specimen retrieval

1. Methods for specimen removal from the peritoneal cavity
after laparoscopic excision
Andreas Stavroulis MRCOG,a,
* Maria Memtsa BSc MBBS,b
Wai Yoong MD FRCOG
c
a
MAS Clinical Fellow, Department of Obstetrics and Gynaecology, University College London Hospitals NHS Foundation Trust, EGA Wing, 235
Euston Road, London NW1 2BU, UK
b
Clinical Research Fellow, Early Pregnancy and Gynaecology Diagnostic Unit, University College London Hospitals NHS Foundation Trust, EGA
Wing, 235 Euston Road, London NW1 2BU, UK
c
Consultant, Department of Obstetrics and Gynaecology, North Middlesex University Hospital NHS Trust, Sterling Way, London N18 1QX, UK
*Correspondence: Andreas Stavroulis. Email: stavroulis@btinternet.com
Accepted on 3 July 2012
Key content
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.
Learning objectives
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.
Ethical issues
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.
Keywords: benign mass / excision / laparoscopy / retrieval
Please cite this paper as: Stavroulis A, Memtsa M, Yoong W. Methods for specimen removal from the peritoneal cavity after laparoscopic excision. The
Obstetrician Gynaecologist 2013;15:26–30.
Introduction
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.1
Chemical peritonitis is a rare
complication of a dermoid cyst spillage with an incidence
rate of between 0.22
and 8%3
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,4
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.5
For
26 ª 2013 Royal College of Obstetricians and Gynaecologists
DOI: 10.1111/j.1744-4667.2012.00148.x
The Obstetrician Gynaecologist
http://onlinetog.org
2013;15:26–30
Review

2. 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.6
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
guided7
or laparoscopic aspiration followed by intracorporal
ovarian cyst wall stripping performed endoscopically.8
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.
G€
oc
ßmen et al.9
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%.10
Although most hernias present within
10 days from the procedure, delayed hernias have been
reported up to a year from the initial operation.10
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 sites11
and most of these
occur as Richter’s hernias, without peritoneal lining, and
contain small or large intestine or omentum.12
This can be a
serious complication requiring laparotomy in the majority
of patients and intestinal resection in about 20%.11
Even with
5-mm lateral port sites, the risk of hernia exists13
as result of
stretch and tear of the fascia secondary to the instrument
manipulation or the passage of the tissue through the port
site.14
It is true that the risk of a hernia at the umbilicus is lower
compared with ancillary ports, unless the umbilical wound is
enlarged.15
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.14
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.16
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).16
ª 2013 Royal College of Obstetricians and Gynaecologists 27
Stavroulis et al.

3. 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.18
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 reported19
(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.
Morcellation
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.14
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.20
Morcellators decrease the operative time21
and the risk of
port site herniation22
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.14
Mini-laparotomy
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.23
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.23
Colpotomy
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
28 ª 2013 Royal College of Obstetricians and Gynaecologists
Specimen retrieval after laparoscopic excision

4. reintroduced and successfully used to deliver solid and semi-
solid tumours following operative laparoscopy.24
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.6
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.6
A vaginal cystectomy is
performed with or without cyst decompression.6
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.25
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.26
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.25
The first case of
successful incidental vaginal appendicectomy at the time of
vaginal hysterectomy was described by Bueno in 1949,26
while, more recently Tsin and colleagues26
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.26
Advantages of the
transvaginal route include the ease of insertion of rigid
instrumentation, suitability for specimen removal and proven
safety record.25
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.26
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.
Conclusion
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
None declared.
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ª 2013 Royal College of Obstetricians and Gynaecologists 29
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