Explain：Recurrent cervical cancer
Clinical Information:
The female patient
had the chief complaint of cervix cancer. Physical examination revealed cervix
cancer. Initial histologic cell type is cervix carcinoma. Patient had received radiotherapy
complete course. Unfortunately, central recurrent of cervical cancer was noted.
Radio-oncologist, protologist, and urologist have been consulted. Oncologic
survey including pelvic and abdominal tomography, MRI, color doppler
sonography, and lower GI series were performed. After the intestinal tract had
been prepared for resection and the patient's permission for a exenteration
surgery was obtained, exenteration operation was plan.
Pelvic and abdominal
CT shows ______________
The biochemical data
are: SCC:_______, CEA:________.
Operative Procedures:
Type of operation: Exenteration: [[anterior posterior
exenteration, retroperitoneal node dissection, multiple peritoneal biopsy, enterolysis,
colostomy, ileal condue, vulva and perineal reconstruction, radiation probe
insertion]].
□ Anterior
exenteration
The purpose of the
operation is to remove the bladder, urethra, upper two-thirds of the vagina,
uterus, and all tissue lateral from the uterus to the pelvic side wall,
including the tissue in the obturator fossa. The rectum and colon are left
intact. The predominant pathophysiologic alteration is elimination of the
bladder and lower ureters and the formation of an intestinal loop urinary
diversion conduit.
The patient is placed on the operating
table in the modified dorsal lithotomy position with the hips abducted
approximately 300, exposing the perineum. The entire abdominal wall, vulva,
perineal area, and vagina are surgically prepped. A foley catheter is inserted
in the bladder. The abdomen is opened through a large lower midline incision
that is extended around the umbilicus. The upper abdomen is thoroughly explored
for tumor. The bowel is packed off, exposing the pelvic brim. The
peritoneum between the cecum and
terminal ileum is opened and the common iliac artery and aortas are exposed. The aorta is explored all the
way to the renal vessels, and any suspicious lymph nodes are removed. The
anterior exenteration is started by performing a lymphadenectomy at the
bifurcation of the aorta and proceeding toward the femoral canal. All the lymph node and pelvic side wall
tissue should be sent for frozen pathology. Exenteration will start if all the frozen section shown no
malignancy metastasis. The peritoneum has been opened from the bifurcation of
the aorta to the femoral canal, and the lymph nodes have been dissected off the
common iliac artery. The ureter crosses the common iliac artery on the right
side medial and inferior to the ovarian vessels. The round ligaments on each
side are cut at the pelvic wall,
and the posterior and anterior
leaves of the broad ligament are
completely opened.As soon as possible, the hypogastric artery on both sides
should be identified, ligated, and incised to reduce blood loss. The ureter
should not be transected until the
surgeon is absolutely confident that the tumor is resectable .When it cut , it
should be cut as low in the pelvis
as possible leaving ample ureter for construction of the urinary
diversion. The pelvis should be
closed with an omental pelvic lid to prevent small bowel contents from falling
into the pelvis and adhering tot the radiated tissue. The remainder of the external iliac artery and vein
are stripped of all lymph nodes . The external iliac vein is deviated laterally
exposing the obturator fossa from which all lymph node bearing tissue is
removed. The ovarian are clamped and doubly tied at the pelvic brim. The ureter
, with a generous portion of its peritoneal attachment left intact , is transected below the common iliac artery . The ureter has been transected
and the distal ureter is gated . The obturator fossa has been cleaned of all contents . The hypogastric artery is cross clamped, transected , and tied with 2/0 silk
suture. The distal portion of the artery is elevated , and its branches are identified , clamped , and tied. Attention is directed to the space of Retzius where the bladder
is easily separated from the rectopubic space with a sweep of the hand..
Fine adhesions to the pelvis wall
can be lysed with Metzenbaum scissors
and any small vessels clamped with hemoclips. The paravesical and pararectal spaces have been
dissected out and while two fingers are left in the respective paravesical and
pararectal spaces , the entire
specimen consisting of bladder and uretus is retracted medially with the hand . Large Wertheim clamps are placed across the
web , the extension of the cardinal ligament to the pelvic wall. The web is transected between clamps .
This procedure is repeated until the levator fascia is reached . The same
procedure is carried out on the opposite side. The stumps of the web are seen
adjacent to the pelvic wall that will include the hypogastric venous plexus .
