CHAPTER 46: Surgeries for Gynecologic Malignancies

The five “types” of hysterectomy are defined in Chapter 30. Of these, radical hysterectomy differs from simple hysterectomy in that the parametrium, paravaginal tissue, and their lymphatics are widely resected to achieve negative tumor margins. Described in this section, type III (radical) hysterectomy is chiefly indicated for stage IB1 to IIA cervical cancer or small central recurrences following radiation therapy, or for clinical stage II endometrial cancer when tumor has extended to the cervix (Koh, 2015).

Type III radical hysterectomy is increasingly being performed by minimally invasive approaches. With these techniques, the principles of the abdominal operation are still applied. Namely, radical hysterectomy is a dynamic operation that requires a focused, consistent surgical approach but also significant intraoperative decision making. Familiarity with its concepts continues to be critically important in developing expertise in complex pelvic surgery.

PREOPERATIVE

Patient Evaluation

Radical hysterectomy is not appropriate for women with higher-stage cancers. Thus, accurate clinical staging is critical prior to selection of this surgery. Pelvic examination under anesthesia with cystoscopy and proctoscopy is not mandatory for smaller cervical cancer lesions, but the clinical staging described in Chapter 30 should be completed before proceeding surgically. To refine patient selection, for most patients with grossly visible cervical tumors, abdominopelvic computed-tomography (CT) or magnetic resonance (MR) imaging is also performed to identify nodal metastases or undetected local tumor extension. That said, there are limitations on what can be reliably detected preoperatively (Chou, 2006).

Consent

Women undergoing hysterectomy are specifically counseled regarding the loss of fertility. In those considering bilateral salpingo-oophorectomy (BSO), a discussion of menopause and hormone replacement is included and detailed in Chapter 43. The tone of the consenting process should reflect the extent of the operation required to hopefully cure or at least begin treatment of the malignancy. Moreover, a patient must be advised that the procedure may be aborted if metastatic disease or pelvic tumor extension is found (Leath, 2004).

Radical abdominal hysterectomy can result in significant morbidity from short- and long-term complications. These complications may develop more frequently in women with obesity, prior pelvic infections, and previous abdominal surgery, in whom surgery may be more difficult (Cohn, 2000). Of potential intraoperative complications, the most common is acute hemorrhage. Blood loss may reach 500 to 1000 mL, and transfusion rates are variable, but high (Estape, 2009; Naik, 2010). Subacute postoperative complications may include significant postoperative bladder or bowel dysfunction from surgical denervation (20 percent), symptomatic lymphocyst formation (3 to 5 percent), and ureterovaginal or vesicovaginal fistula (1 to 2 percent) (Franchi, 2007; Hazewinkel, 2010; Likic, 2008). With any cancer surgery, risk for venous thromboembolism (VTE) is also increased. Additionally, long-term effects on sexual function and other body functions are candidly reviewed and are detailed on page 1139 (Jensen, 2004; Serati, 2009).

Patient Preparation

For this, a blood sample is typed and crossmatched for potential transfusion. Pneumatic compression devices or subcutaneous heparin or both is planned because of the typically longer surgery and postoperative recovery times and the increased VTE risk associated with cancer (Table 39-8) (Martino, 2006).

Bowel preparation with a polyethylene glycol-electrolyte solution (GoLYTELY) is no longer commonly used. Inadvertent bowel injury is rare unless extenuating circumstances are identified. However, it may be helpful to empty the colon to limit fecal spill if extensive pelvic adhesions are anticipated due to prior infection, endometriosis, or radiation therapy.

Suitable perioperative antibiotic prophylaxis to prevent most surgical site infection is found in Table 39-6. Typically, a third-generation cephalosporin is given intravenously at spaced intervals. Compared with simple hysterectomy, the high-volume blood loss during radical hysterectomy clears antibiotics more rapidly from the operative site, and longer surgery may extend past the antibiotic half-life. Both necessitate the additional doses (Bouma, 1993; Sevin, 1991).

Concurrent Surgery

Early-stage cervical cancer most frequently spreads via the lymphatics. Thus, adjunctive lymph node removal seeks to identify occult metastases. Pelvic lymphadenectomy is typically completed just before or immediately after radical hysterectomy, and paraaortic lymphadenectomy may also be indicated in some circumstances (Angioli, 1999).

Spread to the adnexa is much less common than via the lymphatics. Thus, the decision for BSO depends on a woman’s age and potential for metastases (Shimada, 2006). If ovaries are preserved, then salpingectomy alone is recommended to reduce future risk of some epithelial ovarian cancers (Society of Gynecologic Oncology, 2013). In candidates for ovarian preservation, transposition of ovaries out of the pelvis may be considered in young women if postoperative radiation is anticipated. However, ovarian function may be short-lived. Also, in transposed ovaries, symptomatic periadnexal cysts are commonplace (Buekers, 2001). Oocyte and ovarian cryopreservation techniques have advanced and may soon be a more widespread option (Chap. 20).

INTRAOPERATIVE

Surgical Steps

Anesthesia and Patient Positioning

General anesthesia is mandatory, but epidural placement may be considered for postoperative pain control (Leon-Casasola, 1996). Bimanual examination is performed in the operating room before scrubbing to reorient a surgeon to the patient’s individual anatomy. The patient is positioned supine. After anesthesia administration, hair in the path of the planned incision is clipped if needed; a Foley catheter is placed; and abdominal preparation is completed.

Abdominal Entry

A midline vertical abdominal incision provides excellent exposure, but typically prolongs hospital stays and increases postoperative pain. Alternatively, Cherney or Maylard incisions offer postoperative advantages found with transverse incisions and allow access to the lateral pelvis (Chap. 43). However, upper paraaortic nodes are not readily accessible through these transverse incisions. A Pfannenstiel incision offers limited exposure and is reserved only for selected patients (Orr, 1995).

Exploration

After abdominal entry, a surgeon first thoroughly explores the abdomen for obvious metastatic disease. Firm, enlarged lymph nodes and any other suspect lesions are removed or biopsied. Confirmation of metastases or pelvic tumor extension leads to a decision on whether to proceed or abort an operation based on overall intraoperative findings and clinical situation (Leath, 2004).

Entering the Retroperitoneal Space

The uterus is placed on traction with curved Kelly clamps at the cornua. The round ligament is sutured with 0-gauge delayed-absorbable suture as laterally as possible, and the tie is held on tension to aid entry into the retroperitoneal space. Lateral round ligament transection later aids excision of the parametrium out to the pelvic sidewall. Once the round ligament is divided, the broad ligament beneath separates into thin anterior and posterior leaves that contain loose areolar connective tissue between.

Similar to simple hysterectomy, the anterior leaf of the broad ligament is placed on traction and is sharply dissected to the vesicouterine fold. The posterior leaf of the broad ligament is then placed on traction and sharply dissected along the pelvic sidewall parallel to the infundibulopelvic (IP) ligament.

Ureter Isolation

Loose areolar connective tissue of the retroperitoneal space is bluntly dissected in the area lateral to the IP until the external iliac artery is palpated just medial to the psoas major muscle. The index and middle fingers are placed on either side of the artery, and the areolar connective tissue is bluntly finger dissected toward the patient’s head using a backward “walking” motion (Fig. 46-1.1).

To permit further cephalad inspection, the medial portion of the broad ligament’s posterior leaf is elevated. This permits direct identification of the common iliac artery bifurcation and origins of the external and internal iliac arteries. Here, the ureter crosses over the bifurcation. To isolate the ureter at this site, the surgeon bluntly dissects with a finger or suction tip in a sweeping motion from top to bottom along the medial peritoneal leaf to identify and sufficiently mobilize the lateral surface of the ureter.

To free the medial surface, a Babcock clamp grasps the ureter, and Mixter right-angle clamp tips are opened and closed parallel to the ureter to develop an avascular space between it and its medial peritoneal attachment. Through this space, clamp tips are then passed beneath the ureter to grasp a quarter-inch-wide Penrose drain. The drain is then pulled through this space to surround and isolate the ureter. This assists in identifying its location throughout the remainder of surgery.

Creating Spaces

The parametrium that will be removed with the hysterectomy specimen lies between the paravesical and pararectal spaces. Thus, creation of these spaces is needed to isolate the parametrium for transection. The pararectal space is developed by gently placing the right index finger lateral to the IP and between the internal iliac artery and ureter. The finger tracks in a gentle swirling motion at a 45-degree angle downward toward the midline and aiming for the coccyx (Fig. 46-1.2). Once formed, this space is bordered by the rectum and ureter medially, internal iliac artery laterally, cardinal ligament anteriorly, and the sacrum posteriorly.

In contrast, the paravesical space is formed by holding the lateral tie of the round ligament and bluntly following the external iliac artery caudally to the pubic ramus. The index and middle finger of the right hand then sweep intervening avascular areolar tissue deeply and medially toward the midline. The developed paravesical space is bounded by the bladder and superior vesical artery medially, the external iliac vessels laterally, the pubic symphysis anteriorly, and the cardinal ligament posteriorly. Once paravesical and pararectal spaces are created, the parametrium is now isolated between these two openings.

Adnexa

With hysterectomy, ovaries may be retained or removed. If uninvolved with cancer, indications are similar to those for benign hysterectomy (Chap. 43). If ovarian preservation is planned, the surgeon performs salpingectomy by serially clamping, cutting, and ligating the mesosalpinx (Section 43-6). The uteroovarian ligament is then clamped, cut, and ligated close to the uterus. The ovary is tucked laterally during hysterectomy completion. Alternatively, if BSO is planned, the IP ligament is doubly clamped, cut, and ligated. The uteroovarian ligament is left intact and the adnexa are ultimately removed with the uterine specimen.

Uterine Artery Ligation

For this step, lateral reflection of the broad ligament’s lateral leaf just distal to the round ligament will reveal the superior vesical artery. This vessel is bluntly dissected to better define its location and is grasped with a Babcock clamp and placed on lateral traction. A right-angle clamp is used to develop an avascular space beneath the vessel that should accommodate a narrow curved Deaver retractor. Lateral traction on the superior vesical artery prevents its inadvertent ligation and aids in identification of the uterine artery (Fig. 46-1.3).

Next, a surgeon’s left hand is inserted into the pelvis with the middle finger placed in the paravesical space, the index finger in the pararectal space, and the uterus with attached Kelly clamps cupped in the palm. The uterus is held on firm medial traction to expose the lateral pelvic sidewall. To visualize the uterine artery, a surgeon sharply dissects parametrial attachments and intervening areolar connective tissue beginning at the internal iliac artery and continuing caudad to the superior vesical artery. The origin of the uterine artery is found during this caudal dissection.

Tissues surrounding the uterine artery are bluntly dissected, and a right-angle clamp is placed beneath this artery to retrieve a 2-0 gauge silk suture. The uterine artery tie is placed as close as possible to its origin from the internal iliac artery. The process is repeated to place a separate silk suture far enough medial to enable vessel transection. Black silk ties help identify the proximal and distal portions of the uterine artery throughout the remainder of the operation. A small vascular clip (Hemoclip) can also be placed lateral to the silk tie on the proximal uterine artery for additional security of hemostasis. The uterine artery is then cut. The underlying uterine vein may also then be isolated, clipped or tied, and cut.

Uniting Paravesical and Pararectal Spaces

The parametrial tissues have been pressed together by development of the paravesical and pararectal spaces. Parametrial resection to unite the upper (ventral) portion of these spaces begins near the sidewall, moves medially, and can be performed by several methods. These include: (1) clamping, cutting, and suturing, (2) stapling with gastrointestinal anastomosis (GIA) stapler, (3) electrosurgical blade dissection in which a right-angle clamp elevates and isolates parametrial tissue, or (4) use of an electrothermal bipolar coagulator (LigaSure) (Fig. 46-1.4). Dissection is continued until the parametrium overlying the ureter is mobile.

Ureter Mobilization

In this same area of the pelvis, tips of a right-angle clamp are positioned between the ureter and peritoneal leaf. As previously described, opening and closing the tips downward and parallel to the ureter develops an avascular plane to bluntly dissect the ureter from the medial peritoneal leaf. The ureter is placed on gentle lateral traction by grasping the previously placed Penrose drain with the left hand. The right index finger carefully sweeps the ureter downward and laterally until a “tunnel” through the paracervical tissue can be palpated ventromedially as the ureter enters this tissue (Fig. 46-1.5). Additional parametrial dissection is often required to ensure that the uterine artery and surrounding soft tissue has been lifted medially and off the ureter.

Bladder Dissection

Electrosurgical dissection is performed to free the bladder distally from the cervix and onto the upper vagina. This may need to be repeated several times as the tunnel is progressively unroofed and the ureter is more directly visible. To allow adequate vaginal margins, the bladder will eventually need to be dissected so that it lies several centimeters distal to the cervical portio and onto the upper vagina.

Unroofing the Ureteral Tunnel

The uterus is placed on lateral traction, and the proximal ureter is held on traction to straighten it by gently pulling on the Penrose drain. The previously created tunnel opening is palpated. Concurrently, a right-angle clamp is inserted with its tips directed upward, while direct visualization of the underlying ureter is confirmed. The tips are then directed medially toward the cervix, “pop” through the paracervical tissue, and create a new distal opening (Fig. 46-1.6). One tip of a second clamp is placed through the tunnel and then through the new distal opening. The clamp then closes around the paracervical tissue that lies above and lateral to the ureter.

Within the tunnel, the ureter is bluntly dissected and pushed posteriorly toward the tunnel floor. It should be visible below before cutting the overlying paracervical tissue. Delayed-absorbable 3–0 suture ties are used to secure the paracervical tissue pedicles that are held by the right-angle clamps, but significant bleeding is commonplace during these steps. The same procedure may be repeated several times caudally to completely unroof the tunnel and expose the ureter. The dissection proceeds in a proximal to distal fashion with direct visualization of the ureter at all times to prevent injury. After being unroofed, the ureter is retracted upward, and filmy attachments between the it and tunnel bed are sharply divided.

Uterosacral Resection

Posterior radical dissection is often best performed near the operation’s end because exposed retroperitoneal tissues typically ooze until the vaginal cuff is closed. The cervical external os is palpated, and at this level, the electrosurgical blade is used to superficially incise or “score” the peritoneum between the uterosacral ligaments. This score line joins the incision line of the previously cut posterior broad ligament peritoneum.

Between the uterosacral ligaments, a plane is developed by gently pressing a finger toward the vaginal wall without poking through and into the vaginal vault. This rectovaginal plane is developed by gentle pressure toward the sacrum and enlarged laterally until three fingers can be comfortably inserted. This maneuver frees the rectosigmoid from the uterosacral ligaments and prevents inadvertent bowel injury. Remaining peritoneal attachments are sharply dissected to fully expose the rectovaginal space. The exposed uterosacral ligaments can be visualized, palpated, clamped at the pelvic sidewall, then cut, and ligated with 0-gauge delayed-absorbable suture (Fig. 46-1.7). This procedure may need to be repeated to complete transection of the uterosacral ligament and adjacent supportive tissues.

Vaginal Resection

At this point in the operation, the radical hysterectomy specimen is held in place only by the paracolpium and vagina. The bladder and ureters are further bluntly and sharply dissected free until at least 3 cm of upper vagina will be included with the resected specimen. Curved clamps are placed on the lateral paracolpium. The ureter should be lateral and directly visible. Tissue is then cut and suture ligated with 0-gauge delayed-absorbable suture.

The upper vagina can then be: (1) clamped, cut, and suture ligated, (2) stapled, or (3) sharply transected with electrosurgical blade and suture ligated (Fig. 46-1.8). The specimen is carefully examined to ensure an adequate upper vaginal segment and grossly negative margins.

Suprapubic Catheter Placement

This catheter may aid postoperative voiding trials in carefully selected, motivated patients (Pikaart, 2007).

Ovarian Transposition

For those in whom ovarian function preservation is desired, transposing adnexa out of the anticipated pelvic radiation field is an option. A distal portion of the ovary is grasped with a Babcock clamp. Using traction, dissection is performed to mobilize the IP ligament so that the ovary can be lifted into the upper abdomen. For future radiography or CT interpretation, a large vascular clip is placed on the residual uteroovarian ligament stump to serve as an ovarian location marker. For transposition, a 0-gauge silk suture is placed at this stump site and tied. Its needle is covered but remains attached to the suture.

A handheld abdominal retractor is then used to expose an area of the lateral posterior peritoneum as high as possible in the abdomen. The silk suture needle is then uncovered and placed through the peritoneum, and the ovary is elevated by this “pulley-stitch” and tied. The lateral pelvic defect is closed with a continuous running stitch using 0-gauge delayed-absorbable suture to prevent internal herniation, that is, entrapment of bowel within the peritoneal defect. Ovaries are inspected before abdominal closure to exclude vascular compromise by transposition.

Final Steps

Active bleeding should be immediately controlled when the radical hysterectomy specimen has been removed. A dry laparotomy sponge may be held firmly deep in the pelvis for several minutes to tamponade raw surfaces. Topical hemostatic agents may be employed (Table 40-5). With bleeding controlled, a surgeon then assesses the vascular support to the ureter and other sidewall structures. To structures that appear particularly devascularized, an omental J-flap may provide additional blood supply (Section 46-14) (Fujiwara, 2003; Patsner, 1997). Routine pelvic suction drainage and closure of the peritoneum are not necessary (Charoenkwan, 2014; Franchi, 2007).

POSTOPERATIVE

Immediate postoperative care following radical hysterectomy in general follows that for laparotomy. Early ambulation after radical hysterectomy is especially important to prevent thromboembolic complications (Stentella, 1997). Moreover, following laparotomy for cancer, anticoagulants are continued for 2 to 4 weeks postoperatively (American College of Obstetricians and Gynecologists, 2013). Early feeding, including rapid initiation of a clear liquid diet, may also shorten the hospital stay (Kraus, 2000).

Bladder tone returns slowly, and a major cause is thought to be partial sympathetic and parasympathetic denervation during radical dissection (Chen, 2002). Thus, Foley catheter drainage is commonly continued until a patient is passing flatus because improving bowel function typically accompanies resolving bladder hypotonia. Removal of the catheter or clamping of the suprapubic tube should be followed by a successful voiding trial (Chap. 42). A voiding trial may be attempted prior to hospital discharge or at the first postoperative visit. Patients with adequate function are instructed to press gently on the suprapubic area for several days afterward to help completely empty the bladder during voiding and prevent retention. Successful voiding may take several weeks to achieve. In addition to urinary retention, tenesmus and constipation are frequent immediate symptoms that should improve significantly over months or years (Butler-Manuel, 1999; Sood, 2002). Postoperative stool softeners are often prescribed.

Nerve-sparing radical hysterectomy is a method demonstrating improved postoperative bladder function (Raspagliesi, 2006). However, many patients have preexisting abnormal urodynamic findings that are simply exacerbated by radical hysterectomy (Lin, 1998, 2004). In the 3 percent of women who develop long-term bladder hypotonia or atony, intermittent self-catheterization is preferred to indwelling urinary catheterization (Chamberlain, 1991; Naik, 2005).

