Atlas of Procedures in Gynecologic Oncology
Atlas of Procedures in Gynecologic Oncology
Atlas of Procedures in Gynecologic Oncology
GYNECOLOGIC
ONCOLOGY
SECOND EDITION
Douglas A Levine MD
Assistant Attending Surgeon
Department of Surgery
Memorial Sloan-Kettering Cancer Center
New York, NY
USA
Richard R Barakat MD
Chief, Gynecology Service
Department of Surgery
Memorial Sloan-Kettering Cancer Center
New York, NY
USA
Nadeem R Abu-Rustum MD
Associate Attending Surgeon
Department of Surgery
Memorial Sloan-Kettering Cancer Center
New York, NY
USA
© 2008 Informa UK Ltd
Second edition published in the United Kingdom in 2008 by Informa Healthcare, Telephone House, 69–77 Paul
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in this publication, the ultimate responsibility rests with the prescribing physician. Neither the publishers nor
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contained herein. For detailed prescribing information or instructions on the use of any product or procedure
discussed herein, please consult the prescribing information or instructional material issued by the
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A CIP record for this book is available from the British Library.
Paul Abrahams
Tel: +44 207 017 4036
Email: [email protected]
For all of our trainees, who have worked tirelessly to learn these procedures and will share them with future
generations.
Contents
List of contributors vii
Acknowledgments x
I Open Procedures
1 Surgical staging of gynecologic malignancies 1
Eric L Eisenhauer and Yukio Sonoda
5 Pelvic exenteration 93
Douglas A Levine, Bernard H Bochner, and Dennis S Chi
6 Retroperitoneal lymph node dissection 117
Oliver Zivanovic, Nadeem R Abu-Rustum, and Joel Sheinfeld
20 Sentinal lymph node identification for early-stage cervical and uterine cancer 289
Nadeem R Abu-Rustum and Mary L Gemignani
25 Brachytherapy 321
Sang E Sim and Kaled M Alektiar
26 Cystourethroscopy and ureteral catheterization 337
Siobhan M Kehoe and Nadeem R Abu-Rustum
Index 345
Contributors
Nadeem R Abu-Rustum MD, Gynecology Service, Siobhan M Kehoe MD, Gynecology Service,
Department of Surgery, Memorial Sloan-Kettering Department of Surgery, Memorial Sloan-Kettering
Cancer Center, New York, USA Cancer Center, New York, USA
Kaled M Alektiar MD, Department of Radiation Robert J Korst MD, Department of Thoracic Surgery,
Oncology, Memorial Sloan-Kettering Cancer Center, New York Presbyterian Hospital, New York, USA
New York, USA Eric Leblanc MD, Département de Cancérologie
Anuja K Antony MD, Plastic and Reconstructive Gynécologique, Centre Oscar Lambret, Lille, France
Service, Department of Surgery, Memorial Mario M Leitao Jr MD, Gynecology Service,
Sloan-Kettering Cancer Center, New York, USA Department of Surgery, Memorial Sloan-Kettering
Christopher S Awtrey MD, Division Gynecologic Cancer Center, New York, USA
Oncology, Department of Obstetrics and Gynecology, Douglas A Levine MD, Gynecology Service,
Beth Israel Deaconess Medical Center, Boston, MA, Department of Surgery, Memorial Sloan-Kettering
USA Cancer Center, New York, USA
Richard R Barakat MD, Gynecology Service, Sharyn N Lewin MD, Gynecology Service,
Department of Surgery, Memorial Sloan-Kettering Department of Surgery, Memorial Sloan-Kettering
Cancer Center, New York, USA Cancer Center, New York, USA
Bernard H Bochner MD, Urology Service, Department Babak J Mehrara MD, Plastic and Reconstruction
of Surgery, Memorial Sloan-Kettering Cancer Center, Service, Department of Surgery, Memorial
New York, USA Sloan-Kettering Cancer Center, New York, USA
Patrick J Boland MD, Orthopedics Service, Michelle Montemarano PA, Gynecology Service,
Department of Surgery, Memorial Sloan-Kettering Department of Surgery, Memorial Sloan-Kettering
Cancer Center, New York, USA Cancer Center, New York, USA
Carol L Brown MD, Gynecology Service, Department Marie Plante MD, Department of Obstetrics and
of Surgery, Memorial Sloan-Kettering Cancer Center, Gynecology, Laval University, Québec, Canada
New York, USA Denis Querleu MD, Department of Surgery, Institut
Claudius Regaud, Toulouse, France
Dennis S Chi MD, Gynecology Service, Department of
Surgery, Memorial Sloan-Kettering Cancer Center, Marie-Claude Renaud MD, Department of Obstetrics
New York, USA and Gynecology, Laval University, Québec, Canada
Anne Covey MD, Department of Radiology, Memorial Michel Roy MD, Gynecologic Oncology
Sloan-Kettering Cancer Center, New York, USA CHUQ-Hôtel-Dieu, Québec, Canada
John Diaz MD, Gynecology Service, Department of Mark Schattner MD, Department of Medicine,
Surgery, Memorial Sloan-Kettering Cancer Center, G.I./Nutrition, Memorial Sloan-Kettering Cancer
New York, USA Center, New York, USA
Joel Sheinfeld MD, Urology Service, Department of
Eric L Eisenhauer MD, Gynecology Service,
Surgery, Memorial Sloan-Kettering Cancer Center,
Department of Surgery, Memorial Sloan-Kettering
New York, USA
Cancer Center, New York, USA
Moishe Shike MD, Department of Medicine, G.I./
Raja M Flores MD, Thoracic Service, Department of Nutrition, Memorial Sloan-Kettering Cancer Center,
Surgery, Memorial Sloan-Kettering Cancer Center, New York, USA
New York, USA
Sang E Sim MD, Radiation Oncology Service,
Ginger J Gardner MD, Gynecology Service, Department of Regional Operations, Memorial
Department of Surgery, Memorial Sloan-Kettering Sloan-Kettering Cancer Center, Basking Ridge, NJ,
Cancer Center, New York, USA USA
Mary L Gemignani MD, Breast Service, Department Yukio Sonoda MD, Gynecology Service, Department
of Surgery, Memorial Sloan-Kettering Cancer Center, of Surgery, Memorial Sloan-Kettering Cancer Center,
New York, USA New York, USA
George I Getrajdman MD, Department of Radiology, Oliver Zivanovic MD, Gynecology Service,
Memorial Sloan-Kettering Cancer Center, New York, Department of Surgery, Memorial Sloan-Kettering
USA Cancer Center, New York, USA
Preface to the first edition
This atlas has been designed for the purpose of to see how different a real surgical procedure is from
providing a detailed overview of the major procedures that depicted in sketches and diagrams; through the
performed by gynecologic oncologists, using full color use of actual color photographs, the representations
photographs, and is accompanied by a DVD of live within this Atlas should approximate what is actually
surgical footage with spoken commentary. Creating seen in the operating room.
the basis of this text exclusively from color images of
actual surgical procedures offers the reader a vantage Over one hour of actual surgical footage is included
point similar to that seen by the operating surgeon. on an accompanying DVD with spoken commentary.
Owing to the sophisticated computer technology The reader is able to review a procedure with full
that is currently on hand, all the photographs color photographs and then view selected procedures
were captured on digital film and digital videotape. on video. The combination of photographs, written
We have made great effort, except where absolutely text, surgical footage, and spoken commentary is one
necessary, to preclude the use of sketches or of the most realistic approaches to understanding a
black-and-white photographs throughout Atlas of complex surgical procedure without actually scrubbing
Procedures in Gynecologic Oncology. into the case. Indeed, in some respects the material
contained within may serve better to illustrate the
This book should be valuable for those beginning their procedures than actually being in the operating room
surgical training, as well as for senior practitioners. as an observer: here, the reader will see the major
For the medical student and house officer, it will portions of procedures without the surgical staff or
provide an introduction to basic gynecologic oncology the surgical drapes obstructing the view.
procedures such as surgical staging, vulvar surgery,
radical hysterectomy, and others. There are also We have attempted to present all major procedures in
sections on paracentesis, chest tube placement and our specialty. Some of the less frequently performed
central venous access. For the fellow in training, procedures are not illustrated owing to the lack of
procedures, such as laparoscopic lymph node material or space within the text. Subsequent editions
dissection, intraoperative radiation therapy, inguino- of this Atlas will replace some operations with new
femoral lymphadenectomy, and others, will be procedures and will expand as our specialty expands.
indispensable when acting as the first assistant. For Hopefully, we will have the opinions of our readers to
the senior surgeon, the text will introduce new allow each edition to be a better reference work than
technologies and advanced minimally invasive the preceding one. In addition to the commonly
procedures that are not part of the usual surgical performed major procedures, we have also illustrated
armamentarium. Procedures such as laparoscopic many advanced procedures currently performed only
radical hysterectomy, sentinel lymph node biopsy, at specialized centers throughout the world. These
radical vaginal trachelectomy, and others are not procedures are likely to be practiced on a more
typically taught during normal subspecialty training. widespread basis as physicians become sufficiently
All these procedures are illustrated in such detail that trained in minimally invasive surgery. We have tried
any surgeon can appreciate the adaptation of currently to highlight important technical points for each step
practiced surgical procedures to the minimally of the procedures in order to steer the reader away
invasive approach, which may be readily learned from from potential complications.
selected specialists in the field.
