A novel laparoscopic specimen entrapment device to facilitate morcellation of large renal tumors

Intracorporeal electromechanical tissue morcellation: a critical review and recommendations for clinical practice

Electromechanical morcellators have come under scrutiny with concerns about complications involving iatrogenic dissemination of both benign and malignant tissues. Although the rapidly rotating blade has resulted in morcellator-related vascular and visceral injuries, equally concerning are the multiple reports in the literature demonstrating seeding of the abdominal cavity with tissue fragmented such as leiomyomas, endometriosis, adenomyosis, splenic and ovarian tissues, and occult cancers of the ovaries and uterus. Alternatives to intracorporeal electric morcellation for tissue extirpation through the vagina and through minilaparotomy are feasible, safe, and have been shown to have comparable, if not superior, outcomes without an increased need for laparotomy. Intracorporeal morcellation within a containment bag is another option to minimize the risk of iatrogenic tissue seeding. Patient safety is a priority with balanced goals of maximizing benefits and minimizing harm. When intracorporeal electromechanical morcellation is planned, physicians should discuss the risks and consequences with their patients. Although data are being collected to quantify and understand these risks more clearly, a minimally invasive alternative to unenclosed intracorporeal morcellation is favored when available. It is incumbent on surgeons to communicate the risks of practices and devices and to advocate for continued improvement in surgical instrumentation and techniques.

The effect of kidney morcellation on operative time, incision complications, and postoperative analgesia after laparoscopic nephrectomy

INTRODUCTION

Compare the outcomes between kidney morcellation and two types of open specimen extraction incisions, several covariates need to be taken into consideration that have not yet been studied.

MATERIALS AND METHODS

We retrospectively reviewed 153 consecutive patients who underwent laparoscopic nephrectomy at our institution, 107 who underwent specimen morcellation and 46 with intact specimen removal, either those with connected port sites with a muscle-cutting incision and those with a remote, muscle-splitting incision. Operative time, postoperative analgesia requirements, and incisional complications were evaluated using univariate and multivariate analysis, comparing variables such as patient age, gender, body mass index (BMI), laterality, benign versus cancerous renal conditions, estimated blood loss, specimen weight, overall complications, and length of stay.

RESULTS

There was no significant difference for operative time between the 2 treatment groups (p = 0.65). Incision related complications occurred in 2 patients (4.4%) from the intact specimen group but none in the morcellation group (p = 0.03). Overall narcotic requirement was lower in patients with morcellated (41 mg) compared to intact specimen retrieval (66 mg) on univariate (p = 0.03) and multivariate analysis (p = 0.049). Upon further stratification, however, there was no significant difference in mean narcotic requirement between the morcellation and muscle-splitting incision subgroup (p = 0.14).

CONCLUSION

Morcellation does not extend operative time, and is associated with significantly less postoperative pain compared to intact specimen retrieval overall, although this is not statistically significant if a remote, muscle-splitting incision is made. Morcellation markedly reduces the risk of incisional-related complications.

Laparoscopic specimen extraction: morcellation

OBJECTIVES

To review our experience with intact extraction and morecellation of nephrectomy specimen, and the advantages and disadvantages of morcellation indicated by current reports.

PATIENTS AND METHODS

In a previous study, 56 consecutive patients undergoing radical and simple transperitoneal laparoscopic nephrectomy were prospectively evaluated. Morcellation specimens (33) were extracted at the umbilical or lateral port sites and intact specimens (23) through an infraumbilical incision. Data were obtained on pathology, narcotic requirements, hospital stay, complications, estimated blood loss, size of renal mass based on preoperative imaging, specimen weight and extraction incision length.

RESULTS

The mean incision length was 1.2 cm in the morcellation group and 7.1 cm in the intact group (P< 0.001). There were no significant differences in pain or recovery between the groups. In two cases of tumor nephrectomy, microscopic invasion of the perinephric adipose tissue in the intact specimen group were up-staged from clinical T1 to pT3a disease; there was no change in patient treatment based on this information.

CONCLUSIONS

With proper technique, morcellation is safe for extracting renal tumours. The specimen can be evaluated for histology but not for pathological staging, limiting its use with transitional cell carcinoma. Port-site seeding is rare, and does not appear to be more frequent than with open nephrectomy. Although morcellation is cosmetically more desirable, there was no significant advantage in operating time, pain or duration of hospital stay. The choice od extraction method depends on the surgeon's preference and patient choice.