For cervical cancer patients undergoing BSO, estrogen replacement therapy is not contraindicated and may be initiated in the hospital at the discretion of the treating oncologist. Cervical cancer survivors treated with radical hysterectomy have much better sexual functioning than those who receive radiation therapy. Despite this, more than half of surgical patients postoperatively report a worse sex life (Butler-Manuel, 1999). Severe orgasmic problems, uncomfortable intercourse due to reduced vaginal length, and severe dyspareunia may develop but often resolve within 6 to 12 months. However, persistent lack of sexual interest and poor lubrication may be long-term or permanent changes (Jensen, 2004). Disturbed vaginal blood flow response during sexual arousal may account for much of the reported constellation of symptoms (Maas, 2004). Eventually, patients treated by surgery alone can expect a quality of life and overall sexual function similar to peers without a history of cancer (Frumovitz, 2005).

Four procedural differences distinguish a modified radical hysterectomy (type II) hysterectomy from the more radical type III procedure (Section 46-1). First, the uterine artery is transected where it crosses the ureter (rather than at its origin from the internal iliac artery). Second, only the medial half of the cardinal ligament is resected (instead of division at the sidewall). Additionally, the uterosacral ligament is divided halfway between the uterus and sacrum (rather than at the sacrum). And last, a smaller margin of upper vagina is removed. These modifications serve to reduce surgical time and associated morbidity, while still enabling complete resection of smaller cervical tumors (Cai, 2009; Landoni, 2001).

Clear indications for modified radical hysterectomy are few and controversial (Rose, 2001). Stage IA1 (with lymphovascular space invasion) or IA2 cervical cancer are the most common diagnoses (Koh, 2015). Type II hysterectomy is also performed on occasion for: (1) preinvasive or microinvasive disease when a more invasive lesion cannot be excluded, (2) selected stage IB1 disease with <2 cm lesions, and (3) small central postirradiation recurrences (Cai, 2009; Coleman, 1994; Eisenkop, 2005). In addition, a variation of this operation may be performed if more extensive dissection is required for known benign disease. Anatomic landmarks that distinguish a type II hysterectomy are somewhat vague, and thereby allow a surgeon to sculpt the procedure to a patient’s specific situation (Fedele, 2005). Similar to the type III radical procedure, modified radical hysterectomy is increasingly being performed using a minimally invasive approach.

PREOPERATIVE

Preparation for surgery should proceed with the same care and discretion that is essential for the success of radical (type III) abdominal hysterectomy (Section 46-1).

INTRAOPERATIVE

Surgical Steps

Anesthesia and Patient Positioning

Modified radical hysterectomy is performed under general anesthesia with the patient supine. Bimanual examination is performed in the operating room before scrubbing to reorient a surgeon to a patient’s individual anatomy. The abdomen is surgically prepared, and a Foley catheter is placed.

Abdominal Entry

Modified radical hysterectomy may be safely performed through a midline vertical or low transverse incision (Fagotti, 2004).

Retroperitoneal Dissection

The ini­tial steps of modified radical (type II) hystere­ctomy mirror those of the type III procedure. The retroperitoneum is opened to identify structures, the ureter is mobilized, and the paravesical and pararectal spaces are developed to exclude the possibility of parametrial tumor extension before proceeding with this less radical operation (Scambia, 2001). As with radical hysterectomy, adnexa may be spared or removed.

Uterine Artery Ligation

At this point, type II hysterectomy begins to differ from the radical type III procedure. The superior vesical artery does not have to be identified, nor does the entire extent of the internal iliac artery need to be dissected free of adventitial tissue. The ureteral tunnel opening is palpated, and the uterine vessels divided at that location (Fig. 46-2.1). Ligation of the uterine artery as it crosses the ureter allows preservation of distal ureteral blood supply.

Cardinal Ligament Resection

The bladder is mobilized distally off the cervix and onto the upper vagina. Parametrial tissue at the sidewall does not require mobilization over and off the ureter (as in a type III hysterectomy). Posterolateral attachments of the ureter remain intact, and only the medial halves of the cardinal ligaments are resected by successive clamping, cutting, and suture ligation of the paracervical tissue that lies medial to the ureter (Fig. 46-2.2). In contrast to the type III hysterectomy, the ureter is not dissected out of the tunnel bed, but is rolled laterally to expose the medial cardinal ligament.

Uterosacral Resection

Posterior dissection is also modified. Uterosacral ligaments are only clamped halfway to the pelvic sidewall (instead of “at” the pelvic sidewall) and transected (Fig. 46-2.3). The uterus and adjacent parametrium can then be lifted well out of the pelvis and any additional tissues also clamped, cut, and ligated.

Vaginal Resection

At this point, the modified radical hysterectomy specimen is held in place only by the paracolpium and vagina. The bladder and ureters are further bluntly and sharply dissected free until at least 2 cm of upper vagina will be included in the specimen (instead of 3 to 4 cm). Curved clamps are placed on the lateral paracolpium, cut, and suture ligated.

The upper vagina can then be: (1) clamped, cut, and suture ligated, (2) stapled, or (3) sharply transected with electrosurgical blade and suture ligated. The specimen is carefully examined to ensure an adequate upper vaginal segment and grossly negative margins.

POSTOPERATIVE

In general, postoperative care follows that for radical hysterectomy, but the incidence of complications is lower (Cai, 2009). Partial sympathetic and parasympathetic denervation should be much less extensive with a modified radical hysterectomy. Thus, bladder dysfunction is much less likely than following a type III radical hysterectomy, and successful voiding begins much earlier (Landoni, 2001; Yang, 1999). Foley catheter drainage may be discontinued on the second postoperative day and is followed by a voiding trial (Chap. 42). In addition, bowel and sexual dysfunction should also be less pronounced.

Since the 1990s, experience with this procedure has accrued, and rates of both laparoscopic and robotic radical hysterectomy have increased (Wright, 2012). Compared with laparotomy, a minimally invasive surgery (MIS) approach appears to offer comparable cancer survival rates and has similar rates of most surgical complications (Lee, 2010; Yan, 2011). With MIS, less intraoperative blood loss and shorter hospital stays are noted, but operative times can be longer depending on surgeon proficiency (Soliman, 2011).

Whether radical hysterectomy with pelvic lymphadenectomy is completed via laparotomy or with MIS, the cancer indications and surgical steps are the same. Thus, compared with simple hysterectomy (type I), greater resection of parametrial and paracolpium tissue and their lymphatics is essential to help ensure tumor-free surgical margins. This degree of resection requires significantly more retroperitoneal dissection, during which the ureter and major vessels must be identified to aid resection and avoid injury.

PREOPERATIVE

Patient Evaluation

Thorough preoperative pelvic examination reveals factors that help determine the optimal surgical approach for a given patient. For example, a large broad or bulky uterus may be difficult to manipulate during MIS, may block views, and may be too large for vaginal removal. Importantly, morcellation is avoided with any gynecologic malignancy.

General challenges to MIS, such as obesity, are described in Chapter 41. That said, laparoscopy can be a successful option for many obese patients and offers lower rates of postoperative wound infection, which is often a major complication after laparotomy in these patients (Park, 2012). Once a patient is deemed eligible for an MIS approach, the same preoperative evaluation as for an open procedure applies.

Consent

Risks of MIS radical hysterectomy mirror those listed for radical abdominal hysterectomy. Patient factors that contribute include older age, previous abdominal surgery, and prior radiotherapy (Chi, 2004).

General complications related to MIS are discussed in Chapter 41. With minimally invasive radical hysterectomy specifically, there is also increased concern for nerve injury from a longer operation in lithotomy and steep Trendelenburg position. Additionally, the risk of conversion to an open procedure is discussed. This risk may be increased if exposure and organ manipulation are limited.

Patient Preparation

Preoperative preparation is the same as for an open procedure. Thus, antibiotics and VTE prophylaxis are warranted (Tables 39-6 and 39-8). Benefits of mechanical bowel preparation can be debated and are individualized. If considered, an evacuated rectosigmoid may improve colon manipulation and pelvic anatomy visualization. Options are found in Chapter 39.

Concurrent Surgery

Pelvic lymphadenectomy is typically completed just before or immediately after radical hysterectomy, and paraaortic lymphadenectomy may also be indicated in some circumstances. An MIS approach to lymph node removal in these areas is described in Section 46-12.

Planned oophorectomy should depend on a woman’s age and potential for metastases (Hu, 2013). Ovarian metastasis is rare with early-stage cervical cancer, and particularly with squamous cell carcinoma. Thus, if preservation is chosen, the ovary can be transposed with MIS techniques to the upper abdomen. This is done to help extend ovarian function if later radiotherapy is required. However, ovarian longevity may be shortened postoperatively, and symptomatic ovarian cysts are common. Moreover, advancements in oocyte and ovarian cryopreservation may soon provide suitable alternatives.

Regardless of ovarian preservation, salpingectomy is now encouraged for all women undergoing hysterectomy (Society of Gynecologic Oncology, 2013). As explained in Chapter 35, this practice is hoped to lower rates of high-grade ovarian and peritoneal serous carcinomas.

INTRAOPERATIVE

Instruments

Basic MIS tools for laparoscopic or robotic surgery are required. Important instruments for radical hysterectomy include 5- and 12-mm trocars, combined irrigation/suction device, vaginal probe, and energy devices for cutting and vessel sealing. For the latter, several electrosurgical and ultrasonic energy-based devices are adapted for either laparoscopic or robotic cases. These include Harmonic scalpel, electrosurgical monopolar instruments, and electrothermal bipolar coagulator devices (LigaSure, ENSEAL, PK Dissecting Forceps). For laparoscopy, the argon-beam coagulator is another option. While operating in the pelvis, a 0-degree laparoscope can be used, although a laparoscope with a 30-degree lens system may also be advantageous in certain circumstances to provide superior lateral views.

Surgical Steps

Anesthesia and Patient Positioning

The patient is initially supine for general endotracheal anesthesia induction. For VTE prophylaxis, lower extremity compression devices are placed. Legs are then positioned in adjustable booted support stirrups in low lithotomy to permit adequate perineal access. Positioning should permit a transvaginal uterine manipulator to move easily in all directions. As described in Chapter 41, appropriate positioning of legs within the stirrups and arms at the side is crucial to reduce nerve injury risks.

Bimanual examination is performed in the operating room before scrubbing to reorient a surgeon to the patient’s individual anatomy. The abdomen, perineum, and vagina are then surgically prepared, and a Foley catheter is inserted. To avoid stomach puncture by a trocar during primary abdominal entry, an orogastric or nasogastric tube is placed to decompress the stomach.

During MIS radical hysterectomy, a manipulator is frequently placed to aid uterine repositioning and help acquire adequate vaginal surgical margins. Several uterine manipulators are described and illustrated in Chapter 44. Popular options include a RUMI manipulator/KOH ring combination or a V-Care device. However, in cervical cancer cases, if a bulky cervical lesion is present, a blunt vaginal probe in the vaginal fornix may be all that can be inserted.

Port Placement

An illustrated des­cription of MIS entry into the abdominal cavity is found in Chapter 41. Suitable entry methods include the open technique, direct trocar insertion, or transumbilical insertion of a Veress needle. For gynecologic oncology cases, the open technique is often used to minimize vascular or bowel puncture risk. With primary entry, an umbilical or supraumbilical site is preferred. Following entry, a 10- or 12-mm Hassan trocar with a blunt obturator is placed into the abdominal cavity and is secured to the fascia. Through the trocar, the obturator is removed and replaced by a 10-mm laparoscope.

After abdominal insufflation, the abdomen and pelvis are thoroughly inspected to assess the extent of disease and adhesions. At this point, confirmation of metastatic disease or pelvic tumor extension should prompt a surgeon to decide whether to proceed or abort the operation based on intraoperative findings and clinical situation. Moreover, the decision is made to proceed laparoscopically or convert to laparotomy.

For laparoscopy, the surgeon stands on one side of the patient, whereas one assistant occupies the opposite side and another stands between the patient’s legs. To proceed, other ports are placed under direct laparoscopic visualization. Anatomic landmarks are identified to guide port placement and avert vascular puncture injuries. For complex MIS gynecologic procedures, four port sites are preferred (Fig. 46-3.1). Additional ports are placed according to surgeon preference. These ideally have a minimum of 8 cm between them to allow ample range of motion and for robotic cases, to avoid arm collision.

Opening the Retroperitoneum

This is the initial step to opening the paravesical and pararectal spaces bilaterally and identifying the ureter. Development of these spaces allows the parametrial tissue to be isolated and later resected.

First, the assistant angles the uterus to the contralateral side of dissection using a uterine manipulator and/or a grasper holding one cornu. This creates tension across the round ligament, which is divided at its midpoint. Transection may be accomplished using any of the energy-based devices previously listed.

Once the round ligament is transected, the broad ligament beneath it separates into thin anterior and posterior leaves, with loose areolar connective tissue between them. The anterior leaf is tented upward by graspers and sharply incised with monopolar scissors or other energy-based device. Incision extends caudally and medially toward the vesicouterine fold and halts near the midline.

To further expand the retroperitoneal opening, the drape of peritoneum lying between the divided round ligament and infundibulopelvic (IP) ligament is elevated with smooth graspers. Incision of this tented peritoneum is extended cephalad toward the pelvic brim but remains lateral and parallel to the IP (Fig. 46-3.2). This exposes the external iliac vessels and provides access to the ureter.

Ureteral Identification

This is accomplished by precise sharp and blunt dissection just lateral to the medial leaf of the opened peritoneum. For this, a blunt probe or the closed tips of a grasper may be selected. Dissection is advanced downward, medially, and slightly cephalad with gentle back-and-forth cephalad-caudad strokes into the gauzy retroperitoneal tissue and over the presumed ureter path (Fig. 46-3.3). The ureter is identified and traced along the medial leaf of the peritoneum.

Creating Spaces

The uterus remains deviated to the contralateral side to develop the pararectal space. This avascular space is bounded by the rectum and ureter medially, the internal iliac artery laterally, the cardinal ligament and uterine artery caudally, and sacrum cephalad. Within these borders, the tips of closed scissors or other blunt tip push downward and medially through loose connective tissue (Fig. 46-3.4). The surgeon directs dissection downward toward the midline, aims for the pelvic floor, and stops once the levator ani muscles are reached.

For the paravesical space, boundaries are the external iliac vessels laterally, the bladder and obliterated umbilical ligament medially, the pubic symphysis caudally, and the cardinal ligament cephalad. To open this space, the previously incised edge of the broad ligament’s anterior leaf is lifted at a point between the bladder and pelvic sidewall. Superficial loose connective tissue lies medial to the external iliac vessels and is bluntly dissected with closed scissors or grasper (Fig. 46-3.5). Staying medial to the external iliac vein and lateral to the superior vesicle/obliterated umbilical artery, dissection is directed caudally until the curve of the pubic ramus is reached.

Once the paravesical and pararectal spaces are opened, the parametria is now isolated between these two spaces for later resection. This dissection also helps to mobilize the bladder, discussed next, and to expose the external iliac vessels, which will aid later pelvic lymphadenectomy.

Bladder Mobilization

During radical hysterectomy, the bladder is dissected free from the cervix and upper vagina. The mobile bladder is moved caudad and protected during final vaginal transection. To mobilize the bladder, the peritoneum at the vesicouterine fold is grasped with atraumatic graspers and elevated to create tension between it and the underlying cervix (Fig. 46-3.6). The vesicouterine space, the potential space between the bladder and cervix, is opened using sharp and blunt dissection. Only loose connective tissue fibers lie in this space and are easily cut. Incision of these bands is kept close to the cervix to avoid cystotomy. Dissection in the midline minimizes laceration of vessels that course within the vesicocervical ligaments, colloquially termed bladder pillars. Once the correct plane is entered, the pearly white cervix and anterior vaginal wall below are clearly differentiated from the more opaque bladder.

Ultimately, the bladder is moved sufficiently caudad to permit excision of up to 3 cm of proximal vagina at the procedure’s end. This aids acquisition of tumor-free surgical margins. Generous dissection also avoids incorporating bladder fibers into the cuff closure, which could lead to bladder injury or to later genitourinary fistula.

Uterine Artery Ligation

For this step, the pelvic sidewall vessels are exposed. By visually moving from the common iliac artery toward its bifurcation, a surgeon can identify the internal iliac artery. The first anterior branch of the internal iliac artery is the umbilical artery. The uterine artery is the second branch and courses medially and over the ureter.

Alternatively, to isolate the uterine artery, the superior vesical artery is identified by blunt dissection on the medial border of the paravesical space. The vessel is followed cephalad to identify the uterine artery origin. In most instances, the uterine artery originates from the internal iliac artery and is identified by its medial course toward and over the ureter.

To isolate the uterine artery for ligation at its origin from the internal iliac artery, tips of a grasper are positioned beneath the vessel. Opening and closing the grasper tips, while directing dissection downward, develops an avascular plane around the artery. Importantly, the uterine vein lies just beneath the artery, and its injury can compromise visibility from brisk bleeding. Once isolated, the uterine artery is coagulated using a vessel-sealing device and divided (Fig. 46-3.7). The artery ends are then elevated to identify the uterine vein, which is similarly isolated, coagulated, and divided.

Ureteral Mobilization and Para­metrial Dissection

Ultimately, during a radical procedure, the ureter is freed in stages from surrounding tissue until its insertion into the bladder is reached. This dissection allows the ureter to be reflected laterally and protected during the wide parametrial excision required for radical hysterectomy.

During early dissection, atraumatic graspers tent up the medial posterior peritoneal leaf to which the ureter is attached. The tips of a right-angle grasper are then positioned between the ureter and peritoneum. Opening and closing the tips downward and parallel to the ureter develops an avascular plane to dissect the ureter free.

Such dissection continues caudally until parametrial tissue surrounding the ureter is met. This tissue is confined between the paravesical and pararectal spaces, contains the divided uterine vessels, and will be dissected medially and up and off the ureter. For this, connective tissue around the medial coagulated end of the uterine artery is grasped laterally and then lifted up and medially (Fig. 46-3.8). Loose connective tissue bands holding the artery and vein and surrounding parametria to the pelvic floor are coagulated and sharply transected. Dissection is continued medially until the lateral border of the ureter is reached.

For ureterolysis, caudally directed tips of a Maryland grasper are insinuated and opened within the avascular space overlying the ureter. This exposes tissue pedicles on the ureter’s lateral aspect, which are then coagulated and cut. The uterine vessels and parametrium are then pulled medially and reflected off the ureter. They will be removed with the final specimen.

During continued caudal ureterolysis, the ureter is seen to enter a “tunnel” within the pubocervical ligament (Fig. 46-3.9). To open this tunnel and free the ureter, the ureter is retracted downward and laterally. Within the tunnel, caudally directed grasper tips are insinuated and opened within the space overlying the ureter. Tips of an energy-based tool then elevate the tunnel roof above and away from the ureter. This pubocervical ligament roof and the veins within it are then transected. The roof is divided in small increments caudally until completely opened. At this point, the ureteral insertion into the bladder can be identified. The ureter can then be bluntly rolled off the tunnel “floor” and moved laterally with an atraumatic tool to allow later cardinal ligament transection without ureteral injury.