The text here is limited to procedural descriptions
The chapters in Atlas of Procedures in Gynecologic and succinct introductory paragraphs explaining
Oncology are purposely presented in great detail, general indications without a comprehensive review
giving the reader a complete working knowledge of of the literature. A discourse on the management of
each procedure. While we would be amiss in believing gynecologic malignancies is certainly readily available
that one could actually perform a new procedure in many other well-written texts. This text is strictly
simply by reviewing this text, with proper instruction focused on procedures, as will become apparent to
the procedure should be readily grasped. Expertise in the reader. We have attempted to design a high-quality,
a particular procedure can be acquired more quickly comprehensive Atlas and hope that the reader
on account of having a detailed knowledge of the appreciates its distinctiveness and merit.
procedure prior to performing it or observing it for the
very first time. When one studies procedures in Douglas A Levine
gynecologic oncology without the benefit of detailed Richard R Barakat
operative color photographs, it can be quite surprising William J Hoskins
Preface to the second edition
In this second edition of Atlas of Procedures in surgery and radical pelvic surgery. We have added
Gynecologic Oncology we have expanded the subject short chapters illustrating unique procedures such as
area but tried to maintain the general design of hand-assisted laparoscopic splenectomy and a general
providing a detailed overview of the major procedures chapter on urologic procedures. In addition to the
performed by gynecologic oncologists using full color commonly performed major procedures, we have also
photographs. It has been said that ‘good judgment illustrated many advanced procedures currently per-
comes from bad judgment.’ We hope that by offering formed only at specialized centers throughout the
a photographic vantage point similar to that seen by world. These procedures are likely to become prac-
the operating surgeon we can minimize the amount of ticed on a more widespread basis as physicians
trial and error required to obtain expertise in the become sufficiently trained in minimally invasive
operating theater. In this second edition we have and fertility-sparing surgery.
updated or replaced over 30% of the material from
the first edition. In this second edition as well, we We value the opinions of our readers and have
welcome Nadeem R Abu-Rustum as a co-author, who received tremendously positive feedback on our first
has contributed greatly to the completion of the edition. As this second edition goes to press, we hope
current work. to maintain a dialogue with our readers through
written and electronic correspondence. We continue
This book remains valuable for those beginning their to welcome both complimentary and critical responses
surgical training, as well as for senior practitioners. to the second edition. We will be providing an
For the medical student and house officer, it is an electronic comment card on the Atlas’ dedicate
introduction to basic gynecologic oncology proce- website: www.gynatlas.org. Please visit this site to
dures, such as surgical staging, vulvar surgery, radical contact the authors or provide commentary.
hysterectomy, and others. There are also sections
on paracentesis, chest tube placement, and central This surgical guide offers a complete procedure-
venous access. For the fellow in training, procedures oriented manual in gynecologic oncology with full
such as laparoscopic lymph node dissection, intra- color photographs. We have taken every effort to
operative radiation therapy, inguinofemoral lymph- eliminate the use of line drawings and sketches that
adenectomy, and myocutaneous flap reconstruction only detract from a realistic presentation of actual
will be indispensable when acting as the first assistant. surgery. The text is limited to procedural descriptions
For the senior surgeon, the text will introduce new and introductory paragraphs explaining general
technologies and advanced minimally invasive proce- indications without a comprehensive review of the
dures that are not part of the usual surgical armamen- literature. A discourse on the management of gyneco-
tarium. In this edition we have added an extensive logic malignancies is certainly readily available in
chapter on robotics in gynecologic oncology. many other well-written texts. This text is strictly
focused on procedures, as will become apparent to
We have attempted to present all major procedures in the reader. We have attempted to design a high-quality,
our specialty. In this second edition we have added comprehensive atlas and hope that the reader
new procedures and expanded on some of the previ- appreciates its distinctiveness and merit.
ously published work. We have a dedicated chapter
on retroperitoneal lymph node dissection and a new Douglas A Levine
chapter on panniculectomy to facilitate pelvic surgery. Richard R Barakat
There is additional material on fertility-sparing Nadeem R Abu-Rustum
Acknowledgments
The authors are grateful to the staff of Informa Healthcare, including managing editor Kelly Cornish, editorial
assistant Georgina Adams and senior production editor Kathryn Dunn, for their assistance and patience through-
out the development of this book. We would also like to thank the editorial staff at Memorial Sloan-Kettering
Cancer Center for their tremendous effort, including George Monemvasitis, who served as lead copyeditor, and
his colleagues Alexandra MacDonald and Jennifer Grady, for their dedication and organizational skills. We also
acknowledge the device and guidance of William J Hoskins MD who served as an author on the first edition
and helped to lay the groundwork for the entire project. Above all, we are grateful to the contributing authors,
many of whom were gracious contributors to the first edition of this atlas. They have provided not only their
surgical expertise but also their patients and operating time to allow us to photograph ongoing procedures,
without sacrificing the highest level of performance during the diagnosis and treatment of cancer and allied
diseases.
1 Surgical staging of
gynecologic malignancies
Eric L Eisenhauer and Yukio Sonoda
Thorough surgical staging is essential for the treatment mucinous histology is suspected or noted on frozen
of patients with early-stage endometrial and ovarian section, an appendectomy should also be performed.
cancer, as accurate surgical staging is important Many mucinous tumors presumed to originate in the
to guide adjuvant chemotherapy and/or radiation ovary may in fact be metastases from the appendix or
therapy for patients with these cancers. In 1988, other gastrointestinal organs.
surgical staging replaced clinical staging for endome-
trial cancer due to the significant underreporting of In endometrial carcinoma, surgical staging is nearly
extrauterine disease found in clinical Stage I patients. identical to the ovarian cancer staging procedure and
Surgical staging allows more specific reporting for this reason they are presented together in this
of tumor spread and is a more accurate guide for chapter. It includes a midline vertical incision,
additional therapy. Similarly, comprehensive staging peritoneal washings, a thorough exploration of the
is necessary in patients with early-stage ovarian can- abdomen and pelvis, a total abdominal hysterectomy,
cer, in order to determine which patients will benefit bilateral salpingo-oophorectomy and pelvic and
from further therapy following surgery. For patients paraaortic lymph node dissection. Certain practitio-
with advanced ovarian cancer, optimal surgical ners may elect to eliminate the nodal dissection for
cytoreduction is the standard of care and is discussed patients with tumors of favorable histologic grade and
in detail elsewhere within this text. Surgical ‘staging’ subtype that do not invade into the myometrium due
is not a term used for the surgical procedures in these to the relatively low incidence of metastases. In
patients due to the advanced nature of their disease, general, this should be avoided since the frozen-
although lymph node dissection may play a role in section evaluation of depth of invasion is less reliable
their management to ensure resection of all bulky than permanent section, and endometrial biopsy is
tumor. prone to sampling errors that may misrepresent
final histologic grade or subtype. The risk of lymph
The standard procedure for surgical staging in node metastases in minimally invasive, low-grade
early-stage ovarian carcinoma includes an adequate endometrial tumors is approximately 3%, and the
midline vertical incision, peritoneal washings, benefits of detecting metastases in these patients
thorough exploration of the abdominal and pelvic outweigh the risks of the procedure. If the endome-
cavities, biopsy of any suspicious lesions, random trial tumor is predominantly serous or carcino-
peritoneal biopsies from the pelvis, paracolic gutters sarcomatous, the aggressive nature of these tumors
and diaphragm, total abdominal hysterectomy, warrants additional staging procedures, including
bilateral salpingo-oophorectomy, bilateral pelvic and random peritoneal biopsies and subtotal omentec-
paraaortic lymph node dissection, and infracolic tomy and lymph node dissection regardless of
omentectomy. When performing the aortic lymph depth of invasion. In patients with significant
node dissection, it is important to remember that the medical co-morbidities, the overall risks of the proce-
lymphatic drainage pattern of the ovary follows that dure must be weighed, and eliminating or abbreviat-
of the ovarian vein, which empties into the vena cava ing the lymph node dissection may be warranted.
on the right and the renal vein on the left. Thus, Ultimately, the risks of lymph node sampling for an
these high aortic nodes should be removed in order to individual patient must be balanced against the risks
accurately determine the extent of disease, and this of spread based upon depth of invasion and tumor
often requires a generous incision. If a tumor of aggressiveness.
1
2 Atlas of Procedures in Gynecologic Oncology
a b
c d
Figure 1.12. Transecting the round ligament. Figure 1.13. Opening the pelvic peritoneum.
The round ligament is then transected using electrocautery The peritoneum is then dissected free from the underlying
or scissors. The round ligament suture is held for traction, areolar tissue with a right-angled clamp or similar. The
which is useful when opening the pelvic sidewall. peritoneum is incised using electrocautery to skeletonize
the infundibulopelvic ligament.