Novel direct-vision renal morcellation with orthopedic rotary shaver-blade instrumentation

BACKGROUND AND PURPOSE

When small ports are the only entry (and exit) points during laparoscopic nephrectomy, one is forced either to make an accommodating incision for final renal delivery or to perform renal morcellation. To date, morcellation has been performed in a blind manner with a specimen entrapped in a nonpenetrable, nonpermeable sac within the peritoneal cavity. Through the use of current laparoscopic equipment and a novel rotary shaver-blade system, we studied the safety, feasibility, and efficiency of directly observed renal morcellation.

MATERIALS AND METHODS

Ten porcine renal units with a mean mass of 143 g (range 92-192 g) were morcellated via a custom 5.5-mmx28-cm Dyonics (Smith & Nephew, Andover, MA) rotary shaver blade placed through a standard operative laparoscope (ACMI LAP 11-56W). Each kidney was entrapped in a standard 8x10-inch LapSac (Cook Urological, Spencer, Indiana), which was placed in a preconfigured abdomen model. Morcellation was performed under direct visual guidance with continuous-flow irrigation and suction. We then studied the feasibility, safety, technical ease, and efficiency of morcellation; the size of the fragments; and entrapment-bag integrity with each renal morcellation.

RESULTS

The mean time required to complete morcellation was 8:02 minutes (range 4:45-14:00 minutes). The morcellation efficiency mean was 20.7 g/min (range 12.00-31.41 g/min), with the Dyonics EP-1 generator system morcellating most effectively at 2000 rpm in its oscillate mode. Of ten random fragments, the mean size was 8.7x4.7 mm. The integrity of one LapSac was lost when the bag was not filled to complete distention, creating susceptible in folding.

CONCLUSION

This novel technique of laparoscopic renal delivery provides a feasible, safe, technically simple, and efficient means of morcellation. Directly viewed renal morcellation must occur with a kidney freely floating within a completely distended entrapment sac in order to preserve the integrity of the sac itself. Tissue fragments are large enough for pathologic review, which may permit superior oncologic surgical margins.

Laparoscopic nephrectomy: assessment of morcellation versus intact specimen extraction on postoperative status

PURPOSE

We compared pathological evaluation and postoperative recovery in patients undergoing transperitoneal laparoscopic nephrectomy at our institution with morcellated vs intact specimen extraction.

MATERIALS AND METHODS

A prospective evaluation of 57 consecutive patients undergoing radical and simple transperitoneal laparoscopic nephrectomy was reviewed. One patient was excluded from study due to transitional cell carcinoma, which was detected intraoperatively. The 33 morcellated specimens were extracted at the umbilical port and the 23 intact specimens were extracted through a midline infraumbilical incision. Data were obtained on narcotic requirements, hospital stay, complications, estimated blood loss, mass size based on preoperative imaging, specimen weight and extraction incision length.

RESULTS

Mean incision length in the morcellated and intact specimen removal groups was 1.2 and 7.1 cm, respectively (p <0.001). No significant differences in pain or recovery were noted between the 2 groups. Two cases of microscopic invasion of the perinephric adipose tissue in the intact specimen group were up staged from clinical T1 to pT3a disease. No change in patient treatment was made based on this information.

CONCLUSIONS

We did not find a significant difference in surgical time, pain or hospital stay. Only incision length was statistically significant. Postoperative recovery appeared to be similar in these 2 groups. With modern imaging modalities information on pathological stage did not alter patient treatment.

Novel technique of renal entrapment for morcellation

PURPOSE

Renal entrapment for morcellation can be a difficult task, often necessitating additional port placement and awkward maneuvering as well as concern with specimen sack breakage. We describe a novel technique that combines the best features of existing technology to allow easy entrapment and safe morcellation.

MATERIALS AND METHODS

We combined a 15 mm. EndoCatch II (United States Surgical Corp., Norwalk, Connecticut) introducer and frame with an 8 x 10-inch LapSac (Cook Urological, Spencer, Indiana) to facilitate entrapment with a strong reliable specimen sack. The LapSac is sutured in place onto the frame of the EndoCatch device with 3-zero sutures. The device is then rearmed and lubricated prior to introduction.

RESULTS

The described modification greatly enhances our ability more rapidly and easily to entrap nephrectomy specimens prior to tissue morcellation. No additional ports are needed and no morbidity has resulted from the use of the modified entrapment device. Introduction and deployment of the modified entrapment device is straightforward and easily reproducible.

CONCLUSIONS

We recommend this easy and secure technique when tissue morcellation is being considered.

A simple technique for facilitating kidney entrapment using a laparoscopic sack during retroperitoneal laparoscopic radical nephrectomy

The mouth of a LapSac was opened horizontally using a guidewire and, thereafter, the kidney was moved onto the center of the mouth. Forceps lifted the mouth and the specimen entered into the sack automatically under its own weight. Use of this technique facilitated kidney entrapment.