Specimen retrieval during elective laparoscopic cholecystectomy: is it safe not to use a retrieval bag?
Majid et al. BMC Surgery
Specimen retrieval during elective laparoscopic cholecystectomy: is it safe not to use a retrieval bag?
Muhamed Hamid Majid
Sherif El Masry
Background: Since the introduction of laparoscopic surgery for gallbladder disease different types of retrieval devices have been used to extract the gallbladder from the peritoneal cavity. These devises infer additional costs and may lead to associated risks and complications. We aimed to evaluate the safety of gallbladder retrieval without the use of a retrieval device. Methods: A prospective study was conducted across two teaching hospitals in the Republic of Ireland from July 2010-2013. Patients undergoing planed elective day case laparoscopic cholecystectomy in the two institutions were included in the study. Data were collected on patient demographics, the use of a bag, any need for extension of fascial incision, any unexpected over night stay, any 30-day post operative complications and presence of port site hernia within 1 year surgery. Results: There were 373 planned elective day case laparoscopic cholecystectomy performed during the study period. A bag was not used to retrieve the gallbladder in 41 % (n = 152) patients. A retrieval bag was used in the majority of patients (71 %) who required over night stay due to pain. Overall wound infection rate was low (2.4 %), with 57 % of those being in patients where no retrieval bag was used. An increase incision in the fascia was required in 9.7 % of patients. The majority of these were in patients in whom a retrieval bag was used (75 %). At 1 year follow up, there were no recorded cases of port site hernia for the no retrieval bag group and two (0.9 %) cases of umbilical port site hernias in the group where retrieval bag was used. Conclusion: In cases of elective uncomplicated laparoscopic cholecystectomy for radiologically confirmed benign disease there was no benefit in using a retrieval bag. Furthermore, not using a bag was associated with less need for increasing the size of the fascial incision thereby reducing post operative pain and risk of port site hernia.
Laparoscopic cholecystectomy remains one of the most
common surgical procedures performed worldwide .
In the developed world 90 % of cholecystectomies are
completed laparoscopicaly. Since the introduction of
laparoscopic surgery for gallbladder disease different
types of retrieval devices have been used to extract the
gallbladder from the peritoneal cavity. These ranged
from simple non-powdered gloves to several types of
commercially produced bags [2, 3]. The use of retrieval
devices have been advocated for several reasons, including
prevention of wound infection and avoidance of port site
2129 Verdemont, Snugborrough road, Blanchardstown, Dublin 15, Ireland
Full list of author information is available at the end of the article
metastasis [4–10]. In laparoscopic cholecystectomy, their
use is thought to provide the further benefit of reducing
the risk of stone spillage into the peritoneal cavity.
However, the use of retrieval bags can make removal of the
specimen more difficult, requiring enlargement of the port
site incision and potential risk of abdominal organ damage
during bag insertion and retrieval [11, 12].
In cases of elective laparoscopic cholecystectomy,
there is rarely an ongoing inflammatory process which
obviates the risk of wound infection during specimen
retrieval. Furthermore, when the gall bladder is dissected
free without spillage of its contents, there is no further
benefit in placing it in a retrieval bag and in fact further
manipulation by trying to do so may lead to stone
spillage. With these factors in mind, we aimed to evaluate
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A prospective audit of ongoing practice of three consultant
surgeons across two teaching hospitals in the Republic of
Ireland from July 2010–2013 was conducted. All
participating surgeons had more than 10 years experience as
consultants and together over 5000 laparoscopic cholecystectomies
performed. It was standard practice for two of the surgeons
to use a commercially available retrieval bag (EndoCatch ®,
Covidien, USA) for all cases when removing the gallbladder
from the abdominal cavity, while one surgeons standard
practice was to use a retrieval bag only if there was spillage
of bile or stones from the gallbladder.
Pre-operative diagnosis of gall stones was confirmed
using biliary ultrasound scan in all cases. Patients
undergoing planed elective day case laparoscopic
cholecystectomy in the two institutions were included in the study.
Those who had bile or stone spillage during the
procedure were excluded as this necessitated the use of a
retrieval bag for all surgeons. The patients were selected
to undergo their surgery with the participating surgeons
through the standard referral pathway and all had a
consultation with the operating consultant or a member of
their team prior to surgery. All patients gave written
informed consent to undergo laparoscopic
cholecystectomy. The audit of practice conducted for this study was
registered with the hospital audit board. Only patients
with body mass index of <30 kg/m2 were eligible for
admission for elective day-case laparoscopic
cholecystectomy and were included in the study.