1 1
3
2
1
2
3
4
Figure 1.18. Transecting the infundibulopelvic ligament. Figure 1.19. Ligating the infundibulopelvic ligament.
The infundibulopelvic ligament is transected using a The two ends of the infundibulopelvic ligament are now
Metzenbaum scissors, scalpel, or cautery. clearly separated. The distal side is ligated with a simple
free tie, as it will be removed with the specimen. The
proximal side of the infundibulopelvic ligament is first
ligated with a free tie of delayed absorbable material and
then a suture ligature on a CT-1 needle or smaller is placed
above this free tie. It is important not to place the second
suture below the first as this could result in the
development of a retroperitoneal hematoma that may
dissect along the ovarian vessels.
8 Atlas of Procedures in Gynecologic Oncology
a b
a b
a b
1
2
3
1 – Vagina
2 – Cervix
3 – Internal cervical os
4 – Uterine body
1 – Bladder
2 – Vagina
3 – Cervix
Surgical staging of gynecologic malignancies 11
a b
2
3
1 – Cervix
2 – Vagina
3 – Bladder
1
2
a b
a b
Figure 1.34. Pelvic peritoneum. Figure 1.35. Opening of the pelvic peritoneum.
Prior to the start of the pelvic lymph node dissection, the The pelvic peritoneum is opened over the external iliac
pelvic peritoneum covers the pelvic sidewall and iliac artery with electrocautery or Metzenbaum scissors. The
vessels. incision in the peritoneum is extended toward the paracolic
gutter to allow for adequate exposure to perform the lymph
node dissection.
14 Atlas of Procedures in Gynecologic Oncology
a b
1 – Psoas muscle
2 – Left external iliac artery Figure 1.38. Creation of pedicles.
3 – Left ureter
Pedicles are created with blunt or sharp dissection in order
Figure 1.37. External iliac lymph node dissection. to delineate the nodal tissue to be removed.
The pelvic node dissection is started by grasping the
lymphatic tissue overlying the external iliac artery. A
Singley forceps is used to provide traction on the nodal
tissue. The ureter is seen again in the foreground.
Surgical staging of gynecologic malignancies 15
Figure 1.39. Clipping the pedicle. Figure 1.40. Excision of lymph node.
Small perforating vessels and lymphatic channels should be The pedicle has now been transected with Metzenbaum
occluded with hemostatic clips, as shown. scissors. This process of creating pedicles, clipping, and
excising is used throughout the nodal dissection.
2
3
1 – Psoas muscle
Figure 1.41. Further dissection. 2 – Left genitofemoral nerve
3 – Left external iliac artery
Small perforators and lymphatics are clipped and cut in
4 – Left external iliac vein
order to skeletonize the external iliac vessels and facilitate
the dissection. Figure 1.42. Protecting the genitofemoral nerve.
Throughout the dissection, care should be taken to avoid
injury to the genitofemoral nerve, which courses along the
medial aspect of the psoas muscle and just lateral to the
external iliac artery. Injury to this nerve can result in
paresthesias of the medial aspect of the upper thigh. The
size of the nerve is variable, as the genital and femoral
branches may run separately.
16 Atlas of Procedures in Gynecologic Oncology
1
2
1
2
3
1 – Psoas muscle
2 – Left external iliac vessels retracted laterally
3 – Genitofemoral nerve
4 – Left obturator lymph nodes
5 – Left obturator nerve
a b
1
1
2
2
3
3 4
4 5
5 6
6
7
1 – Right deep circumflex iliac vein 1 – Left deep circumflex iliac vein
2 – Right external iliac vein 2 – Psoas muscle
3 – Right anastomotic pelvic vein 3 – Left external iliac vein
4 – Right obturator internus muscle 4 – Genitofemoral nerve
5 – Right obturator nerve 5 – Left external iliac artery
6 – Right obturator vein 6 – Left obturator nerve
7 – Left obturator vein
Figure 1.52. Right peritoneal incision. Figure 1.53. Opening the retroperitoneum.
On the right side, the paraaortic node dissection begins by A right-angled clamp or forceps can be used to separate the
incising the peritoneum overlying the right common iliac peritoneum from the underlying areolar tissue while
artery. Alternatively, the incision used for the pelvic lymph electrocautery or scissors is used to transect it.
node dissection can be extended over the common iliac
artery to the aortic bifurcation. Care should be taken to
identify the ureter as it crosses over the common iliac artery
in order to minimize injury during the peritoneal opening.
1 2
3
4
2 5
1 – Aorta
2 – Left common iliac artery
Figure 1.62. Low, left paraaortic nodes.
3 – Inferior mesenteric artery
Low, left paraaortic nodes can readily be obtained in the
region between the inferior mesenteric artery and the left Figure 1.63. Low, left nodal basin.
aspect of the aorta. Shown here are lymph nodes being After removal of the lymph node package, the boundaries
removed from this area. of this particular dissection can be seen, including the
inferior mesenteric artery. The region can also be easily
reached from a lateral approach, as described above.
Often, the lateral approach will be used to dissect the
lower left paraaortic nodes and the medial approach will
be used to dissect the higher paraaortic nodes.
22 Atlas of Procedures in Gynecologic Oncology
a b
1
2
1
3 2
3
4
2
3
4
5
a b
1 1
2
2
a b
c
Figure 1.71a–c. Clamping pedicles.
Once the omentum has been mobilized off the transverse
colon, the gastrocolic ligament is incised. Avascular areas
are incised with electrocautery or scissors. Vascular
pedicles are doubly clamped with right-angled clamps,
Kelly clamps, Halstead clamps, or similar. A series of
clamps are placed, with each set being transected at the
time of placement. Ligation with free ties is done
successively after several clamps have been placed in order
to conduct the procedure as efficiently as possible. Recent
advances in surgical instrumentation have provided a wide
array of alternative instruments with which to perform the
omentectomy. Currently, options include the use of the
endoscopic stapler, handheld harmonic scalpel, handheld
LigaSure (Valleylab, Boulder, CO), the argon-beam
coagulator, and the LDS stapler. Operator experience will
dictate which device is most suitable for a particular patient
or procedure.
26 Atlas of Procedures in Gynecologic Oncology
a b
c
Figure 1.72. LigaSure.
The LigaSure is a device that can coagulate and transect
tissue in a rapid manner. The device shown here is the
short handheld LigaSure Atlas (a). The jaws are closed by
squeezing the handle until it locks. A foot pedal is then
depressed to activate the bipolar electrocautery, which
effectively seals the tissue and/or vessels up to 7 mm in
diameter. The lever just above the handle is then
depressed to activate a blade within the device that will
transect the cauterized tissue. Squeezing the handle once
again then opens the jaws. The gastroepiploic artery,
which is the main blood supply to the omentum, can
easily be cauterized with the LigaSure (b). Thermal
spread is minimal and the resulting resection leaves a
hemostatic, uninjured segment of transverse colon (c).
1 – Splenic flexure
2 – Supracolic omentum
3 – Hepatic flexure
a b
Appendectomy
1 – Appendix
Figure 1.76. Appendix. 2 – Appendiceal mesentery
The appendix may be removed at the time of staging 3 – Cecum
laparotomy for a variety of reasons. An inflamed,
Figure 1.77. Traction.
erythematous, or suppurative appendix should be removed.
One or two Babcock clamps are placed on the appendix to
If it is thought to be involved with tumor it should be
provide traction and mobility throughout the procedure.
removed as well. Importantly, an appendectomy should be
These particular clamps are useful since they are atraumatic
performed whenever a mucinous ovarian neoplasm is
when used in the manner demonstrated.
diagnosed or suspected. All too frequently, mucinous
ovarian tumors, particularly borderline tumors, are thought
to be primarily from the ovary when in fact they are
metastases from primary appendiceal tumors or other
gastrointestinal tumors.