Adnexectomy or Ovarian Preser­vation

The IP ligament or the uteroovarian ligament will be transected depending on whether the ovary is removed or retained, respectively. Steps for both mirror those with benign hysterectomy and are fully illustrated in Section 43-12. For these steps, a window is made in the posterior broad ligament below the IP ligament. The window can be made bluntly or with an energy-based tool, and the window is then enlarged. The incision is opened parallel to the IP ligament and is extended cephalad toward the pelvic brim and medially toward the uterosacral ligament. The ureter should be clearly identified to avoid its injury.

For adnexectomy, the IP ligament is divided with a vessel-sealing device followed by cutting. In contrast, if the ovary is to be preserved, then salpingectomy alone is first completed. For this, the mesosalpinx is divided with a vessel-sealing and cutting device, and resection progresses from the fimbria to its union with the uterus. Next, the uteroovarian ligament is transected with the same device, and the ovary is tucked over to the sidewall until hysterectomy completion.

If ovarian preservation is chosen, the ovary can be transposed laparoscopically. With this, the IP ligament is further dissected cephalad by extending the peritoneal incision on both the medial and lateral sides of the IP ligament. This mobilizes the ovary, whose uteroovarian ligament stump is then sutured to the lateral peritoneum in the upper abdomen as described on page 1138. Importantly, following transposition, the ovary is inspected to confirm adequate blood supply. A clip can be placed at the uteroovarian stump so that it can be delineated on future imaging studies.

At this point, steps 3 through 9 are completed on the contralateral side.

Rectovaginal Space

Developing this potential space moves the rectum downward to isolate the uterosacral ligaments for wide resection. It also permits adequate excision of the proximal vagina for tumor-free margins without rectal injury. First, the uterus is retracted upward in the midline, and the peritoneum between the uterosacral ligaments is incised at the level of the external cervical os (Fig. 46-3.10). The peritoneal edge closer to the rectum is then grasped and tented outward with atraumatic graspers, and the rectovaginal space is open with a blunt dissector moved side to side. This exposes connective tissue bands and small vessels between the rectum and vagina. These bands are cauterized and transected close to the vagina with an energy-based device (Fig. 46-3.11). Dissection continues 4 cm caudally to ultimately allow a 3-cm vaginal resection.

Uterosacral Ligament Transection

The uterosacral ligaments, which are now isolated, can then be ligated as close to the sacrum as possible with an energy-based tool (Fig. 46-3.12). Before division of the ligament, the ureter is retracted laterally for protection.

Cardinal Ligament Division

Next, the lateral attachments of the cervix to the pelvic sidewalls are coagulated and transected with an energy-based device in a caudal direction (Fig. 46-3.13). During this step, the deep uterine vein is usually encountered and should be sufficiently sealed and divided. Also, the plane of transection stays at or slightly below the level of the ureter. This avoids extensive autonomic pelvic plexus damage, which exacerbates bladder and possibly bowel and sexual dysfunction.

Vaginal Resection

With complete mobi­lization of the bladder and rectum, the anterior and posterior vagina should be easily identified. The radical hysterectomy specimen is now held in place only by the paracolpium and vagina. The goal of radical hysterectomy resection is to remove approximately 3 cm of the upper vagina. For this, transverse anterior and posterior colpotomy incisions are made and extended circumferentially around the cervix (Fig. 46-3.14). Delineating marks on the uterine manipulator can help direct colpotomy.

The uterus, cervix, vaginal margin, and parametrial tissue are then freed. The specimen is removed intact through the vagina. The final specimen is labeled “radical hysterectomy specimen” and includes cervix, uterus, vaginal margin, and parametrial tissue (Fig. 46-3.15).

Vaginal Cuff Closure

Closure of the vaginal cuff can be performed by multiple methods. As noted earlier, one option is cuff closure from a vaginal approach as done during simple vaginal hysterectomy (Section 43-13). Alternatively, suitable endoscopic closure techniques are described and detailed in Section 44-11. Following cuff closure, lymphadenectomy is begun and is described in Section 46-12.

Both the ureters and bladder can be injured during these procedures. If injury is suspected, cystoscopy at the end of the procedure can aid injury recognition (Section 45-1).

Port Removal and Fascial Closure

Once procedures have been completed, an inspection for hemostasis is performed. Ports are then removed under direct visualization. All fascial defects larger than 10 mm are closed with 0-gauge delayed-absorbable suture to avoid hernia development at the site. Various methods of skin closure are described in Chapter 40.

POSTOPERATIVE

Immediate postoperative care following minimally invasive radical hysterectomy in general mirrors that for other minimally invasive procedures. Diet is advanced more quickly than with open procedures, and most patients will tolerate a regular diet early on postoperative day 1. Patients are often discharged home on postoperative day 1 or 2 since their pain is well controlled. As with open radical procedures, the same principles for retaining a Foley catheter do apply. Therefore, many patients will be sent home with the Foley catheter and return to clinic for a voiding trial (Chap. 42).

Following minimally invasive radical hysterectomy, patients may be at increased risk for vaginal cuff dehiscence compared with an open approach. In one series, the rate was 1.7 percent and was similar whether surgery was completed laparoscopically or robotically (Nick, 2011). The closure technique of the vaginal cuff is the suggested cause. Thus, many advocate vaginal rather than endoscopic cuff closure to decrease this risk (Fanning, 2013; Uccella, 2011).

Total pelvic exenteration removes the bladder, rectum, uterus (if present), and surrounding tissues. It is generally indicated for curative situations when less radical surgery, chemotherapy, or radiation options have been exhausted. The most common indication is centrally persistent or recurrent cervical cancer after radiation therapy. Less frequent indications include some instances of recurrent endometrial adenocarcinoma, uterine sarcoma, or vulvar cancer; locally advanced carcinoma of the cervix, vagina, or endometrium when radiation is contraindicated such as prior radiotherapy or malignant fistula; and melanoma of the vagina or urethra (Berek, 2005; Goldberg, 2006; Maggioni, 2009). Palliative exenterations may be of benefit on rare occasions when selected patients have severe, unrelenting symptoms (Guimarães, 2011).

Because exenteration commonly follows radiation therapy, the uterus and cervix usually have lost their distinct tissue architecture and boundaries. As a result, traditional hysterectomy steps and anatomic landmark identification are typically not possible. Minimally invasive exenterative procedures have been reported and may rarely be indicated in highly selected patients (Martinez, 2011; Puntambekar, 2006).

Total pelvic exenterations are subclassified based on the extent of pelvic floor muscle and vulvar resection (Table 46-4.1) (Magrina, 1997). Supralevator (type I) exenteration may be indicated when a lesion is relatively small and does not involve the lower half of the vagina. Most total pelvic exenterations will be infralevator (type II). This type is selected if vaginal contracture, prior hysterectomy, or the inability to otherwise achieve adequate margins is present. Rarely, tumor extension warrants an infralevator exenteration with vulvectomy (type III).

PREOPERATIVE

Patient Evaluation

Initially, biopsy confirmation of recurrent invasive disease is performed. With confirmation, the single most important preoperative challenge is to search for metastatic disease that would abort plans for surgery. Chest radiography is mandatory. Abdominopelvic CT is also routinely indicated, but a positron emission tomography (PET) scan may be particularly helpful (Chung, 2006; Husain, 2007). Hydroureter and hydronephrosis are not absolute contraindications unless they are due to obvious pelvic sidewall disease.

Patients often initially reject the entire concept of this operation even when faced with the knowledge that it represents their only chance for cure. Counseling is essential, and overcoming denial may take several visits. Regardless, not all eligible women will wish to proceed.

Consent

The consenting process is the ideal time to finalize plans for the type and location of urinary conduit, plans for colostomy or low rectal anastomoses, and need for vaginal reconstruction or other ancillary procedures. A patient is also advised that the procedure may need to be aborted based on intraoperative findings.

For those who undergo exenteration, the perioperative mortality rate approaches 5 percent (Marnitz, 2006; Sharma, 2005). However, the mortality rate from progressive cancer would otherwise be 100 percent. Patients should be prepared for admission to an intensive care unit (ICU) postoperatively. Infection, wound breakdown, bowel obstruction, and venous thromboembolic events are common short-term complications. Additionally, intestinal fistulas or anastomotic leaks or strictures may develop. Reoperation may be required. Most women will experience significant morbidity and unforeseen complications (Berek, 2005; Goldberg, 2006; Maggioni, 2009). Preexisting medical problems, morbid obesity, and malnutrition increase these risks.

Long-term effects on sexual function and other body functions are candidly reviewed. Patients with two ostomies have a lower quality of life and poorer body image. However, in those who retain vaginal capacity, quality of life and sexual function is reportedly improved compared with those without reconstruction. Thus, counseling regarding vaginal reconstruction is part of the preoperative dialogue (Section 46-9). In general, a woman returns to baseline functioning within a year postoperatively, but quality of life is often affected by worries regarding tumor progression (Hawighorst-Knapstein, 1997; Rezk, 2013). Patients should be aware that more than half will develop recurrent disease despite exenterative surgery (Benn, 2011; Westin, 2014).

Patient Preparation

Prior to surgery, stoma sites are marked, the consent form is reviewed, and final questions are answered. To minimize fecal contamination during bowel excision, aggressive bowel preparation such as with a polyethylene glycol with electrolyte solution (GoLYTELY) is mandatory. Ileus is common following exenteration and nutritional demands are increased. Thus, total parenteral nutrition (TPN) is often initiated as early as possible when needed. In addition, routine antibiotic prophylaxis has been shown to decrease infectious complications (Goldberg, 1998). Pneumatic compression devices or subcutaneous heparin is particularly important due to the anticipated long operation and extended postoperative recovery. Patients are typed and crossmatched for potential blood product replacement. Critical care team consultation may be indicated, and an ICU bed is requested.

INTRAOPERATIVE

Instruments

To prepare for complicated resections, a surgeon should have access to all types and sizes of bowel staplers. These include end-to-end anastomosis (EEA), gastrointestinal anastomosis (GIA), and transverse anastomosis (TA) staplers. Additionally, an electrothermal bipolar coagulator (LigaSure) may speed pedicle ligation while decreasing blood loss (Slomovitz, 2006).

Surgical Steps

Anesthesia and Patient Positioning

General anesthesia with or without epidural placement for postoperative pain management is mandatory. An arterial line for monitoring is typically added as a necessary precaution. Bimanual examination is performed to reorient a surgeon to a patient’s individual anatomy. The abdomen, perineum, and vagina are surgically prepared, and a Foley catheter is inserted. Legs should be positioned in low lithotomy in booted support stirrups to permit adequate perineal access.

Abdominal Entry

The type of abdominal entry may be dictated by an intended rectus abdominis flap, which requires a low transverse incision. Otherwise, a midline vertical incision is ideal. A less commonly employed option is to initially assess by laparoscopy a patient’s suitability for exenteration. This minimally invasive approach may avoid unnecessary laparotomy in up to half of candidate patients (Kohler, 2002; Plante, 1998).

Exploration

The most common reason that exenterations are aborted is the presence of metastatic peritoneal disease (Miller, 1993). Thus, following positioning of an abdominal self-retaining retractor, a surgeon thoroughly explores for disseminated disease that may not have been suspected preoperatively. Typically, numerous adhesions must also be lysed to inspect and palpate abdominal contents. Suspicious lesions are removed or biopsied.

Lymph Node Dissection

A significant number of exenterations will be aborted intraoperatively due to identification of lymph node metastases (Miller, 1993). For this reason, pelvic and paraaortic node sampling and frozen section analysis is performed to exclude metastatic disease before proceeding. Additionally, retroperitoneal dissection provides a surgeon with a sense of the degree of pelvic sidewall fibrosis, which may render the vessels, ureters, and other important structures virtually indistinguishable from the surrounding soft tissue.

Pelvic Sidewall Exploration

As des­cribed in Section 46-1, the retroperitoneum is entered and the external iliac and internal iliac artery bifurcation is bluntly dissected free of overlying areolar connective tissue. The ureter is placed on a Penrose drain for identification. The paravesical and pararectal spaces are developed.

Parametrial tumor extension is the third most common reason for aborting exenteration (Miller, 1993). Thus, the pelvic sidewall should be verified to be clinically free of disease by inserting one finger into the paravesical space, another into the pararectal space, and palpating the intervening tissue down to the levator plate. There must be a grossly negative margin at the pelvic sidewall to proceed. Tissues may be biopsied and frozen section analysis performed to confirm this impression. Often, it is difficult to know with absolute certainty whether the margins are clear due to the varying extent of retroperitoneal fibrosis encountered.

Bladder Mobilization

The bladder blade is removed from the self-retaining retractor to permit entry into the space of Retzius and blunt reflection of the bladder from the back of the pubic symphysis. To achieve this, downward traction on the bladder and urethra will expose filmy attachments that may be electrosurgically incised (Fig. 46-4.1). Laterally positioned false ligaments of the bladder are divided between clamps or transected with an electrothermal bipolar coagulator. This joins the retropubic and paravesical spaces. The bladder should be floppy in the pelvis from loss of its supporting pelvic attachments and is completely freed ventrally. However, the urethra is still attached to the bladder.

Rectal Mobilization

Following mobilization of the bladder, the ureters are held laterally, and the overlying peritoneum at the pelvic brim is divided on each side in a medial direction up to the sigmoid colon mesentery. By inserting a finger into each pararectal space and sweeping medially, it should be possible to develop the avascular plane between the rectosigmoid and the sacrum (retrorectal space).

Surgeons should be confident that there is no sacral tumor invasion and that they will be able to lift the rectosigmoid out of the pelvis to achieve a posterior margin that is tumor free. This is the last decision to be made before dividing the bowel and beginning steps of the operation that are irreversible.

Once all the tumor boundaries have been assessed, exenteration proceeds by dividing the sigmoid colon with a GIA stapler and dividing the intervening mesenteric tissue (Section 46-21). The proximal sigmoid colon is then packed into the upper abdomen. The distal rectosigmoid is held ventrally and cephalad while a hand is inserted posteriorly to bluntly dissect the adventitial tissue between the rectum and sacrum in the midline (Fig. 46-4.2). This maneuver is continued distally to the coccyx to develop the retrorectal space and isolate the laterally located rectal pillars.

Cardinal Ligament Division

The mobilized bladder and distal rectum with uterus (if present) are held together on contralateral traction, while a hand is placed with one finger in the paravesical space and the other in the pararectal space to isolate the lateral pelvic attachments. The cardinal ligaments, internal iliac vessels, and ureter are often not distinguishable in a typically radiated field, but lie within this tissue. Beginning anteriorly, these fibrous attachments are serially divided at the pelvic sidewall (Fig. 46-4.3). Vascular clips should be available in case of tissue slippage or inadvertent bleeding.

Internal Iliac Vessels and Ureter Division

As the pelvic sidewall dissection continues dorsally, the anterior branches of the internal iliac artery, venous channels, and distal ureter ideally are individually located and ligated to optimize hemostasis (Fig. 46-4.4). However, blood vessels and ureters frequently will lie within fibrous ­tissue and may be relatively indistinguishable. Thus, clamps or the electrothermal bipolar coagulator are placed around smaller pedicles to minimize the possibility of inadvertent blood loss. At minimum, the ureter is located, isolated, and divided as distally as possible to provide extra length for reaching the urinary conduit. Later, any damage at the distal tip can be trimmed as needed to ensure healthy tissue for urinary conduit creation. A large vascular clip is placed on the proximal end of the ureter to distend the lumen and aid later anastomosis into the planned conduit. Dissection is then repeated on the contralateral side, and any remaining lateral attachments along the levator ani muscles are divided as the pelvic floor curves toward the perineum.

Rectal Pillar Division

The exenteration specimen is now chiefly tethered by the rectal stalks and distal mesenteric attachments posteriorly. These can be skeletonized with a right-angle clamp and divided along the pelvic floor (Fig. 46-4.5). This maneuver is continued distally to expose the entire posterior pelvic floor. The exenteration specimen is then circumferentially inspected and additional dissection is performed to completely release it from all attachments leading through the levator ani muscles. At this point, steps diverge depending on whether supralevator or infralevator exenteration is planned.

Supralevator Exenteration: Final Steps

Removal of the specimen above the levator muscles begins by posterior traction on the bladder. The Foley catheter should be palpable within the urethra, and all surrounding tissue should already be dissected away. An electrosurgical blade is used to transect the distal urethra (Fig. 46-4.6). The distal opening does not require closure and may function as a natural orifice drain postoperatively. Next, the vagina is transected and then closed with 0-gauge delayed-absorbable suture in a running fashion. The transverse anastomosis (TA) or curved cutter stapler (Contour) is placed across the distal rectum and fired (Fig. 46-4.7). This completes detachment of the specimen, which includes bladder, uterus, rectum, and surrounding tissue. The pelvic floor is then carefully assessed to identify bleeding points (Fig. 46-4.8). A laparotomy pad is packed firmly into the pelvis to tamponade any surface oozing, while the exenteration specimen is inspected to confirm grossly negative margins.

Infralevator Exenteration: Perineal Phase

With infralevator exenteration, once abdominal dissection reaches the levator muscles, a second surgical team begins the perineal phase. The use of two teams typically shortens operative time and reduces bleeding. The planned perineal resection is outlined to encompass the tumor. As shown in Figure 46-4.9, resection may require infralevator exenteration with or without vulvectomy.

The perineal incision ideally begins concomitantly with division of the levator muscles by the abdominal team. At the perineum, a skin incision is first performed, followed by use of an electrosurgical blade to dissect through the subcutaneous tissues surrounding the urethra, vaginal opening, and anus.

Infralevator Exenteration: Partial Resection of the Levator Muscles

Within the abdomen, the primary surgical team places the specimen on traction. Electrosurgical blade dissection is used to circumferentially incise the levator muscles lateral to the area of tumor extension (Fig. 46-4.10). The dissection proceeds distally toward the perineum.

Infralevator Exenteration: Connecting the Perineal and Abdominal Spaces

After the perineal incision has reached the fascial plane, four spaces are developed: subpubic space, left and right vaginal spaces, and retrorectal space. It is helpful to have the abdominal surgeon place a hand deep into the pelvis and guide the electrosurgical dissection by the perineal team (Fig. 46-4.11). Five pedicles are identified that separate these avascular spaces: two pubourethral pedicles, two rectal pillar pedicles, and the midline posterior anococcygeal pedicle. Electrosurgical dissection that is directed by the abdominal surgeon’s finger is performed to open the intervening spaces. From below, the five vascular pedicles are divided and ligated using the electrothermal bipolar coagulator.

Infralevator Exenteration: Removal of the Specimen

Circumferential dissection will result in complete detachment of the specimen that can be removed either vaginally or abdominally (Fig. 46-4.12). Hemostasis is then achieved with a series of sutures, vascular clips, or clamps and ties. Finally, the pelvic floor and pedicle sites are carefully reinspected (Fig. 46-4.13).

Infralevator Exenteration: Simple Closure

If vaginal reconstruction in not planned, the most straightforward and quickest way to close the perineum is for the second team to perform a layered closure of the deep tissues with 0-gauge delayed-absorbable suture (Fig. 46-4.14). The perineal skin is closed with the same type of delayed-absorbable suture in a running fashion.

