Minimally invasive procedures are utterly remarkable.  The fact that one can dissect and mobilize an entire specimen with just tiny incisions is a testament to surgical skill and the amazing technologies available in the operating theater.  After a challenging extirpative laparoscopic case there is great satisfaction in seeing the large specimen mobilized.

But that’s where the sense of accomplishment often ends.  Specimen entrapment — i.e. placing the specimen in an impermeable sack — and extraction remain a major challenge.

In a recent case I mobilized a kidney containing a large tumor and significant perinephric fat. I carefully deployed an Endocatch sack, then opened and unrolled it. Actually everything went quite well until it was time for the specimen to go into the sack. The biggest Endocatch, to my knowledge, can hold approximately 1200cc. Unfortunately, the large kidney and tumor were about 1400cc.  Needless to say, this was a big problem, and the sack came off the deployment mechanism as I struggled to pack in the kidney.  We had no choice thereafter but to proceed with an intact extraction. After a strong laparoscopic effort, it just broke my heart to make a large incision.

The whole experience is even more frustrating in a historical perspective.  When Clayman, Kavoussi and colleagues did the very first laparoscopic nephrectomy in 1990, they were able to extract the specimen in a Cook LapSac and morcellate it, which permitted removal via a 12-mm incision. At present, there is no electrical morcellator on the market designed for urologic use. Although manual morcellation is feasible, it is sloppy and inefficient; moreover, many patients (and even some surgeons) fear the practice. Although I certainly understand these concerns, it still does not make it any less painful to make a large incision after a neat, laparoscopic case.