The Sydney Contained in Bag Morcellation Technique Joanne B. McKenna, MB, BCh, BAO*, Trupti Kanade, MD, Sarah Choi, MB, ChB, Brian P. Tsai, MD, David M. Rosen, MBBS, Gregory M. Cario, MBBS, and Danny Chou, MBBS From the Sydney Women’s Endosurgical Centre, Kogarah, New South Wales, Australia (all authors).
ABSTRACT Study Objective: To demonstrate a modification of the Shibley single-port technique suitable for morcellation of large myomatous uteri after total laparoscopic hysterectomy in a contained environment within the abdominal cavity [1]. Design: Step-by-step explanation of the technique using descriptive text and an educational video. Setting: In light of recent concern about the use of power morcellators and increasing the risk of disseminating occult leiomyosarcomatous myoma fragments throughout the abdominal cavity, we propose this new technique for management of morcellation of large myomatous uteri after total laparoscopic hysterectomy, to contain the morcellation process and minimize the risk. This technique, which we have coined ‘‘Sydney Contained in Bag Morcellation’’ involves introduction of a sterile plastic bag (Dual Drawstring Bag, 460 ! 460 mm; Southern Cross Hospital Supplies, Northmead, NSW, Australia) before introducing an optical port and the power morcellator. Before insertion this bag is modified in several ways to facilitate bag opening and specimen retrieval. The dual drawstring is removed and replaced with a 150-cm length of PDS I (polydioxanone) suture material as the new drawstring, with its exit at the mouth of the bag in the 6 o’clock position. Five stay sutures are placed around the bag mouth, corresponding to the 12, 1, 5, 7, and 11 o’clock positions. This assists with opening the mouth of the bag intraabdominally and enables orientation to be maintained. The bag is then inserted in a McCartney tube (Gates Healthcare, Cheshire, UK). Corresponding slits are made in the tip of the tube to enable the end of the stay sutures to be securely held in place during tube insertion. These ends are then retrieved using atraumatic graspers and exteriorized and clipped alongside their corresponding port sites. After hysterectomy the uterus is placed in the bag, and the stay sutures maintain the mouth opening. The bag is closed and its mouth exteriorized onto the abdominal wall at the site of the umbilical trocar. The 12-mm umbilical trocar is then replaced within the bag, and pseudopneumoperitoneum is created. Once established, an optical trocar is introduced via one of the lower quadrant port sites using a balloon tip trocar (Kii; Applied Medical, Rancho Santa Margarita, CA). The insufflation tubing is attached to this trocar, and the umbilical trocar is replaced with the morcellator device. Morcellation is performed under direct vision in a contained environment. Once complete, all fragments are removed, and the bag is washed out. The original pneumoperitoneum is re-established. The bag is then removed during aspiration to encourage negative pressure relative to the re-established pneumoperitoneum, minimizing aerosolized fragment leakage. Intervention: Contained in bag morcellation of a large myomatous uterus during total laparoscopic hysterectomy. This technique has been specifically developed to address the concerns of morcellating large myomatous uteri after hysterectomy. In the case of supracervical hysterectomy or myomectomy, in which there would be no vaginal conduit to exploit, we use an endocatch bag, inserted in the usual manner, with reintroduction of the umbilical trocar within the mouth of the bag to enable creation of pseudopneumoperitoneum. Again, an optical trocar would be introduced in a lower lateral port, and morcellation would be performed under direct vision. An article describing this technique has recently been published [2]. Conclusion: The Sydney Contained in bag Morcellation technique offers a possible solution to the risk of dissemination of benign morcellated and potentially leiomyosarcomatous myoma fragments. Certain aspects of the procedure are key to its success. The stay sutures are essential to facilitate orientation and opening of the bag mouth. The McCartney tube enables easier insertion of the flaccid bag into the vagina, and the suture-retaining slits enable the mouth of the bag to be opened quickly and easily. We have used this technique in 5 cases with uteri ranging in weight from 350 to 978 g. Recently, similar techniques have been described for use in single-port surgery and conventional laparoscopy [1,2]. Our technique is suitable for use with large uteri after total laparoscopic hysterectomy because the large capacity of the bag enables containment of uteri Disclosures: None declared. Corresponding author: Joanne Bernadette McKenna, MB, BCh, BAO, Sydney Women’s Endosurgical Centre, 1 South St, Kogarah, NSW 2217, Australia. 1553-4650/$ - see front matter Ó 2014 AAGL. All rights reserved. http://dx.doi.org/10.1016/j.jmig.2014.07.007
Submitted May 29, 2014. Accepted for publication July 6, 2014. Available at www.sciencedirect.com and www.jmig.org
McKenna et al.
Sydney Contained in Bag Morcellation Technique
985
that would exceed the capacity of manually deployed specimen retrieval bags. This technique offers an alternative to vaginal morcellation, with the advantage of improved vision during morcellation and the ability to morcellate large uteri using a familiar instrument and view. Journal of Minimally Invasive Gynecology (2014) 21, 984–985 Ó 2014 AAGL. All rights reserved. Keywords:
DISCUSS
Fibroid uterus; Morcellation
You can discuss this article with its authors and with other AAGL members at http://www.AAGL.org/jmig-22-1-JMIG-D-14-00277
Use your Smartphone to scan this QR code and connect to the discussion forum for this article now*
Supplementary Data Supplementary data related to this article can be found online at http://dx.doi.org/10.1016/j.jmig.2014.07.007. References 1. Shibley KA. Enclosed morcellation using a large bowel isolation bag. OBG Manage J. Jan 2014. 2. Einarsson JI, Cohen SL, Fuchs N, Wang KC. In bag morcellation. J Minim Invasive Gynecol. 2014 Apr 25. pii: S1553-4650(14)00256-8. http://dx.doi.org/10.1016/j.jmig.2014.04.010. [Epub ahead of print].
