title: The Sydney Contained In Bag Morcellation technique.
abstract: OBJECTIVE
  To demonstrate a modification of the Shibley single-port technique suitable for morcellation of large myomatous uteri after total laparoscopic hysterectomy in a contained environment within the abdominal cavity [1].
  
  
  METHODS
  Step-by-step explanation of the technique using descriptive text and an educational video.
  
  
  METHODS
  In light of recent concern about the use of power morcellators and increasing the risk of disseminating occult leiomyosarcomatous myoma fragments throughout the abdominal cavity, we propose this new technique for management of morcellation of large myomatous uteri after total laparoscopic hysterectomy, to contain the morcellation process and minimize the risk. This technique, which we have coined "Sydney Contained in Bag Morcellation" involves introduction of a sterile plastic bag (Dual Drawstring Bag, 460 × 460 mm; Southern Cross Hospital Supplies, Northmead, NSW, Australia) before introducing an optical port and the power morcellator. Before insertion this bag is modified in several ways to facilitate bag opening and specimen retrieval. The dual drawstring is removed and replaced with a 150-cm length of PDS I (polydioxanone) suture material as the new drawstring, with its exit at the mouth of the bag in the 6 o'clock position. Five stay sutures are placed around the bag mouth, corresponding to the 12, 1, 5, 7, and 11 o'clock positions. This assists with opening the mouth of the bag intraabdominally and enables orientation to be maintained. The bag is then inserted in a McCartney tube (Gates Healthcare, Cheshire, UK). Corresponding slits are made in the tip of the tube to enable the end of the stay sutures to be securely held in place during tube insertion. These ends are then retrieved using atraumatic graspers and exteriorized and clipped alongside their corresponding port sites. After hysterectomy the uterus is placed in the bag, and the stay sutures maintain the mouth opening. The bag is closed and its mouth exteriorized onto the abdominal wall at the site of the umbilical trocar. The 12-mm umbilical trocar is then replaced within the bag, and pseudopneumoperitoneum is created. Once established, an optical trocar is introduced via one of the lower quadrant port sites using a balloon tip trocar (Kii; Applied Medical, Rancho Santa Margarita, CA). The insufflation tubing is attached to this trocar, and the umbilical trocar is replaced with the morcellator device. Morcellation is performed under direct vision in a contained environment. Once complete, all fragments are removed, and the bag is washed out. The original pneumoperitoneum is re-established. The bag is then removed during aspiration to encourage negative pressure relative to the re-established pneumoperitoneum, minimizing aerosolized fragment leakage.
  
  
  METHODS
  Contained in bag morcellation of a large myomatous uterus during total laparoscopic hysterectomy. This technique has been specifically developed to address the concerns of morcellating large myomatous uteri after hysterectomy. In the case of supracervical hysterectomy or myomectomy, in which there would be no vaginal conduit to exploit, we use an endocatch bag, inserted in the usual manner, with reintroduction of the umbilical trocar within the mouth of the bag to enable creation of pseudopneumoperitoneum. Again, an optical trocar would be introduced in a lower lateral port, and morcellation would be performed under direct vision. An article describing this technique has recently been published [2].
  
  
  CONCLUSIONS
  The Sydney Contained in bag Morcellation technique offers a possible solution to the risk of dissemination of benign morcellated and potentially leiomyosarcomatous myoma fragments. Certain aspects of the procedure are key to its success. The stay sutures are essential to facilitate orientation and opening of the bag mouth. The McCartney tube enables easier insertion of the flaccid bag into the vagina, and the suture-retaining slits enable the mouth of the bag to be opened quickly and easily. We have used this technique in 5 cases with uteri ranging in weight from 350 to 978 g. Recently, similar techniques have been described for use in single-port surgery and conventional laparoscopy [1,2]. Our technique is suitable for use with large uteri after total laparoscopic hysterectomy because the large capacity of the bag enables containment of uteri that would exceed the capacity of manually deployed specimen retrieval bags. This technique offers an alternative to vaginal morcellation, with the advantage of improved vision during morcellation and the ability to morcellate large uteri using a familiar instrument and view.
authors.affiliation: Sydney Women's Endosurgical Centre, Kogarah, New South Wales, Australia.
authors.forename: Joanne B
authors.initials: JB
authors.lastname: McKenna
authors.affiliation: Sydney Women's Endosurgical Centre, Kogarah, New South Wales, Australia.
authors.forename: Trupti
authors.initials: T
authors.lastname: Kanade
authors.affiliation: Sydney Women's Endosurgical Centre, Kogarah, New South Wales, Australia.
authors.forename: Sarah
authors.initials: S
authors.lastname: Choi
authors.affiliation: Sydney Women's Endosurgical Centre, Kogarah, New South Wales, Australia.
authors.forename: Brian P
authors.initials: BP
authors.lastname: Tsai
authors.affiliation: Sydney Women's Endosurgical Centre, Kogarah, New South Wales, Australia.
authors.forename: David M
authors.initials: DM
authors.lastname: Rosen
authors.affiliation: Sydney Women's Endosurgical Centre, Kogarah, New South Wales, Australia.
authors.forename: Gregory M
authors.initials: GM
authors.lastname: Cario
authors.affiliation: Sydney Women's Endosurgical Centre, Kogarah, New South Wales, Australia.
authors.forename: Danny
authors.initials: D
authors.lastname: Chou
mesh_terms: D005260:Female; D006801:Humans; D007044:Hysterectomy / Q000295:instrumentation / Q000379:methods; D010535:Laparoscopy / Q000295:instrumentation / Q000379:methods; D007889:Leiomyoma / Q000473:pathology / Q000601:surgery*; D047368:Tumor Burden; D063186:Uterine Myomectomy / Q000295:instrumentation* / Q000379:methods*; D014594:Uterine Neoplasms / Q000473:pathology / Q000601:surgery*
keywords: Fibroid uterus; Morcellation