aggressive handling and have a low incidence of tearing and subsequent content spillage. The majority of commercially available specimen retrieval bags are introduced into the body via a 10‐ to 12‐mm cannula; however, smaller retrieval bags are also available for use with 5‐mm cannulas. Commercially available retrieval bags typically have a rigid expandable rim (Figure 4.25c), designed to maintain the bag in an open position to facilitate tissue manipulation into the bag. The expandable ring expands as the bag is deployed from its hollow instrument shaft and collapses again upon withdrawal [3, 4, 6]. (Video 4.1). Examples of homemade cost‐effective specimen retrieval bags include sterilized latex glove fingers (powderless), zipper storage bags, and condoms [3, 4, 6] (Figure 4.26a and b).
Prior to physical removal of the tissue‐occupied retrieval bag from a body cavity, the tissue to be extracted should be adjusted to the bottom of the bag. This can often be achieved by simply elevating the bag and allowing the weight of the tissue to shift its position deeper inside of the bag. In scenarios with less working space, an instrument is used to push the tissue to the bottom of the bag.
Some commercially available products allow for intracorporeal bag closure using an embedded purse string around the opening (see Figure 4.25b). The long tethers of the purse string are withdrawn out of body cavity through the desired exit site (typically a cannula), pulling the closed specimen bag along with them. Once the opening of the bag is within the cannula, the bag and cannula can be pulled from the site as a single unit. Bags with small tissue volumes can often be successfully removed through a larger cannula (12 mm). Bags with large tissue volumes can often be slowly pulled through the incision after the cannula is removed without the need to extend the size of the incision. If the specimen is too large for the cannula incision, manual or power tissue morcellation of the tissue within the bag, or enlargement of the port incision, may be performed to facilitate removal. Manual morcellation is performed by bringing the bag opening to the enlarged cannula incision and using a blunt‐tipped standard surgical forceps (eg. carmalt, ring) to disrupt the contained tissues into smaller, more pliable tissue. Firmer tissue can be clamped, partially exteriorized, and surgically debulked without disruption of the specimen bag. Fluid‐filled structures, such as an excised gallbladder, can have their contents removed or aspirated while inside a bag to facilitate extraction. Surgeons should avoid overzealously pulling or forcing a retrieval bag through an insufficient incision. When in doubt, the incision should be extended to enable safe removal of the occupied bag without undue risk of disruption and subsequent contamination. In particular, homemade retrieval bags are often more fragile and care is required to avoid tears during extraction from the abdomen [3, 4, 6].
Figure 4.25 (A). Homemade retrieval bags are cost effective. (B). Commercially available retrieval bags have a purse string that closes the bag before exteriorizing it through a port site. (C). Commercially available retrieval bags have a rigid rim that maintains a large opening of the bag, greatly facilitating insertion of tissue.
Figure 4.26 (A). A homemade retrieval bag for small lesions can be made out of a surgical glove. (B). Whereas a homemade retrieval bag requires a grasper to hold on to the bag, commercial bags often include a delivery system.
Suction and Irrigation Devices
Figure 4.27 (A). A suction irrigation device with a 2‐way stopcock and lateral fenestrations. (B, C). Image of 2‐way stopcock in different positions depending on the use of irrigation or suction.
Wound Protector and Retractor Devices
Wound retraction devices (Figures 4.29 and 4.30) are used in minimally invasive procedures to improve surgical exposure with 360° wound edge retraction, protect wound edges from contamination, and facilitate laparoscopic‐assisted procedures [10]. Wound retractors improve surgical exposure by applying even, outward circumferential pressure to the wound margins, transitioning a linear incision to a circular opening with improved working space. This improved surgical exposure is achieved without the need for lengthening the incision and enables the surgeon to insert at least one finger into the abdomen, providing palpation and haptic feedback during exploration [11]. Benefits of using a wound retraction device include atraumatic circumferential wound retraction, barrier protection of the body wall and skin against contamination by bacteria and/or neoplastic cells, and improved extracorporeal intestine exposure without compromising vascular supply [11–13]. Reports in human medicine demonstrate a significant decrease in the occurrence of surgical site infection in patients undergoing major
