Citation: BJOG: An International Journal of Obstetrics and Gynaecology. 2013, 120, 601-602
Author: Minas V.; Chong D.; Aust T.
Abstract: Objectives To demonstrate the challenges and suggest practical tips and techniques when operating laparoscopically and needing to extract a very large specimen. Methods A 45-year-old woman presented with abdominal pressure symptoms arising from a 30-week size fibroid uterus (Figure). A laparoscopic subtotal hysterectomy was planned. Entry to the peritoneal cavity was achieved by direct optical entry through Palmer's point. A 10 mm laparoscope was used through a port placed right below the xiphisternum. Two lateral and an umbilical secondary ports were used. Subtotal hysterectomy and left salpingo-oophorectomy were performed using bipolar forceps, scissors and LigaSure. An Alexis O wound retractor was inserted through a 4 cm transverse suprapubic incision and the specimen was retrieved with open knife morcellation. Results Placement of the laparoscope port subxiphisternally provided a satisfactory view of the large specimen. Use of angled lenses helped significantly with access around the uterus. A subtotal hysterectomy was thus successfully performed laparoscopically. During the procedure it became clear that access to the left ovary was very limited to safely separate it from the uterus and preserve it. Thus, a decision to sacrifice the ovary was taken. The patient had been counselled preoperatively about this eventuality. The challenge of extracting the specimen was tackled by using a wound retractor, commonly used by general and
urologic surgeons, through a 4 cm suprapubic transverse incision. The specimen was retrieved by open morcellation with a scalpel. It weighed 1.6 kg. The patient made uneventful recovery and was discharged home on the third postoperative day. Conclusions Adjustments to usual laparoscopic techniques are required when dealing with a very large specimen. In our case, entry through Palmer's point, placement of the laparoscope port well above the umbilicus, use of angled lenses, use of a surgical wound retractor and
extraction by open knife morcellation made this procedure possible. The patient underwent a laparoscopic operation with a 4 cm suprapubic transverse incision instead of a large midline laparotomy which would normally be required. Open morcellation is a safe alternative when having to extract a large specimen which makes closed morcellation unsafe due to access limitations. On occasion it may be necessary to sacrifice one ovary when undertaking a laparoscopic hysterectomy for a large uterus; therefore the patient should be consented accordingly.
