Opening Bag and Specimen Entrapment

The mouth of the bag is opened using a grasper on each of the tabs (i.e., anterior and posterior), and the specimen is placed into the bag. Some advocate the placement of an additional port to facilitate triangulation of the mouth. However, we routinely perform transperitoneal laparoscopic radical nephrectomy using four ports, and are able to entrap the kidney using a total of three instruments. Although this can be a challenging task, coordination between the surgeon and the assistant can reduce the time to under a minute or two.

Maneuvers to aid specimen manipulation, particularly with larger masses, include placing the patient in the Trendelenberg position, obtaining a firm grasp on Gerota's fascia distant from the tumor, and dragging the specimen as far into the bag as possible prior to releasing the forceps; then, the remainder of the specimen can be maneuvered by pushing with the grasper. In addition, we utilize the largest LapSac in nearly all situations.

Several groups have reported techniques to simplify specimen entrapment using the LapSac. Sundaram et al. described threading a hydrophilic guidewire through the holes surrounding the mouth of the bag, alongside the existing drawstring (20). After intracorporeal introduction, the elasticity of the wire helps open the mouth of the bag while the rigidity eases positioning. Pautler et al. constructed a reusable instrument, similar to the EndoCatch, to which the LapSac is attached using a Prolene suture threaded through the drawstring-holes (21). The bag is rolled around the instrument, inserted through a port, and deployed within the body, opening the ring (15 cm diameter) along with the mouth of the bag. Similarly, User and Nadler adapted the EndoCatch II device for the LapSac (22). After removal of the original sack from a 15 mm instrument, the large LapSac (8 X 10 in.) is fixed circumferentially to the ring with silk sutures, and the drawstring is tied to the deployment suture on the EndoCatch. The LapSac is then tightly rolled around the closed ring and drawn into the shaft, aided by lubrication; the preparation time was reported to be 10 to 15 minutes. The modified device is introduced directly through the skin at the site of the largest port and opened, simultaneously expanding the flexible ring and mouth of the LapSac. Retraction of the plunger pulls the drawstring, closing the bag, and the silk sutures are either broken or cut to allow bag closure.

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