a b
a b
c d
a b
a b
a b
a b
Radical abdominal hysterectomy has been the In 1974, Piver et al described five classes, or types, of
standard of care for surgical management of early- hysterectomy (Table 2.1).10 The Class III hysterectomy,
stage cervical carcinoma since its development and or radical hysterectomy, is the most commonly
refinement in the late 1800s and early 1900s.1 It is a performed, although some authors feel that a Class II
procedure that was initially fraught with significant hysterectomy, or modified radical hysterectomy, is as
morbidity and mortality. However, developments in effective.11 The main difference between these two
the use of antibiotics, surgical techniques, anesthesia, types of hysterectomy is the amount of parametrial
and pre- and postoperative care have significantly tissue taken along with the hysterectomy specimen
reduced the morbidity and mortality associated with and the degree of ureteral dissection. The choice of
this procedure.1–3 abdominal incision is based on the patient habitus
and desire for cosmesis. Low transverse incisions
The most common indication for radical hysterectomy (Maylard, Cherney, or Pfannenstiel) may provide suffi-
is early-stage [International Federation of Gynecology cient exposure in certain cases.1,12 Abdominopelvic
and Obstetrics (FIGO) Stages IA2–IIA] invasive washings are not needed since they provide little
cervical carcinoma. Radical hysterectomy is also information in the setting of cervical carcinoma.13
indicated in patients with Stage IA1 invasive cervical Upon opening the abdomen, the paraaortic nodal
cancers that have lymph–vascular invasion. Further region is inspected and palpated. Gross paraaortic
indications include selected cases of early-stage nodal disease usually requires abandonment of the
(FIGO Stages I and II) invasive vaginal cancer limited procedure, although some benefit to complete resec-
to the upper third of the vagina, selected cases of tion of grossly involved nodes has been reported.14
endometrial cancer with gross cervical involvement Involved pelvic nodes are not an absolute contraindi-
(FIGO Stage II), and selected cases of persistent or cation to the procedure if they can be completely
recurrent cervical cancers, which after radiotherapy resected. The two most crucial initial steps of the
are limited to the cervix or proximal vaginal fornix.1,4,5 procedure are the development of the pelvic spaces
Radiotherapy has always been considered equivalent and mobilization of the bladder. Opening the pelvic
to surgery for the definitive treatment of early-stage spaces permits inspection and palpation of the para-
cervical carcinoma. However, the combination of metria. Mobilization of the bladder confirms that dis-
radical surgery and radiotherapy is associated with ease has not penetrated anteriorly through the cervix
significant morbidity.3 Surgery offers the possibility and that an adequate parametrial and vaginal resec-
of primary tumor removal, a shorter treatment time, tion should be possible. Unresectable parametrial
more limited tissue injury, a specimen for patho- disease or inability to sufficiently mobilize the
logic evaluation from which to tailor adjuvant treat- bladder is an indication to abandon the procedure.
ments, the potential to preserve ovarian function,
and, in certain cases, the potential to maintain repro- Radical hysterectomy involves removal of the uterus,
ductive function (see Chapter 12).1,2,5 Patients with cervix, and upper one-third to one-half of the vagina
Stages IIB–IVA are best treated with concurrent along with the parametrial tissue. The uterine artery
chemoradiation.6–8 Recent reports have also suggested is divided at its origin from the anterior division
that patients with Stage IB2 and IIA cervical carci- of the internal iliac artery, and the ureter is com-
noma benefit most from chemoradiation;9 however, pletely unroofed to its insertion into the bladder
this approach has never been directly compared allowing for resection of the entire parametrial tissue.
to radical hysterectomy followed by appropriate Resection of the uterosacral ligaments near their
adjuvant therapies. distal-most attachments is also performed. Removal
33
34 Atlas of Procedures in Gynecologic Oncology
of uninvolved ovaries is not a required part of the The extent of dissection associated with a Class III
procedure and should be performed based upon radical hysterectomy results in greater morbidity
independent considerations. If adjuvant radiation as compared to a Class II hysterectomy. The most
therapy is anticipated, the ovaries can be transposed common morbidities include bladder and rectal
above the iliac crests to help reduce the risk of dysfunction, vesicovaginal fistulae, ureteral obstruc-
radiation-induced menopause. This procedure is tion, hemorrhage, infection, and nerve injury.
typically accompanied by a bilateral pelvic lymph- Improvements in antibiotics and surgical technique
adenectomy, which may be performed before or have greatly reduced the incidence of these
after the hysterectomy. The pelvic lymph nodes should complications.
be closely examined to determine resectability.
Unresectable lymph nodes would lead to abandoning New surgical approaches are emerging that may
the radical hysterectomy. Although some practitio- become acceptable alternatives to the radical abdomi-
ners place pelvic drains at the conclusion of the pro- nal hysterectomy in select patients. Among these are
cedure, a recently published, prospective, randomized the radical vaginal hysterectomy (Schauta–Amreich)
trial from the EORTC-GCG comparing the use of and the laparoscopic radical hysterectomy, both
drains versus no drains after radical hysterectomy described in other sections of this text. Also, radical
demonstrated no difference in incidence of postoper- vaginal trachelectomy can offer the potential to pre-
ative lymphocyst formation or complications between serve fertility in very select groups of patients.16 The
the two study arms.15 For the few patients who require use of robotic technology may improve the surgeon's
prolonged bladder catheterization after radical hyster- ability to perform a radical hysterectomy using
ectomy, intermittent self-catheterization or placement minimally invasive techniques. Nonetheless, abdomi-
of a suprapubic catheter can be performed. The abdo- nal radical hysterectomy remains the current gold
men is closed in a fashion appropriate to the chosen standard to which all other techniques should be
type of incision. compared.
Radical abdominal hysterectomy 35
a b
1 1
2
2
3
a b
1
2
1
3
a b
1
2
2
3
3
4
a b
1 3
1 – Right common iliac artery bifurcation 1 – Right deep circumflex iliac vein
2 – Right genitofemoral nerve
3 – Right external iliac vein
c d
1
2
3
4
5
a b
1
2
3
4
1
2
c d
1
2
3 2
4
5 3
6
1 – Right deep circumflex iliac vein 1 – Left deep circumflex iliac vein
2 – Right genitofemoral nerve 2 – Left genitofemoral nerve
3 – Right external iliac artery 3 – Left obturator nerve
4 – Anastomotic pelvic vein
5 – Right obturator nerve
6 – Right obturator vein
a b
1 1
2
2 3
4
a b
1
2
2
3
1
2
1 – Right ureter
2 – Right parametrium Figure 2.12. Dissection of the rectovaginal space.
The rectovaginal peritoneum is incised with electrocautery,
Figure 2.11. Unroofing the ureter. and the rectovaginal space is developed with sharp or blunt
The ureter is unroofed through the parametrial tunnel to its dissection. Care should be taken to avoid injury to the
insertion into the bladder. This is accomplished with blunt rectum. Once the peritoneum is incised, the vagina is
and sharp dissection using a right-angled clamp and suture separated from the rectum.
ligatures as needed. Unroofing the ureter allows complete
mobilization of the parametrium toward the specimen. The
parametrial tissue can be seen attached to the cervix. Care
should be taken during this dissection, and small vessels
should be ligated with suture ligatures or hemoclips, since
significant blood loss can occur during this part of the
procedure. Electrocautery should be avoided, since the
dissection is in such close proximity to the ureter.
Radical abdominal hysterectomy 41
a b
1
2
1
2
a b
1
2
c
d
References
1. Abu-Rustum NR, Hoskins WJ. Radical abdominal 9. Keys HM, Bundy BN, Stehman FB et al. Cisplatin,
hysterectomy. Surg Clin North Am 2001;52:815–28. radiation, and adjuvant hysterectomy for bulky stage IB
2. Chi DS, Lanciano RM, Kudelka AP. Cervical cancer. cervical carcinoma. N Engl J Med 1999;340:1154–61.
In: Pazdur R, Coia LR, Hoskins WJ, Wagman LD (eds). 10. Piver SM, Rutledge F, Smith JP. Five classes of extended
Cancer management: a multidisciplinary approach, hysterectomy for women with cervical cancer. Obstet
5th edn. Melville, NY: PRR, 2001:359–84. Gynecol 1974;44:265–72.
3. Landoni F, Maneo A, Colombo A et al. Randomised study 11. Landoni F, Maneo A, Cormio G et al. Class II versus
of radical surgery versus radiotherapy for stage Ib–IIa class III radical hysterectomy in stage IB–IIA cervical
cervical cancer. Lancet 1997;350:535–40. cancer: a prospective randomized study. Gynecol Oncol
4. Hoskins WJ, Perez CA, Young RC (eds). Principles and 2001;80:3–12.
practice of gynecologic oncology, 3rd edn. Philadelphia: 12. Scribner DR, Kamelle SA, Gould N et al. A retrospective
Lippincott, Williams & Wilkins, 2000. analysis of radical hysterectomies done for cervical cancer:
5. Chi DS, Gemignani ML, Curtin JP, Hoskins WJ. Long-term is there a role for the Pfannenstiel incision? Gynecol Oncol
experience in the surgical management of cancer of the 2001;81:481–4.
uterine cervix. Semin Surg Oncol 1999;17:161–7. 13. Estape R, Angioli R, Wagman F et al. Significance of
6. Rose PG, Bundy BN, Watkins EB et al. Concurrent intraperitoneal cytology in patients undergoing radical
cisplatin-based radiotherapy and chemotherapy for locally hysterectomy. Gynecol Oncol 1998;68:169–71.
advanced cervical cancer. N Engl J Med 1999;340: 14. Potish RA, Downey GO, Adcock LL et al. The role of
1144–53. surgical debulking in cancer of the uterine cervix.
7. Morris M, Eifel PJ, Lu J et al. Pelvic radiation with Int J Radiat Oncol Biol Phys 1989;17:979–84.
concurrent chemotherapy compared with pelvic and 15. Franchi M, Trimbos JB, Zanaboni F et al. Randomised
paraaortic radiation for high-risk cervical cancer. trial of drains versus no drains following radical
N Engl J Med 1999;340:1137–43. hysterectomy and pelvic lymph node dissection: a
8. Whitney CW, Sause W, Bundy BN et al. Randomized European Organisation for Research and Treatment of
comparison of fluorouracil plus cisplatin versus Cancer–Gynaecological Cancer Group (EORTC-GCG) study
hydroxyurea as an adjunct to radiation therapy in stage in 234 patients. Eur J Cancer 2007;43:1265–8.
