We present an original technique to rapidly extract a large uterus during laparoscopic hysterectomy. Manually morcellating the uterus is a safe and effective technique that overcomes the technical difficulties associated with traditional electrical morcellators.
Problem: difficult extraction of a large uterus
Although laparoscopic total hysterectomies are gaining more popularity over the abdominal approach, these techniques are limited when the patient has a large uterus. In these cases, surgeons have traditionally used electrical morcellators to extract specimens. However, electrical morcellation has been associated with vascular and bowel injury from the morcellator blade, spillage of specimen into the abdomen, tumor dissemination in the case of occult malignancy, iatrogenic endometriosis, and increased surgical time.
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Our solution
Essentially, the uterine corpus is placed into an endoscopic bag intraabdominally and then manually morcellated. This technique has been used for laparoscopic supracervical hysterectomies and for total laparoscopic hysterectomies when the specimen is too large to be extracted vaginally.
We routinely employ a polyurethane Endo Catch II 15-mm specimen pouch (Covidien Surgical, Mansfield, MA), which can accommodate a uterus that is as large as 22 weeks. First, the cannula is removed from the 10-mm port, and the pouch is inserted through the port site. The endobag is opened intraabdominally, the uterus is placed into the specimen bag with graspers, and the incision is extended to 20-30 mm so that the edge of the bag can be elevated through the incision ( Figure 1 ).
