1. Morcellation of specimen : Fact or fiction? Gustavo Plasencia MD, FACS, FASCRS

2. Historical Technique Sufficient mobilization so that distal and proximal bowel reach point of extraction at abdominal wall Sufficient mobilization so that distal and proximal bowel reach point of extraction at abdominal wall Intracorporeal devascularization requires smaller incisions Intracorporeal devascularization requires smaller incisions Transecting bowel intracorporeally, may require smaller incision, vs loop extraction Transecting bowel intracorporeally, may require smaller incision, vs loop extraction Incisions should be muscle splitting; bulky pathology may require cutting muscles Incisions should be muscle splitting; bulky pathology may require cutting muscles

3. Historical Technique Incision size should be as small as technically feasible Incision size should be as small as technically feasible Wound protectors necessary in malignant pathology Wound protectors necessary in malignant pathology Inject local long acting anesthetic at incisions Inject local long acting anesthetic at incisions

4. Incision Transverse/Longitudinal Muscle Splitting/Sparing Wound Protector- helps prevent wound recurrence/infection

5. Current Steps of Colectomy Anastomosis and Extraction independent of each other Devascularization should be done intracorporeally to facilitate extraction Intact or Morcellated specimen Extraction through incision of anterior abdominal wall, through trochar, through natural orifice

6. Intracorporeal Anastomosis Totally intracorporeal colectomy Totally intracorporeal colectomy Transrectal extraction (NOTES) Transrectal extraction (NOTES) 1990 1990

7. Introduction Tissue Morcelation Common for spleen, uterus,kidney, in benign diseases Common for spleen, uterus,kidney, in benign diseases Piecemeal extraction of tissues Piecemeal extraction of tissues Avoid extraction incisions. Use only trochar sites; may be slightly enlarged, dilated Avoid extraction incisions. Use only trochar sites; may be slightly enlarged, dilated

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

9. Principles for morcellation cont. Change gloves after tissue extraction Change gloves after tissue extraction Any manipulation should be done with atraumatic instruments Any manipulation should be done with atraumatic instruments Perform under laparoscopic visualization Perform under laparoscopic visualization

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

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

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

13. How we do it Cook endo bag used Cook endo bag used Tissues morcellated without any extra equipment. Tissues morcellated without any extra equipment.

14. How we do it Three 3mm or 5mm trochars for graspers and camera Three 3mm or 5mm trochars for graspers and camera 5mm thirty degree scope gives better visualization 5mm thirty degree scope gives better visualization One 15mm port for placement of stapler, through which well lubricated head of circular stapler is passed, and tissue extracted One 15mm port for placement of stapler, through which well lubricated head of circular stapler is passed, and tissue extracted May have to enlarged by blunt dilatation (opened Kelly clamp) May have to enlarged by blunt dilatation (opened Kelly clamp)

15. How we do it Take mesentery either at base or close to bowel. Divide bowel at rectosigmoid jct Take mesentery either at base or close to bowel. Divide bowel at rectosigmoid jct Introduce into abdomen, head of circular stapler with spear and loop of 1-0 prolene attached Introduce into abdomen, head of circular stapler with spear and loop of 1-0 prolene attached Choose proximal margin of resection, a few cm distally make an incision on antimesenteric border Choose proximal margin of resection, a few cm distally make an incision on antimesenteric border

16. How we do it Pass the head with attached spear and prolene proximally into bowel. Let prolene stick out Pass the head with attached spear and prolene proximally into bowel. Let prolene stick out Transect bowel at proximal margin of resection with endostapler. Place no tension on prolene suture. Stapler will not cut suture Transect bowel at proximal margin of resection with endostapler. Place no tension on prolene suture. Stapler will not cut suture Pull on suture until tip of spear pushes staple line and apply countertraction until spear perforates staple line. Pull on suture until head is flat on staple line. Pull on suture until tip of spear pushes staple line and apply countertraction until spear perforates staple line. Pull on suture until head is flat on staple line. Place an endoloop around circular head for security. Remove spear Place an endoloop around circular head for security. Remove spear

17. How we do it Perform transrectal anastomosis. Perform transrectal anastomosis. Place specimen in bag Place specimen in bag Exteriorize bag through 15mm trochar. Exteriorize bag through 15mm trochar. Extract specimen piecemeal or with morcelator Extract specimen piecemeal or with morcelator

18. Results 10 pts 10 pts Avg age 66y (range 52 – 81) Avg age 66y (range 52 – 81) 4 males, 6 females 4 males, 6 females Length of stay 2.4 days (range 1-4) Length of stay 2.4 days (range 1-4) Time to flatus 1.4 days (range 1-3) Time to flatus 1.4 days (range 1-3)

19. Pain Control KETOROLAC iv started intraop, continued as needed for first 24 hrs. on all pts, then switched to propoxyphene, ibuprofen or acetaminophen KETOROLAC iv started intraop, continued as needed for first 24 hrs. on all pts, then switched to propoxyphene, ibuprofen or acetaminophen one pt required ketorolac for 48 hrs one pt required ketorolac for 48 hrs Three pts required ketorolac and narcotics (HYDROMORPHONE) for first 48 hrs Three pts required ketorolac and narcotics (HYDROMORPHONE) for first 48 hrs Three pts used propoxyphene after being discharged, the rest used ibuprofen or acetaminophen Three pts used propoxyphene after being discharged, the rest used ibuprofen or acetaminophen

20. Complications One pt (male with acute and chronic diverticulitis) converted to normal laparoscopic colectomy, due to incomplete anastomosis One pt (male with acute and chronic diverticulitis) converted to normal laparoscopic colectomy, due to incomplete anastomosis No leaks No leaks 1 mild cellulitis at extraction site, treated with oral antibiotics 1 mild cellulitis at extraction site, treated with oral antibiotics 1 pt travelling from South America discharged post op day 1, readmitted and treated for severe diarrhea 1 pt travelling from South America discharged post op day 1, readmitted and treated for severe diarrhea

21. Future? Incisionless Natural Orifice Hybrid (Laparoscopic+Morcelation+NOTES)

22. Sigmoid Morcelization Video