Methods for specimen removal from the peritoneal cavity after laparoscopic excision
Correspondence: Andreas Stavroulis. Email: firstname.lastname@example.org
- Mini laparotomy (suprapubic, transumbilical, ancillary port-site) and posterior colpotomy are methods that have been used for the removal of specimens excised laparoscopically, with the use of morcellators and endoscopic bags growing in popularity in recent years.
- The size, cystic versus solid component and the risk of malignancy are essential factors influencing the route of specimen retrieval. The risk of spillage (especially in suspected early malignancy) has to be considered during excision and retrieval.
- Natural orifice transluminal endoscopy (NOTES) may be the operative and retrieval route of the future.
- To be aware of the different methods and routes of retrieving laparoscopically excised specimens.
- To be aware of the risks associated with each method and route.
- To review the factors that will influence the optimal choice of route and method.
- In the age of specialisation, a clinician who is not specially trained in operative laparoscopic surgery should not be practicing it. To minimise complications, the excision and retrieval of specimens via minimally invasive incisions should be limited to specially trained individuals.
Laparoscopy has developed into an essential component of the operative gynaecological palette. The advantages of laparoscopic surgery include small incisions, less postoperative pain, short hospital stay, earlier recovery and improved quality of life during the postoperative period. However, one of the challenges of laparoscopic surgery is being able to retrieve the specimen after excision with minimal spillage.
The risk of spillage of the cyst contents is associated with complications such as pseudomyxoma peritonei (mucinous cystadenoma), chemical peritonitis (dermoid cyst) and the potential dissemination of malignancy.
Spillage rate depends on the cyst size, surgical expertise and route of retrieval. The spillage of an endometrioma is common as the tissue planes involved are often poorly defined and the cyst capsule may be inadvertently ruptured. If peritoneal lavage of the endometriotic material is performed, associated complications are rare. The spillage rates of dermoid cysts are reported to be between 15 and 100% when removed by laparoscopy compared with only 4 to 13% via laparotomy. Chemical peritonitis is a rare complication of a dermoid cyst spillage with an incidence rate of between 0.2 and 8% that can result in pelvic adhesive disease, bowel obstruction, abdominal wall abscesses and fistulas as well as a detrimental impact on fertility.
Because of the technical difficulty of the trocar insertion and specimen retrieval as well as poor visualisation, conventional laparotomy is still the mode of treatment for most patients with large ovarian cysts. Previous authors have suggested that ovarian masses of >10 cm are best managed by laparotomy, but for smaller specimens <10 cm, retrieval through the transumbilical port, with or without endoscopic bags, has been advocated on the basis that this site represents the thinnest and most distensible portion of the anterior abdominal wall. For simple cysts, which can be decompressed, this technique may be possible, but solid or semi-solid ovarian tumours (such as dermoid cysts and fibromas) may prove more challenging.
Different techniques have been described to facilitate the retrieval of excised masses without needing to enlarge the abdominal incision. Specimen extraction in laparoscopic surgery is more time consuming than open procedures and tissue removal must be performed in an expeditious manner if the time efficiency of the technique is to be maintained. Needless to say, the route of retrieval must not compromise patient safety, either intra or postoperatively.
This article is a review of the various routes of retrieval for large benign specimens following laparoscopic excision (as well as the pros and cons) and a discussion of associate risks and how these can be overcome.
Laparoscopy-assisted cystectomy for large adnexal cysts
Large adnexal cysts exceeding 10 cm on preoperative imaging can be initially decompressed either through ultrasound guided or laparoscopic aspiration followed by intracorporal ovarian cyst wall stripping performed endoscopically. Limitations of laparoscopic treatment in these cases include spillage (chemical peritonitis, such as dermoid or unsuspected malignancy), difficulty in introduction of Veress needle, limited visualisation of the ureters, and the technical challenge of retrieving the mass.
Göçmen et al. described the following technique for the removal of benign adnexal cysts of a diameter between 10 and 20 cm.