Final Steps

A dry laparotomy pad may be held firmly deep in the pelvis to tamponade surface oozing, while the conduit, colostomy or bowel anastomosis, other surgical procedures, or vaginal reconstruction are performed. In some instances, intraoperative radiation therapy may be a useful adjunct for an obviously positive or clinically suspicious resection margin (Backes, 2014; Foley, 2014; Koh, 2015). An omental J-flap may provide additional blood supply to the irradiated, denuded pelvic floor (Section 46-14). The type of postoperative suction drainage may be dictated by these ancillary procedures but should be used judiciously (Goldberg, 2006).

POSTOPERATIVE

The morbidity of total pelvic exenteration depends on various factors, which include preoperative health of the patient, intraoperative events, extent of the procedure, ancillary procedures, and postoperative vigilance. Hospitals that treat a relatively high volume of such patients report lower surgical in-hospital mortality rates (Maggioni, 2009). However, unlike a few decades ago, few institutions perform this operation on a regular basis.

The immediate life-threatening concerns are massive bleeding, acute respiratory distress syndrome, pulmonary embolism, and myocardial infarction (Fotopoulou, 2010). Every effort is made to encourage early ambulation as soon as the patient is stable. A prolonged ileus or partial small bowel obstruction will typically respond to expectant management but may require TPN for weeks. Intestinal fistulas and leaks are more common when using mesh to cover the pelvic floor or when performing low rectal anastomoses. Omental pedicle grafts and rectus abdominis or gracilis myocutaneous flaps may prevent such complications. Pelvic abscess and septicemia are additional subacute complications that develop commonly (Berek, 2005; Goldberg, 2006; Maggioni, 2009).

Removal of the uterus, vagina, bladder, urethra, distal ureters, and parametrial tissues with preservation of the rectum is meant to be a less morbid operation than total pelvic exenteration (Section 46-4). Patients are carefully selected for this more limited procedure to still achieve negative surgical margins. Women who have previously had a hysterectomy are not usually good candidates, because a complete resection of a central recurrence involving the vaginal cuff would typically require removal of both bladder and rectosigmoid colon. The most common indications include small recurrences confined to the cervix or anterior vagina after pelvic radiation. In gynecologic oncology, up to half of all exenterations performed are anterior (Berek, 2005; Maggioni, 2009).

PREOPERATIVE

The preoperative evaluation is similar to that described for total pelvic exenteration (Section 46-4). Although preservation of the rectum is planned, patients are advised that potentially unforeseen clinical circumstances may dictate bowel resection and colostomy or low rectal anastomosis. Accordingly, a complete bowel preparation is still mandatory.

INTRAOPERATIVE

Surgical Steps

Initial Steps

Anterior exenteration is technically similar to total pelvic exenteration, described earlier. Patients are positioned in low lithotomy in booted support stirrups, the appropriate skin incision is made, the abdomen is explored, lymph nodes are removed, and spaces are developed to exclude metastatic or unresectable disease. The procedure begins to differ after the bladder has been mobilized. A surgeon then makes the final decision to leave the rectum intact and proceed with anterior pelvic exenteration.

Developing the Rectovaginal Space

Instead of mobilizing the rectum and dividing the sigmoid colon, the rectovaginal space is developed much as in a type III radical hysterectomy. The uterosacral ligament and the entire length of the rectal pillars are divided to free the exenteration specimen posteriorly.

Lateral Pelvic Attachments

The mobi­lized bladder and uterus are held medially to aid in isolation of the cardinal ligaments, internal iliac vessels, and ureter. These structures are successively divided with an electrothermal bipolar coagulator (LigaSure) or clamped, cut, and individually ligated.

Removal of the Specimen

After the anterior pelvic exenteration specimen has been completely mobilized, the urethra and vagina are divided (Figs. 46-5.1 and 46-5.2). The urethra is left open, and the vaginal cuff is closed with 0-gauge delayed-absorbable suture in a running fashion.

Final Steps

Typically, the lesion is small and lies above the levator ani muscles, thus a perineal phase is not required. For this reason, placement of a myocutaneous flap for vaginal reconstruction may be more problematic in these patients due to limited space in the pelvis.

POSTOPERATIVE

Morbidity of anterior pelvic exenteration is comparable with that of total pelvic exenteration (Section 46-4) (Sharma, 2005). Ideally, the operation is shorter and restoration of bowel function is more rapid. Some patients will experience tenesmus or long-term rectal symptoms that likely stem from interruption of the autonomic nervous system in surrounding tissue.

Removal of the uterus, vagina, rectum, and parametrial tissues with preservation of the ureters and bladder is meant to be a less morbid operation than total pelvic exenteration (Section 46-4). Patients are carefully selected for this more limited procedure to still achieve negative surgical margins. For this reason, women who have previously had a hysterectomy are not usually good candidates. The most common indications include small postirradiation recurrences primarily involving the posterior vaginal wall or coexisting with a rectovaginal fistula. In gynecologic oncology, fewer than 10 percent of exenterations are posterior (Berek, 2005; Maggioni, 2009).

PREOPERATIVE

Preoperative evaluation is largely identical to that described for total pelvic exenteration (Section 46-4). A surgeon’s judgment and experience are critical in deciding to proceed with a more limited operation. However, patients are advised that potentially unforeseen clinical circumstances may dictate resection of the ureters and bladder with formation of a urinary conduit.

INTRAOPERATIVE

Surgical Steps

Initial Steps

Posterior pelvic exenteration is technically similar to a type III radical hysterectomy but with the addition of rectosigmoid resection and a more extended vaginectomy (Section 46-1). The operation begins as a total pelvic exenteration. Patients are positioned in low lithotomy in booted support stirrups, the appropriate skin incision is made, the abdomen is explored, lymph nodes are removed, and spaces are developed to exclude metastatic or unresectable disease (Section 46-4). A surgeon then makes the final decision to leave the bladder intact and proceed with posterior exenteration.

Ureteral Dissection

As with type III radical hysterectomy, the retroperitoneum is entered, ureters are mobilized, uterine arteries are ligated at their internal iliac artery origin, and parametrial tissue is divided at the pelvic sidewall. The bladder is then mobilized away from the cervix and vagina, and ureters are unroofed from the paracervical tunnels. The lateral attachments are then divided all the way to the levator ani muscles. However, typically these steps are much more tedious in a previously irradiated field because of tissue fibrosis and scarring.

Mobilizing the Rectum

The sigmoid colon is divided with the mesentery and peritoneal attachments, as described for low anterior resection. The retrorectal space is bluntly dissected to mobilize the rectum and enable transection of the rectal pillars and uterosacral ligaments.

Removal of the Specimen

The en­tire specimen may then be placed on traction to aid placement of the transverse anastomosis (TA) or curved cutter stapler (Contour) and division of the rectum. The rectum is divided below the tumor to leave grossly negative margins.

To encompass the tumor for removal, dissection is continued circumferentially to (or through) the levator ani muscles (Fig. 46-6.1). The distal vagina is transected and sewn closed in a running fashion with 0-gauge delayed-absorbable suture. The specimen is removed.

Final Steps

Typically, the lesion is small and lies above the levator ani muscles, and thus a perineal phase is usually not required. As a result, placement of a myocutaneous flap for vaginal reconstruction may be more problematic in such patients due to limited space in the pelvis.

POSTOPERATIVE

Morbidity of posterior pelvic exenteration is comparable with that of total pelvic exenteration (Section 46-4) (Sharma, 2005). Ideally, the operation is shorter and urinary complications are less frequent. However, posterior exenteration in a previously irradiated patient frequently results in a contracted bladder and intractable urinary incontinence.

Removal of the bladder during total or anterior exenteration is the main indication for an incontinent urinary conduit. Less commonly, an otherwise irreparable postirradiation vesicovaginal fistula may warrant urinary diversion. Following cystectomy, an isolated resected segment of bowel that maintains its mesenteric connection and vascular supply is used as the new urine reservoir. A stoma is crafted using one end of the bowel segment and an opening in the anterior abdominal wall. Ureters are reimplanted into the opposite end of this isolated bowel segment.

Various techniques are available to create such urinary conduits, and these are categorized as incontinent diversions or continent diversions. An incontinent diversion is the simplest to create, but postoperatively a patient must continuously wear an ostomy bag. These conduits are often preferable for medically compromised patients, the elderly, and anyone with a short life expectancy. Alternatively, a continent urinary reservoir can be created that is emptied by intermittent patient self-catheterization of the bowel stoma.

Of incontinent diversions, an ileal conduit has historically been the most common urinary diversion used in gynecologic oncology (Goldberg, 2006). However, this bowel segment and distal ureters invariably lie within a previously irradiated field. Conduit construction with radiation-damaged bowel may lead to higher rates of stenosis or leakage at the ureteral anastomotic sites (Pycha, 2008). More recently, the transverse colon conduit has proven to be a very successful alternative for previously irradiated patients (Segreti, 1996b; Soper, 1989). Sigmoid conduits are generally less desirable due to preexisting radiation damage and proximity to a concurrent colostomy site. The jejunal conduit is another rarely used option that typically lies outside the radiation field.

The basic principles of constructing an incontinent urinary conduit are the same, regardless of the intestinal segment used. First, healthy-appearing bowel with a good blood supply is selected. Second, wide-caliber ureterointestinal anastomoses and stenting are essential to minimize the risk of anastomosis stenosis. Third, sufficient mobility of the ureters and bowel segment is important to prevent tension that might lead to anastomotic leaks. Fourth, creation of a straight tunnel through the abdominal wall helps prevent bowel kinking and obstruction.

PREOPERATIVE

Patient Evaluation

The preoperative evaluation is usually dictated by the preceding exenterative procedure. The specific decision is whether to plan for an incontinent or continent urinary conduit. Patients are extensively counseled regarding the differences. The type of conduit selected should be considered permanent, although later conversions are possible (Benezra, 2004).

Consent

Patients are advised that intraoperative findings may dictate revision of an original surgical plan. Postoperatively, urinary infections with or without pyelonephritis are very common with any type of conduit. Anastomotic leaks are less frequent with routine ureteral stent placement but can contribute to a prolonged ileus, the need for CT-guided drainage, or potentially, surgical reexploration with revision. Episodes of small bowel obstruction are possible and often develop at the site where the bowel segment was harvested and the remaining bowel ends were reanastomosed. In the long term, ureteral strictures or stenosis may compromise renal function. Infrequently, reoperation is necessary for complications that do not respond to conservative management (Houvenaeghel, 2004).

Patient Preparation

Bowel preparation is mandatory, but preparation is typically dictated by the preceding exenterative surgery (Section 46-4). Ideally, an enterostomal therapist is available to mark a conduit stoma site, typically on the patient’s right side, that is unobstructed in the supine, sitting, and standing positions.

INTRAOPERATIVE

Surgical Steps

Initial Steps

To avoid unnecessary traction on its anastomoses, the incontinent urinary conduit is constructed as the last major intraabdominal step during exenterative surgery. Hemostasis is achieved before beginning the conduit. Anesthesia, patient positioning, and skin incisions are typically dictated by the preceding operation.

Exploration

The bowel segment for the planned conduit is carefully inspected. It must be healthy appearing, not tethered, and lie close to the distal ureters. The final decision is now made regarding which type of incontinent conduit is best for the circumstances. If the distal ileum has the typical leathery, pale, mottled appearance of radiation injury, a conduit should be prepared from the transverse colon. Overlooking the importance of this decision can lead to various otherwise preventable complications intraoperatively and postoperatively.

Ileal Conduit: Preparing the Bowel Segment

The ileocecal junction is located, and the ileum is elevated to identify a bowel segment with the most mobility to reach the right side of the anterior abdominal wall where the stoma will be located. Ideally, the proximal end of the segment lies 25 to 30 cm from the ileocecal valve. At the selected site, the mesentery is scored on each side with an electrosurgical blade to aid insertion of a hemostat directly beneath the bowel loop. A Penrose drain is pulled through to mark this proximal end along the ileum that will eventually become the distal part of the conduit and will form the abdominal wall stoma.

The conduit length depends on subcutaneous tissue depth and ileum mobility but should measure approximately 15 cm. The conduit’s butt end will house the ureteral anastomoses and is selected by measuring the ileum that lies distal to the Penrose drain, and again the mesentery is scored. The gastrointestinal anastomosis (GIA) stapler is then inserted to divide the distal bowel segment (Fig. 46-7.1). The point of division should ideally be at least 12 cm from the ileocecal valve. The conduit is remeasured prior to dividing the proximal ileum, to account for possible shrinkage of the intervening segment and to again ensure sufficient length.

Once the bowel is stapled and divided, the conduit mesentery is also carefully divided on each end of the segment. This tissue division is angled inward and toward the base of the mesentery near its insertion to the posterior abdominal wall. This provides adequate mobility. The vasculature may be compromised if too much mesentery is divided, whereas too little will result in tension on the conduit. A perfect balance is required.

When convenient, intestinal continuity, minus the excised segment, is reestablished anterior to the conduit. This is completed by end-to-end small-bowel reanastomosis using the GIA and TA staplers as described in Section 46-20.

Ileal Conduit: Preparing the Ure­ters

The staple line is excised from the stomal end of the conduit, and the conduit is irrigated into a basin. The ureters should now be engorged from the vascular clips placed earlier during exenteration. The distal end of the ureters should have a stay suture placed for traction. To prevent focal necrosis that may impede successful anastomosis, ureters are never directly grasped with forceps or roughly handled. They are sharply freed from their retroperitoneal attachments so that they easily reach past the point of their planned anastomosis into the conduit. The left ureter is brought under the inferior mesenteric artery (IMA) to prevent acute angulation and kinking. This ureter ultimately exits from beneath the base of the sigmoid colon mesentery to reach the conduit.

Ileal Conduit: Ureteral Anastomoses

Adson forceps are used to grasp a small section of the ileal serosa to which the left ureter will reach. This site is ideally approximately 2 cm from the butt end of the conduit on the anterior side of the antimesenteric surface. Metzenbaum scissors remove a small, full-thickness section of bowel wall (Fig. 46-7.2). The ileal mucosa should be easily visible.

The distal tip of the left ureter is cut at a 45-degree angle just behind the vascular clip placed during exenteration. If the distal ends of the ureters exhibit fibrosis, they are trimmed to reach healthy-appearing tissue. The prior distal stay-suture is removed with this trimming. Urine will drain into the abdomen while a 4–0 delayed-absorbable stay suture is placed outside-to-in through the ureter’s distal tip. The needle is left on this traction stitch since it will be the final suture in the anastomosis. Fine tip scissors are used to spatulate the ureter for approximately 1 cm, but the length is customized depending on the caliber of the ureteral lumen (Fig. 46-7.3). This maneuver helps to reduce the possibility of future ureteral stenosis.

The first suture is placed at the apex of the spatulation with a full-thickness bite through the ureteral wall and bowel mucosa (Fig. 46-7.4). Two or three adjoining mucosa-to-mucosa sutures are placed. A 7F ureteral stent is then placed through the stomal end of the conduit and advanced through the anastomosis into the left renal pelvis. The stent is held against the wall of the midsection of the conduit with one hand and secured with a 3–0 or 4–0 gauge chromic catgut suture through the entire bowel wall and around the stent to hold it in place. The left ureteral anastomosis is completed with additional circumferential sutures to achieve a watertight closure (Fig. 46-7.5).

The anastomotic site for the right ureter is selected at least 2 to 3 cm distal to that of the left along the length of the conduit. The entire procedure is then repeated. Saline with methylene blue dye is used to fill the conduit and observe for watertight integrity. Any anastomotic leaks must be reinforced with additional sutures and retested. If leakage persists or if there is concern about the mucosa-to-mucosa apposition, then the entire anastomosis should be redone.

This butt end of the conduit is next secured to the sacral promontory, iliopsoas muscle, or posterior peritoneum with two or three delayed-absorbable sutures through the seromuscular layer of the conduit. Stabilizing the conduit in this way will prevent undue tension on the ureteral anastomoses when the patient is upright and gravity allows the intestines to slide into the pelvis.

Ileal Conduit: Stoma Creation

The skin at the proposed stoma site is elevated with a Kocher clamp. An electrosurgical blade, set on cutting mode, is used to excise a small circle of skin. The subcutaneous fat is separated by blunt dissection until the fascia is visible. A cruciate incision is made with an electrosurgical blade (Fig. 46-7.6). The rectus abdominis muscle is split longitudinally and another cruciate incision is created in the peritoneum. The opening is bluntly expanded until it easily accommodates two fingers.

The stoma and stents are carefully pulled through the incision until at least 2 cm of ileum protrudes through the skin. The mesentery may need to be trimmed or the abdominal wall opening further dissected to accommodate the conduit. The mucosal edge of the bowel is everted. The stoma is completed with 3–0 gauge delayed-absorbable “rosebud” stitches that include the ileal mucosa, intervening bowel serosa, and skin dermis (Fig. 46-7.7). Circumferential sutures are placed. Both stents are trimmed to fit in the stoma bag. To enable correct identification postoperatively, the right ureteral stent is cut at a “right” angle. Individual silk sutures placed through each stent may be secured at the skin to prevent stent dislodgment over the first few postoperative days.

Transverse Colon Conduit

For this type of conduit, the hepatic and splenic flexures of the transverse colon are fully mobilized. In addition, the omentum is detached. Division points are marked with Penrose drains and transected (Fig. 46-7.8). The transverse mesocolon is then divided, as shown by the dotted lines, to provide sufficient mobility while preserving the middle colic artery. When performed in the usual setting of an exenteration with left lower quadrant colostomy, the bowel segment must measure approximately 20 cm to reach the right lower quadrant. Often, this requires incorporation of the hepatic flexure into the conduit and yields an antiperistaltic orientation, that is, urine ultimately flows through the conduit in the opposite direction that fecal waste would normally be propelled. Thus, the proximal bowel segment (nearest the cecum) will be the end of the conduit that eventually is brought through the abdominal wall.

Ureters are sufficiently mobilized in the retroperitoneal space, and both are brought out through a commodious peritoneal opening to reach the conduit. The left ureter will need to be brought across the aorta proximal to the IMA (unlike the ileal conduit). The ureteral anastomoses are then completed, ideally at the teniae coli, over stents. To prevent postoperative sliding and tension on the anastomoses, the conduit’s butt end is secured to the sacrum, iliopsoas muscle, or posterior peritoneum with interrupted delayed-absorbable suture. Intestinal continuity is reestablished anterior to the conduit by a functional end-to-end anastomosis using EEA and TA staplers, as described in Section 46-18. The stoma can be made at the preselected site, but it can be repositioned almost anywhere that the conduit will comfortably reach. The stomal end of the conduit is brought through the anterior abdominal wall and secured (Fig. 46-7.9).

Final Steps

Mesenteric defects require closure to prevent internal hernias but not so tightly as to compromise blood supply. A suction drain may be placed if integrity of the anastomoses and leakage is a concern. If the stoma appears dusky, the abdominal wall tunnel may be too tight, the mesentery may be twisted or placed on too much tension, or the blood supply may not be sufficient. The last circumstance is the worst, and it generally requires trimming of the distal end of the bowel or occasionally redoing the entire conduit. Either is preferable to avoid problematic retraction, stricture, or necrosis.

