Introduction

The laparoscopic approach to the removal of solid organs has evolved over the past decade. Within the genitourinary system, the most significant impact has been for upper urinary tract tumors, and currently laparoscopic radical nephrectomy and nephroureterectomy are well accepted for renal and urothelial malignancies, respectively. Recent data from multiple centers have demonstrated both the safety of the procedures and excellent long-term cancer outcomes (1-3).

Despite the increased application of the minimally invasive approach and excellent descriptions of the various surgical techniques, debate persists regarding the optimal method of specimen retrieval. Some perform intact specimen removal from an extended port site, lower abdominal incision, or the vagina (4-6); others remove the kidney piecemeal after intracorporeal fragmentation within an impermeable bag (7,8).

The minimally invasive approach was initiated for the diagnosis and management of pelvic conditions, and primarily developed and propagated by gynecologic surgeons. In parallel fashion, the early considerations for specimen handling and extraction were within the realm of the gynecologists. Issues of specimen removal were relevant for both laparoscopy and transvaginal surgery in the removal of the entire uterus or after myomectomy for fibroids.

Descriptions of piecemeal removal of the uterus, using a minimally invasive technique, date back to the late 1800s. These methods of uterine removal involved the bivalving, intramyometrial coring, or wedge morcellation of the uterus through the transvaginal route (9-11). Subsequently, laparoscopy was employed to either facilitate the transvaginal operation or completely perform the hysterectomy or myomectomy (12). The specimen was typically quite large and therefore required fragmentation to preserve the benefits of improved cosmesis and shorter convalescent time. Typically, the tissue was cut or fragmented within the peritoneal cavity and the pieces removed through a trocar or a minilaparotomy incision. Specialized laparoscopic instruments were developed to facilitate the tissue retrieval, such as a manual tissue punch with the instrument shaft containing the cored fragments. The instrument has been modified with motorization of the cylindrical blade (13). The currently available commercial morcellators, designed for gynecologic applications, include the manual serrated edged macro-morcellatora, Moto-Drive serrated edged macro-morcellator, and electro-mechanical Steiner morcellator.b Nevertheless, the methods remain tedious aWISAP, M√ľnchen, Germany. bKarl Storz, Tuttlingen, Germany.

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