Depending on the cyst size and location, either an umbilical or subcostal primary trocar is used. A 10 mm suprapubic trocar is inserted in the cyst and its content aspirated using a cannula introduced through the suprapubic port. A grasping forceps inserted through a 5 mm lateral port site is used to close the cyst puncture site and minimise spillage of cyst contents. After decompression, the suprapubic incision is enlarged to 20 mm and a ring forceps is introduced through this. The cyst wall is then held by the ring forceps and the adnexal extracted onto the abdomen and an extracorporal cystectomy performed. Alternatively, a 5 mm trocar sleeve can be inserted close to the dome of the cyst, the trocar is then removed and a suction-washing system is inserted into the mass through the sleeve. A purse suture or endoscopic loop can be placed around the cyst incision to avoid spillage. This method is thought to have a shorter operation time and less blood loss compared with the usual laparoscopic intracorporal ovarian cystectomy.
The incidence of trocar site hernia is estimated to be between 0.65 and 2.80%. Although most hernias present within 10 days from the procedure, delayed hernias have been reported up to a year from the initial operation. The early onset hernias present most commonly with small bowel obstruction, while delayed hernias tend to be associated with dehiscence of fascial plane with a sac consisting of peritoneum. Large trocar size, incomplete closure of fascia at the trocar site, midline trocars, stretching the port site for organ retrieval, the effect of a partial vacuum during port withdrawal, obesity, poor nutrition and operation site infection are some of the common factors associated with the development of these hernias. The risk of postoperative hernia is increased especially when enlarging laterally placed port sites and most of these occur as Richter's hernias, without peritoneal lining, and contain small or large intestine or omentum. This can be a serious complication requiring laparotomy in the majority of patients and intestinal resection in about 20%. Even with 5-mm lateral port sites, the risk of hernia exists as result of stretch and tear of the fascia secondary to the instrument manipulation or the passage of the tissue through the port site. It is true that the risk of a hernia at the umbilicus is lower compared with ancillary ports, unless the umbilical wound is enlarged. Currently, the closure of the fascia of port sites larger than 5 mm is recommended, with the only exception being the umbilical port where practice is individualised.
Specimen retrieval bags
To avoid the possibility of cyst spillage, several authors have described the use of impermeable endoscopic specimen bags for the removal for laparoscopically excised mass. Apart from intraperitoneal spillage, the use of such a bag also has the advantage of avoiding contamination of the wound. The bags generally require a 10–12 mm port, although the site can be enlarged for specimen removal. Once the cyst is securely in the bag, it can be decompressed to facilitate removal; if a solid (fibroma) or semi-solid (dermoid) mass is large, it can be ‘piece-mealed’ in the bag with scissors, harmonic scalpel or morcellator. However, the use of any instrument within the specimen bag can potentially perforate the bag and therefore should be used with caution. The operator should continuously view the device tip completely, in order to avoid inadvertent damage to intra-abdominal organs as well as risking spillage.
Commercial bags can be costly, difficult to manipulate and available only in standard sizes. There are bags with a frame that make it easier to drop the specimen into the bag. Several enterprising authors have described ‘easy-to-make’ frameless bags from surgical glove fingers (powder-free), condoms and zipper-type plastic bags. While these are inexpensive, simple to make and available in a choice of sizes, ‘home-made’ bags are not subject to industry quality control and can tear when submitted to traction through the abdominal wall (although this can be reduced with the addition of a purse-ring suture, which allows easy closure and pulling as well as reopening).
The endoscopic bag pouches are usually introduced and removed through a 10 mm port site; this is primarily the umbilical port although other sites might be preferred. Many surgeons prefer to use a 5 mm laparoscope for visualisation through an ancillary port while retrieving the specimen in a bag through the umbilical 10 mm one (likewise monitoring the morcellation of the mass). Exteriorising the endoscopic bag opening on the anterior abdominal wall before removal of the specimen avoids leakage or spillage into the peritoneal cavity, which may lead to chemical peritonitis or malignant cell spread. While there is little correlation between spillage and cyst size, specimens retrieved without endoscopic pouches are four times more likely to spill compared with specimens retrieved with endoscopic pouches.[6, 17]
In addition, a posterior colpotomy can also be used in conjunction with an endoscopic bag as described later.