POSTOPERATIVE

The stoma is regularly checked for viability during the immediate postoperative recovery period. Both stents should be functioning. A dry stent that does not respond to irrigation should prompt an imaging study to exclude ureteral obstruction. Urinary fistulas and ureteral obstruction are uncommon but are potentially life-threatening if not addressed with percutaneous drainage or reoperation. Prolonged bowel dysfunction may indicate an anastomotic urine leak or small-bowel obstruction.

Patients often are readmitted within a few weeks of surgery due to partial small bowel obstruction, urinary infection, wound separation, or other relatively minor complications of exenteration. These typically resolve with targeted supportive care. Long-term complications include ureteral stenosis and renal loss. Renal function may deteriorate due to chronic infection and reflux. When patients cannot be otherwise managed, they may require long-term percutaneous nephrostomy tubes, indwelling stents, or reoperation and conduit or stoma revision.

Predictably, the overall morbidity of creating an incontinent conduit is much higher in previously irradiated patients (Houvenaeghel, 2004). Tissue quality and mobility are especially important in these patients.

Removal of the bladder during total or anterior exenteration is the main indication for a continent urinary conduit. Vesicovaginal fistulas and disabling incontinence following radiation therapy are other less common reasons. Following cystectomy, urine is diverted into a reservoir created from a resected bowel segment. Depending on their construction, these diversions may render a woman continent or incontinent. An incontinent conduit reservoir chronically drains into an ostomy bag, whereas that of a continent conduit does not leak urine. Patients empty the reservoir by intermittent self-catheterization.

Continent conduits, however, may not be appropriate for all patients. The operation is more complex than an incontinent diversion procedure and may lead to more postoperative complications (Karsenty, 2005). It also requires a highly motivated patient who is capable of long-term self-catheterization. An ideal candidate for a continent conduit is a young, otherwise healthy woman without a colostomy.

There are several continent diversion methods. In gynecologic oncology, the continent ileocolonic urinary reservoir (Miami pouch) has become the most popular choice (Salom, 2004). This pouch is technically straightforward to construct and uses tissues that characteristically lie in nonirradiated areas (Penalver, 1998).

A Miami pouch includes a distal ileum segment, the ascending colon, and a portion of transverse colon. The basic steps involve opening the colon segment along the length of the tenia and folding it onto itself. The walls of the ascending and transverse colon are then sewn together to achieve a reservoir with low intraluminal pressure. The ileal segment is tapered and purse-string sutures are placed at the level of the ileocecal valve to achieve continence. The free ileal segment end is then exteriorized as a stoma to allow catheterization (Penalver, 1989).

PREOPERATIVE

Patient Evaluation

Preoperative evaluation is usually dictated by the preceding exenterative procedure. The specific decision is whether to plan for an incontinent or continent urinary conduit. Patients are extensively counseled regarding the differences. The presence of a permanent colostomy removes the apparent advantage of a continent conduit and an abdominal wall without draining stomas. Catheterization may be more problematic in very obese women. In addition, some patients with prior high-dose radiation or chronic bowel disease may also not be good candidates due to poor tissue quality and increased associated risks of anastomotic leaks, ureteral stricture, or fistula.

Consent

Patients are advised that intraoperative findings such as poor bowel appearance and dense adhesions may dictate a change in surgical plans. In addition, complications are common and should be reviewed. Even in experienced centers, half of patients will have one or more early pouch-related complications: ureteral stricture with obstruction, anastomotic leak, fistula, difficulty in catheterization, pyelonephritis, or sepsis. One third will develop late complications beyond 6 weeks. Ten percent of patients will ultimately require reoperation to revise the Miami pouch (Penalver, 1998). As a result, many patients would not choose the continent urinary conduit again (Goldberg, 2006).

Patient Preparation

Bowel preparation is mandatory but generally is dictated by the preceding exenterative surgery. Ideally, an enterostomal therapist is available to mark a conduit stoma site in the right lower abdomen that is unobstructed in the supine, sitting, and standing positions.

INTRAOPERATIVE

Surgical Steps

Initial Steps

To avoid unnecessary traction on anastomoses, the continent urinary conduit is constructed as the last major intraabdominal procedure during exenterative surgery. Before beginning the conduit, hemostasis should be achieved. Anesthesia, patient positioning, and skin incisions are typically dictated by the preceding operation.

Exploration

The conduit bowel segment is carefully inspected. It must be healthy appearing and lack severe radiation injury. At this point, the final decision to proceed with creation of a Miami pouch is made.

Preparing the Bowel Segment

The right colon is freed along the white line of Toldt from the cecum, around the hepatic flexure, to the proximal transverse colon. The white line of Toldt marks the lateral attachment of ascending and descending colon’s peritoneum to the posterior abdomen’s parietal peritoneum. The conduit will require approximately 25 to 30 cm of colon and at least 10 cm of ileum. With these measurements in mind, a surgeon selects sites to divide the bowel.

The mesentery is scored with an electrosurgical blade, and a Penrose drain is placed around the sections to be divided. Within the mesentery, the underlying vasculature is reviewed to ensure sufficient conduit blood supply. A gastrointestinal anastomosis (GIA) stapler is used to divide the bowel at both sites marked with the Penrose drains (Fig. 46-8.1).

The mesenteries are incised down through the avascular areas to the posterior peritoneum. At this point, intestinal continuity is reestablished by a functional end-to-end stapled ileotransverse enterocolostomy using the GIA and transverse anastomosis (TA) staplers. The mesenteric defect is closed with 0-gauge delayed-absorbable suture in a running fashion to prevent internal herniation.

Detubularizing the Bowel

The conduit staple lines on both ends of the bowel segment are removed with Metzenbaum scissors, and the bowel is irrigated into a basin. Of this bowel segment, the entire colonic portion is opened with an electrosurgical blade along the tenia of the antimesenteric border to “detubularize” the bowel (Fig. 46-8.2). This is extended to remove the appendix.

Creating the Pouch

The colon segment is folded in half and four delayed-absorbable stay sutures are placed at the corners to begin creation of the pouch. The lateral edge is closed in two layers with 2–0 and 3–0 gauge delayed-absorbable suture in a running fashion (Fig. 46-8.3).

Tapering the Ileum

A 14F red rubber catheter is inserted through the terminal ileum segment into the pouch. Two purse-string, 0-gauge delayed-absorbable sutures are placed 1 cm apart at the ileocecal junction. The ileum is elevated with Babcock clamps, and a GIA stapler is used to taper the terminal ileum on its antimesenteric border over the catheter (Fig. 46-8.4). An anterior abdominal wall opening is made in the right lower quadrant so that the ileal segment of the conduit can be pulled through to approximate its final position.

Ureteral Anastomoses

Both ureters are further mobilized from their retroperitoneal attachments and brought into position under the ascending mesocolon using a 4–0 gauge delayed-absorbable stay suture at the tip. Manipulation with this suture avoids crush injury by forceps and subsequent necrosis. As in the transverse colon conduit, the left ureter is brought over the aorta and above the origin of the inferior mesenteric artery (IMA).

The ureteral anastomotic sites to the pouch are selected based on ureter length and their ability to have a straight course to the pouch. One ureter is usually brought through on either side of the pouch suture line. The ureters are trimmed and spatulated (see Fig. 46-7.3). In creating the openings for the ureters, the bowel mucosa is incised at sites away from the suture line. A hemostat is poked through the bowel wall, grasps the ureteral stay suture, and thereby pulls 2 cm of each ureter into the pouch.

Each ureter is secured to the bowel mucosa with interrupted stitches of 4–0 gauge delayed-absorbable suture (Fig. 46-8.5). Single-J ureteral stents (7F) are inserted and sutured to the bowel wall with 3–0 gauge chromic to stabilize their placement. To enable correct identification postoperatively, the right ureteral stent is cut at a “right” angle.

Closing the Pouch

A large Malecot catheter is brought into the pouch through an incision made away from the ileocecal valve. The ureteral stents are brought out through the pouch next to the Malecot (Fig. 46-8.6). Here, where the catheters exit the pouch, a watertight purse string using 3–0 plain catgut suture is placed. Absorbable suture is used for this purse string, as the Malecot catheter will be removed only 2 to 3 weeks postoperatively.

The remaining edges of the pouch are closed with two layers of 2–0 and 3–0 gauge delayed-absorbable suture in a running fashion. Continence may be tested by inserting a red rubber catheter through the plicated ileum, filling the pouch with 250 to 300 mL of saline, removing the red rubber catheter, and gently squeezing the pouch. Additional purse-string sutures may be placed at the ileocecal valve if incontinence is demonstrated. The completed pouch (Fig. 46-8.7) is now ready to be brought to the abdominal wall.

Final Steps

The two stents and Malecot drain are brought out through a separate stab wound on the abdominal wall away from the stoma site. The Malecot drain is individually fixed to the skin with nylon sutures. The ileal segment is pulled through the abdominal wall and may require trimming to sit flush. The pouch is stabilized by suturing it to the undersurface of the abdominal wall, and the stoma is created by placing interrupted stitches of 3–0 gauge delayed-absorbable suture between the dermis and ileal mucosa as described in Section 46-7, Step 6. A red rubber catheter is inserted and withdrawn to make sure that the pouch can be easily accessed. A Jackson-Pratt (JP) drain is then placed near the pouch to monitor for urine leakage and is brought out through a separate stab wound away from the stoma.

POSTOPERATIVE

The Miami pouch initially requires more care than an incontinent urinary conduit. Mucus will be produced by the colonic bowel ­segment. Therefore, the Malecot catheter is irrigated every few hours to permit urine drainage. In contrast, the ureteral stents are irrigated only if one of the catheters becomes obstructed. Two to 3 weeks postoperatively, an intravenous pyelogram (IVP) and gravity pouchogram are performed. The IVP excludes anastomotic leaks, ureteral stricture, and fistulas. The pouchogram involves retrograde filling of the conduit to search for leaks. If these tests are normal, the ureteral stents, Malecot catheter, and JP suction drainage tube may all be removed. The hole in the conduit that housed these tubes will heal secondarily.

A patient is taught self-catheterization using an 18F to 22F red rubber catheter and antiseptic technique. The interval between catheterizations is progressively increased over weeks to reach 6 hours during the day and span sleep hours at night. In addition, the pouch requires periodic irrigation to remove mucus. An IVP, pouchogram, and serum electrolyte and creatinine level measurement are performed at 3 months postoperatively and then every 6 months to evaluate the pouch, renal function, and upper urinary tracts.

More than half of patients will have a conduit-related complication postoperatively. Fortunately, most may be successfully managed conservatively without the need for reoperation (Ramirez, 2002). The most common urinary complications are ureteral stricture or obstruction, difficult catheterization, and pyelonephritis (Angioli, 1998; Goldberg, 2006). The gastrointestinal complication rate attributed to Miami pouch is less than 10 percent and includes fistulas (Mirhashemi, 2004).

Patients undergoing exenterative surgery are typical candidates for creation of a new vagina. Other less common indications include congenital absence of the vagina, postirradiation stenosis, and total vaginectomy. There are innumerable ways to perform the procedure, and the type of reconstruction is typically determined by both the surgeon’s personal experience and the patient’s clinical circumstances.

Vaginal reconstruction at the time of exenteration is a very personal choice. Not every woman will desire a new vagina, and others will be unhappy with the functional result (Gleeson, 1994a). Moreover, reconstruction may significantly prolong an already lengthy operation and lead to additional perioperative morbidity (Mirhashemi, 2002). However, proponents suggest that filling the large pelvic defect and bringing in a new source of blood supply may actually prevent postoperative fistula or abscess formation (Goldberg, 2006; Jurado, 2000).

To create a functional neovagina, one of the following is performed: (1) surrounding skin and subcutaneous tissue is mobilized and positioned into the defect (skin flap), (2) skin from another part of the body is harvested and transferred to replace the vaginal mucosa (split-thickness skin graft), or (3) skin and underlying tissue outside the radiated field are mobilized on an attached section of muscle with its dominant blood supply (myocutaneous flap). Of the three choices for vaginal reconstruction, skin flaps, such as rhomboid flaps, pudendal thigh fasciocutaneous flaps, and advancement or rotational flaps, are technically the easiest to perform (Burke, 1994; Gleeson, 1994b; Lee, 2006). Split-thickness skin grafts (STSG) provide the ability to cover large surfaces if primary closure is not possible. However, these require that most of the native subcutaneous tissue has been retained at the neovagina site and require months of stenting with a vaginal mold to prevent stricture (Kusiak, 1996). Rectus abdominis myocutaneous (RAM) flaps and gracilis myocutaneous flaps are technically more challenging and take longer to perform, but they demonstrate the most satisfying functional results (Lacey, 1988; Smith, 1998). Importantly, RAM flaps may be inappropriate in those with a prior Maylard incision or any other procedure that resulted in ligation of the inferior epigastric artery, which is the dominant blood supply to this type of flap.

Regardless of reconstruction technique, sexual function is often significantly impaired in women after pelvic exenteration (Hockel, 2008; Ratliff, 1996). Other techniques are used less commonly and are not covered in this section.

PREOPERATIVE

Patient Evaluation

The surgeon should have an open discussion with the patient regarding the risks and benefits of vaginal reconstruction. Some women may have unrealistic expectations that are important to address preoperatively. Others may not wish to incur additional morbidity. The patient should also be aware that intraoperative complications may dictate a change of plans and the need to abort reconstruction.

Consent

The potential morbidity of the neovagina depends on the type of reconstruction. Flap necrosis, prolapse, wound separation, or other complications may require reoperation and/or lead to an unsatisfying end result. Postoperative patient concerns are expected and include self-consciousness about being seen in the nude by their partner and vaginal dryness or discharge (Ratliff, 1996).

Patient Preparation

The preceding exenterative surgery typically dictates preoperative preparation. Modifications may be required, depending on the type of neovaginal reconstruction. For example, the legs may need to be surgically prepped beyond the knees for a gracilis flap or a suitable donor site identified for STSG.

INTRAOPERATIVE

Surgical Steps

Anesthesia and Patient Positioning

General anesthesia is required for vaginal reconstruction. The abdomen, perineum, and vagina have been surgically prepared, and a Foley catheter inserted. Legs are positioned in standard lithotomy in booted support stirrups to permit adequate perineal access.

Pudendal Thigh Fasciocutaneous Flap

From a perineal approach, the planned incisions are marked along the skin from the non-hair-bearing areas just lateral to the labia majora. Flaps are roughly 15 × 6 cm. The most inferior skin margin should be level with the lower part of the gaping perineal defect. The skin incision is begun at the superior flap margin and dissected to include the underlying subcutaneous tissue and fascia lata (Fig. 46-9.1). The posterior labial artery, a branch of the internal pudendal artery, provides blood supply (Fig. 38-28).

The flap’s edges are approximated in a running, subcuticular suture line with 4–0 gauge delayed-absorbable suture. The edges both marked “A” in the figure are joined, as are both edges marked “B.” The tubular neovagina is inserted into the perineal defect such that the end labeled with letters becomes the new vaginal apex. The incision sites are closed with interrupted stitches of 3–0 gauge delayed-absorbable suture, and bilateral JP drains are placed beneath these suture lines. The perineal defect requires sculpting of tissue folds and suturing to form a functional end result (Fig. 46-9.2). The apex of the neovagina may then be abdominally sutured to the hollow of the sacrum as in a traditional sacrocolpopexy (Section 45-17). Intraabdominally, the neovagina is then covered with an omental J-flap to provide additional neovascularization.

Split-Thickness Skin Graft with Omental J-Flap

Modification of the omental flap, which is normally used to close off the pelvic inlet after exenteration, can create a cylinder for a new vagina. Notably, in thin patients, a thin, poorly vascularized, attenuated omentum may be inadequate to form a substantial cylinder and cover the mold.

From an abdominal approach, the omentum is detached from the stomach with a ligate-divide-staple (LDS) device or electrothermal bipolar coagulator (LigaSure). Resection is usually from right to left, until it will comfortably reach the pelvis as a J-flap (Section 46-14). Only three quarters of the omentum is divided, so as to preserve the left gastroepiploic artery for blood supply. The distal omentum is rolled into a cylinder and sutured together with interrupted stitches of 3–0 gauge delayed-absorbable suture (Fig. 46-9.3).

The proximal end can be closed abdominally with similar interrupted sutures or the transverse anastomosis (TA) stapler without dividing it entirely. From the perineal side, the omental cylinder is then sutured to the vaginal introitus.

Next, the STSG is harvested from the donor site and sutured over a vaginal mold with 4–0 gauge delayed-absorbable suture in a manner similar to the McIndoe procedure described in Section 43-25. The mold is placed into the neovaginal space and sutured into place at the introitus (Fig. 46-9.4). Each of the remaining smaller perineal defects, now above and below the neovagina, is closed in the midline with interrupted stitches of 3–0 gauge delayed-absorbable suture.

Gracilis Myocutaneous Flap

From a perineal approach, a reference line is drawn on the medial thigh from the pubic tubercle to the medial tibial plateau following the adductor longus muscle. Inferior to this line, an island of skin, its associated subcutaneous tissue, and the gracilis muscle will serve as the flap. The planned elliptic incision is marked, and a full-thickness skin incision through the reference line is continued through the subcutaneous fat and the fascia lata. The belly of the gracilis muscle is isolated at its distal margin and divided. The remainder of the incision is completed around the marked skin island margin. The gracilis muscle is fully mobilized with blunt and sharp dissection from distal to proximal. This preserves the dominant vascular pedicle—a branch of the medial femoral circumflex artery—as it enters the deep anterior belly of the muscle 6 to 8 cm from the pubic tubercle.

Through the operative site on the thigh, a subfascial tunnel is bluntly developed medially to the open perineal defect. The left gracilis muscle flap is rotated clockwise against the thigh, that is, rotated first posteriorly and then medially. It is placed through the tunnels and allowed to hang freely between the patient’s legs. The right flap is rotated counterclockwise and similarly positioned (Fig. 46-9.5).

Beginning at the distal tip, the tubular gracilis neovagina is constructed by suturing the skin edges of the right and left skin islands together with interrupted stitches using 4–0 gauge delayed-absorbable suture. The proximal opening should accommodate two or three fingers. The neovagina is rotated cephalad into the pelvis and posteriorly anchored to the levator plate abdominally with interrupted stitches of 0-gauge delayed-absorbable suture to prevent vaginal prolapse. Redundant flap skin is trimmed, and the proximal skin is sutured to the introitus with interrupted stitches of 3–0 gauge delayed-absorbable suture.

Each of the remaining smaller perineal defects, now above and below the neovagina, is closed in the midline with interrupted stitches of 3–0 gauge delayed-absorbable suture. Each thigh incision is similarly closed.

Rectus Abdominis Myocutaneous (RAM) Flap

A skin and muscle island can be harvested from any location on the abdominal wall as long as the base of its shape is at the umbilicus. Typically, a 10 × 15 cm skin island is marked. At the superior border of the island, which will ultimately form the vaginal opening, the skin, subcutaneous tissue, and anterior rectus sheath are incised. One belly of the rectus abdominis muscle is freed with blunt dissection from the posterior sheath. The belly is divided proximally, and its anastomotic vessels connecting to the superior epigastric system are ligated.

