A Safe and Simple Laparoscopic Cold Knife Section Technique for Bulky Uterus Removal: Bag Containment System Placement

Introduction: The morcellation of the bulky uterus after total laparoscopic hysterectomy (TLH) is a challenge for those dealing with advanced laparoscopic surgery. However, there are no laparoscopic standardized procedures available to date. We developed a laparoscopic cold knife technique with the aim of demonstrating a simple and reproducible method of sectioning and vaginal retrieval of the bulky uterus. After the U.S. Food and Drug Administration's (FDA) statement 1 discouraging the use of power morcellation for hysterectomy and myomectomy, we developed and introduced a containment system to improve the safety of the technique, avoiding myometrial spillage into the abdomen. Materials and Methods: From June 2012 to June 2014, patients who underwent TLH for benign indication, with a uterus size over 12 gestational weeks, were prospectively admitted into the clinical study. After the U.S. FDA statement in April 2014, we adopted a protective bag during the section of the uterus. The video highlights the steps of its placement. After the colpotomy, a cylindrical sterile wrapping bag (50 by 27 cm), packaged preoperatively, with drawstring thread forming a running noose, and placed round the two open ends of the pouch, was inserted through the umbilical trocar and stretched to envelope the uterus. The drawstring thread of the cranial V-shape end of the bag was left outside the pelvis along the umbilical trocar; the drawstring thread of the caudal circular end was pulled through the vaginal canal, closing the caudal end of the pouch around the cervix. The anterior wall opening was obtained by pulling out the two threads connected to the bag through the ancillary trocars, allowing the uterus sectioned by the laparoscopic knife. Results and Conclusions: Twenty-nine women with bulky uterus were treated by TLH and cold knife section technique. We adopted a containment system in the last four patients, with an average uterine size of 325 g. The average time for bag placement was 7.2 minutes. Our developed containment system seems to be a feasible and cheap option to overcome the low risk of disseminations that occur with this technique. Its use on a wider population and any improvements will shorten the placement time and simplify its handling. Further studies in a controlled setting are advisable to enhance safety and investigate outcomes. No competing financial interests exist. Runtime of video: 3 mins 6 secs