Successive carried down to the
levator ani muscles . The rectum remains intact . The uterosacral ligaments
have been cut adjacent to the pelvic wall posteriorly. The hypogastric vein and
artery have been cut and tied
. The stumps of the web are seen
on the pelvic wall . The specimen
has been completely freed down to the levator sling and retracted medially .The
ureterosacral ligaments have been cut and tied . The peritoneum of the culdesac
of Douglas has been transected, and the posterior vaginal wall has been dissected off of the
rectum . The specimen is now retracted cephalad . A scalpel is used to transect
the urethra near its meatus . The vagina is transected across the introitus at the level of
the levator sling . Any remaining
rectal stalks attaching the posterior vaginal wall to the rectum are lysed and
the specimen is removed. The
vaginal cuff has been reefed with a running lock 1/0 chromic catgut suture .The ureters are seen to squirt
urine below the pelvic brim. Maximum attention , at this stage , is turned
toward hemostasis within the pelvis. .An intestinal loop urinary diversion is
constructed from an ileal loop . The left and right ureters have been implanted
into the loop over a silastic urethral anastomosis catheter . The loop and bowel resections are
performed with the
automatic surgical stapler (GIA) or sutured with 3/0 Vicryl suture. The
loop is retracted downward . The
ileoiloostomy is performed above the loop with Vicryl suture in an end-to -end
functional anastomosis. The anastomosis is completed by cross clamping the
opening in the mesenteric borders of
the two segments of bowel .
Excess bowel is trimmed away . An omental vascular pedicle J flap is created .
The ileal loop has been brought out through the right lower quadrant and sutures to the skin .
The omental J flap is
brought into the pelvic and
sutured around the iliopectineal line and across the rectosigmoid colon , as a
pelvic lid . The abdominal is
closed in layers . A sump
nasogastric tube is inserted in the stomach and multiple Penrose drains
inserted in the abdominal culdesac
are placed.
□ Posterior
exenteration
Basically , a
posterior exenteration is a combination of a radical Wertheim hysterectomy and
an anterior resection of the rectosigmoid colon . The purpose of the operation
is to remove the uterus , tubes ,
ovaries ,the rectosigmoid colon , and all parametrial tissue from the uterus to the pelvic wall. The patient is
placed on the operating table in the modified dorsal lithotomy position with
the hips abducted 30 . A Foley catheter is inserted into the
bladder . The abdomen is opened through a middling incision extended around the
umbilicus .After opening the abdomen; cavity it should be explored and all
suspicious areas of tumor identified and removed for frozen section analysis.
If positive lymph nodes are encountered in the common iliac or aortic area ,
the procedure should not be performed for the treatment of patient with
squamous carcinoma of the cervix , vagina , or vulva. Once the decision has been made to proceed with
the operation , the peritoneum is opened along the right common iliac artery .
All lymphatic tissue is removed ,
taking care to preserve the ureter . The ovarian vessels seen crossing the common iliac artery
will be ligated. The round ligament
is clamped , transected , and tied at the pelvic wall . The posterior leaf of the broad ligament is opened ,
exposing the entire external iliac
artery. The proximal colon should
be transected as low in the
pelvis as possible to permit the maximum amount of colon available for
reanastomosis . Care should be taken to identify the left ureter as one opens
the mesentery of the rectosigmoid colon . The dissection off the ureter in the
tunnel must be performed with reticulous surgical technique to avoid
vesicovaginal fistula. Control of hemorrhage is constantly a factor in performing
this operation . The lymph nodes
are removed from the external iliac artery , vein , and obturator
fossa . The ovarian vessels are clamped., ligated . and
tied . The same procedure is
performed on the other side. The
obturator fossa has been cleaned
of lymph nodes and preserving the obturator nerve. The hypogastric
artery is clamped , ligated , and incised with its branches . The same procedure is carried out on the opposite side.
The mesentery of the rectosigmoid colon is opened in an avascular area and a
Penrose drain passed through this opening as a source of traction on the colon . The peritoneum covering
the mesentery is opened . Care
taken at this identify the left
ureter because the mesentery of the rectosigmoid colon generally points to the
left ureter at its base. The colon is retracted caudad . A finger has been
inserted in the opening of the mesentery under the rectosigmoid colon . The peritoneum covering the
medial side of the mesentery is opened. The vessels in the mesentery of the
rectosigmoid colon a have been clamped and tied with 2/0 silk suture . Cephalad
retraction is made on the combined special men of uterus and rectosigmoid colon
. As hand is inserted into the
presacral space to dissect the rectum from the sacrum down to the coccyx . It is important to keep the dissecting hand in the
midline in order to prevent
evulsion of the presacral veins on the lateral margin on the sacrum .