IIB–IVA carcinoma of the cervix with negative paraaortic 16. Dargent D, Martin X, Sacchetoni A, Mathevet P.
lymph nodes: a Gynecologic Oncology Group and Laparoscopic vaginal radical trachelectomy: a treatment to
Southwest Oncology Group study. J Clin Oncol preserve the fertility of cervical carcinoma patients. Cancer
1999;17:1339–48. 2000;88:1877–82.
3 Surgery for carcinoma of
the vulva
Mary L Gemignani
Vulvar cancer is relatively rare among the female In this chapter, the anatomical and surgical tech-
genital tract cancers. In 2007, an estimated 3490 cases niques of radical vulvectomy, skinning vulvectomy,
of cancer of the vulva were diagnosed in the USA.1 inguinofemoral lymphadenectomy, and sentinel node
The surgical procedures performed for this cancer biopsy will be demonstrated.
have changed drastically over the past several decades.
Initially, the surgical treatment was an en-bloc removal
of the vulva to include bilateral inguinofemoral
lymphadenectomy. The morbidity associated with Radical vulvectomy
this radical approach included wound complications
and lymphedema in almost all patients.
45
46 Atlas of Procedures in Gynecologic Oncology
a b
Figure 3.3. Dissection off the pubic periosteum. Figure 3.4. Dissection base of the clitoris.
Superiorly, the specimen is dissected off the pubic The dissection of the superior portion of the vulva
periosteum and adductor fascia; the dissection is continued continues medially and laterally to expose the pubic
in this manner inferiorly. The lateral portions of this part of periosteum and adductor fascia (bilaterally). The base of
the procedure are also taken deeply until the adductor the clitoris is identified, clamped, transected, and ligated
fascia is encountered. at this point. The dissection is completed and joined
medially by making a transvestibular mucosal incision
above the urethra.
Surgery for carcinoma of the vulva 47
Skinning vulvectomy
Inguinofemoral lymphadenectomy
Figure 3.14. Skin incision. Figure 3.15. Identification of the boundaries of the
The patient is placed in the dorsolithotomy position, with dissection.
minimal flexion at the hip to allow the groin area to be as It is important to identify the boundaries of the dissection.
flat as possible. The skin incision is 8–10 cm long, is made The adductor longus muscle is palpated medially and the
parallel to the inguinal ligament, and is carried down to incision is carried down to, but not through, the fascia of
Camper’s fascia. This is not a true fascia and can be easily this muscle. Laterally, the sartorius muscle, shown in this
transected if not carefully identified. Skin hooks are used to figure, is identified. The upper dissection border consists of
elevate the skin and facilitate the creation of flaps, which the mons pubis and pubic tubercle medially and the
separates the fat pad containing lymph nodes from the skin external oblique aponeurosis overlying the inguinal canal
subcutaneous tissue. It is important not to make the skin superiorly.
flaps too thin, as doing so may lead to necrosis of the flaps.
Either a knife or electrocautery is used during this part of
the dissection.
2 1
2
Figure 3.17. Opening the cribriform fascia. Figure 3.18. The common femoral vein.
The dissection is carried deeper in the direction of the Small tributaries of the saphenous vein are ligated as they
femoral triangle. Feeling for the pulsation of the femoral are encountered during the medial part of the dissection.
artery is helpful, and the femoral artery is identified by Dissection and clearing of the nodal tissue continues over
opening the cribriform fascia. The cribriform fascia should the anterior surface of the common femoral vein with a
be opened along the anterior aspect of the femoral artery. combination of blunt and sharp dissection, using
The content of the fossa ovalis is noted. The dissection electrocautery and hemoclips as needed. Removal of the
performed over the top of the artery is continued over the fat pad from the femoral triangle begins laterally and
anterior surface of the vein, mobilizing the specimen to continues medially; the structures encountered laterally to
the medial aspect of the femoral vein. There is no need to medially are nerve, artery, vein, and lymphatics. The
dissect under the artery or between the femoral artery femoral nerve is best identified close to the inguinal
and vein. ligament because it begins to branch more distally.
1
2
2
3 3
4
4
Figure 3.19. External pudendal artery. Figure 3.20. Saphenous vein identified at the
While clearing the femoral artery proximally, the most saphenofemoral junction.
proximal branches are the superficial external pudendal The great saphenous vein enters the common femoral vein
artery, the superficial epigastric artery, and the superficial cephalad at the point at which the external pudendal artery
circumflex iliac artery. The superficial external pudendal crosses the common femoral vein. The proximal 1–2 cm of
artery, shown here, is the most medial proximal branch of the saphenous vein is isolated and ligated with permanent
the femoral artery. This small branch should be identified, sutures at the level of the common femoral vein wall, and
isolated, and ligated. transected. It is important not to compromise the lumen of
the femoral vein while ligating the saphenous vein.
52 Atlas of Procedures in Gynecologic Oncology
1 – Specimen
2 – Great saphenous vein
3 – Left femoral vein
4 – Left femoral artery
1
2
3
INJ.SITE
a b
a b
References
1. Jemal A, Siegel R, Ward E et al. Cancer statistics, 2007. 4. Cody HS III, Borgen PI. State-of-the-art approaches to
CA Cancer J Clin 2007;57:43–66. sentinel node biopsy for breast cancer: study design,
2. Albertini JJ, Lyman GH, Cox C et al. Lymphatic mapping patient selection, technique, and quality control at
and sentinel lymph node biopsy in the patient with breast Memorial Sloan-Kettering Cancer Center. Surg Oncol
cancer. JAMA 1996;276:1812–22. 1999;8:85–91.
3. Thompson JF, McCarthy WH, Bosch CM et al. Sentinel 5. Levenback C, Coleman RL, Burke TW et al. Intraoperative
lymph node status as an indicator of the presence of lymphatic mapping and sentinel node identification with
metastatic melanoma in regional lymph nodes. blue dye in patients with vulvar cancer. Gynecol Oncol
Melanoma Res 1995;5:255–60. 2001;83:276–81.
4 Surgical cytoreduction
Eric L Eisenhauer, Mario M Leitao Jr, and Dennis S Chi
Ovarian cancer is the fifth most common malignancy that in which the maximum diameter of residual
in women and the second most common gynecologic tumor is ≤1 cm. The benefit of optimal cytoreduction
malignancy, but it is the leading cause of death of has also been reported for patients with Stage IV
all gynecologic malignancies in the USA.1 There were disease (i.e. parenchymal liver metastases, distant
an estimated 22 430 new cases of ovarian cancer in metastases, and/or malignant pleural effusions).13–16
2007 and an estimated 15 280 deaths in the USA.1 Currently, there are no accurate or validated methods
Early-stage ovarian cancer has a high cure rate with of preoperatively predicting optimal cytoreduction.
surgery and chemotherapy. Unfortunately, 75% of Active research endeavors include using a
patients will present with disease that is no longer combination of computed tomography (CT) scanning,
confined to the ovary (FIGO Stage II–IV), in which CA-125 levels, and physical examination to deter-
long-term survival is poor.2 Ovarian cancer can be mine if the success of surgical cytoreduction can be
thought of as a ‘chronic’ disease in the sense that predicted.
many patients develop multiple recurrences that
can often be induced into remission with further The rate of optimal cytoreduction varies between
surgery and/or chemotherapy. Also, complications institutions, and to some degree depends on specialty
such as bowel obstruction are often a result of training, philosophy, and surgical aggressiveness.17,18
advanced, persistent, or recurrent ovarian cancer. It is essential that the surgeon is able to make a
Surgery is an essential modality in the treatment of reasonable judgment as to the feasibility that any
ovarian cancer, and its role may be either therapeutic aggressive procedure will lead to optimal cytoreduc-
or palliative. tion. The surgical morbidities must always be
considered. Most often for the gynecologic oncologist,
Advanced ovarian cancer is initially treated with a the extent of upper abdominal disease and bowel/
combination of surgery and chemotherapy. Surgery is mesenteric involvement may limit the ability to
most often performed prior to the initiation of chemo- perform optimal cytoreduction. Aggressive attempts
therapy. The goal of surgery in this setting should be at tumor resection may require radical hysterectomy,
to achieve a complete gross resection (complete omentectomy, resection of either small or large
cytoreduction) of all visible disease. Griffiths3 first intestine, splenectomy, diaphragmatic peritonectomy,
demonstrated the value of surgical cytoreduction in hepatic resection, or other related procedures.
