86 Fernando J. Kim,1 Riccardo Autorino,2 & Rodrigo Donalisio da Silva3 1 Division of Urology, Urology‐Denver, Denver, CO, USA 2 Division of Urology, Virginia Commonwealth University, Richmond, VA, USA 3 University of Colorado Denver, Denver Health Medical Center, Denver, CO, USA Laparoscopic techniques (standard and robot‐assisted) have revolutionized the field of urologic surgery over the past quarter century and have established their role in the management of the entire spectrum of benign and malignant urologic diseases [1–3]. A growing body of evidence has demonstrated that these minimally invasive techniques allow quicker postoperative recovery for patients, ultimately improving their quality of life. On the other hand, the spread of laparoscopic techniques has resulted in unique complications specifically associated with their implementation [4–6]. Most urologic laparoscopic procedures are performed via the transperitoneal approach. However, the laparoscopic retroperitoneal access follows the same principles to exit the surgical field safely. This chapter focuses on the technique and instrumentation needed to safely and effectively accomplish the final step of any laparoscopic or robotic urologic procedure, which has been referred to as “laparoscopic exit” [7]. This step can be divided into three key segments, each one important and each with specific challenges related to the unique conditions under which laparoscopy is conducted: specimen retrieval, incision closure, and drainage. Any shortcuts have a strong potential to convert a straightforward case into a formidable venture with unintended postoperative complications such as delayed bleeding, dehiscence, or a postoperative hernia, increasing patient morbidity. The “laparoscopic exit” should follow a systematic, step‐by‐step approach (Figure 86.1) as described in the following sections. Figure 86.1 Exit strategy in laparoscopic and robotic procedures: a step‐by‐step systematic approach. Entrapment and extraction of surgical specimens are important steps that require specific laparoscopic skills and knowledge. Previous familiarity with materials and devices used during this step and knowledge of the specimen dimensions will ensure the safe removal of the surgical specimen, especially during oncological surgery to prevent tumor seeding in the extraction site [8, 9]. The retrieval site must be planned to optimize the cosmetic and pain‐related outcomes. A wide variety of single‐use retrieval devices are commercially available. All these devices feature sac permeability, resistance, stability, and easy handling. However, each one has specific characteristics, and the use of one over the others is mainly dictated by surgeon’s preference as well as availability. These devices come in different sizes (5–15 mm), and the use of one size depends on the size of the specimen to be retrieved. In urology, a 10 mm bag is usually suitable for the laparoscopic partial nephrectomy, radical prostatectomy, adrenalectomy, or lymphadenectomy, whereas a larger 15 mm bag is needed for larger specimens retrieved during radical cystectomy or radical nephrectomy. Retrieval devices can be divided into two categories: Table 86.1 Laparoscopic entrapment devices: simple bags. Table 86.2 Laparoscopic entrapment devices: bags with closing/opening system. Pure sacs were commonly used before the advent of devices with a plunger and pouches with mouth opening deployment capability. Placement of retrieval bags with plungers must be done under direct visualization to avoid injuries to the abdominal organs, ensure adequate opening of the bag, and verify complete entrapment of the surgical specimen with closure of the bag to prevent spillage or partial removal of the specimen. Alternative “low‐cost” solutions have been described to minimize costs, such as the use of sterile gloves and other materials, but the safety and efficiency of these devices have not been tested to ascertain industry guidelines and quality assurance [10]. Morcellation is the mechanical fragmentation of an (entrapped) specimen into smaller pieces using a manual or morcellator technique. It is used to minimize the extraction site incision, optimizing cosmetic and pain‐related outcomes. Morcellation has been closely scrutinized in gynecology due to the risk of bag perforation and bowel injuries [11]. The other concern relates to the challenges faced by the pathologist in accurately staging and defining the surgical margins. The use of morcellation in urology has been limited and is mainly restricted to laparoscopic benign cases; it is performed under laparoscopic visualization. Furthermore, no advantage of morcellation (over intact specimen extraction) could be found in studies looking at postoperative recovery, wound‐related complications, and surgery‐related quality of life [12, 13]. Extraction of the intact specimen can be accomplished through different sites depending on the size of the specimen. Small specimens (prostate, lymph nodes, or adrenal gland) can be easily removed by extending a trocar site. A larger specimen can present a more challenging scenario to the laparoscopic surgeon during procedures such as a radical nephrectomy. In this case, different access options can be considered (Figure 86.2): Figure 86.2 Extraction sites for laparoscopic nephrectomy/nephrourecterectomy. Factors to consider when choosing between these options are the patient’s preference, the surgeon’s experience, cosmetic result, and risk of related complications. Many surgeons prefer an umbilical or periumbilical incision due to familiarity with the midline abdominal wall anatomy. In this case, the incision is made through the umbilical scar to optimize the cosmetic outcome. This method has been popularized with the recent adoption of laparoendoscopic single‐site (LESS) surgery, where the entire procedure can be performed through a periumbilical incision [14]. Several investigators have reported the risk of complications associated with the extraction sites. Elashry et al. found a higher risk of hernia when using lower flank port connecting incision for specimen removal and suggested a midline or subcostal incision instead, especially when other risk factors (such as obesity) are present [15]. Bird et al. compared three different sites (umbilical, paramedian, and lower quadrant) and found that incisional hernias were more likely to occur in patients with high body mass index and/or paramedian extraction site [16]. The use of a Pfannenstiel incision after laparoscopic nephrectomy has been associated with potential advantages of better cosmesis and reduced pain [17]. During a transperitoneal laparoscopic nephrectomy, a Pfannenstiel incision can be used [18]. A skin incision is made about two fingerbreadths above the pubic symphysis. Instead of incising all the planes transversally along the same plane as originally described [18], just the skin can be incised transversally while the fascia is incised vertically, and the rectus muscles can be spread to enter the peritoneal cavity; this incision has been adopted for laparoscopic donor nephrectomy [19]. In the case of retroperitoneal nephrectomy, a “modified” Pfannenstiel incision can be used where the skin incision is biased toward the side of the nephrectomy, and after the anterior rectus fascia is exposed, a paramedian incision is made medial to the lateral border of the rectus muscle [20]. Then, after perforating the transversalis fascia, the Retzius (retroperitoneal) space is entered, and blunt finger dissection is used to gain access to the upper retroperitoneum [20]. In cases where this cannot be used (such as the presence of prior suprapubic incisions or in morbidly obese patients), a muscle‐splitting extraperitoneal Gibson incision can be used [21]. The Pfannenstiel incision has also been described for LESS surgery [22]. Surgeons should be aware of the risk of ilioinguinal and iliohypogastric neuropathy with lower abdominal incisions [23]. In some female patients the transvaginal route can be performed by a laparoscopic transverse colpotomy made at the posterior fornix. After the specimen is extracted via the vagina, the posterior colpotomy is repaired transvaginally. The authors pointed out that vaginal extraction is indicated in patients with an intact uterus and a surgically unoperated pelvis where vaginal adhesions are not present [24, 25]. Vaginal extraction is not indicated (because of size concerns) for younger nulliparous females, those with atrophic vaginitis, vaginal infection, or when the specimen is too large. More recently, the transvaginal route has gained momentum with the introduction of natural orifice transluminal endoscopic surgery (NOTES) [26]. After completion of the laparoscopic procedure, careful examination of the surgical field is mandatory to rule out inadvertent injury to adjacent organs and to check the hemostasis. Intuitively, this is a fundamental step to minimize the risk of unrecognized intraoperative complications that can lead to significantly increased surgical morbidity, requiring more challenging management in the postoperative period. Inadvertent organ injury can happen not only during the procedure itself but also very early when laparoscopic access is gained [27]. This more commonly occurs in special situations, such as when extensive adhesiolysis is needed [28]. Depending on the anatomical region where the surgery is performed, key structures need to be inspected. For right‐sided renal procedures, the liver and duodenum should be examined and for left‐sided procedures, the spleen and distal pancreas are frequently mobilized and retracted to access the kidney via transperitoneal laparoscopic approach [29, 30]. Diaphragmatic injuries can happen during dissection of the upper pole of the kidney but often changes in ventilation and oxygenation are observed requiring immediate action [31]. For pelvic procedures, attention should be paid to the small bowel, sigmoid colon, nerves, and vascular structures [32]. Careful inspection is also required to identify unrecognized bleeding, which can be tricky in the conditions under which laparoscopy is performed (i.e. with pneumoperitoneum). Although arterial bleeding is usually evident and easier to recognize, venous bleeding may be masked by abdominal pressure (~15 mmHg) during the laparoscopic procedure. Therefore, a key step of the “laparoscopic exit” is to lower the insufflation pressure to a minimum (<5 mmHg) and ensure proper hemostasis. In case of extraction of larger specimens requiring an extended incision, we recommend that the trocar site fascia defects should have a preplaced port site defect suture using a fascia closure device.
Laparoscopic Exit: Specimen Removal, Closure, and Drainage
Introduction
Specimen retrieval
Retrieval devices
Commercially available devices
Name
Description
SimplyStrong™ (Genicon, Winter Park, FL, USA)
Nylon with polymer coating; monofilament cinch string without introducer; grab points to extract bag; radiopaque thread
Endobag™ (Covidien/Medtronic)
5 in × 8 in; supplied in a dispensing tube; 10–12 mm trocar
TrapBag™ (Karl Storz, Tuttlingen, Germany)
Transparent; insertion through a pusher; memory wire; self‐opening; “fish trap” patented system
LapSac™ (Cook Medical, Bloomington, IN, USA)
Reinforced nylon with integral polyurethane inner coating and polypropylene drawstring; 10–12 mm trocar; not self‐opening
Name
Description
GeniStrong™ (Genicon)
Nylon with polymer coating; transparent introducer; preloaded spring automatically opens bag upon deployment; flexible metal ring holding bag mouth open for specimen loading; in different sizes: small and medium for 10 mm trocar; large for 12 mm trocar; XL for 15 mm trocar; rigid plastic shaft for stability; indicator for bag orientation; radiopaque thread
Endopouch™ retriever (Ethicon)
One‐handed deployment, bag opening maintained by a metallic ring, string with a slip knot enables closing the bag; 10 mm diameter; 4 in × 6 in size
Anchor Tissue Retrieval System™ (ConMed Corp., Utica, NY, USA)
Nylon material; automatic opening; different sizes for 10–15 mm trocars; multiple use in single patient
Inzii™ Retrieval System (Applied Medical, Rancho Santa Margarita, CA, USA)
Also in 5 mm size; allows multiple uses in a single patients
Endo Catch™ (Covidien/Medtronic)
10 mm or 15 mm; polyurethane pouch
Homemade (low‐cost) devices
Morcellation
Extraction site: where and how?
Inspection
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