All patients underwent standard four port laparoscopic
cholecystectomy with initial para-umbilical camera port
inserted using Hasson technique, a further 10 mm
epigastric port and two 5 mm ports on right side were inserted
under direct vision. Once the gallbladder was dissected free,
it was retrieved through the umbilical port (either using a
retrieval bag or not) under direct laparoscopic visualisation
by moving the camera into the epigastric port. The
gallbladder was not aspirated, and stones were left intact within
the gallbladder. In cases where the specimen was too large
for extraction the facial incision was increased to facilitate
extraction. Standard prophylactic antibiotics included single
dose of 1.2 g Co-Amoxiclav at the time of induction, with
patients who were known penicillin allergic receiving 1.5 g
Cefuroxime instead. There was no protocol in place for
pre-operative bathing and all patients were admitted to the
hospital on the day of their procedure. Umbilical port
site closure was with polyglyconate absorb-able sutures
(0-Maxon). Skin incisions were closed with either metal
skin clips or a subcuticular suture using 4-0 monocryl.
The operative protocol, antibiotics use, pre- and post
operative management of patients was the same in both
institutions as its was the same medical team (surgical
and anaesthetic) working across both sites. Furthermore
both institutions were under same management, allowing
for homogeneous care across the two institutions.
Follow up for all patients was standardized, with each
arranged to attend their general practitioner (GP) 1 week
after surgery. Patients were given written information on
the signs and symptoms of wound infection, and given a
contact number for urgent out patient assessment in cases
where a wound infection was suspected. Similar written
information was provided to GPs with instructions to
contact the research team in cases where post operative
wound infection was suspected.
A superficial wound infection was defined as a skin or
subcutaneous infection requiring antibiotics. A deep
wound infection was defined as an infection requiring
drainage and exploration of the wound.
A 1-year follow-up appointment was provided to all
patients to assess for any delayed complications of surgery.
All patients who attended the hospital after 1 year
underwent a thorough clinical exam to look for a port site hernia.
If there was any doubt about the clinical findings the
patient was sent for an abdominal wall ultrasound to look for
the presence of a hernia.
Data were collected on patient demographics, the use of
a bag, any need for extension of fascial incision and any
unexpected over night stay. The collected data were
maintained in an institutional review board-approved database.
Categorical data were compared using the two-tailed
Fisher exact test and a p-value less than 0.05 was
There were 373 planned elective day case laparoscopic
cholecystectomy performed during the study period, the
majority of whom were women (76.4 %, n = 285). A bag
was not used to retrieve the gallbladder in 41 % (n =
152) patients compared to 69 % (n = 221) in whom a
retrieval bag was used. Retrieval bag rupture was recorded
in three patients (1.4 %). Table 1 outlines the
demographics data of the patients.
Overall 1.9 % (n = 7) of patients required unexpected
over night stay due to pain, 71 % (n = 5) of these were
patients in whom a retrieval bag was used and the remaining
29 % (n = 2) in patient in whom retrieval bag was not used.
There were no other recorded cases of unexpected over
night stay and all patients who stayed over night for
analgesic control were discharged on post operative day one.
There were nine (2.4 %) recorded wound infections
during the study, with the vast majority being superficial
wound infections (78 %, n = 7). Of the patients presenting
with superficial wound infections, 57 % (n = 4) were in
patients in whom retrieval bag was not used and the
remaining 43 % (n = 3) in patients where a retrieval bag
Table 1 Demographics
Follow up after 1 year
Missing 1 year follow up data
Mean = 52 (range 21–71)
24 % (n = 88)
76 % (n = 285)
51.5 % (n = 192)
48.5 % (n = 181)
No retrieval bag used
Mean = 53 (range 23–67)
23 % (n = 35)
77 % (n = 117)
54 % (n = 82)
46 % (n = 70)
Mean = 52 (range 21–71)
24 % (n = 53)
76 % (n = 168)
50 % (n = 110)
50 % (n = 110)
was used. All superficial wound infections were treated
with oral antibiotics and required no further intervention.
There were two recorded deep wound infections, one in
each group (retrieval bag used and retrieval bag not used).
Both patients required drainage of wound collection.
An increase incision in the fascia was required in
9.7 % (n = 36) of patients. The majority of these were in
patients in whom a retrieval bag was used (75 %, n = 27).
One year follow up data was collected for 51.5 % (n =
192) of patients with the remaining 48.5 % (n = 181) not
returning to their 1 year follow up appointment. The post
operative 1 year follow up attendance between the two
groups was similar at 54 % (n = 82/152) and 50 % (n = 110/
221) for the no retrieval bag used and retrieval bag used
groups respectively. At 1 year follow up, there were no
recorded cases of port site hernia for the no retrieval bag
group and two (0.9 %) cases of umbilical port site hernias
in the group where retrieval bag was used. Both of which
were diagnosed on clinical basis and required no imaging.
Histological examination showed no evidence of
malignancy in any of the removed specimens.
