Page 14 - Peer Reviewed Laparoscopic Jornal

Nuzhat Amer et al

Specimen can be retrieved through vaginal route by Morcellator is not acceptable in cases where suspicion
colpotomy. It was first documented over a 100 years ago of infection or malignancy is there. Morcellated tissue may
but was not used much due to technical difficulties, poor disturb the pathological findings on histopathology in cases
exposure and increased risk of infection. 5 of suspected malignancy. 3
Some surgeons prefer to use plastic bag for drainage Large diameter morcellator remove tissue in less time
2
package as endobag as it minimizes the tearing effect as in but is associated with incisional hernia formation. This
glove finger bag (Figs 3A and B). 7 complication can be avoided by port closure with sutures.
Transvaginal route has been popular again for last few Now morcellator with diathermy instead of blade are also
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years. Removal of the intact specimen through colpotomy available. Since, morcellator decrease the operative time
is more important. so the risk of port site herniation decreases due to decreased
Colpotomy is generally safe and easily learnt technique. manipulation. 1
To minimize the risk of spillage, endoscopic bags can be During morcellator use, caution must be taken as there
used during removal of tissue under direct vision but, is risk of inadvertent injury to the normal tissue. This can
whenever incision is given in the posterior vagina, be avoided by bringing specimen toward the morcellator
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(colpotomy) pneumoperitoneum greatly affected. 8 rather moving the morcellator toward specimen.
To maintain the pneumoperitoneum, counter pushing Natural orifice, transluminal endoscopic surgery
by other instrument inside the vagina is effective. 1 (NOTES) is another advancement of minimally invasive
intra-abdominal surgery in which peritoneal cavity is
This problem can be overcome by suturing the posterior
vaginal wall laparoscopically. 8 approached by incising and traversing the lumen of natural
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orifices.
Colpotomy may result injury to nearby structures, Natural orifices, like oral, anal, vaginal and urethral
bladder or bowel perforation, ureter injury, vaginal wall routes, have been described but optimal route is still to be
hematoma. Extra care has to be taken during specimen determined. Vaginal access has been used for long time due
removal through vagina as it may tear or lacerate. Risks to its ease of access and more capacity. Closure of vaginal
will be more, if patient is nulliparous or morbid obese. 5 wound can be done under direct vision and complication
Obstetric forceps can be used to extract the specimen rate is also low. 12
enclosed in an endobag. It can help to protect the integrity Vaginal approach is not possible in some situations, like
of the bag and specimen and minimize the diameter of fixed retroverted uterus, obliteration of Pouch of Douglas,
the sac. 9 due to endometriosis or previous pelvic inflammatory
Morcellator is another technique to retrieve the solid disease. 8
tissue from abdominal cavity. It is important instrument for In hand-assisted laparoscopic surgery (HALS), the
tissue removal in myomectomy and splenectomy. surgeon can insert a hand through a small incision via
Morcellator works through sharp cylindrical blade over the pressurized sleeve. It is a new advancement in MAS. HALS
specimen and change tissue into small strips (Figs 4A initially was started for tissue retrieval and surgeons can
and B). Morcellator do not affect the pneumoperitoneum use their hand for exploration, isolation and removal of
during its work. 1 tissue (Fig. 5). 1

A B
Figs 3A and B: Plastic bag used as endobag
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