1975. Many retrospective studies and reviews since Splenectomy, diaphragmatic peritonectomy, and
have confirmed that the amount of residual tumor hepatectomy, as well as the elimination of peritoneal
strongly correlates with survival.4–10 The adequacy implants, can be safely performed in carefully selected
of surgical cytoreduction is based on the maximum patients with upper abdominal disease.11,17,19–21 These
diameter of the largest residual tumor after cytoreduc- procedures should be considered if they would result
tion and has been defined by specific cut-off levels. in an optimal cytoreduction, since patients with
Older studies reported that cytoreduction to <2 cm optimally resected upper abdominal disease have
provided a significant survival advantage.4 Recent similar outcomes to other patients who are optimally
studies, however, have demonstrated that cytoreduc- cytoreduced.22 Bowel resection is often necessary, is
tion to no visible disease offers the greatest survival safe to perform, and will offer a survival benefit if
benefit, and that cytoreductive surgery offers no the end result is optimal cytoreduction.9,23 Ovarian
survival benefit unless residual disease can be cancer rarely progresses below the pelvic peritoneal
reduced to ≤1 cm.4,5,11,12 Based on these and other reflection and therefore it is possible to safely
recent analyses, the Gynecologic Oncology Group perform low colorectal anastomoses in the majority of
(GOG) currently defines optimal cytoreduction as cases.23
57
58 Atlas of Procedures in Gynecologic Oncology
Patients who develop recurrent disease, or those with to be in the upper abdomen and radical pelvic surgery
disease noted at the time of surgical reassessment pro- is unlikely. More commonly, radical pelvic and
cedures, will also benefit from cytoreduction.6,19,24–27 colorectal surgery must be anticipated, and the patient
These secondary cytoreductive procedures offer the should be placed in the low lithotomy position. The
best survival benefits in patients with long disease- skin should be antiseptically prepared from the
free intervals, solitary lesions, initial optimal cyto- breasts to the mid-thigh and perineum. A Foley
reduction, and who have responded well to prior catheter is placed in the urinary bladder. All patients
chemotherapy.25–27 In carefully selected patients, undergoing abdominal or pelvic surgery for
complete cytoreduction may be possible and appears gynecologic cancer should have pneumatic compres-
to offer the best survival benefit if performed prior sion devices placed on the calves prior to the
to the initiation of salvage chemotherapy.27 The degree induction of anesthesia and should receive postopera-
to which tumor must be cytoreduced to offer a benefit tive deep venous thrombosis prophylaxis with sub-
varies among reports. The goal in this setting should cutaneous low-molecular-weight or unfractionated
be to resect to no visible disease, but cytoreduction to heparin.
<1 cm may also be beneficial. Surgical cytoreduction
has also been shown to benefit patients with advanced A large vertical midline incision is critical. The peri-
or recurrent ovarian and endometrial cancer.28–30 toneal cavity is then entered carefully and any ascites
Therefore, the techniques and theories behind the suctioned. Omental tumor is generally removed first
procedures described in this chapter apply to to aid in visualization. Then, resection of the pelvic
properly selected patients with ovarian or endometrial and abdominal disease is performed. Retroperitoneal
cancer. nodal disease is usually assessed and resected after
gross pelvic and abdominal disease has been removed.
The role of palliative surgery for patients with Entering the retroperitoneum and identifying the
persistent or recurrent ovarian cancer is not as well ureters and aortoiliac vessels early is essential in
defined. A common manifestation of persistent or accomplishing successful cytoreduction and mini-
recurrent ovarian cancer is intestinal obstruction. mizing complications. If isolated disease is the target
These patients often have few remaining chemother- of resection, this is carried out after thorough evalua-
apy options. Patients should be thoroughly counseled tion of the abdomen and pelvis to identify unexpected
that surgery in this setting will not be curative. sites of disease. A vigorous preoperative bowel regi-
Palliative surgery for intestinal obstruction has been men is not necessary and may increase postoperative
shown to provide patients with symptomatic relief, morbidity in some patients.
prolonged survival, and the ability to ingest liquids
and solids.6 Since surgical morbidity can be high, In this chapter, after a brief overview of advanced
patients should understand that the benefits of ovarian cancer, the procedures commonly performed
palliative surgery are not realized in all patients. The for surgical cytoreduction of advanced and recurrent
option of placing a percutaneous gastrostomy ovarian and endometrial cancers will be presented.
tube and receiving intravenous hydration should be Some procedures, such as the radical hysterectomy,
discussed. omentectomy, and lymphadenectomy, are described
elsewhere in this Atlas and will therefore only be
Successful surgical cytoreduction requires thorough briefly touched upon in this chapter. Other specific
knowledge of pelvic and abdominal anatomy. Normal procedures, such as the partial hepatectomy, will not
anatomical structures and relations are often distorted be presented here and may be found described in
in advanced ovarian cancer. The patient can be placed general surgical atlases and texts. Most procedures
in the supine position if preoperative imaging are equally applicable to widely disseminated
and physical examination indicate the bulk of disease advanced disease and to isolated recurrences.
Surgical cytoreduction 59
a b
a b
a b
a b
a b
Diaphragmatic stripping
a b
1
1
2
2
1 – Diaphragm 1 – Diaphragm
2 – Central tendon 2 – Residual peritoneum
a b
1
2
1
3
4
2 5
3
1 – Liver retracted medially
2 – Inferior vena cava
3 – Diaphragm
4 – Right renal vein
5 – Right kidney
1 – Diaphragm
2 – Liver retracted medially
3 – Inferior vena cava
2 3
1 – Uterus 1 – Sigmoid
2 – Sigmoid 2 – Peritoneal reflection
3 – Presacral space
Figure 4.18. Initiating the resection.
The uterus and rectosigmoid are targeted for removal. Figure 4.19. Developing the presacral space.
Removal of the uterus en bloc with the rectosigmoid is The presacral space is then developed with care to
referred to as a ‘modified posterior exenteration’. Removal mobilize the sigmoid colon. Sharp dissection is used to
of the rectosigmoid by itself is a ‘low anterior resection’. If ensure that the dissection takes place in the proper plane
the resection does not progress below the peritoneal and the risk of presacral bleeding is minimized. If the plane
reflection, then it is simply an ‘anterior resection’. In of dissection remains above Waldeyer’s fascia, presacral
ovarian cancer, the resection is almost always limited to bleeding can easily be avoided. Bleeding from the sacral
above the pelvic diaphragm, resulting in sufficient rectal veins can be difficult to manage, as the vessels may retract
length to perform a stapled low rectal anastomosis. The into the sacral foramina. Sterile tacks or bone cement may
development of the retroperitoneal space is the first part of be used to control such bleeding. Here, the rectosigmoid is
the procedure. After entering the retroperitoneum, the seen being retracted anteriorly, with the ureter identified
ureters are identified and the infundibulopelvic ligaments with a white vessel loop and the presacral space
are divided if the ovaries have not been previously developed.
removed.
a b
1
1
2 2
3
3
a b
1
2
3
1 – Vaginal apex
2 – Cervix rotated cranially
3 – Cul-de-sac tumor
4 – Uterus
a b
1
1
2
2
1 – Rectum
2 – Recurrent tumor
a b
c d
4
5
6
7
8
9
3 2
1 – Vaginal apex 6 – Right internal iliac artery
2 – Sacral hollow 7 – Right external iliac artery
3 – Left ureter 8 – Right common iliac artery
4 – Right external iliac vein 9 – Psoas muscle
5 – Ligated right uterine artery
a b
1
2
1 – Proximal sigmoid
2 – Uterine body
3 – Cervix
4 – Distal rectum
c
Figure 4.28. Modified posterior exenteration and low
anterior resection specimens.
(a) Shown is the en bloc modified posterior exenteration
specimen consisting of the uterus and rectosigmoid. (b) The
1
distal rectum opened with tumor invading from the
posterior cul-de-sac through the rectal mucosa. (c) In a low
anterior resection, the uterus has been previously removed
and the tumor can be seen within the diseased
rectosigmoid.
2
1 – Recurrent tumor
2 – Distal rectum
72 Atlas of Procedures in Gynecologic Oncology
a b
1 – Anvil
2 – Purse string
End colostomy
Figure 4.35. Stoma.
An enterostomal therapist preoperatively marks the patient
to serve as a guide when creating the stoma. Generally, the
stoma is placed midway between the umbilicus and the
anterior superior iliac spine: it should come out through the
rectus muscles. It is helpful to mark the patient prior to
surgery, with the patient in a variety of positions. This will
allow the patient to participate in the location of the stoma
and allow her to meet the enterostomal therapist prior to
the procedure. If the patient does not have a prior midline
incision that goes around the umbilicus, it is prudent to
place the incision to the right of the umbilicus so that the
left-sided colostomy is ultimately further away from the
incision. If the patient has a previous high midline incision,
it is not a good idea to create a second scar on the opposite
side of the umbilicus.
a b
1 – Sigmoid
2 – Recurrent pelvic tumor
a b
a b
1 – Small bowel
2 – Recurrent tumor
a b
a b
a b
c d
Figure 4.52. Approximating the bowel. Figure 4.53. Opening the bowel.
