against the mouth of the tube. Cylinders of tissue are cut, which are pulled up the shaft and are suitable for histologic examination. The speed and direction of rotation of the tube can be varied.

With the potential for severe trauma to intraabdominal organs certain precautions are recommended.

. Only adequately trained surgeons should use the device, which should always be correctly maintained and functioning properly.

. The rotating cylinder should only be in motion when under continous visual control.

. The sharp tip should be maintained in the same position within the abcomen at all times.

A new version of this device is equipped with a springloaded retractable trocar sleeve, which covers the cutting edge of the cylinder.

    Large volumes of tissue that need isolation before removal can be placed within one of the larger laparoscopic bags. Suitable specimens include ovarian teratomas and mucinous cysts, and any ovary that may be neoplastic.

  Errors in laparoscopic assessment of ovarian cysts are well documented (Maiman et al.,1991). Others have shown that with strict adherence to guidelines of preoperative ultrasound assessment and intraoperative inspection, laparoscopic management of adnexal cystic masses appears to be safe (Mage et al., 1990). Indeed some now advocate laparoscopic management of stage 1A and B ovarian carcinoma (Reich et.,1990).

Once inside a bag cystic messes can be decompressed by incision and aspiration of their contents. This can be done inside the abdomen or after pulling the mouth of the bag outside the abdominal wall. Although malignant tumors can be safely removed using aspiration and morcellation with the mouth of the bag outside the abdomen (Clayman et al., 1991), some authors are against this technique for suspicious masses, advocating intact extraction using a bag and an enlarged abdominal or colpotomy incision (Canis et al., 1994).

Complications

1. Incisional Hernia

    . Rist increase with the size of incision even if attempts are made to close the facial defect. It is more common with laterally placed ports.

2. Posterior Colpotomy:-

. Infection

. Dyspareunia

. Adhesion formation

. Rectal injuries

  . Ureteric Injury

3. Spillage-

  . Residual trophoblastic tissue.

. Endometiosis can implant in the abdomen wall scar endometriosis

. Dissimination of malignant cells.

. Fecal contamination can occur during appendicectomy.

  . Spillage of contents of a mucinous cyst adenoma may cause Psuedo myxoma peritonei.  

  . Chemical peritonitis and granuloma formation with intestinal obstruction have been reported after laparoscopic surgery for Dermoid cyst of ovary.

4.Specimens may be lost in the abdominal cavity. It may be possible to recover the lost specimens by filling the upper abdomen with the saline and patient in the

trendelenburg position and then reversing the position with aspiration in the cul de sac.

    5.Vascular injury during enlarging the port site.

    6. Condoms- The potential risks include

• • questionable asepsos,
  • latex anaphylaxis
  • Splitting and fragmentation of the condom

Conclusion[edit | edit source]

With patience and ingenuity the specimens generated by operative laparoscopy can be removed without resorting to enlarged incisions, through the port sites or by culdotomy by using easily available condoms or plastic bags.

Reference[edit | edit source]

1. Corfman, Randle S.; Diamond, Michael P.; Decherney, Alan H. (1998). Complications of laparoscopy and Hysteroscopy.
2. Endoscopic Surgery for Gynaecologists Second edition 1997 Edited by Chris Sutton University of London UK, Michael P. Diamond Detroit USA, Wayne State University School of Medine
3. The SAGES Manual1999 fundamentals of laparoscopy and GI Endoscopy Carol E.H. Scott-ConnerMD,PhD, University of Iowa Hospitals and Clinic