The remaining borders of the skin island are incised through the anterior rectus sheath to the arcuate line. The subcutaneous fat is mobilized along the lateral and medial margins of the rectus muscle belly. The rectus muscle is then bluntly dissected from the posterior sheath until reaching the arcuate line, which is the caudal margin of this sheath. Next, the posterior peritoneum is cut inferiorly along the full length of the midline incision well beyond the flap. The RAM flap is now fully detached, but it needs to be further mobilized on its vascular pedicle to be able to swing into the pelvis. At the distal portion of the skin island, the rectus muscle is then bluntly dissected inferiorly from the anterior sheath to its insertion onto the pubic bone.

The flap, consisting of skin, subcutaneous tissue, anterior sheath, and rectus belly, is coiled around a syringe to form a tube (Fig. 46-9.6). The skin edges are approximated with 4–0 gauge delayed-absorbable suture. The syringe is removed, and the tube is placed into the pelvis. The pelvic end of the tube is closed. The RAM flap must be put into the pelvis without tension to prevent occlusion of its dominant vascular supply from the inferior epigastric artery.

The open end of the neovagina is brought out under the pubic symphysis to the perineum where it is attached to the vulvar defect using interrupted vertical mattress stitches using 0-gauge delayed-absorbable suture. An omental J-flap may also be prepared to provide additional blood supply.

Each of the remaining smaller perineal defects, now above and below the neovagina, is closed in the midline with interrupted stitches of 3–0 gauge delayed-absorbable suture. Abdominal wall posterior rectus fascia is reapproximated with no. 1 polydioxanone monofilament (PDS). Skin is closed with staples.

POSTOPERATIVE

The presence of a vagina significantly improves quality of life for many women, as well as reducing sexual problems after exenteration (Hawighorst-Knapstein, 1997). Reconstruction may be beneficial to a woman’s self-image, and the knowledge that intercourse is possible may be reassuring even if she chooses not to be sexually active postoperatively. Morbidity from the procedure largely depends on the type of neovagina.

Pudendal thigh flaps are reliable and easy to harvest, but perhaps are the most likely to be nonfunctional. Long-term sequelae may include vulvar pain, chronic vaginal discharge, hair growth, and protrusion of the flaps. These symptoms may discourage patients and their partners from attempting sexual activity (Gleeson, 1994b).

STSG neovaginas may become infected at the donor or recipient site. Graft sloughing due to vascular compromise or development of a seroma is another common complication. Postoperatively, patients must initially be immobilized to aid healing, and stenting with a vaginal mold is required for months to prevent vaginal stenosis or contracture (Fowler, 2009).

Gracilis myocutaneous flaps may be difficult to pass into the pelvis during the procedure and have the potential for partial or complete tissue loss due to necrosis from an inherently tenuous blood supply (Cain, 1989). Flap loss is significantly more common if rectosigmoid anastomosis is performed concurrently during exenteration (Soper, 1995). Long-term prolapse is another relatively common problem. Residual scarring on the legs is a frequent, albeit relatively minor, complaint postoperatively.

Rectus abdominis muscle flaps are perhaps the best choice for vaginal reconstruction at the time of pelvic exenteration (Jurado, 2009). Ideally, they fill pelvic dead space, reduce the risk of fistulas, and provide fulfilling sexual activity (Goldberg, 2006). However, the donor site may be difficult to close primarily or may lead to a postoperative hernia or dehiscence. The operating time is also increased because, unlike a gracilis flap where the abdominal team can be proceeding with exenteration while the perineal team is beginning the reconstruction, two surgical teams are not possible when performing a RAM flap. Flap necrosis, enterocutaneous fistula, and vaginal stenosis are other frequent complications (Soper, 2005).

Pelvic lymph node removal and evaluation is a fundamental tool in accurate cancer staging. As such, it is commonly indicated in women undergoing surgery for uterine, ovarian, or cervical cancer. Also, in those with grossly involved nodes, pelvic lymphadenectomy may serve to optimally debulk tumor burden.

The aim of lymphadenectomy is bilateral complete removal of all fatty lymphatic tissue from the areas predicted to carry nodal metastases (Cibula, 2010). These nodes lie within well-defined anatomic boundaries that include: the midportion of the common iliac artery (cephalad), deep circumflex iliac vein (caudad), psoas muscle (laterally), ureter (medially), and obturator nerve (dorsally) (Whitney, 2010). Ideally, the procedure yields numerous pelvic nodes from multiple sites within these boundaries (Huang, 2010). Groups specifically sampled are the external iliac artery, internal iliac artery, obturator, and common iliac artery nodal groups. Removal of at least four lymph nodes from each side (right and left) is a minimum requirement to validate that an “adequate” lymphadenectomy has been performed (Whitney, 2010). In general, the extent of pelvic lymphadenectomy will depend on the clinical circumstances, such as degree of associated scarring and patient habitus.

Additional definitions are commonly used in association with lymphadenectomy. For example, pelvic lymph node “sampling” is a more limited procedure within the same anatomic boundaries and is particularly intended to remove any enlarged or suspicious nodes (Whitney, 2010). Sampling is limited to easily accessible pelvic regions and does not address all nodal groups (Cibula, 2010). Pelvic lymph node “dissection” is a vague term that may range from sampling to lymphadenectomy.

Pelvic lymphadenectomy can be performed via laparotomy or a minimally invasive abdominal approach. In contrast, although the pelvic lymph nodes lie retroperitoneally, a lateral abdominal wall approach to reach these without entering the peritoneal cavity, that is, extraperitoneal pelvic lymphadenectomy, is not commonly performed (Larciprete, 2006). Last, emerging advancements in lymphatic mapping and sentinel node techniques are designed to limit the short- and long-term complications associated with extensive lymphatic resection.

PREOPERATIVE

Patient Evaluation

Imaging studies such as CT, MR, or PET imaging may suggest pelvic lymphadenopathy and help guide a surgeon to suspicious areas. However, the ability to preoperatively detect microscopic metastases is limited.

Consent

With proper technique, pelvic lymphadenectomy is a straightforward procedure with relatively few complications. These include postoperative lymphocele, nerve and vascular injury, acute hemorrhage, infection, and chronic lymphedema.

Patient Preparation

Bleeding is a common problem with pelvic lymphadenectomy and may be exacerbated with obese patients, grossly enlarged or densely adhered lymph nodes, and pelvic vessel anatomic variants. Accordingly, units of packed red blood cells are typed and crossmatched. Topical hemostatic agents may also prove valuable.

Routine bowel preparation and antibiotic prophylaxis are not required for lymphadenectomy but may be indicated for other concurrent surgeries. Prevention of VTE is warranted, and options are listed in Table 39-8.

INTRAOPERATIVE

Surgical Steps

Anesthesia and Patient Positioning

This surgery may be performed under general or regional anesthesia with a patient supine. A Foley catheter is placed, and the abdomen is surgically prepared.

Abdominal Entry

A midline vertical or low transverse abdominal incision that allows access to the previously noted anatomic boundaries is appropriate for this procedure. A Pfannenstiel incision offers limited exposure and is reserved for only selected patients.

Abdominal Exploration

Pelvic and paraaortic lymph nodes are routinely inspected during initial abdominal exploration. Unexpected grossly positive nodes may indicate that a proposed operative plan should be abandoned (for example, radical hysterectomy for cervical cancer) or revised (Whitney, 2000).

Retroperitoneal Exploration

The retroperitoneal space has typically already been entered through the round ligament during preceding surgical procedures. However, to extend retroperitoneal access, a surgeon may further incise the anterior and posterior leaves of the broad ligament.

Palpation of the external iliac artery pulsation just medial to the psoas major muscle is the starting point. Its identification permits a surgeon to locate relevant anatomy, as vascular anomalies are regularly encountered. Blunt dissection is then performed cephalad to see the common iliac artery bifurcate into the external and internal iliac arteries. The ureter is isolated as previously described. The remaining pelvic sidewall structures are covered with fatty-lymphoid tissue and are not yet easily visible.

To summarize the planned en bloc specimen excision, dissection begins proximally along the psoas major muscle and external iliac artery and proceeds distally to reach the inguinal ring where the nodal specimen is reflected medially and off the external iliac vein. Next, dissection along the internal iliac artery begins cephalad and moves caudad, and last enters the obturator space for nodal dissection here. The entire nodal bundle is lifted and removed. Separately, nodes excised from along the distal common iliac artery can be included in the final specimen.

External Iliac Nodes

For this nodal group, an index finger is placed atop the psoas major muscle and lateral to the external iliac artery at a point distal to the common iliac artery bifurcation. The finger bluntly dissects caudally and parallel to the external iliac artery to separate the lateral preperitoneal fat from the fatty-lymphoid tissue covering the external iliac vessels (Fig. 46-10.1). The general absence of lateral branches from these vessels enables more aggressive blunt separation to be performed unless there is significant fibrosis. The genitofemoral nerve, which is visible parallel to the external iliac artery, can often be spared with careful dissection. Injury to this nerve results in ipsilateral labium majus and proximal thigh numbness.

Next, forceps traction is typically required to lift all adventitial tissue up and above the external iliac artery beginning at the common iliac artery bifurcation. This countertraction helps maintain the correct dissection plane moving distally as bands between nodal tissue and the artery are divided using electrosurgical cutting (Fig. 46-10.2).

As dissection continues caudally, the distal self-retaining retractor blade may be temporarily removed to allow resection of all pelvic nodes heading toward the inguinal canal. For this, the fatty nodal tissue overlying the caudal portions of the psoas major muscle and external iliac artery is grasped with forceps. With an incision made parallel and superficial to the artery, distal nodal tissue is freed. Mobilization of this tissue exposes the deep circumflex iliac vein, which crosses laterally over the distal external iliac artery. The deep circumflex iliac vein originates from the distal part of the external iliac vein and serves as the caudal boundary for this nodal group.

The mobilized nodal tissue is next reflected medially to reveal the entire external iliac artery. Medial traction is applied with forceps, and fine adventitial bands that connect the nodes to the underlying external iliac vein are transected using electrocautery cutting or Metzenbaum scissors. Once completed, this external iliac nodal group dissection later permits safe entry into the obturator space, outlined in Step 7.

Internal Iliac Nodes

Next, ureterolysis, if not previously performed, is completed (Section 46-1, Step 5). The ureter is moved and held medially by a Penrose drain or narrow retractor for protection and improved pelvic sidewall visualization. Spatially, nodes that have been dissected off the external iliac vessels and the fatty nodal tissue bridging the external iliac vein and the internal iliac artery lie in the same plane. Beginning at the common iliac artery bifurcation, the free nodal bundle is elevated and placed on tension. Initial sharp dissection of the internal iliac nodal group continues caudally along the internal iliac vessels and then along the superior vesical artery. As dissection approaches the distal aspect of the superior vesical artery, the nodal attachments are fine and enable electrocautery dissection without the need for clips or ligatures. At this point, both the external iliac and internal iliac nodes are completely dissected and can be submitted as one specimen or combined with obturator fossa lymph nodes, depending on surgeon preference.

Obturator Fossa Node Group

To reach this nodal group, an index finger is gently inserted between the psoas major muscle and external iliac artery, and blunt dissection progresses downward to the obturator fossa. Lateral arterial or venous branches may need vascular clip application and transection. During this dissection, nodal tissue may be identified behind the external iliac vessels and added to the specimen.

As a result, the external iliac vein is mobilized and can be retracted upward and laterally by a vessel retractor to expose the obturator fossa (Fig. 46-10.3). If present, nodal tissue along the inferomedial wall of the external iliac vein is transected with blunt and electrosurgical blade dissection. Also, accessory venous branches may be identified and clipped.

With the vein retractor in place, the obturator nodal tissue is grasped with forceps. This nodal bundle lies deep to the external iliac vein but superficial to the obturator nerve. With upward traction applied, blunt forceps or a suction tip moved gently side-to-side disrupts nodal tissue attachments to the obturator nerve. The blunt dissection is performed in the center of the fossa to minimize injury to surrounding deep pelvic vasculature. This also clears off tissue to permit obturator nerve identification.

Once this nerve is localized, dissection should purposely remain superficial to it. Firm fibrotic attachments may be electrosurgically transected under direct visualization. As the caudal end of the bundle is reached, it is usually tethered to the sidewall. To free it, a vascular clip is placed distal to the bundle, and the tethered attachment is divided proximal to the clip. At the cephalad end of the bundle, nodes are carefully separated sharply from the inferior aspect of the external iliac vein while avoiding obturator nerve injury.

Nodal tissue deep to the obturator nerve is not routinely removed since the obturator artery and vein traverse this area. Laceration of either vessel can result in retraction and catastrophic hemorrhage that is difficult to control.

Distal Common Iliac Lymph Nodes

To remove this group, the upper retractor blade is readjusted to expose the distal half of the common iliac artery. The colon may require mobilization using electrosurgical dissection along the white line of Toldt. Once this line is incised, bowel can then be retracted sufficiently to allow access to the common iliac nodes. The ureter is further mobilized medially before beginning node dissection.

Lateral fatty-lymphoid tissue may be removed by first grasping and elevating with forceps and using electrosurgical dissection to establish a plane. Blunt dissection to further separate the nodal tissue from the artery is continued cephalad. Electrosurgical coagulation or clips plus sharp incision are used to detach these nodes (Fig. 46-10.4). Laterally, the nodes are dissected off the psoas major muscle. Importantly, on the patient’s right side, the common iliac vein and inferior vena cava (IVC) lie beneath the lateral margin of the common iliac artery, and thus, careful dissection is warranted. Further dissection is performed atop the distal common iliac artery, which serves as the medial border of dissection for this nodal group.

Final Steps

Gauze sponges may be opened and tightly placed into the obturator fossa and medial to the external iliac vein to tamponade any surface oozing while additional procedures are performed. Topical hemostatic agents are employed as needed (Table 40-5). Closing the retroperitoneal space and using suction drainage does not minimize hematoma or lymphocele development (Charoenkwan, 2014).

POSTOPERATIVE

Neurologic injuries involving the obturator, ilioinguinal, iliohypogastric, genitofemoral, or femoral nerves may result from direct surgical trauma, stretch injury, suture entrapment, or retractor placement (Cardosi, 2002). Their specific neurologic deficits and management are described in Chapter 40. Notably, transection of the obturator nerve is ideally immediately noted intraoperatively and an epineural repair performed (Vasilev, 1994).

Surgical blunt dissection techniques decrease the risk of inadvertent vessel or nerve injury, but these may increase the chance of postoperative lymphocele formation. Also known as lymphocyst, these usually asymptomatic and transient lymph collections may form a thick fibrotic wall. Postoperative pelvic hematomas are also not uncommon.

Removal of paraaortic lymph nodes typically follows pelvic lymphadenectomy to surgically stage women with uterine and ovarian cancer because of these cancers’ unpredictable lymphatic dissemination patterns (Burke, 1996; Negishi, 2004). Moreover, removal of enlarged paraaortic nodes may provide optimal debulking of ovarian cancer and may also confer a survival benefit in selected endometrial and cervical cancer patients (Cosin, 1998; Havrilesky, 2005).

Paraaortic lymphadenectomy implies bilateral complete removal of all nodal tissue from within an area with well-defined anatomic boundaries: inferior mesenteric artery (cephalad), midlength of common iliac artery (caudad), ureter (lateral), and aorta (medial). The completeness of the procedure will vary by clinical setting, but an adequate dissection requires that lymphatic tissue at least be demonstrated pathologically from both the right and left sides (Whitney, 2010).

Paraaortic lymphadenectomy can be performed via laparotomy or minimally invasive approach. The proximal dissection is usually only extended to the inferior mesenteric artery (IMA), unless a “high” lymphadenectomy is indicated (Whitney, 2010). With this modification, a surgeon extends dissection to reach the renal veins. Most often, this is performed during ovarian cancer staging or in high-risk endometrial cancer cases to debulk tumor and more accurately stage these cancers (Mariani, 2008; Morice, 2003).

PREOPERATIVE

Patient Evaluation

As described earlier, imaging studies may help guide a surgeon to the most suspicious lymph nodes but are not entirely reliable in identifying small nodal metastases.

Consent

Paraaortic lymphadenectomy is not routinely performed worldwide due to the procedure’s technical difficulty and potential for complications (Fujita, 2005). Of these, acute hemorrhage and postoperative ileus occur most often. Other complications should be infrequent. In obese women, operative visibility is hindered, and thus, procedure complexity and operative times are considerably greater.

Patient Preparation

Bleeding is a common problem with this lymphadenectomy. Accordingly, units of packed red blood cells are typed and crossmatched. Topical hemostatic agents may also prove valuable. Routine bowel preparation and antibiotic prophylaxis are not typically required. However, other concurrent surgeries may dictate their use. Prevention of VTE is warranted, and options are listed in Table 39-8.

INTRAOPERATIVE

Surgical Steps

Anesthesia and Patient Positioning

Lymphadenectomy may be performed under general or regional anesthesia with a patient supine. A Foley catheter is placed, and the abdomen is surgically prepared.

Abdominal Entry

A midline vertical abdominal incision that allows access to the previously noted anatomic boundaries is appropriate for this procedure. Low transverse incisions offer limited exposure and are reserved for only selected patients.

Abdominal Exploration

Paraaortic lymph nodes are routinely palpated during initial abdominal exploration. A hand is placed beneath the small bowel mesentery to palpate the aorta. The index and middle fingers are then used to straddle the aorta and palpate for lymphadenopathy. Suspicious or grossly positive paraaortic nodes are typically removed as an initial step. Unexpected positive nodes may indicate that the proposed operative plan should be abandoned or revised (Whitney, 2000). For most instances, in which no adenopathy is present, the dissection is usually performed last due to the possibility of triggering catastrophic bleeding that might otherwise limit further surgery.

Visualization

Exposure and proper retractor positioning is perhaps the most important part of this procedure. Thus, a self-retaining retractor is positioned to allow access to the aorta. The sigmoid colon and descending colon are gently retracted in a lower left direction, whereas small bowel and transverse colon are packed into the upper abdomen by laparotomy sponges. Modified Trendelenburg patient positioning is also helpful to shift bowel from the operative field. Additional sharp dissection along the right paracolic gutter peritoneum (white line of Toldt) may be necessary to sufficiently mobilize and move the cecum from the dissection field. Once bowel has been cleared, the peritoneum overlying the aorta and right common iliac artery should be visible. Both vessels are palpated before proceeding. Also, as described on page 1135, the ureter is isolated and held laterally on a Penrose drain to avoid its injury.

Opening the Retroperitoneal Space

Beginning atop the midportion of the right common iliac artery, a right-angle clamp is used to guide electrosurgical blade incision of the posterior parietal peritoneum. Following each vessel’s course, the incision moves cephalad and medially over the right common iliac artery and then cephalad atop the aorta (Fig. 46-11.1). Staying directly above these arteries is recommended to avoid inadvertent laceration of the right common iliac vein or IVC. Continuing cephalad in the midline, sharp incision of the peritoneum is extended through the caudal and then left lateral aspect of the duodenal peritoneal reflection to mobilize the duodenum cephalad. An upper midline self-retaining retractor blade is repositioned to retract this bowel.

