Three Techniques of Contained Morcellation for the Minimally Invasive Gynecologic Surgeon.

Since 1993 (and prior, WISAP® [WISAP Medical Technology GmbH, Brunnthal, Germany] hand morcellators), laparoscopic power morcellation has been an indispensably employed technique for minimally invasive gynecologic surgery, contributing both to laparoscopic myomectomies and hysterectomies. However, the technique was highlighted with concern by the FDA for the given potential to disseminate neoplastic and non-neoplastic cells by morcellating an unexpected uterine sarcoma (Fig. 1). Given this concern, many gynecologists are either resorting to performing traditional laparotomies or risking dissemination with uncontained power morcellation techniques. The purpose of this article is to address these concerns by illustrating three techniques to perform contained power morcellation, thereby reaping the benefits of the technique without the disadvantage of possible dissemination of neoplastic cells. The techniques outlined in this article include the use of trans-abdominal mini-laparotomy manual contained morcellation, trans-vaginal manual contained morcellation, and the new Contained Tissue Extraction (CTE) System (Olympus America, Inc., Center Valley, Pennsylvania) for power morcellation.

Closing the Gap: Novel Abdominal Wound Closure Techniques.

Traditionally, surgical procedures within the realm of both general and gynecological surgery employ the use of staples and interrupted sutures that run continuously with knot tying or subcuticular sutures to ensure closure of large wound incisions, subcuticular incisions, and fascial repair. However, these methods may not always be cosmetically favorable and, thus, result in an unpleasant outcome for the patient, adding to their surgery-related stress. It is, therefore, imperative that surgeons and gynecologists are aware of alternative methods of wound closure that are not only cosmetically favorable, but also ensure rapid wound recovery and infection control. Two such products available include DERMABOND™ PRINEO™ Skin Closure System (Ethicon Inc., Somerville New Jersey) and STRATAFIX™ Symmetric PDS™ Plus Knotless Tissue Control Device (Ethicon Inc., Somerville New Jersey). The DERMABOND™ PRINEO™ Skin Closure System is a topical mesh and skin adhesive that creates a strong polymeric bond across wound edges. This permits natural healing to occur, but with a synthetic flexible microbial barrier providing in vitro protection against organisms. The STRATAFIX™ Symmetric PDS™ Plus, on the other hand, is a knotless tissue control device that permits soft tissue approximation in appropriate situations where such absorbable sutures are permitted. This can be used for large fascial closure as well as on the skin. The purpose of this article is to review and share our experience with two alternative methods of wound closure (one for fascia and one for skin) with a review of their composition and benefits and to illustrate their common applications in gynecologic or general surgery when laparotomy is necessary.

Biosurgicals and the Minimally Invasive Gynecologic Surgery (MIGS) Surgeon.

Biosurgical materials (biosurgicals) have a wide array of uses for providing hemostasis, including decreasing the risk of postoperative bleeding and, intraoperatively, controling bleeding. These materials are especially useful in situations where electrocautery, sutures, or clips are not feasible. Biosurgicals have long been used in general surgery and surgical subspecialties to provide hemostasis; however, they still are not commonly used during obstetric and gynecologic procedures. Three commonly used classes of biosurgicals will be discussed in this article: oxidized regenerated cellulose, flowables, fibrin sealants, and fibrin sealant patches. Each of these agents has a different role to play during minimally invasive gynecologic surgery (MIGS), either singularly or in combination with each other. One unique fibrin product is a fibrin sealant patch, which is a combination of products used to treat bleeding of various intensities, including acute, severe hemorrhagic situations. It is important for the MIGS surgeon to understand the nature and use of each product to be able to use biosurgicals appropriately for hemostasis management. This article reviews biosurgical products, their composition, and application in minimally invasive gynecologic surgery. Included will be a few of the "on label" and "off-label" uses of biosurgicals-either singularly or in combination-and tips for introducing these materials during MIGS procedures.

An Update on the Use of Barbed Suture in Minimally Invasive Gynecological Surgery (MIGS).

The use of barbed suture has enabled general and minimally invasive gynecological surgery (MIGS) surgeons to close surgical wounds more efficiently with minimal complications. This article reviews developments in barbed (knotless) sutures and related devices.