After resecting the diseased portion of small bowel, the The antimesenteric corners of the previous staple line are
stapled ends are approximated. Ultimately, the excised from each limb of the bowel. If too much tissue is
enteroenterostomy will be created along the antimesenteric excised, bowel contents may spill and the created
edges of the small bowel. The bowel is appropriately enterotomy may be too large to close in the standard
aligned, and one to two stay sutures are placed to maintain fashion.
orientation. The small bowel is clamped with non-crushing
clamps to prevent spillage of the small-bowel contents
when the bowel is opened.
a b
c
Figure 4.56. Closing the anastomosis.
Allis clamps are used to close the enterotomy. (a) After
ensuring hemostasis, the clamps are placed equidistant
across the lumen of the bowel. (b) A linear non-cutting
stapler is placed just beneath the clamps and fired. (c) The
residual tissue is then excised with scissors or a scalpel. A
portion of the previous staple line will be excised along
with this tissue, and a scalpel is often inadequate for the
resection.
a b
a b
a b
c d
a b
3
4
1
2
3
4
Splenectomy
a b
1
2
a b
2
3
1 – Tumor
2 and 3 – Splenic artery branches
a b
1 – Tail of pancreas
a b
a b
1
2 2
1 – Pancreatic duct
2 – Pancreatic parenchyma
1 – Spleen
2 – Resected distal pancreas
3 – Tumor in splenic hilum
References
1. Jemal A, Siegel R, Ward E et al. Cancer Statistics, 2007. 17. Eisenkop SM, Spirtos NM. Procedures required to
CA Cancer J Clin 2007;57:43–66. accomplish complete cytoreduction of ovarian cancer: is
2. Ozols RF, Rubin SC, Thomas GM et al. In: Hoskins WJ, there a correlation with “biological aggressiveness” and
Perez CA, Young RC (eds). Principles and practice of survival? Gynecol Oncol 2001;82:435–41.
gynecologic oncology, 3rd edn. Philadelphia: Lippincott, 18. Eisenkop SM, Spirtos NM. What are the current surgical
Williams & Wilkins, 2000. objectives, strategies, and technical capabilities of
3. Griffiths CT. Surgical resection of tumor bulk in the gynecologic oncologists treating advanced epithelial
primary treatment of ovarian carcinoma. Natl Cancer Inst ovarian cancer? Gynecol Oncol 2001;82:489–97.
Monogr 1975;42:101–4. 19. Chen L, Leuchter RS, Lagasse LD, Karlan BY. Splenectomy
4. Hoskins WJ, McGuire WP, Brady MF et al. The effect of and surgical cytoreduction for ovarian cancer.
diameter of largest residual disease on survival after Gynecol Oncol 2000;77:362–8.
primary cytoreductive surgery in patients with suboptimal 20. Chi DS, Fong Y, Venkatraman ES, Barakat RR. Hepatic
residual epithelial ovarian carcinoma. Am J Obstet resection for metastatic gynecologic carcinomas. Gynecol
Gynecol 1994;170:974–80. Oncol 1997;66:45–51.
5. Eisenkop SM, Friedman RL, Wang HJ. Complete 21. van Dam PA, Tjalma W, Weyler J et al. Ultraradical
cytoreductive surgery is feasible and maximizes survival debulking of epithelial ovarian cancer with the ultrasonic
in patients with advanced epithelial ovarian cancer: a surgical aspirator: a prospective randomized trial.
prospective study. Gynecol Oncol 1998;69:103–8. Am J Obstet Gynecol 1996;174:943–50.
6. Hoskins WJ, Chi DS, Boente MP, Rubin SC. State of the art 22. Eisenhauer EL, Abu-Rustum NR, Sonoda Y et al. The
surgical management of ovarian cancer. Cancer Res Ther addition of extensive upper abdominal surgery to achieve
Control 1999;9:373–82. optimal cytoreduction improves survival in patients with
7. Marsden DE, Friedlander M, Hacker NF. Current stages IIIC–IV epithelial ovarian cancer. Gynecol Oncol
management of epithelial ovarian carcinoma: a review. 2006;103:1083–90.
Semin Surg Oncol 2000;19:11–9. 23. Obermair A, Hagenauer S, Tamandl D et al. Safety and
8. Holschneider CH, Berek JS. Ovarian cancer: epidemiology, efficacy of low anterior en bloc resection as part of
biology, and prognostic factors. Semin Surg Oncol cytoreductive surgery for patients with ovarian cancer.
2000;19:3–10. Gynecol Oncol 2001;83:115–20.
9. Scarabelli C, Gallo A, Franceshi S et al. Primary 24. Hoskins WJ, Rubin SC, Dulaney E et al. Influence of
cytoreductive surgery with rectosigmoid colon resection secondary cytoreduction at the time of second-look
for patients with advanced epithelial ovarian carcinoma. laparotomy on the survival of patients with
Cancer 2000;88:89–97. epithelial ovarian carcinoma. Gynecol Oncol
10. Chi DS, Liao JB, Leon LF et al. Identification of prognostic 1989;34:365–71.
factors in advanced epithelial ovarian carcinoma. 25. Segna RA, Dottino PR, Mandeli JP et al. Secondary
Gynecol Oncol 2001;82:532–7. cytoreduction for ovarian cancer following cisplatin
11. Eisenkop SM, Nalick RH, Wang HJ, Teng NNH. Peritoneal therapy. J Clin Oncol 1993;11:434–9.
implant elimination during cytoreductive surgery for 26. Munkarah A, Levenback C, Wolf JK et al. Secondary
ovarian cancer: impact on survival. Gynecol Oncol cytoreductive surgery for localized intra-abdominal
1993;51:224–9. recurrences in epithelial ovarian cancer. Gynecol Oncol
12. Chi DS, Eisenhauer EL, Lang J et al. What is the optimal 2001;81:237–41.
goal of primary cytoreductive surgery for bulky stage IIIC 27. Eisenkop SM, Friedman RL, Spirtos NM. The role of
epithelial ovarian carcinoma (EOC)? Gynecol Oncol secondary cytoreductive surgery in the treatment of
2006;103:559–64. patients with recurrent epithelial ovarian carcinoma.
13. Curtin JP, Malik R, Venkatramann ES et al. Stage IV Cancer 2000;88:144–53.
ovarian cancer: impact of surgical debulking. Gynecol 28. Chi DS, McCaughty K, Diaz JP et al. Guidelines and
Oncol 1997;64:9–12. selection criteria for secondary cytoreductive surgery in
14. Liu PC, Benjamin I, Morgan MA et al. Prognostic patients with recurrent, platinum-sensitive epithelial
significance of residual disease in patients with stage IV ovarian carcinoma. Cancer 2006;106:1933–9.
epithelial ovarian cancer. Gynecol Oncol 1997;64:4–8. 29. Chi DS, Welshinger M, Venkatraman ES, Barakat RR. The
15. Munkarah AR, Hallum AV, Morris M et al. Prognostic role of surgical cytoreduction in Stage IV endometrial
significance of residual disease in patients with stage IV carcinoma. Gynecol Oncol 1997;67:56–60.
epithelial ovarian cancer. Gynecol Oncol 1997;64:13–17. 30. Scarabelli C, Campagnutta E, Giorda G et al. Maximal
16. Bristow RE, Montz FJ, Lagasse LD et al. Survival impact of cytoreductive surgery as a reasonable therapeutic
surgical cytoreduction in stage IV epithelial ovarian alternative for recurrent endometrial carcinoma. Gynecol
cancer. Gynecol Oncol 1999;72:278–87. Oncol 1998;70:90–3.
5 Pelvic exenteration
Douglas A Levine, Bernard H Bochner, and Dennis S Chi
Pelvic exenteration is one of the most radical surgical by tumor, has not been subject to previous surgery,
procedures performed by gynecologic oncologists. has adequate mobility, and a rich vascular supply.
The most common indication is for a central pelvic The major drawback to using the distal ileum is that
recurrence of cervical cancer. Alexander Brunschwig it may have been included in the previous radiation
first described the procedure in 1948 as ‘the most field. A continent conduit is created by establishing
radical surgical attack so far described for pelvic an intestinal reservoir and an efferent limb, which is
cancer’.1 The initial report described the en bloc brought out through the abdominal wall. Depending
removal of the pelvic organs with the creation of a on the type of continent conduit created, the ureters
‘wet colostomy’ by implanting the ureters into the are either directly inserted into the intestinal reservoir
sigmoid colon, which was then brought out as an end or into an afferent limb that drains into this reservoir.
colostomy. Today, reconstruction after a total pelvic The most commonly performed continent conduits
exenteration consists of separate bowel and urinary are the Miami and the Indiana pouches. The ureters
conduits. A total pelvic exenteration consists of the are inserted into a detubularized segment of ascending
en bloc removal of the bladder, rectum, vagina, and colon that serves as a low-pressure, high-capacity
tumor. In an anterior exenteration, the rectum is not reservoir. The appendix is removed and the distal
removed. In a posterior exenteration, the bladder and ileum is brought out as a urostomy. The reported
ureters remain intact. In all cases the uterus and incidence of early and late complications is approxi-
adnexa are removed if they have not been previously mately 60%, with the most common complications
removed as part of primary therapy or for unrelated being ureteral obstruction, difficult catheterization, or
reasons. A pelvic exenteration may be further sub- pyelonephritis.2,3 A modified Penn pouch offers certain
classified into a supralevator or infralevator exentera- attractive advantages over the more standard pouches
tion, depending on whether or not the perineum is and will be described in this chapter.
