Morcellation Gustavo Plasencia MD, FACS, FASCRS Clinical Professor of Surgery Florida International University Stelio Rekkas MD

Disclosures Ethicon Endosurgery Consultant

Incisions

Morcellation

You are driving down the road in your car on a wild, stormy night, when you pass by a bus stop and you see three people waiting for the bus: 1.An old lady who looks as if she is about to die. 2. An old friend who once saved your life. 3. The perfect partner you have been dreaming about. Which one would you choose to offer a ride to, knowing that there could only be one passenger in your car?

"I would give the car keys to my old friend and let him take the lady to the hospital. I would stay behind and wait for the bus with the partner of my dreams. Never forget to "Think Outside of the Box”

To Morcellate or Not to Morcellate, that is the question. Why aren’t we doing this more?

Pathology Relatively unchanged techniques Is there a better way to evaluate our specimens? Progressive Pathologist Preop Radiological Staging Preop Histopathological staging

Introduction: Tissue Morcellation Morcellation—the grinding and removal of tissue Etymology ▫Medieval Latin morsellum “to bite”

Introduction: Tissue Morcellation Common used for spleen, uterus, kidney, in benign diseases Piecemeal extraction of tissues Avoid extraction incisions. Use only trocar sites; may be slightly enlarged, dilated

Principles for Morcellation Only performed for benign disease Requires impermeable entrapment bag Check bag for perforation Maintenance of pneumoperitoneum Avoid overflow in the bag by frequent suction of fluid and tissues

Principles for Morcellation Change gloves after tissue extraction Any manipulation should be done with atraumatic instruments Perform under laparoscopic visualization

Advantages Less post-operative pain Improved cosmesis Potential advantages ▫Reduced risk of incisional hernias ▫Decreased risk of wound infection ▫Quicker return to activities

Disadvantages Injury to adjacent tissues when morcellating Extra cost if using morcellating device Longer OR times Not recommended for malignant disease today

Indications Benign Disease ▫Diverticulitis ▫Inflammatory Bowel Disease ▫Ischemic Colitis ▫Rectal Prolapse ▫Colonic Inertia ▫Volvulus ▫AVM

Indications Malignancy ▫When staging is not imperative  Palliative resection

Malignancy? Cannot obtain adequate staging of cancer, due to destruction of primary as well as lymph nodes

Electric Morcellators Cook morcellator Coherent morcellator Storz Morcellator Ethicon morcellator

Electric Morcellators Organ isolated in bag ▫Prefabricated or fashioned Used blades to grind tissue, suction to remove Dangerous because bag easily punctured Where are the colon morcellators?

How we do it Tissues morcellated without any equipment. Or as an alternative a Morcellator Lapsac used

Machine Morcellation Video

Conclusions Indicated for benign or palliative colon surgery New forms of tissue analysis and staging evaluation are needed preoperatively Preoperative radiological staging will improve Histopathological analysis should also be improved upon We need to always be thinking of the future and how to better serve our patients Possible and Safe

To Morcellate or Not to Morcellate, that is the question. TO MORCELATE

The End