Specimen Extraction

In most cases of laparoscopic colorectal resections, specimens that are to be extracted are originally larger than the laparoscopic port site. The port site is therefore enlarged at the beginning of the extraction procedure. This wound enlargement is further justified because it also facilitates certain extracorporeal procedures, e.g., bowel anastomosis, as required. An excessive wound enlargement, however, may result in the elimination of known advantages of laparoscopic surgery such as less pain and better cosmesis. Nevertheless, an adequate specimen extraction technique including a "minimal" wound enlargement, is necessary and wound size should never compromise treatment of the disease.

In general, all colorectal specimens should be isolated in the retrieval bags before extraction, or drawn out of the abdomen with a wound protector in place, to prevent the peritoneal cavity, abdominal wound, and soft tissue from contamination with the colonic contents. It is not recommended to reduce the size of specimen by removing the contents or by cutting the specimen in pieces, because these may increase risks of infection and cancer dissemination. In addition, destruction of the specimen may also lead to incomplete postoperative pathologic evaluation.

An appropriate choice of retrieval bag is crucial for safe specimen delivery in laparoscopic colorectal surgery. Among various commercially available bags, our current recommendation is a 15-mm Endo Catch™ II (USSC-Tyco) specimen pouch (see Chapter 2). The Endo Catch™ II consists of a long cylindrical tube and a polyurethane pouch. The system seems suitable for colorectal laparoscopy, because: 1) the opening diameter (5 inches) and depth (7 inches) are sufficient for most colorectal specimens; 2) the polyurethane pouch prevents spillage and minimizes intraoperative contamination by isolating possible colonic contents coming with the specimen; 3) the pouch is maintained in an open position by a flexible metal ring, allowing for an easy placement of the specimen without the aid of additional instruments; 4) the pouch and attached string are durable enough for aggressive retrieving procedures. Although the Endo Catch™ II officially requires a 15-mm trocar sleeve for its insertion, it can be inserted via a regular 10/12-mm port site, by withdrawing the trocar sleeve and slightly enlarging the port site with surgeon's index finger, then inserting the shaft of the Endo Catch™ II without a cannula.

After completely isolating the specimen into the bag (Figure 6.26), the attached string or the shaft is pulled up with trocar sleeve (if placed) until the neck of the pouch appears outside the incision. The neck of the pouch is secured with a Kocher clamp outside the incision and the trocar sleeve is removed (Figure 6.27). At this point, the pouch is inspected to see if there is air or fluid in it. If air is trapped in the pouch, simply enlarging the neck of the pouch may allow air to escape. If fluid is entrapped, careful suction may be used to remove excess fluid. Care must be taken not to spill the fluid in the incision. The skin incision is then "minimally" enlarged to complete the removal procedure (Figure 6.28). For most colorectal specimens, a final incision length of 4-5 cm is usually required. Pneumoperitoneum is switched on and off, and the bag is pulled up gradually in rotating motion. Excessive pulling force may tear the pouch and lead to inappropriate specimen removal and wound contamination. In actuality, the Endo Catch™ bag is remarkably resistant to tearing, and permits a surprisingly small incision to be made for specimen extraction.

Endo Catch Bag

Figure 6.26.

Specimen extraction using a plastic bag equipped with a draw string. The complete isolation of the specimen into the bag.

Figure 6.26.

Specimen extraction using a plastic bag equipped with a draw string. The complete isolation of the specimen into the bag.

Laparoscopic Specimen Retrieval

Figure 6.27.

Specimen extraction using a plastic bag equipped with a draw string. The neck of the pouch is secured with a Kocher clamp as soon as it is drawn out of the abdominal wall.

Figure 6.27.

Specimen extraction using a plastic bag equipped with a draw string. The neck of the pouch is secured with a Kocher clamp as soon as it is drawn out of the abdominal wall.

Pleural Effusion Pneumoperitoneum
Figure 6.28. Specimen extraction using a plastic bag equipped with a draw string. The incision is minimally enlarged to allow extraction of the bag. Maintaining the pneumoperitoneum helps push the specimen out through a small incision.

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Responses

  • Roosa
    What does the endocatch bag consist of?
    8 years ago
  • johan
    What is name of bag used to remove specimens laparoscopically?
    7 years ago

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