ABSTRACT Study Objective: To demonstrate a modification of the Shibley single-port technique suitable for morcellation of large myomatous uteri after total laparoscopic hysterectomy in a contained environment within the abdominal cavity [1]. Design: Step-by-step explanation of the technique using descriptive text and an educational video. Setting: In light of recent concern about the use of power morcellators and increasing the risk of disseminating occult leiomyosarcomatous myoma fragments throughout the abdominal cavity, we propose this new technique for management of morcellation of large myomatous uteri after total laparoscopic hysterectomy, to contain the morcellation process and minimize the risk. This technique, which we have coined ‘‘Sydney Contained in Bag Morcellation’’ involves introduction of a sterile plastic bag (Dual Drawstring Bag, 460 ! 460 mm; Southern Cross Hospital Supplies, Northmead, NSW, Australia) before introducing an optical port and the power morcellator. Before insertion this bag is modified in several ways to facilitate bag opening and specimen retrieval. The dual drawstring is removed and replaced with a 150-cm length of PDS I (polydioxanone) suture material as the new drawstring, with its exit at the mouth of the bag in the 6 o’clock position. Five stay sutures are placed around the bag mouth, corresponding to the 12, 1, 5, 7, and 11 o’clock positions. This assists with opening the mouth of the bag intraabdominally and enables orientation to be maintained. The bag is then inserted in a McCartney tube (Gates Healthcare, Cheshire, UK). Corresponding slits are made in the tip of the tube to enable the end of the stay sutures to be securely held in place during tube insertion. These ends are then retrieved using atraumatic graspers and exteriorized and clipped alongside their corresponding port sites. After hysterectomy the uterus is placed in the bag, and the stay sutures maintain the mouth opening. The bag is closed and its mouth exteriorized onto the abdominal wall at the site of the umbilical trocar. The 12-mm umbilical trocar is then replaced within the bag, and pseudopneumoperitoneum is created. Once established, an optical trocar is introduced via one of the lower quadrant port sites using a balloon tip trocar (Kii; Applied Medical, Rancho Santa Margarita, CA). The insufflation tubing is attached to this trocar, and the umbilical trocar is replaced with the morcellator device. Morcellation is performed under direct vision in a contained environment. Once complete, all fragments are removed, and the bag is washed out. The original pneumoperitoneum is re-established. The bag is then removed during aspiration to encourage negative pressure relative to the re-established pneumoperitoneum, minimizing aerosolized fragment leakage. Intervention: Contained in bag morcellation of a large myomatous uterus during total laparoscopic hysterectomy. This technique has been specifically developed to address the concerns of morcellating large myomatous uteri after hysterectomy. In the case of supracervical hysterectomy or myomectomy, in which there would be no vaginal conduit to exploit, we use an endocatch bag, inserted in the usual manner, with reintroduction of the umbilical trocar within the mouth of the bag to enable creation of pseudopneumoperitoneum. Again, an optical trocar would be introduced in a lower lateral port, and morcellation would be performed under direct vision. An article describing this technique has recently been published [2]. Conclusion: The Sydney Contained in bag Morcellation technique offers a possible solution to the risk of dissemination of benign morcellated and potentially leiomyosarcomatous myoma fragments. Certain aspects of the procedure are key to its success. The stay sutures are essential to facilitate orientation and opening of the bag mouth. The McCartney tube enables easier insertion of the flaccid bag into the vagina, and the suture-retaining slits enable the mouth of the bag to be opened quickly and easily. We have used this technique in 5 cases with uteri ranging in weight from 350 to 978 g. Recently, similar techniques have been described for use in single-port surgery and conventional laparoscopy [1,2]. Our technique is suitable for use with large uteri after total laparoscopic hysterectomy because the large capacity of the bag enables containment of uteri Disclosures: None declared. Corresponding author: Joanne Bernadette McKenna, MB, BCh, BAO, Sydney Women’s Endosurgical Centre, 1 South St, Kogarah, NSW 2217, Australia. 1553-4650/$ - see front matter Ó 2014 AAGL. All rights reserved. http://dx.doi.org/10.1016/j.jmig.2014.07.007
Submitted May 29, 2014. Accepted for publication July 6, 2014. Available at www.sciencedirect.com and www.jmig.org
McKenna et al.
Sydney Contained in Bag Morcellation Technique
985
that would exceed the capacity of manually deployed specimen retrieval bags. This technique offers an alternative to vaginal morcellation, with the advantage of improved vision during morcellation and the ability to morcellate large uteri using a familiar instrument and view. Journal of Minimally Invasive Gynecology (2014) 21, 984–985 Ó 2014 AAGL. All rights reserved. Keywords:
DISCUSS
Fibroid uterus; Morcellation
You can discuss this article with its authors and with other AAGL members at http://www.AAGL.org/jmig-22-1-JMIG-D-14-00277
Use your Smartphone to scan this QR code and connect to the discussion forum for this article now*
Supplementary Data Supplementary data related to this article can be found online at http://dx.doi.org/10.1016/j.jmig.2014.07.007. References 1. Shibley KA. Enclosed morcellation using a large bowel isolation bag. OBG Manage J. Jan 2014. 2. Einarsson JI, Cohen SL, Fuchs N, Wang KC. In bag morcellation. J Minim Invasive Gynecol. 2014 Apr 25. pii: S1553-4650(14)00256-8. http://dx.doi.org/10.1016/j.jmig.2014.04.010. [Epub ahead of print].
