Use of Natural Orifice for Specimen Extraction in Laparoscopic Solid Organ Surgery

Background: One of the limitations of laparoscopic solid organ surgeries is making a relatively big incision for specimen extraction. This is often encountered with large tumors and in cases where morcellation of the specimen would distort the tissue architecture hindering pathological examination. This report highlights the use of a natural orifice for specimen extraction to avoid the above mentioned difficulty. Case report: A 34 year old female with Hodgkin’s Lymphoma underwent concomitant laparoscopic splenectomy for massive splenomegaly and laparoscopic assisted vaginal hysterectomy and bilateral salpingo-oophorectomy for menometrorrhagia. Given the significant size of the specimen, 17 x 10 x 3.5 cm, there was concern preoperatively about the need to make a significant incision in the abdomen for specimen extraction. After the initial laparoscopic splenectomy through the transabdominal approach, the specimen was placed in an endocatch bag and left in the upper abdomen. Laparoscopic vaginal hysterectomy was then done. Prior to the closing of the vaginal cuff, with persistent gentle manipulation, the spleen was extracted through the vagina without any architectural distortion. The vaginal cuff was then repaired in a routine manner. This avoided a large incision in the abdomen. Estimated blood loss was 150 ml. The spleen weighed 425 grams. Patient recovered well from the surgery. Conclusions: Use of natural orifice for solid tumor extractions may be feasible in selected patients without oncological compromise. Laparoscopic resections for massive splenomegaly, although challenging, can be safely accomplished even in a community setting. Concomitant laparoscopic gynecologic and general surgery procedures can be done with good functional outcomes.