Arnold Advincula's Surgical Techniques
Keys to success
- Perfect the cutting technique; it is imperative to achieve tissue removal in long strip-like pieces for efficiency. Achieving the “saw cut” is like connecting the dots on a piece of paper with a pencil, where you try not to lift up the pencil (or the scalpel in this case). Rock the tissue back and forth with your nondominant hand and pull the specimen flush to the incision. This helps expose maximal surface area so you can continue to cut tissue pieces that are as large as possible. When rocking, move your dominant (cutting) and nondominant (holding the specimen with the tenaculum) hands in opposite directions.
- Ensure that the appropriate amount of tissue is cut when performing the C-incision. If the tissue strip is too thick, it becomes hard to see and incise the tissue, especially as you come around the back curve of the C. Limited visualization will increase your risk of cutting the retractor or the bag. If the cut is too thick, angle the scalpel in to make the tissue strip thinner (ie, make a “V-like” incision into the noncut surface). If the tissue strip becomes small, do the opposite; instead of cutting at a diagonal toward the noncut surface, aim out from your last incision (“V-out”). You should re-grasp below the narrowed area of the strip in this case before continuing to cut to prevent premature breakage of the strip.
- Maintain traction on the specimen. Keep it flush against the abdominal wall and the opening of the self-retaining rectractor. Use your finger to help “roll” the specimen when continuing the C-incision, if necessary. Maintaining traction will help avoid the need to use your finger.
- If you cannot remove the tissue fully intact, reorient or resect, and move forward. When the tissue is not easily extractable, try to roll the specimen by pushing near or behind the junction of the cut surface and the specimen. This helps reorient the specimen and exposes more smooth, noncut surfaces so coring can continue. The strip of tissue may need to be completely incised at times. If this occurs, drop the specimen back into the bag, find a smoother surface, re-grasp, and begin the C-incision again.
To view ExCITE performed in real-time during removal of an 8-cm, 130-g fibroid after a robot-assisted laparoscopic myomectomy, access the video “The Extracorporeal C-Incision Tissue Extraction (ExCITE) technique” at obgmanagement.com, found in Arnold Advincula’s Surgical Techniques Video Channel.
Building the ExCITE simulation model
Creation of the ExCITE simulation model can be broken down into 4 simple steps: creating the self-retaining retractor, building the torso, preparing the specimen, and simulating the ExCITE technique.
Supplies
To complete all 4 steps, you will need several materials, all of which are easily accessible and easy to prepare for simulation (FIGURE 4).
FIGURE 4 Supplies
- 1 beef tongue (2−3 lb)
- 1 pantyhose
- 2 silicone rings (4−5 cm in diameter, such as those used as wrist bracelets for cancer awareness)
- 1-gallon resealable (Ziploc) plastic bags
- 8x12 cardboard/corrugated box (or plastic storage box)
- duct or masking tape
- instruments:
– #11-blade (or your preference) scalpel
– penetrating clamps (tenaculum, Lahey, or towel clamps)
Note that beef tongue, given its muscular texture, closely mimics uterine tissue and therefore is used to represent the fibroid or uterus during simulation. Sometimes, a piece of beef tongue can be marbleized, or fatty, in which case it can simulate a degenerated fibroid. Beef tongue usually comes in one large piece, which could be suitable for up to 4 surgical exercises. The cost of a single tongue is approximately $20 to $30, so it averages about $5 to $7 per exercise/surgical trainee.