Chatzipapas et al. reported the ‘remote control’ laparoscopic bag, which is made using the sterile wrapping of disposable suction connecting tubing and two long surgical sutures, which act as drawstrings. Although this bag is not in general use, its advantages include cost effectiveness, ease of use, and safety, and additional secondary ports are not required. Because the bag can be large, operating within the bag is a possibility, thus reducing the risk of spillage inside the peritoneal cavity.
An endoscopic bag extractor has also been reported (but is not generally available) and this is an instrument that facilitates extraction of any type of endobag without the need of conventional mini-laparotomy. After inserting it through the skin, its blades create an enlarged canal through which the bag can be removed without the risk of endobag rupture as the size of the canal can be adjusted.
Electronic power morcellators excise large masses and enable the specimen to be brought out in strips through the sheath of the morcellator. They work by rotating a sharp cylindrical blade against the specimen and have an in-line valve to prevent loss of the pneumoperitoneum at the time of tissue extraction and a blade protector (sheath) where the sharp blade can be brought back in to prevent inadvertent shearing of the tissue. Currently, many companies manufacture morcellators, each with unique differences and cost. Larger diameter morcellators (which use larger incisions) remove tissue faster but are associated with a higher risk of subsequent hernia formation. Newer morcellators that use diathermy instead of a mechanical blade are also available. Morcellators decrease the operative time and the risk of port site herniation as the fascia is not torn or stretched. There is a risk of inadvertent injury of adjacent organs and the operator must remember to bring the specimen towards the rotating morcellator tip rather than advance the morcellator towards the mass. In some instances, following initial laparoscopic myomectomy, fibroid remnants, which had been left behind, had to be removed through a second laparoscopic procedure as they were causing pain.
Randomised controlled trials have compared laparoscopy with mini-laparotomy in the management of ovarian cysts and concluded that operative laparoscopy is the best approach for the management of adnexal cysts but that mini-laparotomy can be considered an acceptable minimally invasive approach yielding similar results. Clearly the major concern of the laparoscopic management of large adnexal masses is the probability of intraperitoneal spillage of an unexpected malignant cyst, in addition to the technical problem and longer operative time associated with larger masses. Although the above concerns are reduced with mini-laparotomy, as compared with conventional laparotomy, one could argue the anti-aesthetic result and the postoperative morbidity.
Usually the site for the mini-laparotomy is chosen at a suprapubic level. A diagnostic laparoscopy can be added to the traditional mini-laparotomy and this allows an inspection of the whole abdomen and therefore reduces the risk of unrecognised malignancy. It also aids the surgeon to plan where and how large the mini-laparotomy incision is to be made. The excised mass can then be removed through the incision. In addition, the cyst can be brought out through the incision and be excised the conventional way. When the size does not allow this, the cyst can be brought to the surface of the incision for the cyst contents to be aspirated, while controlling the spillage by either clump or a purse suture around the cyst incision site. Another example where this technique is preferred is during treatment of bowel endometriosis where the colorectal surgeons use a mini-laparotomy site to remove the excised bowel and when appropriate, re-anastomose it at the same time.
Randomised trials have shown that, while mini-laparotomy is associated with significant increase in minor postoperative discomfort and recovery time, and more pain and need for analgesia as well as more aesthetic concerns, operative times are shorter and rates of intraperitoneal spillage are significantly reduced.
Posterior colpotomy has been extensively documented in the past but has fallen out of favour because of the perceived technical difficulties, poor exposure, increased risk of pelvic sepsis, bowel perforation, haemorrhage, injury to the bladder and ureters, vaginal wall haematoma as well as vaginal scarring. In more recent years, this attractive route has been reintroduced and successfully used to deliver solid and semi-solid tumours following operative laparoscopy. Colpotomy is generally a safe and easily learnt technique as long basic surgical principles such as perioperative prophylactic antibiotics and good haemostasis, are followed.