Table 2 outlines the comparative results of length of
stay (LOS), wound infection, need for increasing fascial
incision and port site hernias between the two groups.
There remains controversy regarding the optimal
retrieval device for laparoscopic cholecystectomy. In this
small study, using no retrieval device in cases of intact
gall bladder in uncomplicated cases showed no statistically
significant difference in the post operative LOS, wound
Table 2 Comparing variables between the two groups
infection rates, need for fascial incision extension and port
site hernia rates at 1 year follow up. Although there was no
statistical significant difference between the two groups, it
was noted that post operative pain, need for increasing
fascial incision and occurrence of port site hernias were
more common in patients where a retrieval bag was used.
The incidence of port site infection is quite low in
laparoscopic cholecystectomy, however it remains unclear as to
whether port site infection is due to contamination with
the contents of the gallbladder or from bacteria present on
the patients skin. A study performed by R. Harling et al. 
showed that in the majority of cases cultures grown from
port site infections were skin rather than biliary organisms.
As patients with intra-operative bile leak were excluded in
this study, it is likely that organisms responsible for wound
infections would be similar to those reported by Hurling et
al. However it is acknowledged that no swabs were taken in
this study to assess whether port site infections occurring
in patients who had their gallbladder removed without the
use of bag were skin or biliary organisms. Despite the
exclusion of patients who had bile leakage, it was noted that
wound infection rates were almost twice as common in
patients in whom a retrieval device was not used. While this
value did not reach statistical significance in the current
study, the noted trend would raise the possibility that mare
contact of the intact gall bladder may increase the risk of
wound infection. However the patients in this study were
not controlled for material used for skin closure which may
have been a more important factor in development of
wound infections. While there is lacking data on the
difference of wound healing after laparoscopic cholecystectomy
when using skin clips rather than subcuticular sutures. In
other studies sutured closure of wounds are suggested to
be superior to stapled closure [13–15].
All patients included in this study were planned to
undergo day case laparoscopic cholecystectomy. The
unexpected over night stay rate was 1.9 % which is within
the acceptable range and comparable to other institutions
. While no statistically significant difference was noted
between the two groups with regards to need for over night
stay, more patients having their gallbladder retrieved using
a bag were kept over night than those in whom a bag was
not used. Similarly the patients in whom a bag was used
required more frequent extension of the fascial incision and
it was only in this group that incisional hernias were
recorded. These findings would suggest that the use of bag
may more frequently lead to the need for increasing fascial
incision, thereby increasing post operative pain and risk of
incisional hernia. However the numbers did not reach
statistical significance. The size and weight of the gallbladder in
each case was also not recorded, which may well be a more
important factor for the need to extend the fascial incision
than the use of a retrieval bag.
The 1 year post operative follow up in this study was
just over 50 % which further limits the interpretation of
rates of insicional hernia recorded. However the recorded
rate of 1.8 % in the cohort in which a retrieval bag was
used is comparable to reported rates in other studies .
An often raised concern for why a retrieval bag should
be used is to reduce the risk of cutaneous seeding of
potential malignant cells if there is histological gallbladder
malignancy. Previous studies have shown the incidence of
malignancy at the time of cholecystectomy to range from
0.44 to 1.28 % [18–20]. There were no recorded cases of
gallbladder malignancy in this study. With adequate
preoperative imaging and normal gallbladder appearance
intraoperatively, this risk should be extremely low, but can
never be eliminated.
While many retrieval devices have been developed and are
frequently used across the world in laparoscopic
cholecystectomy, there is no consensus on the optimal retrieval
method. This study is the first to evaluate whether in fact
any retrieval device is necessary in cases of uncomplicated
elective laparoscopic cholecystectomy. The findings suggest
that where there is radiological confirmed benign disease
there is no benefit in using a retrieval bag. Furthermore,
not using a bag may reduce the need for increasing the size
of the fascial incision thereby reducing post operative pain
and risk of port site hernia.
We wish to acknowledge Mr El Masry as the senior author for this paper, his
conception of the idea for the audit of practice conducted, and the expert
directions provided. Dr Kohar and Majid for their hard work in data collection and
analysis and Dr Meshkat for analysing the results and writing the manuscript.
Availability of data and materials
Due to data protection, the raw data obtained for this is stored in Our Lady
of Lourdes Hospital and will only be available upon specific request.
MHM contributed to data collection and writing of the article. BM contributed
to data analysis and writing of article. HK contributed to data collection and
analysis. SEM development of study concept, supervision of data collection,
correction of article. All authors read and approved the final manuscript.
The authors have no competing interests to declare.
Ethics approval and consent to participate
As this study was a prospective audit of ongoing clinical practice, it was
registered as an audit with the hospital audit board.
Snugborrough road, Blanchardstown, Dublin 15, Ireland. 3Our Lady of
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