These can be a source of
troublesome bleeding if lacerated. The stalks on each side of the rectum are progressively clamped,
incised and tied with 2/0 silk suture . This frees the rectum from its lateral
attachments. The anterior leaf of the broad ligament is incised down and across
the bladder peritoneum . The vesicoperitoneum is elevated and the bladder is
dissected off the lower uterine cervix and anterior vagina for a distance of at
least 6 to 8 cm. The uterus is retracted medially . The paravesical and
pararectal spaces are dissected . Notice that in talking down the rectal stalks
the pararectal space has been
removed . The ureter crosses the superior medial portion of the web as it
enters the tunnel . The hypogastric artery and vein have been retracted
medially. The external iliac artery and vein have been retracted laterally revealing
the obturator fossa and nerve . The dissection of the ureter to the web by
delicately elevating the ureter with a vein retractor . The attachments of the
ureter to the web are lysed with Metzenbaum scissors .A Kelly clamp is inserted
on top of the ureter underneath the tunnel towards the bladder. The dotted line indicates the incision
to be made in the web adjacent to the pelvic wall . The tunnel is taken down in
successive bites and tied with 3/0chromic catgut. When the tunnel has been
completely transected , the course of the ureter can be seen all the way to
uretervesical junction . The web is taken down in successive bites and tied
with 2/0 silk suture all the way to the levator muscle . The specimen is free
of lateral attachment to the pelvic
wall and posteriorly from the sacrum . The specimen consisting of the uterus , its lateral attachments ,
rectum , ureterosacral and rectal stalk ligaments along with the hypogastric artery , vein and its branches can be elevated . The ureter is freed all the way to the bladder. By firm cephalad traction on the
specimen the vagina has been transected with a scalpel at the level of the
levator muscle . The rectum is
transected below the tumor but preferably above the levator sling. The
completed operative field , the stumps of the various lateral attachments of
the uterus and rectum , the
dissected ureters , the intact bladder , with the vaginal cuff left open
but whose edge has been reefed with a running 1-0 chromic catgut suture are
shown . The rectum is available for reanastomosis of the descending colon. As
the surgeon looks into the pelvis the descending colon is mobilized . The
splenocolic ligament is clamped and tied . The peritoneum lateral to the
descending colon is opened to the pelvic brim. The rectosigmoid and descending
colon is mobilized further by transecting the left colic branch of the inferior
mesenteric artery. An attempt should be made to preserve as many of the
branches of the inferior mesenteric artery as possible to give maximum blood
supply to the descending colon at its anastomosis with the rectum. However, if
the marginal artery of the colon is intact, the inferior mesenteric artery
itself may be clamped and tied to produce complete mobility of the colon is
intact, the inferior mesenteric artery itself may be clamped and tied to
produce complete mobility of the colon. There must be no tension on the
colorectal anastomosis. The marginal artery of the colon allows sacrifice of
the superior hemorrhoidal and left colic branches of the inferior mesenteric
artery if needed to achieve a tension-free anastomosis. Purse string suture is
applied to the distal end of the descending colon. A purse string suture is
placed in the proximal edge of the rectal stump and the automatic surgical stapler
is inserted through the anus and activated. The descending colon has been
stapled to the rectum. Penrose drains are placed in the open vaginal cuff and
reperitonealization is carried out as much as possible considering the
excessive amount of tissue removed from the pelvis. In this particular drawing
maximum peritonealization has been achieved. This is frequently impossible. In
this particular drawing maximum peritonealization has been achieved. This is
frequently impossible. In all radiated cases, and any case in which there is
some double about the healing properties of the anastomosis, a protective
temporary diverting colostomy should be performed. This may be closed in 2 to 3
months.
The abdominal wall was closed layer by layer. The peritoneum below the umbilicus was
approximated by 1-0 chromic catgut, the abdominal fascia was closed by 1-0 PDS
continuous suture, the sub-cutaneous fat was approximated by 1-0 vicryl,
and the skin was approximately by 3-0 vicryl subcutaneously. Scrupulous normal saline irrigation
before closure of abdominal wall and between layers of closure was done to wash
out the possible floating tumor cells. The patient was sent to POR intensive
care unit for recovery and respiratory support. The patient stood the
procedure well and in stable condition.
Operative Findings:
Complication:
Pathology:
Dr:________________. Date: _______________.