In Bag Morcellation

This video demonstrates a stepwise approach to In Bag Mechanical Morcellation, which can be performed either abdominally or vaginally. The technique consists of five major steps, including introducing and retrieving the bag into the abdomen, placing the specimen inside the bag, bringing out the bag containing the specimen, performing mechanical morcellation and delivering the specimen, and finally, checking the bag’s integrity at the end of the procedure. The process varies slightly depending on whether morcellation is performed abdominally or vaginally.

In Bag Mechanical Morcellation Procedure Summary:

• In Bag Mechanical Morcellation: a stepwise approach performed abdominally or vaginally
• Step One: Introduce and retrieve the bag into the abdomen
• Step Two: Place the specimen inside the bag
• Step Three: Bring out the bag containing the specimen
• Step Four: Perform mechanical morcellation and deliver the specimen
• Step Five: Check the integrity of the bag at the end of the procedure
• Vaginal morcellation: Use the colpotomy created during laparoscopic hysterectomy
• Introduce bag: Fold an 8×10 inch LapSac and place it in the vaginal obturator
• Retrieve bag into abdomen: Pull on threads using a grasper
• Seal the bag opening: Pull on the thread after placing the specimen inside
• Morcellation: Perform mechanical coring using a scalpel
• Abdominal morcellation: Extend the umbilical incision
• Introduce bag: Tightly roll the bag over the introducer
• Stabilize and unroll the bag inside the abdomen using a grasper
• Bring out the bag opening: Extend the umbilical incision and pull out the ends
• Place a self-retaining ring retractor and roll over the edges of the bag
• Check the bag’s integrity: Look for leaks or inadvertent tears

Presented By

Affiliations

University of Ottawa, The Ottawa Hospital

See Also

• All our gynecology education videos and articles.

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What is In Bag Mechanical Morcellation?

In Bag Mechanical Morcellation is a surgical technique used to break down and remove large tissue specimens, such as a uterus or fibroids, through a minimally invasive approach. The procedure can be performed either abdominally or vaginally and consists of five main steps:

1. Introduction and retrieval of a specially designed containment bag, such as the LapSac, into the abdomen.
2. Placement of the tissue specimen inside the bag.
3. Bringing the bag containing the specimen out of the body, either through the vagina or an extended umbilical incision.
4. Performing mechanical morcellation by coring the specimen using a scalpel, reducing its size for easier removal.
5. Checking the integrity of the bag at the end of the procedure to ensure there are no tears or leaks.

This technique minimizes the risk of tissue dissemination during morcellation and allows for the safe and efficient removal of large tissue specimens.

What are the risks of In Bag Mechanical Morcellation?

Risks may include:

• Containment Bag Failure: If the bag ruptures, there is a risk of spreading tissue fragments, which could be problematic especially if the tissue is malignant.

• Potential for Cancer Spread: If the tissue being morcellated is cancerous and not previously identified, even with containment there’s a risk of spreading cancer cells.

• Incomplete Morcellation: Fragments of tissue may not be fully morcellated, complicating the extraction and possibly requiring conversion to open surgery.

• Longer Operating Time: The use of a containment bag and morcellation often extends the length of the surgery, which increases anesthesia-related risks.

• Bleeding and Hemorrhage: The morcellation process can cause blood vessels to be cut, risking excessive bleeding.

• Infection: Any surgical procedure has the risk of infection, and the act of morcellation could theoretically increase this risk by exposing more tissue surfaces.

• Damage to Surrounding Organs: The morcellator can accidentally injure nearby organs like the bowel, bladder, or blood vessels.

• Postoperative Adhesions: The process might increase the risk of scar tissue formation, leading to adhesions which can cause future complications.

• Instrument Malfunction: Like any mechanical device, the morcellator itself could malfunction, requiring a change in surgical approach.

It’s crucial to consult a healthcare provider to fully understand the risks and benefits of In Bag Mechanical Morcellation and to determine if it is the most appropriate option for your condition.

Video Transcript: In Bag Morcellation

This video will describe a stepwise approach of In Bag Mechanical Morcellation that can be performed either abdominally or vaginally. 

The technique is probably divided into five major steps.

• Step One: Introduction and retrieval of the bag into the abdomen.
• Step Two: Placement of the specimen inside the bag.
• Step Three: Bring out the bag containing the specimen.
• Step Four: Performing the mechanical morcellation and delivering the specimen.
• Step Five: Check the integrity of the bag at the end of the procedure.

Vaginal morcellation is accomplished using the colpotomy created during the laparoscopic hysterectomy.

To introduce the bag, an eight by ten inch LapSac by Cook Medical is folded in an accordion fashion. This is placed in the vaginal obturator with open ends and thread facing up.

The vaginal obturator is then placed through the colpotomy, and the bag is retrieved into the abdomen by pulling on the threads using a grasper.

The bag is unfolded, and the specimen is placed inside. Larger size bags can be used for bigger specimens. 

After ensuring that the whole specimen is placed inside, the opening can be sealed by pulling on the thread. To bring out the opening of the bag through the vagina, the thread is fitted to the obturator, and the ends are retrieved by pulling on the thread. 

A small self-retaining ring retractor is placed and the ends of the bag are rolled over it. Retractors are placed, and a tenaculum is applied to the specimen for traction. 

Morcellation of the specimen is then performed by mechanical coring using a scalpel until the specimen is small enough to deliver through the colpotomy. 

Visual inspection of the bag to look for any inadvertent tears should be done at the end. 

Morcellation, when performed abdominally, is accomplished by extending the umbilical incision. 

For the introduction, the same bag is tightly rolled over the introducer. 

The camera is then transferred on a five millimetre scope. And the bag on the introducer is pushed through the ten millimetre umbilical port as far as possible.

With the help of the grasper, the bag is stabilized and unrolled inside the abdomen.

This is followed by the placement of the specimen inside the bag. 

To bring out the opening of the bag, the umbilical incision is extended up to two to three centimetres, and the ends are pulled out. 

A small self-retaining ring retractor is then placed and is rolled over the edges of the bag. This optimizes the visualization of the specimen inside the bag.

Mechanical morcellation of the specimen is performed in a similar fashion.

At the end of the procedure, the integrity of the bag should be checked. This can be done by looking for any leaks due to inadvertent tears.