Now You See It: Using Angled Laparoscopes in Minimally Invasive Gynecologic Surgery.

As minimally invasive gynecologic surgery (MIGS) becomes more complex, and cases more difficult, surgeons must adapt to the challenges not only by using innovative equipment but also using the lessons learned from other disciplines. Many years after general surgeons learned the "art of laparoscopy," it is clear that general surgeons in the United States-and those around the world-have surpassed the "masters of laparoscopy" (gynecologists) with their use of new techniques and new equipment. Surgeons are using less traumatic graspers and perform a higher percentage of surgeries laparoscopically than gynecologic surgeons. With the essential need for more integrated ergonomics and a suitable laparoscopic operating room environment, this article describes the benefits of using angled laparoscopes and includes basic techniques to enable gynecologic surgeons to master "driving" the angled laparoscope.

The New HARMONIC ACE®+7 Shears: A Game Changer in Ultrasonic Hemostasis.

The latest version of HARMONIC®, the HARMONIC ACE®+7 Shears by Ethicon US, LLC, is now commercially available. While earlier models also had easy-to-use handles and a fine, non-stick tip, the HARMONIC ACE®+7 Shears adds a new hemostasis feature. The "7" in HARMONIC ACE®+7 stands for the device's ability to coagulate and divide 7-mm vessels. This is accomplished via an Advanced Hemostasis Mode and button located on both sides of the handle. The HARMONIC ACE®+7 will prove itself the leader in the ultrasonic energy field.

Laparoscopic Morcellation and Tissue Spillage Containment Using the LI Endofield™ Bag.

There are many times during laparoscopic surgery that a surgeon, whether gynecologist or general surgeon, must work in an environment where spillage of tissue or organ contents should be avoided. In gynecologic surgery, this involves management of ovarian cysts as well as containment of tissue fragments during morcellation of uteri or fibroids. Unfortunately, many laparoscopic containment bags on the market today are not large enough to remain open on their own during the entire procedure. The LI Endofield™ and LI Endofield™ TV bag offer a solution and provide an adjustable and suturable "field bag." Surgeons can work in an adjustable "field," are able to see through the bag, and can remove it at the end of the procedure. With the recent FDA cautions on power morcellation, our team only morcellates fibroids and uteri using one of these bags.

Use of the ENSEAL® G2 tissue sealer in gynecologic surgery.

Minimally invasive surgery (MIS) has become the standard of care for a variety of surgical conditions, and reliable vessel sealing and precise cutting are essential. A variety of tissue-sealing devices have been used successfully to decrease operating time and control bleeding during hysterectomy and other MIS gynecologic procedures. One development involves the next generation of advanced bipolar devices by ETHICON (Ethicon Endo-Surgery Inc., Cincinnati, OH), called ENSEAL® G2 Tissue Sealers. Tip improvements to the ENSEAL® have included stronger jaws and a welded positive electrode in the stationary jaw, thus enabling the new ENSEAL® G2 Tissue Sealer to provide reliable vessel sealing and precise cutting all in the same instrument. The patented I-BLADE® forces the jaws of the device together as it advances, resulting in high, uniform compression along the entire length of the jaws. The temperature-regulating Positive Temperature Coefficient (PTC) material in the jaws is designed to minimize sticking, and the offset electrode configuration is designed to minimize thermal spread. The ergonomics provided by the ENSEAL® G2 Tissue Sealer offer significant improvement over previous devices and may make this a much more cost-effective choice for benign gynecologic procedures.

Laparoscopic Management of Ovarian Cysts with Controlled Tissue Sealing - The "Cross Bag" Technique.

When ovarian preservation is desired, a minimally invasive laparoscopic surgical procedure using a "cross bag" technique is effective to consistently manage and remove ovarian cysts of concern. In addition to the standard preoperative preparation of patients, a bowel prep is critical, especially if the mass is large or the patient obese. Visualization of all internal structures is achieved using a multi-screen HD system and 5-mm laparoscope. Over 100 cases have been performed using the "cross bag" technique with no spillage of cysts.