ExCITE: Minimally invasive tissue extraction made simple with simulation

1. Create the self-retaining retractor
Supplies: pantyhose, 2 silicone rings

A self-retaining retractor is tubular and made up of a thin plastic material that has a pliable ring on either end. The pantyhose is used to simulate the tubular plastic material, and the silicone bracelets serve as the ring ends of the retractor. The retractor should be large enough so that it does not slip through the incision.

First, cut off the toe end of the pantyhose. Measure and cut a pantyhose strip to approximately 38 cm (15 in). Place one end of the pantyhose through the center of one of the silicone bracelets and wrap it around the edges of the bracelet. Make it as even as possible all the way around the ring. Roll the pantyhose over the bracelet twice more to secure it. Repeat these steps for the other end of the pantyhose to create the simulated self-retaining retractor (FIGURE 5).

FIGURE 5 Simulated self-retaining retractor

2. Build the torso
Supplies: cardboard (ie, office paper box) or plastic box, scissors, duct tape

Place the cardboard box upside down and cut a hole (approximately 2−3 cm wide) at the center of the box top (technically the bottom of the box) to simulate the umbilical incision. Cut another opening on either side of the box (large enough to fit a hand so that the specimen can be inserted inside the box). When performing the ExCITE technique, a constant upward traction is required. In order to keep the box from lifting off the table, tape the box to the table with masking or duct tape. Alternatively, place weights in the bottom of the inside of the box.

3. Prepare the specimen
Supplies: beef tongue, resealable plastic bag

To simulate the contained fibroid or uterus, slice the beef tongue into 3 to 4 pieces (approximately 1-lb pieces) and place one piece of beef tongue inside the resealable plastic bag. Using the side opening in the box, place the bag with the specimen inside the box, and pull the bag through the “umbilical incision” hole, just as you would in a real case. When exteriorizing the bag, ensure some slack so the simulated self-retaining retractor can be placed inside the bag with the ring rolled over it (FIGURE 6).

FIGURE 6 “Torso” box and placement of self-retaining retractor

4. ExCITE technique simulation: Grasp, cut, extract
Supplies: #11-blade scalpel, penetrating clamps (tenaculum, Lahey, or towel clamps).

After exteriorizing the bag, place the self-retaining retractor inside the bag and roll the silicone ring until the retractor is flush with the anterior abdominal wall. Grab the specimen (beef tongue) inside the bag. Perform the ExCITE technique using the beef tongue and the simulated model to fully remove the specimen (FIGURE 7).

FIGURE 7 Intact, extracted beef tongue specimen

Ready, set, simulate
There are many advantages to being able to teach and practice the ExCITE technique outside of the OR. Simulation helps the surgeon to better understand the nuances of tissue extraction in a risk-free environment, and it can improve efficiency in the OR. Building the simulation model as we have described is simple, quick, and inexpensive. We hope that this technique will add to your surgical armamentarium so that you can continue to provide your patients minimally invasive gynecologic surgical options. We recommend that you view both of our videos related to the ExCITE technique and its simulation model at obgmanagement.com, and soon you will be ready to teach or practice the ExCITE technique.

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