Difficulties with extracting the specimen are a frequent problem; however, they can be avoided by proper planning. It is important to make sure that adequate mobilization has been carried out intracorporeally before attempting to extract the specimen. The incision has to be tailored to the size of the specimen. The maximum transverse dimension of a tumor in cancer cases should be known to the operating surgeon and the extraction incision should be at least of that size to avoid fracturing of the specimen during extraction. Similarly, when extracting proctectomy specimens, the surgeon has to make allowance for a bulky mesorectum and make the extraction incision accordingly. If there is a struggle in extracting the mesorectum, it may tear leading to a suboptimal specimen. Prior to extraction, one has to make sure that the specimen is mobilized and completely free from the surrounding structures. It helps to place the specimen back in its anatomical position and utilized gravity to make sure the small intestine is not entangled in a way which will make extraction difficult. The exact patient positioning that will facilitate smooth specimen extraction will depend on whether it is a right colon resection, left colon resection, or low anterior resection that is being carried out. It is best to make a longer mark on the skin with a marking pen at the proposed extraction site so that if the incision has to be enlarged it remains in a straight line. We routinely use a wound protector during extraction of the specimens. If facing difficulty during extraction, the following factors should be looked into:
Sometimes, there will be a suction effect created inside the abdominal cavity during attempts at extraction. Insert your index finger and sweep around the colon to break that suction effect. This will also make sure that a portion of the specimen is not entrapped under the wound protector.
Make sure that the incision is big enough. Place your index finger while you are pulling and assess if that difficulty is due to a small incision. Sometimes, it helps to extract the appendices epiploicae using the index finger as they may be the reason why the specimen is stuck in a snug incision. If that does not help, extend the incision cranially or caudally and retry.
If the colon was not returned back to its normal anatomical position prior to extraction, it can get intertwined with small intestine loops, causing difficulty in extraction. This should not happen but is something to be kept in mind, especially if you come in to help someone else during the extraction phase of the operation. If not sure then insufflate and take a look laparoscopically.
Difficulty in extraction could be because of unrecognized attachments/incomplete mobilization. When the colon is exteriorized and pulled, an index finger is inserted, and these attachments can be felt and divided.
If it is not easy to divide these or specimen extraction is unusually difficult for any reason then re-insufflate the ...