Twenty-one consecutive patients underwent uterine tissue morcellation from June to September 2014 for the removal of uterine tissue during laparoscopic myomectomy or laparoscopic hysterectomy at Aleris Hamlet Hospital in Copenhagen, Denmark. All morcellations were performed in a plastic bag, and no laparotomy was performed. The described technique is now a standard procedure at our institution, when removal of uterine tissue requires morcellation during laparoscopy. Informed consent was obtained from all patients for being included in the study.
The preoperative workup to evaluate risk of genital tract cancer included a recent Pap test, endometrial sampling in cases of irregular bleeding and imaging with abdominal and pelvic ultrasonography. Demographic information included patient age, obstetric history, body mass index, physical status, surgical history and indication for surgery. Perioperative information collected prospectively included type of procedure performed, operative time (time from incision to closure), time for placing bag in the abdomen including placement of uterine tissue in the bag and time for placing lateral port in bag (representing extra time used for performing this technique), estimated blood loss (anaesthetic nurse estimate recorded in the operative record), specimen weight, intact status of specimen retrieval pouch (obtained by visual inspection of the bag by the surgeon), length of hospital stay, intraoperative complications, readmission to hospital and reoperation.
A 12-mm port is placed in the umbilicus and additional three 5-mm ports. Two are placed on the level of the umbilicus, laterally on both sides, and one port approximately 6 cm above the umbilicus in the midline, in order to give a good overview when placing the bag (Fig. 1). To avoid slippage of the right lateral trocar from its location within the isolation bag and avoid spillage during morcellation, a balloon-tipped 5-mm trocar (Kii Fios, Applied Medical, Rancho Santa Margarita, CA, USA) is used (Fig. 2). Morcellation is performed with a reusable electromechanical 15 or 20 mm morcellator (Wolf, Hamburg, Germany) (Fig. 1). A standard 30° 5-mm optic (Olympus, Hamburg, Germany) is used enabling us to port jump. The plastic bag used is a standard (8 Euro) plastic isolation/transport bag 47 cm × 46 cm, with a strap in the rim, normally used for bowel placement during laparotomy (Microtec Medical, Zutphen Netherlands).
The plastic isolation bag, mounted on two curved blunt metal probes, is inserted through a 2-cm incision in the umbilicus after the laparoscopic hysterectomy or myomectomy (Fig. 3a, b). Inside the abdomen, the upper metal probe is turned 180°, and the two probes in the rim of the bag forms a ring like a traditional “endobag” which facilitates the placement of the uterine tissue into the bag (Fig. 3c, d). After the placement of the tissue in the bag, the strap in the rim of the bag is pulled back, the probes are retracted at the same time and the opening of the bag is brought extra-abdominally. A blunt 12-mm trocar is introduced through the opening of the bag in the umbilicus, and the bag is insufflated under laparoscopic guidance. The space outside the bag is desufflated through the vents of the other ports. When fully inflated, visual inspection through the 12-mm trocar is carried out to confirm that the uterine tissue is located inside the plastic bag and to check that the bag fully lines the abdominal cavity.
To facilitate insufflation and continuous laparoscopic visualization during the insertion of the morcellator through the umbilical incision, the inflated bag is pierced by the 5-mm balloon-tipped trocar in the right lateral port and the balloon tip is insufflated (Fig. 2). In order to facilitate the penetration of the plastic bag and to avoid lesions in the bowel, which may be relocated during the insufflation of the bag, a special technique is recommended: The tip of the balloon-tipped right lateral 5-mm trocar is inserted into the tube of the 12-mm trocar, visually guided by the 5-mm optic located in the 12-mm trocar. When the two trocars are aligned, the optic is withdrawn, the 5-mm trocar is inserted into the tube of the 12-mm trocar and the plastic bag is easily penetrated. The balloon tip is then inflated again while retracting the 5-mm port from the tube of the 12-mm port. The defect in the bag is now “sealed” by the balloon (Fig. 2). The 5-mm optic and CO2 insufflation are shifted to the right lateral 5-mm port. The 12-mm trocar is removed from the bag, and the morcellator device is introduced into the inflated bag through the umbilical incision. The morcellation is now performed under continuous laparoscopic visualization, and all remnants and blood are captured in the bag (Fig. 4). After morcellation, the lateral 5-mm trocar is removed after deflation of the tip, and the plastic bag is removed and tested for perforations. After the specimen is removed, a laparoscopic survey of the abdomen and pelvis is performed in order to watch haemostasis and secure that no morcellated tissue has escaped the bag.