1. Morcellation Gustavo Plasencia MD, FACS, FASCRS Clinical Professor of Surgery Florida International University Stelio Rekkas MD

2. Disclosures Ethicon Endosurgery Consultant

3. Incisions

5. Morcellation

6. You are driving down the road in your car on a wild, stormy night, when you pass by a bus stop and you see three people waiting for the bus: 1.An old lady who looks as if she is about to die. 2. An old friend who once saved your life. 3. The perfect partner you have been dreaming about. Which one would you choose to offer a ride to, knowing that there could only be one passenger in your car?

7. "I would give the car keys to my old friend and let him take the lady to the hospital. I would stay behind and wait for the bus with the partner of my dreams. Never forget to "Think Outside of the Box”

8. To Morcellate or Not to Morcellate, that is the question. Why aren’t we doing this more?

9. Pathology Relatively unchanged techniques Is there a better way to evaluate our specimens? Progressive Pathologist Preop Radiological Staging Preop Histopathological staging

10. Introduction: Tissue Morcellation Morcellation—the grinding and removal of tissue Etymology ▫Medieval Latin morsellum “to bite”

11. Introduction: Tissue Morcellation Common used for spleen, uterus, kidney, in benign diseases Piecemeal extraction of tissues Avoid extraction incisions. Use only trocar sites; may be slightly enlarged, dilated

12. Principles for Morcellation Only performed for benign disease Requires impermeable entrapment bag Check bag for perforation Maintenance of pneumoperitoneum Avoid overflow in the bag by frequent suction of fluid and tissues

13. Principles for Morcellation Change gloves after tissue extraction Any manipulation should be done with atraumatic instruments Perform under laparoscopic visualization

14. Advantages Less post-operative pain Improved cosmesis Potential advantages ▫Reduced risk of incisional hernias ▫Decreased risk of wound infection ▫Quicker return to activities

15. Disadvantages Injury to adjacent tissues when morcellating Extra cost if using morcellating device Longer OR times Not recommended for malignant disease today

16. Indications Benign Disease ▫Diverticulitis ▫Inflammatory Bowel Disease ▫Ischemic Colitis ▫Rectal Prolapse ▫Colonic Inertia ▫Volvulus ▫AVM

17. Indications Malignancy ▫When staging is not imperative  Palliative resection

18. Malignancy? Cannot obtain adequate staging of cancer, due to destruction of primary as well as lymph nodes

19. Electric Morcellators Cook morcellator Coherent morcellator Storz Morcellator Ethicon morcellator

20. Electric Morcellators Organ isolated in bag ▫Prefabricated or fashioned Used blades to grind tissue, suction to remove Dangerous because bag easily punctured Where are the colon morcellators?

21. How we do it Tissues morcellated without any equipment. Or as an alternative a Morcellator Lapsac used

22. Machine Morcellation Video

23. Conclusions Indicated for benign or palliative colon surgery New forms of tissue analysis and staging evaluation are needed preoperatively Preoperative radiological staging will improve Histopathological analysis should also be improved upon We need to always be thinking of the future and how to better serve our patients Possible and Safe

24. To Morcellate or Not to Morcellate, that is the question. TO MORCELATE

26. The End