Right Paraaortic Nodes

With the ureter still held laterally, the surgeon first establishes the medial border of the right paraaortic nodal group. Atop the midportion of the right common iliac artery, the lymph node bundle is elevated with forceps to reveal fibrous bands connecting it to the artery. A right-angle clamp is placed beneath these bands, which are then sharply divided to free the distal bundle from the artery. Using electrosurgical cutting atop the right common iliac artery, cephalad and slightly medial dissection continues following the vessel course. Once the aortic bifurcation is reached, cephalad dissection progresses atop the right lateral border of the aorta to reach the level of the IMA. Small perforating vessels may be encountered and are coagulated.

To establish the lateral border of this nodal group, the ureter is again held laterally. Blunt cephalad dissection with a suction tip atop the iliopsoas muscle separates the retroperitoneal fat from the right border of the IVC. The upper right abdominal retractor blade may need to be repositioned to improve visibility.

At this point, the right paraaortic node bundle has been largely detached medially, distally, and laterally. Next, the bundle is again grasped distally with forceps and elevated as gentle sharp dissection beneath this bundle in the midline is directed cephalad. Delicate perforating veins along the IVC warrant meticulous dissection to reduce bleeding. One of these, the “fellow’s vein,” is routinely encountered near the level of the aortic bifurcation and is occluded with a vascular clip for hemostasis (Fig. 46-11.2). Upon reaching the level of the IMA, the nodal bundle can be removed by placing large vascular clips across the cephalad end and transecting it before the clip. Once excised, this right nodal bundle is sent as a separate specimen.

Repair of Venous Bleeding

A surgeon should prepare for small lacerations in the wall of the IVC or common iliac veins caused by inadvertent avulsion of perforating venous tributaries. Hemorrhage may be copious and immediate. Initially, pressure is applied with a sponge-stick or finger, and anesthesia staff is informed of the potential for increased blood loss. Second, exposure is assessed. Blood is suctioned from the abdominal cavity, retractors are repositioned, and incisions are extended if necessary. Last, proper vascular instruments are obtained. Lacerated veins can usually be simply repaired with vascular clips (Fig. 46-11.3).

Left Paraaortic Nodes

The medial border of this nodal group is developed using electrosurgical dissection that begins at the IMA. To advance, the medial side of the bundle is elevated with forceps to create tension across fibrous bands connecting it to the aorta. These fibers are sharply divided and free the proximal bundle. Moving caudally, continued similar dissection progresses atop the left border of the aorta toward its bifurcation. Upon reaching the bifurcation, dissection then advances caudally and slightly lateral to follow atop the left common iliac artery’s course. This artery’s midlength marks the caudad border.

Once this medial dissection is completed, fibrovascular attachments between the sigmoid colon mesentery and left side of the distal aorta are sharply transected. This aids access to laterally located paraaortic nodes.

To develop the lateral border of this nodal group, fingers or suction tip carefully separate the lateral fatty lymphoid tissue from the overlying sigmoid colon mesentery and from the underlying ovarian vessels and ­ureter. Opening this potential space allows clear identification of the ureter and the ovarian vessels, which lie medial to the ureter. A handheld vein retractor is positioned to gently lift up the sigmoid colon mesentery, its adjoining vessels, and ureter.

Establishing these medial and lateral borders delineates the left paraaortic lymph node bundle for removal. To free this bundle caudally, nodal tissue over the common iliac artery is elevated on traction with forceps. A vascular clip is placed across the bundle’s caudal end, which is transected before the clip and freed. The distal nodal bundle is next elevated and lifted cephalad (Fig. 46-11.4). Fibrovascular attachments between the bundle and the medial aorta and lateral iliopsoas muscle are transected with electrosurgical blade or with vascular clips and Metzenbaum scissors as dissection moves progressively cephalad to the level of the IMA. Importantly, dissection into the lumbar vessels, which originate from the aorta’s posteromedial aspect, is avoided. At the level of the IMA, the cephalad end of the left paraaortic lymph node bundle is clipped and transected. The entire nodal group is removed in toto and submitted as an individual specimen.

Interiliac Nodes

Optionally, additional lymph nodes may be removed by excising the fatty tissue between the common iliac vessels. For this, the posterior peritoneum at the aortic bifurcation is grasped, and electrosurgical incision is extended caudally atop the inner side of both common iliac arteries. The crossing left common iliac vein is visible directly beneath.

The peritoneum is reflected caudally, and the fatty tissue beneath is grasped and placed on tension. Sharp dissection is performed along the surface of both common iliac veins, which have very few small perforating vessels. Once mobilized between the common iliac vessels, the triangle-shaped area of fatty-lymphoid tissue is freed by electrosurgical division of bands connecting it to the sacrum.

High Paraaortic Lymphadenectomy

For this extended lymph node removal, anatomic boundaries begin caudally at the level of the IMA and reach cephalad to the entry level of the right ovarian vein and left renal vein (Whitney, 2010). To begin, the former midline peritoneal incision atop the aorta is incised further cephalad, and the duodenal loop is bluntly dissected off the aorta. Repositioning of the retractor blade to move this loop cephalad aids exposure.

On the aorta’s right side, the caudal end of the high paraaortic nodal bundle is grasped with blunt forceps, and dissection atop the right lateral border of the aorta is continued cephalad until the right ovarian vein, before its insertion into the IVC. Here, the nodal bundle can be clipped, divided, and incorporated within the specimen.

On the left side, high paraaortic node dissection begins with identification, clipping, and cutting of the IMA between ties, which allows access to upper nodal tissue. The mesenteric circulation has an extensive collateral network that permits IMA ligation without subsequent bowel ischemia. Alternatively, the IMA may be preserved if adequate exposure is available. This avoids potential bowel ischemia in those with poorly developed collateral vessels.

Dissection continues cephalad atop the left border of the aorta and reaches the left renal vein, which was exposed by prior cephalad displacement of the duodenum. Removal of the left paraaortic nodes includes elevation of the distal nodal bundle and sharp dissection to isolate and electrosurgically divide lymphatic attachments. At the left renal vein, the bundle is clipped and transected (Fig. 46-11.5).

Retroaortic Lymphadenectomy

This more extended dissection is optional and begins after left-sided paraaortic lymphadenectomy has been completed. The left-sided lumbar arteries can be seen branching directly from the aorta. These vessels may be clipped and cut to allow manual rolling of the aorta from left to right, which provides access to the retroaortic nodal chain. Typically, this procedure is performed when imaging studies have demonstrated suspicious nodes in the region.

Final Steps

Gauze sponges may be opened and gently placed in areas of nodal dissection to tamponade any surface oozing. Closing the retroperitoneal space or routinely using suction drainage does not minimize hematoma or lymphocele development (Morice, 2001).

POSTOPERATIVE

The postoperative course following paraaortic lymphadenectomy in general follows that after laparotomy. However, the incidence of postoperative ileus is increased due to ­longer operative time, increased bowel manipulation, incision extension, and additional blood loss. As with pelvic lymphadenectomy, lymphoceles and hematomas may develop.

Minimally invasive surgery (MIS) can often be used for surgical staging that includes pelvic and paraaortic lymph node excision and sometimes omentectomy and peritoneal biopsy. Also, for those without comprehensive staging at their primary surgery, MIS may allow a less morbid completion of cancer staging. Specific MIS qualities that are suited to lymphadenectomy include expanded magnified views within deep or narrow spaces and the ability to achieve fine dissection. In terms of landmarks and fields of dissection, MIS lymphadenectomy procedural steps are the same as those with the open abdominal approach described on pages 1169 and 1172. However, with an MIS approach to cancer staging, paraaortic lymphadenectomy is typically completed first. The needed pneumoperitoneum gradually distends bowel, and thus surgery higher in the abdomen is performed early to permit adequate bowel manipulation and displacement.

PREOPERATIVE

Patient Evaluation

A thorough pelvic examination and history reveal factors that help determine the optimal surgical route for an individual patient. As described in Chapter 41, when considering MIS, patients with suspected extensive adhesive disease, morbid obesity, or significant cardiopulmonary disease may be poor candidates. Regardless of approach, preoperative imaging studies prior to lymphadenectomy may help guide the surgeon to suspicious lymph nodes.

Consent

General complications related to MIS are discussed in Chapter 41 and include entry injury to the major vessels, bladder, ureters, and bowel. More specific to MIS staging, acute hemorrhage is the most commonly associated complication. Additionally, ureteral damage, postoperative lymphocele, and nerve injuries can occur, particularly to the obturator and genitofemoral nerve. In addition, the risk of conversion to an open procedure is discussed. Conversion to laparotomy may be necessary if exposure and organ manipulation are limited or if acute hemorrhage cannot be controlled with MIS techniques. Finally, port-site metastasis is a rare but possible complication.

Patient Preparation

As mentioned, bleeding is a frequent problem with pelvic lymphadenectomy and may be exacerbated by retroperitoneal fibrosis. Accordingly, units of packed red blood cells are typed and crossmatched. Topical hemostatic agents may also prove valuable. Routine bowel preparation and antibiotic prophylaxis are not required for lymphadenectomy but may be indicated for other concurrent surgeries. Thromboembolism prophylaxis is warranted because of the VTE risk associated with cancer. Options are listed in Table 39-8.

INTRAOPERATIVE

Instruments

Important basic MIS tools for laparoscopy include blunt graspers and scissors, whereas the EndoWrist monopolar scissors and the EndoWrist bipolar Maryland grasper are used with the robot. Additional instruments needed for lymphadenectomy include a combined irrigation/suction device, which clears fluid and bluntly dissects; endoscopic bag for node removal; two to three 5-mm instrument ports; 10-mm laparoscope port; 12-mm endoscopic-bag port; and energy devices for cutting and vessel sealing. For the last, several electrosurgical and ultrasonic energy-based devices are adapted for either laparoscopic or robotic cases. These include Harmonic scalpel, electrosurgical monopolar instruments, and electrothermal bipolar coagulator devices (LigaSure, ENSEAL, PK Dissecting Forceps). For laparoscopy, the argon-beam coagulator is another option. Laparoscope selection varies by surgeon, and a 0-degree scope is frequently used. For others, a 30-degree scope permits greater visibility in tight or angulated spaces.

Surgical Steps

Anesthesia and Patient Positioning

Laparoscopic lymphadenectomy is performed under general anesthesia. For VTE prophylaxis, lower extremity compression devices are placed, and legs are then positioned in adjustable booted support stirrups. Typically, low lithotomy position is selected due to concurrent hysterectomy, although supine may be appropriate for restaging procedures. As described in Chapter 41, appropriate positioning of legs within the stirrups and arms at the side is crucial to reduce nerve injury risks. Also, the patient is secured to the bed by means of a gel pad or bean bag with appropriate protective padding. This keeps the patient from sliding when placed in steep Trendelenburg position, which is needed to reflect bowel for retroperitoneal access.

To avoid stomach puncture by a trocar during primary abdominal entry, an orogastric or nasogastric tube is placed to decompress the stomach. To avert similar bladder injury, a Foley catheter is inserted. The abdomen is then surgically prepared. If hysterectomy is planned, then vaginal preparation is also done.

Port Placement

As described in Section 46-3, a 10-mm primary trocar for the laparoscope is placed either at or approximately 1 to 2 cm above the umbilicus using an open abdominal entry method. For paraaortic dissection, this port is placed far enough cephalad to permit visualization of the lower aorta. Accessory ports include a right and left lateral abdominal trocar and one above one of the anterior superior iliac spines, as shown in Figure 46-3.1.

Additional ports are placed according to surgeon preference or clinical circumstances. All ports ideally have a minimum of 8 cm between them to allow ample range of motion and for robotic procedures, to avoid arm collision.

Visual Inspection

Following insertion of the laparoscope, lymph nodes are grossly inspected during initial abdominal exploration. Unexpected positive nodes may alter a proposed operative plan in certain cases, particularly with cervical cancer. In addition, a decision is made to proceed with the MIS approach or convert to laparotomy.

Paraaortic Lymphadenectomy: Open­ing the Retroperitoneal Space

With the patient in steep Trendelenburg position, the small bowel is gently moved into the right and left upper quadrants. The first landmarks identified are the aortic bifurcation and right common iliac artery. The peritoneum over the midlength of the right common iliac artery is grasped, elevated, and sharply incised. This peritoneal incision is extended superiorly atop the right common iliac artery and then atop the aorta. Following each vessel’s course, the incision progresses to the curve of duodenum overlying the aorta (Fig. 46-12.1). Once the peritoneum is opened at this level, it is held anteriorly and cephalad by an assistant surgeon using graspers. Blunt and sharp dissection is performed by the surgeon to lift and displace the duodenum cephalad to expose the aorta. This small bowel is progressively lifted until the level of the inferior mesenteric artery (IMA) is reached as it exits from the aorta on the left.

Ureter Identification

For this, the lateral peritoneal cut edge atop the right common iliac artery is grasped and elevated. Blunt dissection beneath this peritoneum progresses laterally until the right ureter is located as it crosses the common iliac artery. Once identified, the ureter is directed laterally with gentle blunt traction. This lowers ureteral injury risks during the remaining nodal dissection.

Right Paraaortic Lymph Nodes

To summarize lymphadenectomy within this anatomic area, the caudal end of the fatty, lymph node-containing tissue bundle is freed first. The surgeon then develops medial, lateral, and deep bundle margins and last frees the cephalad tip to permit bundle removal.

To begin, with the ureter held laterally and the inferolateral peritoneal edge elevated, the surgeon first develops the caudal border of this nodal group. Dissection begins at the midlength of the right common iliac artery and atop this artery’s lateral border. Within the overlying fatty tissue, small spaces are bluntly developed to create fibrous pedicles that can be lysed or coagulated and divided. In doing so, the distal end of the nodal bundle is progressively freed from the artery and can be elevated and brought cephalad.

Dissection then follows the artery’s course and moves medially atop its lateral border. During this dissection, small fibrous bands between the nodal bundle and the right common iliac artery are sequentially transected. Crossing the IVC and reaching the lower aorta, dissection continues atop the right lateral margin of the aorta until reaching the level of the IMA.

To establish the lateral border of this nodal group, the surgeon revisits the dissection’s starting point at the right common iliac artery’s midlength. Here, a plane is bluntly developed between the lateral border of the IVC and psoas major muscle. Blunt dissection in this plane frees the retroperitoneal fat and is extended cephalad to the level of the IMA.

At this point, the right paraaortic node bundle has been largely detached medially, distally, and laterally, and division of the deep bundle attachments can be performed. The nodal tissue is elevated and separated from the underlying IVC with gentle blunt dissection progressing cephalad. This dissection moves proximally atop the IVC to reach the level of the IMA (Fig. 46-12.2). During this progression, small pedicles that often contain minor vessels are developed. These pedicles and their multiple perforating vessels are sequentially isolated, clipped or coagulated, and divided. Typically, this is the most difficult part of the dissection because inadvertently avulsed vessels may bleed profusely. For control, hemostatic clips or coagulation can be used. Moreover, a small gauze sponge can be prophylactically placed into the abdomen to provide quick tamponade if required.

At the level of the IMA, the nodal bundle can be excised by placing large vascular clips across the cephalad end and transecting it before the clip. Lymph nodes are extracted intact using an endoscopic bag through a 12-mm port. Once removed, this right nodal bundle is sent as an individual specimen.

Left Paraaortic Lymph Nodes

Ac­qui­sition of the left paraaortic lymph nodes begins atop the aorta at the level of the IMA. As on the right side, after the initial bundle tip is freed, the medial, lateral, and deep margins are developed. However, dissection moves caudally rather than cephalad and ends at the left common iliac artery’s midlength.

The cephalad end of this nodal group is first developed using sharp or electrosurgical dissection that begins just below the IMA (Fig. 46-12.3). Small spaces within the fatty tissue are bluntly opened to create fibrous pedicles that can be lysed or coagulated and divided. This frees the proximal end of the nodal bundle.

To advance, the lateral peritoneal edge and colon mesentery are elevated to the left on tension, and fibrovascular attachments to left side of the distal aorta are sharply transected. This permits lateral retraction of the colon mesentery for exposure. The medial side of the bundle is next elevated with forceps to create tension across fibrous bands connecting the nodal bundle and aorta. These fibers are sharply divided. Similar dissection continues caudally atop the left border of the aorta toward its bifurcation. Upon reaching the bifurcation, dissection then moves caudally and slightly laterally atop the left common iliac artery’s lateral border to finish at this artery’s midlength.

To access the lateral border of this nodal group, a blunt tip carefully sweeps laterally to separate the lateral fatty lymphoid tissue from the overlying sigmoid colon mesentery and from the underlying ureter. The ureter serves as the lateral boundary of this nodal group. Opening this potential space allows the ureter and the ovarian vessels, which lie medial to the ureter, to be clearly identified. A blunt probe is then repositioned to gently lift the colon mesentery, its adjoining vessels, and ureter. With this lateral border now developed, dissection of nodal attachments continues caudad, staying medial to the ureter and reaching the midlength of the left common iliac artery.

After establishing the medial and lateral boundaries of the left paraaortic nodal group, the caudad tip of the nodal bundle is again grasped and elevated. From the midlength of the left common iliac artery, dissection beneath the bundle moves cephalad while transecting deep attachments between it and the lateral aorta and between it and the psoas major muscle (Fig. 46-12.4). Upon reaching the level of the IMA, the cephalad end of the fatty tissue is clipped and transected. The entire nodal group bundle is removed in toto within an endoscopic bag through the 12-mm port. It is submitted as an individual specimen.

High Paraaortic Lymphadenectomy

In some instances, a surgeon may elect an extended laparoscopic dissection. The anatomic boundaries of a high paraaortic lymphadenectomy begin distally at the IMA and reach proximally to the entry level of the right ovarian vein and left renal vein into the IVC, respectively (Whitney, 2010). Typically, this extension is possible only in selected patients with favorable anatomy, such as thin body habitus. Otherwise, upper abdominal exposure is problematic. Other helpful maneuvers include having a second surgical assistant and placing additional right and left upper quadrant trocars. In contrast, robotic paraaortic lymphadenectomy stops at the level of the IMA. High paraaortic dissection to the level of the renal vein is technically difficult and infrequently performed. Reasons include poor visualization, limitations in spanning the distance with the robotic arms, and inability to turn the patient around without undocking and placing additional ports.

To begin laparoscopically, the peritoneum overlying the aorta at the level of the IMA is grasped and elevated cephalad to displace small intestine into the upper abdomen and provide exposure to the aorta. The surgeon dissects retroperitoneally atop the aorta to further mobilize the duodenum and displace it cephalad. Often a laparoscopic fan retractor positioned in the retroperitoneal space aids exposure of the upper aorta.

To develop the medial border of the right high paraaortic nodal group, the nodal bundle overlying the IVC is regrasped and held on traction to dissect and divide the fibrous attachments from the aorta’s anterior surface and right border. This begins caudally at the level of the IMA and ends cephalad at the right ovarian vein.

For the lateral border of this nodal group, the right ureter is identified and again retracted to the right. The lateral portion of the nodal bundle is then bluntly separated from the psoas muscle in a proximal direction. The ovarian vein will be encountered and may be individually sealed and divided depending on its proximity to lymph nodes slated for removal.

With both lateral and medial borders defined, the deep middle attachments of this nodal bundle are freed by gentle cephalad dissection over the IVC until the level of the right ovarian vein is reached. Last, the proximal border of the nodal bundle is detached and removed as described earlier.

