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Master Class In Gynecologic Surgery: Morcellation

The Ob. Gyn News’ Master Class in Gynecologic Surgery is hosted by AAGL SurgeryU, and is edited by Dr. Charles E. Miller, a past president of the AAGL, and a long standing faculty member of SurgeryU. This month’s edition of the Master Class covers strategies for performing enclosed morcellation of the uterus.

Power Morcellation Within a Specimen Bag During a Three-Port Laparoscopic Hysterectomy and Myomectomy

By Dr. Charles Miller and Dr. Aarathi Cholkeri-Singh

The FDA recently warned against the use of electro-mechanical power morcellation for hysterectomy and myomectomy because of potential tissue splatter within the abdomen and pelvis. In this video, we describe the use of a 3,100-cc ripstop nylon specimen bag along with power morcellation to minimize or potentially eliminate inadvertent tissue spread. The contained morcellation technique is explained and demonstrated including hysterectomy and multiple myomectomy specimens.

 

Enclosed Vaginal Morcellation of an Enlarged Uterus After Total Laparoscopic Hysterectomy and Bilateral Salpingo-Oophorectomy

By Ceana Nezhat, MD, and Erica Dun, MD
Atlanta Center for Minimally Invasive Surgery & Reproductive Medicine

Specimen extraction through small incisions and natural orifices has been an important dilemma in minimally invasive surgery. Intraperitoneal electro-mechanical morcellation can seed both benign and malignant tissue. In this video we demonstrate transvaginal morcellation of a large uterus within an enclosed endoscopic bag. This technique avoids the intraperitoneal dissemination of pathology.  After completion of the hysterectomy, the endoscopic specimen bag is inserted transvaginally through a wound retractor, the specimen is placed in the bag, and the neck of the bag is exteriorized. The cervix, ovaries, and fallopian tubes are removed en block, and the uterus is morcellated with a scalpel within the bag.

 

Multi-Port Power Morcellation Within An Insufflated Endobag
By Douglas Brown, MD, Massachusetts General Hospital

In our approach to safer and feasible power morcellation after a multi-port hysterectomy or myomectory, a 50×50-cm abdominal isolation bag is folded accordian-style and inserted into the abdomen through the umbilical incision. The bag is properly placed into the pelvis, using the lateral ports as necessary, and the specimen is contained.  The neck of the bag is exteriorized and the 15-mm trocar is replaced inside the bag for insufflation. To visualize morcellation, a lower lateral 5-mm trocar is punctured into the insufflated isolation bag; a balloon-tip trocar can be used to stabilize the bag and provide a seal. The 15-mm umbilical trocar is then removed and the morcellator is inserted.  These steps as well as completion of the procedure are shown and described in this video.

 

LESS Technique of Contained Morcellation Within an Artificial Pneumoperitoneum
By Tony Shibley, MD, OB/GYN Specialists, Minneapolis

The creation of an artificial pnemoperitoneum within a large isolation bag not only provides for the containment of morcellated tissue; it also creates a safe working space, reducing the risk of morcellator-related mechanical injuries, and allows for direct visualization of the morcellation process. In this video, I describe my approach to enclosed morcellation after single-site hysterectomy. I utilize a 50 x 50-cm isolation bag and an articulating endoscope. The bag is inserted through an open TriPort 15 (Advanced Surgical Concepts, Bray, Ireland) single-port cannula. The multi-port cap is replaced, and the bag is positioned to form a pocket opening into which the uterus is then guided with rotational movement. The cap is removed, and approximately 20 cm of the bag is externalized. The bag is insufflated, and morcellation is carried out under direct vision through the TriPort 15 multiple port hub. 

 

Multi-Port Laparoscopic Concealed Morcellation of the Uterus
By Bernard Taylor, MD, Carolina Medical Center-Advanced Surgical Specialties Center

Transumbilical morcellation of the uterus can be achieved in an endobag when the uterus is small, but this approach is cumbersome for the larger uterus. This video describes both a case of morcellation in an endobag using a scapel, as well a case of concealed morcellation using a 18 x 18-inch isolation bag in a patient with a larger uterus who elected to be treated by minimally invasive total laparoscopic hysterectomy and bilateral salpingo-oopherectomy. In the latter approach, insufflation of the bag can be achieved through a 15-mm port placed through the opening of the externalized part of the bag or, as in the case depicted here, a SILS Tri-Port (Covidien, MA). Morcellation is visualized through a lower lateral port after a 5-mm balloon-tip trocar is advanced to perforate the bag.

 


Filed under "Master Course in Gynecologic Surgery".

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