To avoid spillage, which can occur with this technique, a laparoscopic-assisted modification using an endoscopic bag has been described, which allows large solid specimens to be removed safely and with minimal spillage. With this technique, the excised specimen is placed in a bag, which is then placed into the pouch of Douglas under direct laparoscopic view. When the vagina is incised, the sudden expulsion of CO2 from the peritoneum delivers the ‘specimen in a bag’ through the posterior colpotomy, after which the incision is sutured.
Laparoscopy can be used to assess adnexal mobility of dermoid cysts, which were then manoeuvred into the pouch of Douglas, after which a posterior colpotomy incision can be made and the cyst exteriorised. A vaginal cystectomy is performed with or without cyst decompression. This technique combines the advantages of laparoscopy and open surgery, with laparoscopy being the first and last step of this procedure.
Natural orifice transluminal endoscopic surgery (NOTES)
NOTES represents an advancement of minimally invasive intra-abdominal procedures, whereby access to the peritoneal cavity is achieved by incising and traversing the lumen of a natural orifice, in an attempt to avoid abdominal wall incisions. It has to be pointed out that the advantages of this technique are still being assessed before it becomes routine practice, if ever. Several natural orifices have been described as routes for access to the peritoneal cavity and these include oral, anal, vaginal, or urethral orifices, although the optimal access route is yet to be determined. Ease of access and closure, potential for infection, security of closure, space limitations for instrument insertion and specimen retrieval, as well as relationship to the target anatomy are some of the factors considered in the debate of the best portal for performing NOTES. Because of its ease of access and capaciousness, the vagina is in fact the most commonly used NOTES portal of entry.
Historically, transvaginal access to the abdominal cavity or culdoscopy, was first performed by Albert Decker in 1928, and the technique was perfected by Palmer in 1942 using pneumoperitoneum. Culdoscopy was widely used as a method to investigate subfertility, until the introduction of laparoscopy into clinical practice. The first case of successful incidental vaginal appendicectomy at the time of vaginal hysterectomy was described by Bueno in 1949, while, more recently Tsin and colleagues reported a modified laparoscopic technique of vaginal cholecystectomy after simultaneous hysterectomy (‘culdolaparoscopy’).
In early 2007, the first NOTES transvaginal cholecystectomy human cases were achieved by different groups. Access to the peritoneal cavity is obtained by simple dissection of the posterior fornix to enter the pouch of Douglas, while many groups favour a hybrid procedure during which laparoscopic umbilical visualisation after peritoneal insufflation is used before vaginal trocar placement. Advantages of the transvaginal route include the ease of insertion of rigid instrumentation, suitability for specimen removal and proven safety record. Closure of the vaginal wound is not a problematic issue, as it is performed under direct vision using absorbable sutures by conventional instruments and techniques. In addition, the potential for complications such as fistula and peritonitis is low. On the other hand, bladder catheterisation and use of antibiotics is imperative, while more research into the potential development of dyspareunia and subfertility is needed to increase the procedure profile and, therefore patient acceptance. Contraindications to this approach include a fixed retroverted uterus and obliteration of the pouch of Douglas (due to adhesions either because of endometriosis, past pelvic infections or prior surgery), acute circumstances and male gender.
Although laparoscopy has replaced open surgery for many gynaecological procedures, the retrieval of the excised specimen from the abdominal cavity following laparoscopic excision still represents a challenge and can be frustrating for the surgeon as the majority of procedures could be performed using ports of 5 mm. Using ports of larger diameter, or enlarging or stretching the port sites has cosmetic drawbacks but can also increase the risk of vascular injuries, postoperative pain and hernia formation.
Specimens placed in impermeable endoscopic bags can be retrieved through 10 mm ports, a mini laparotomy incision or posterior colpotomy. The route of retrieval should be specifically catered for individual patients who should be counselled about the advantages and disadvantages.
While it is still a relatively new technique under assessment, NOTES may be the operative and retrieval route of the future.
Conflict of interest