Dissection of the high left paraaortic nodal group begins by placing laparoscopic clips on the IMA and dividing between using a vessel-sealing device. Alternatively, the IMA may be preserved if adequate exposure is available. This avoids potential bowel ischemia in those with poorly developed collateral vessels. The left ureter is again identified as the lateral border of this high nodal group and is held laterally by an assistant.

The surgeon performs blunt dissection with intermittent coagulation and division of fibrous or vascular pedicles to detach the nodal bundle in a cephalad direction. Dissection continues until it reaches the left renal vein, where the bundle is detached and removed.

Pelvic Lymphadenectomy: Retro­peritoneal Entry

For this nodal resection, lymphoid tissue is removed within the area bounded by the psoas major muscle (lateral), the superior vesical artery (medial), the midlength of the common iliac artery (cephalad), and the deep circumflex iliac vein (caudad). To begin, the round ligament is transected, and the peritoneal leaf between the round and infundibulopelvic (IP) ligament is grasped, elevated, and incised parallel to the IP. Gentle traction is again applied to the round ligament, and the broad ligament’s anterior peritoneal leaf is opened to reach the vesicouterine fold in the midline. If radical hysterectomy is planned after pelvic lymphadenectomy, then pararectal and paravesical spaces are completely developed as described on page 1144 prior to pelvic lymph node removal.

Pelvic Lymphadenectomy: Distal Common Iliac Nodes

Bowel is first retracted sufficiently to allow access to the distal half of the common iliac artery. To remove this nodal group, the prior peritoneal incision atop the common iliac artery is extended from its midlength caudally to expose the artery. Ureterolysis, if not previously performed, is completed as described in Section 46-3, Step 4. The ureter is then bluntly retracted medially before beginning node dissection.

Lateral fatty lymphoid tissue may be removed by first elevating it with a blunt grasper and using electrosurgical dissection atop the common iliac artery’s lateral margin to establish a plane between the nodal bundle and artery. Blunt dissection to further separate the nodal tissue from the artery is continued caudad. Electrosurgical coagulation plus sharp incision is used to detach these nodes. Importantly, on the patient’s right side, the common iliac vein and inferior vena cava lie beneath the common iliac artery’s lateral margin, and thus careful node excision is prudent. Further dissection is performed atop the distal common iliac artery, which serves as the medial border for this nodal group. Upon reaching the common iliac artery bifurcation, lymphatic tissue excision continues caudally to incorporate the external iliac nodal group.

External Iliac Nodes

Removal of this lymph node group starts by freeing its lateral border. Tissue previously resected along the common iliac artery is elevated and placed on tension. Dissection then extends caudally along the lateral side of the external iliac artery until reaching the deep circumflex iliac vein. This vein crosses the distal external iliac artery and serves as the caudal boundary of this nodal group. Along this path, dissection bluntly develops a plane between medially located lymphoid tissue and lateral preperitoneal fat found above the psoas major muscle (Fig. 46-12.5). During dissection, the genitofemoral nerve running atop the psoas major muscle is ideally identified and protected.

Next, grasper traction is typically required to lift the nodal bundle above the external iliac artery beginning at the common iliac artery bifurcation. During caudal dissection, a blunt tool gently pushes into the fibrofatty tissue to create distinct pedicles that attach the nodal bundle to the artery. These pedicle attachments can then be coagulated and divided. Electrosurgery can be also used to obtain hemostasis as the lymph node bundle is progressively excised caudally.

The mobilized nodal bundle is next reflected medially to reveal the entire external iliac artery (Fig. 46-12.6). Medial traction is applied with forceps, and fine adventitial bands that connect nodes to the underlying external iliac vein are transected using electrosurgical cutting. In contrast to open surgery, the pneumoperitoneum and Trendelenburg position used during laparoscopy result in vein collapse. As a result, the external iliac vein is harder to distinguish and can be easily injured. Once completed, this external iliac nodal group dissection later permits safe entry into the obturator space, outlined in Step 13.

Internal Iliac Nodes

The ureter is moved and held medially by a blunt instrument for protection and improved pelvic sidewall visualization. Beginning at the distal aspect of the superior vesical artery, the free nodal bundle is again elevated and placed on tension. Initial sharp excision of the internal iliac nodal group continues cephalad along the superior vesical artery and then along the internal iliac vessels (Fig. 46-12.7). As dissection approaches the common iliac artery bifurcation, the nodal attachments are fine and allow blunt disruption. At this point, both the external iliac and internal iliac nodes are completely dissected and can be submitted as one specimen or combined with obturator fossa lymph nodes, depending on surgeon preference.

Obturator Fossa Nodes

With the assistant surgeon holding medial traction on the superior vesical artery, the obturator fossa can be exposed. This fossa may be entered medially, between the external iliac artery and the psoas major muscle. Thereafter, the external iliac vessels are retracted medially so that the obturator space can be accessed from a lateral approach. Or, the obturator space can suitably be entered medially.

If present, nodal tissue along the inferomedial wall of the external iliac vein is transected with blunt and electrosurgical dissection. Also, accessory venous branches may be identified and coagulated.

Within the exposed fossa, obturator nodal tissue is grasped with forceps. This nodal bundle lies deep to the external iliac vein but superficial to the obturator nerve. With upward traction applied, blunt forceps or a suction/irrigation device tip moved gently side-to-side disrupts nodal tissue attachments to the obturator nerve (Fig. 46-12.8). This blunt dissection is performed in the center of the fossa to minimize injury to surrounding deep pelvic vasculature. This also clears off tissue to permit obturator nerve identification.

Once this nerve is localized, dissection should purposely remain superficial to it. Firm fibrotic attachments may be electrosurgically transected under direct visualization. As the caudal end of the bundle is reached, it is usually tethered to the sidewall and freed sharply. At the cephalad end of the bundle, nodes are carefully separated sharply from the inferior aspect of the external iliac vein while avoiding obturator nerve injury. Nodal tissue deep to the obturator nerve is not routinely removed since the obturator artery and vein traverse this area. Laceration of either vessel can result in retraction and catastrophic hemorrhage that is difficult to control.

Pelvic lymph nodes are then removed in toto via endoscopic bag. The identical procedure is performed on the contralateral side.

Completion of Laparoscopic Staging and Omentectomy

The staging procedure for ovarian cancer includes obtaining multiple peritoneal biopsies from the cul-de-sac, pelvic sidewalls, and pelvic gutters, and from the diaphragm bilaterally. This can be performed with a blunt grasper and laparoscopic scissors, with or without electrosurgical coagulation. The surgical staging for ovarian cancer and for certain histologic subtypes of endometrial cancer (papillary serous and clear cell carcinoma) also includes omentum removal.

A laparoscopic omentectomy is performed by identifying and elevating the omentum away from the transverse colon. Avascular windows are created within the proximal omentum. The intervening vascular attachments are then ligated with a vessel-sealing energy tool or endoscopic stapler. Once completely dissected, the omentum is placed in an endoscopic bag and removed through a transabdominal 12-mm port. In many women, the omentum is large and therefore is brought through the vagina if a laparoscopic hysterectomy is performed. All specimens undergo minimal manipulation and are removed through an endoscopic bag to help decrease the risk of port-site or intraabdominal tumor implantation.

Port Removal and Fascial Closure

Once procedures are completed, areas are inspected for bleeding. Topical hemostatic agents may be used and are listed in Table 40-5. If hemostasis is achieved, trocars are removed and port sites closed. Fascial defects larger than 10 mm are sutured to decrease the risk of herniation at those sites. Interrupted stitches of 0-gauge delayed-absorbable suture are placed to reapproximate this fascia. Alternatively, a dedicated trocar-site closure device, described in Chapter 41, can be used. Regardless of technique, the defect is palpated to confirm adequate closure.

POSTOPERATIVE

The postoperative course following MIS staging lymphadenectomy generally follows that after other major laparoscopic surgery. Patients usually are able to tolerate clear liquids quickly, followed by a regular diet and discharge on postoperative day 1. With their pain typically controlled with oral pain medication, patients ambulate early.

Postoperative complications may include pelvic lymphocele formation, neurologic injuries, or trocar-site herniation. One long-term potential complication of pelvic lymphadenectomy is lymphedema. The exact incidence is unknown, but estimates range from 1 to 27 percent after surgical ­staging for endometrial cancer (Todo, 2010). The risk increases if more lymph nodes are removed or if pelvic radiation is administered after surgery. Treatments, which may or may not be successful, often include compression stockings, lower extremity wrapping, and massage therapy to manipulate lymph channels. Although generally not associated with an adverse outcome, this complication can significantly lower a patient’s quality of life postoperatively.

Ovarian cancer with contiguous encasement of the reproductive organs, pelvic peritoneum, cul-de-sac, and sigmoid colon is the main indication for en bloc pelvic resection. Also known as radical oophorectomy, this effective technique aids a maximal cytoreductive surgical effort. As a result of removing all microscopic and infiltrative peritoneal tumor in the pelvis, improved survival rates can be expected in patients with advanced epithelial ovarian cancer (Aletti, 2006b). Moreover, pelvic recurrence rates are low and reflect the completeness of pelvic tumor eradication (Hertel, 2001). Many of the principles of en bloc pelvic resection mirror those of other procedures in gynecologic oncology.

PREOPERATIVE

Patient Evaluation

Pelvic examination may reveal a relatively immobile mass, and abdominopelvic CT images typically demonstrate a pelvic mass and ascites. With the presumed diagnosis of advanced ovarian cancer, patients are prepared for anticipated cytoreductive surgery. However, the need for en bloc resection is usually dictated by intraoperative findings rather than preoperative testing.

Consent

In general, women with advanced ovarian cancer undergoing cytoreductive surgery are at significant risk for complications. Minor postoperative problems such as incisional cellulitis, superficial wound dehiscence, urinary tract infection, or ileus are common. Major postoperative complications of en bloc resection include anastomotic leaks and various fistulas (Bristow, 2003; Park, 2006).

Patient Preparation

Primary anastomosis without colostomy is typical for most patients. Thus, bowel preparation is commonplace for any type of cytoreductive ovarian cancer surgery, but particularly if en bloc pelvic resection is a possibility. One or more bowel resections may be required to achieve optimal debulking, and often, preoperative determination of the exact location of tumor infiltration is not entirely accurate. The combination of pneumatic compression devices and subcutaneous heparin is particularly important due to the anticipated longer operation length, coagulability risk associated with malignancy, and possibility of extended postoperative recovery. Moreover, patients are routinely typed and crossmatched for packed red blood cell replacement, as transfusions are frequently indicated (Bristow, 2003).

INTRAOPERATIVE

Instruments

En bloc pelvic resection requires access to multiple sizes of bowel staplers, including gastrointestinal anastomosis (GIA), transverse anastomosis (TA), and end-to-end anastomosis (EEA) staplers. Additionally, a ligate-divide-staple (LDS) device or electrothermal bipolar coagulator (LigaSure) may be used to divide vascular tissue pedicles.

Surgical Steps

Anesthesia and Patient Positioning

Bimanual examination under general anesthesia is especially important to confirm the need for low lithotomy leg positioning in booted support stirrups. Access to the perineum is crucial any time the EEA device may need to be placed in the rectum. Sterile preparation of the abdomen, perineum, and vagina is performed, and a Foley catheter is placed.

Abdominal Entry

Typically, a vertical incision is selected for ovarian cancer debulking surgery since the extent of disease cannot be precisely known beforehand and upper abdominal disease requires excision. At first, the incision extends up to the umbilicus. After exploration and determination of tumor resectability, it can be lengthened as needed.

Exploration

The abdomen is thoroughly explored to first determine whether all gross disease can be safely removed. For example, unresectable upper abdominal tumor makes the prospect of a radical pelvic operation less attractive.

Frequently during exploration, it is difficult to distinguish uterus, adnexa, and adjacent tumor. As shown in Figure 46-13.1, both ovaries may be grossly enlarged with tumor and densely fixed into the posterior cul-de-sac with contiguous involvement of the uterus, rectosigmoid, and lateral sidewalls. Moreover, superficial implants often coat the fallopian tubes, the vesicouterine fold, and much of the surrounding pelvic peritoneum. En bloc pelvic resection will allow removal of all this gross disease.

Lateral Pelvic Dissection

For cases in which the round ligaments cannot be located with certainty, the lateral peritoneum is grasped with an Allis clamp, and an electrosurgical blade is used to enter the retroperitoneum (Fig. 46-13.2). The loose areolar connective tissue of this space is bluntly dissected and the overlying peritoneum is sharply incised to create an opening in which the external iliac artery can be palpated. This artery is bluntly followed to the bifurcation with the internal iliac artery. The medial peritoneal leaf of the broad ligament is elevated to identify the ureter, around which a one-quarter inch Penrose drain is looped.

The infundibulopelvic (IP) ligament will typically not be entirely distinguishable due to induration and anatomic distortion by tumor. A window is bluntly opened just superior to the ureter as it crosses above the pelvic brim to isolate a tissue pedicle that will include the IP ligament. The ligament is isolated, clamped, cut, and tied with 0-gauge delayed-absorbable suture. The entire sequence is repeated on the contralateral side. The ureter may then be mobilized distally, and the anterior portion of the broad ligament is incised toward the vesicouterine fold using an electrosurgical blade. The round ligament will be identified during this dissection and separately divided.

Vesicouterine Dissection

The anterior broad ligament dissection is continued with a right-angle clamp guiding the electrosurgical blade (Fig. 46-13.3). The peritoneum is typically edematous and thick. En bloc removal of tumor implants within the vesicouterine fold will require a wide excision of the peritoneum over the bladder dome. Thus, the proximal end of the vesicouterine fold may be held on traction, and an electrosurgical blade used to sharply dissect in a caudal direction toward the cervix while encompassing the tumor. The bladder mucosa is typically not entered, but it may be simply repaired if an inadvertent cystotomy occurs (Chap. 40). After removal of this peritoneum, the bladder may then be advanced distally in the usual manner as for simple hysterectomy. The whitish cervix will be visualized through the anterior vaginal wall. The ureters are held laterally while the uterine vessels are freed of surrounding connective tissue (skeletonized), clamped, cut, and ligated.

Dividing the Sigmoid Colon

This step mirrors those in Steps 5 and 6 of low anterior resection, illustrated on page 1201. First, the ureters are held laterally, while a right-angle clamp guides an electrosurgical blade during posterior peritoneum incision. This incision moves medially on each side to reach the midline sigmoid colon mesentery. The sigmoid colon segment that lies proximal to the tumor is selected, and the underlying mesentery is superficially incised on each side with the electrosurgical blade. A GIA stapler is then inserted to divide the bowel.

After colon division, the remaining mesentery is scored superficially with the electrosurgical blade and divided with the electrothermal bipolar coagulator. Larger pedicles, such as those including the inferior mesenteric vessels, will need to be clamped, cut, and ligated separately. As during total pelvic exenteration, the avascular retrorectal space between the rectum and the sacrum may then be bluntly dissected to completely mobilize the rectosigmoid down to the cervix (Fig. 46-13.4).

Retrograde Hysterectomy

The blad­der is separated from the upper vagina with sharp electrosurgical blade dissection. The anterior vaginal wall distal to the tumor margin is grasped with a Kocher clamp. The anterior vaginal wall is then incised at 12 o’clock with the electrosurgical blade, and the incision is extended laterally to the right and left. The cervix is grasped with a Kocher clamp and retracted to expose the posterior vaginal wall. An electrosurgical blade is used to incise this wall transversely and enter the rectovaginal space. Two Allis clamps grasp the upper vagina to apply caudad traction and aid further dissection. A retrorectal hand is placed to assess whether the tumor extends into the rectovaginal septum beyond the cervix. With large masses, distal dissection may be required into the rectovaginal septum to reach a point distal to the tumor’s leading edge. If so, further distal vaginal wall excision may be needed to reach tumor-free margins. Alternatively, smaller tumors may allow proximal dissection in the rectovaginal septum. This gains additional rectal length distal to the tumor and allows for creation of a higher colon reanastomosis. Finally, the remaining uterosacral and cardinal ligaments are clamped, analogous to that during radical hysterectomy, but in a retrograde fashion. With this, distal portions of the cardinal ligament are transected first, and then more cephalad portions are clamped, cut, and ligated. For protection, ureters are held laterally (Fig. 46-13.5).

Distal Rectal Division

The mucosa of the rectal segment distal to the tumor is circumferentially dissected free of mesenteric attachments and rectal pillars by constant traction on the en bloc specimen. The TA or contour cutting (Contour) stapler is inserted into the pelvis and fired to transect the rectum (Fig. 46-13.6, dotted line). The specimen, which contains the uterus, adnexa, rectosigmoid, and surrounding peritoneum, is then lifted out of the pelvis. The vaginal opening is closed in a running fashion with 0-gauge delayed-absorbable suture. The final appearance Fig. 46-13.7 is shown with completed rectosigmoid anastomosis, which is described in Section 46-21.

Final Steps

A surgeon then proceeds with additional procedures if necessary to complete the ovarian cancer debulking surgery. A colostomy or rectosigmoid anastomosis may require mobilization of the splenic flexure and is performed near the end of surgery. Postoperative drains may be placed at the surgeon’s discretion. Occasionally, the bladder may also be retrograde filled to exclude cystotomy during vesicouterine dissection. All pedicles sites are reexamined for hemostasis.

POSTOPERATIVE

En bloc pelvic resection of primary and recurrent ovarian cancer permits a high rate of complete debulking with acceptable morbidity and mortality rates (Park, 2006). Urinary tract infection, pneumonia, deep-vein thrombosis, wound cellulitis, and postoperative ileus are relatively common events following major abdominal surgery for ovarian cancer. Reoperation for anastomotic breakdown or postoperative hemorrhage specific to en bloc pelvic resection is uncommon (Bristow, 2003; Clayton, 2002).

The omentum is typically removed for two reasons: (1) tumor debulking or (2) cancer staging. First, patients who present with advanced ovarian cancer almost invariably have metastases to the omentum. The extent of this “omental cake” may be massive and involve the upper gastrocolic ligament, anterior abdominal wall, splenic hilum, and transverse colon (Fig. 35-14). Thus, a surgeon is prepared to encompass the entire tumor with an adequate resection. Second, omentectomy is routinely indicated for staging patients with ovarian cancer or with uterine papillary serous carcinoma who do not have obvious metastatic disease (Boruta, 2009; Koh, 2014; Whitney, 2010).

As a reminder, the proximal omentum has two leaves. Its anterior leaf attaches to the greater curvature of the stomach via the gastrocolic ligament. Its posterior leaf attaches to the caudal margin of the transverse colon. The lesser omental sac lies between these two proximal leaves. Infracolic omentectomy describes transection of the anterior leaf (gastrocolic ligament) at a level below the transverse colon. This is sufficient for most clinical circumstances. Supracolic (total) omentectomy describes transection of the anterior leaf (gastrocolic ligament) at a level above the transverse colon and close to the stomach’s greater curvature. It may be indicated for a large omental cake.

Omentectomy may be completed by laparotomy, as described here. It is also amenable to a MIS approach, as described in Section 46-12, Step 14 (1180).

PREOPERATIVE

Patient Evaluation

Imaging studies may suggest an omental cake, but its extent is difficult