excised as part of the operation. At the conclusion of
the procedure, the colon is either reanastomosed or The most common indication for pelvic exenteration
brought out as an end colostomy. There are many is a central recurrence of cervical cancer. The intent
techniques to create a neovagina, the most common of the procedure is usually curative, although a pallia-
being bilateral gracilis flaps or a rectus abdominus tive exenteration may be appropriate for selected
flap. The details of this reconstruction are described patients with unmanageable symptoms such as
elsewhere in this text and are also readily available intractable pain, uncontrollable bleeding, or gross
elsewhere in more detail for the interested reader. disfigurement. It can also be performed for selected
recurrences of other pelvic malignancies including
The urinary system may be reconstructed into a con- endometrial, vulvar, vaginal, and colorectal cancers.
tinent or non-continent conduit. The most common Current surgical practices, including the use of anti-
non-continent conduit is created from a segment of biotics, modern anesthesia techniques, exceptional
distal ileum into which the ureters are inserted and intensive care units, meticulous surgical technique,
then brought out through a lower quadrant ostomy. blood banking, and advances in interventional radio-
Other segments of the intestinal tract may also be logy, have all contributed to a reduction in periopera-
used as a conduit, the most common alternatives tive morbidity and mortality. Surgical mortality in
being a portion of the jejunum, transverse colon, or recent reports has ranged from 2% to 5% and post-
sigmoid colon. Generally, the distal ileum is the operative major morbidity ranges from 30% to 60%.4–6
easiest portion to use since it is usually not involved In certain centers, a multidisciplinary approach, with
93
94 Atlas of Procedures in Gynecologic Oncology
an urologist, radiation oncologist, plastic surgeon, and positive margins on frozen section, intraoperative
colorectal surgeon, may be useful in achieving opti- radiation therapy offers an attractive technique
mal surgical outcomes. The 5-year survival for patients to help reduce the risk of recurrence.10 Typically,
undergoing pelvic exenteration for recurrent cervical 1500–2000 cGy are given to the tumor bed with a
cancer is between 30% and 50%.7,8 The largest review linear accelerator or a high-dose-rate afterloader.
of exenterative surgery for recurrent endometrial Some practitioners believe that a laterally extended
cancer reported a 5-year survival of 20%.9 In each endopelvic resection is a practical treatment for
of these series, the patients who underwent these recurrent disease that involves the pelvic sidewall.11
procedures were highly selected using various non-
standardized criteria. This chapter will highlight the major aspects of pelvic
exenteration. Although it is not possible to illustrate
Due to the radicality of the procedure, patients must all of the varied techniques available to the practicing
be appropriately counseled regarding the chance for surgeon, important differences will be highlighted.
cure and the physical alterations that can be expected We have elected to illustrate the ileal conduit and
after surgery, as well as the extended postoperative a modified Penn pouch as techniques in urinary
recovery time. For these reasons, exenterative surgery diversion, representing a common technique and a
is usually performed in patients who have had full relatively novel technique for the gynecologic oncolo-
pelvic irradiation either as part of initial treatment gist. Many of the technical aspects of pelvic exentera-
or for the management of recurrent disease. Unfor- tion overlap with the other radical surgical procedures
tunately, the previous pelvic irradiation renders the presented in Chapter 4. Similar techniques will be
surgery and recovery more difficult. For patients who referred to, but are not thoroughly illustrated to avoid
have either suspected positive margins or confirmed repetition.
Exenteration
a b
a b
2
1
2
3
3
4
4 5
5
1 – Right external iliac vessels 4 – Right pararectal space 1 – Left ureter 4 – Left paravesical space
2 – Right paravesical space 5 – Right ureter 2 – Left pararectal space 5 – Left external iliac vessels
3 – Right internal iliac artery 3 – Left internal iliac artery
c
Figure 5.4. Pelvic spaces.
After exploring the abdomen, both pelvic sidewalls are
opened and the pelvic spaces are developed, which aids in
the dissection and resection of the pelvic tumor. Incising
the peritoneum lateral to the medial umbilical ligament
develops the paravesical space. Loose areolar tissue will be
1 encountered, which can be gently dissected to arrive at the
2 base of the paravesical space. The pararectal space is
developed between the hypogastric artery and the ureter.
3
The dissection is carried inferiorly and dorsally along the
curve of the sacrum. (a) The right paravesical and
pararectal spaces; (b) The left paravesical and pararectal
spaces. (c) The right pelvic sidewall has been opened and
the deep circumflex iliac vein can be seen passing over the
1 – Deep circumflex iliac vein right external iliac artery. The paraaortic and/or common
2 – Right external iliac vein iliac lymph nodes have been sampled prior to proceeding
3 – Right external iliac artery with pelvic exenteration. The presence of metastases in
these areas is suggestive of systemic disease, making the
possibility of cure after exenteration unlikely.
Pelvic exenteration 97
a b
1
2
2
1 – Left ureter
2 – Left hypogastric vessels 3
c 4
a b
1
2
1 – Sigmoid colon 3
2 – Superior rectal artery
4
1 – Sigmoid colon
2 – Right ureter
3 – Right external iliac vessels
4 – Superior rectal artery
a b
a b
1
1
2 2
3
3 4
a b
a b
a b
c
Figure 5.12. Perineal resection.
Allis clamps are used to evert the perineum. The labia
majora can be temporarily sutured to the medial thigh to
improve exposure if they do not need to be resected. The
specimen is elevated, and the posterior incision is
continued until it meets the pelvic dissection. (a) A surgeon
performing the perineal phase can work with an assistant
whose hand is in the pelvis to serve as a guide for depth
and orientation during the perineal dissection. (b) The
specimen is then retracted laterally and the incision is
continued circumferentially. A Lace self-retaining retractor
is shown providing additional exposure. (c) Once the
specimen is free, it can be delivered through the perineum.
102 Atlas of Procedures in Gynecologic Oncology
a b
a b
a b
1 – Sigmoid
2 – Uterus
3 – Bladder
c
Figure 5.17. Specimen.
(a) The posterior view of the specimen shows the distal
sigmoid in relation to the uterus, which is elevated with a
1 clamp. (b) The superior view shows the bladder in relation
2 to the uterus, with the sigmoid seen posteriorly. (c) The
anterior view shows the relations within the perineum.
1 – Urethra
2 – Vagina
3 – Rectum
Pelvic exenteration 105
a b
a b
c
Figure 5.21. Enterotomy.
If a stent is used, it must be guided through the conduit.
(a) A long fine-tipped clamp, such as a tonsil clamp, is
placed through the conduit to a point a few centimeters
from the staple line. (b) A small enterotomy is then made
over the tip of the clamp with the scissors, not
electrocautery. (c) The stent is placed into the jaws of the
clamp and removed through the conduit. It will later be
brought out through a lower quadrant ostomy. Often the
first few ureteral sutures are placed prior to passing the
stent to avoid visual obstruction from the stent while
suturing.
Pelvic exenteration 107
a b
1
2
3
1
a b
Figure 5.24. Creating the stoma. Figure 5.25. Filling the pelvis.
An ostomy is created in the right lower quadrant. It is Prior to closing the abdomen, it is prudent to fill the pelvis
recommended that an enterostomal therapist evaluates the with some sort of material. If a neovagina is created, this
patient preoperatively and marks the appropriate ostomy will provide bulk in the pelvis. Otherwise, an omental
sites. The site should be chosen in a location that will not pedicle flap may be placed to fill in this defect. A delayed
be cumbersome for the patient to change the appliance or absorbable mesh offers an attractive alternative to a tissue
interfere with the normal position of clothing. If the site has flap in the pelvis. It will keep the small bowel from
not been previously marked, it should be placed two-thirds prolapsing into the pelvis and decrease the likelihood of
from the anterior iliac spine toward the umbilicus. It is small-bowel obstruction and fistula formation. In
important that the ileum is brought through the rectus comparison to a permanent mesh, it has a lower likelihood
abdominus muscle to minimize the risk of stomal of resulting in a serious pelvic infection that would require
herniation. mesh removal. Closed suction drains are placed in the
pelvis and beneath the ureteral anastomoses.
1
2
1 – Cecum
2 – Appendix
3 – Terminal ileum
Figure 5.28. Cannulating the appendix.
Figure 5.27. Anatomy. The mesentery of the appendix is carefully mobilized,
The appendix serves as the perfect source for the taking care not to disrupt the appendiceal artery as this will
catheterizable limb of the continent urinary conduit if it has lead to subsequent ischemia and necrosis. The tip of the
not been previously removed, demonstrates no significant appendix is resected, and the appendix is cannulated first
radiation damage, and has an adequate lumen. If the with a fine probe or an 8F pediatric feeding catheter.
appendix has been removed, alternative configurations Subsequently, the appendix is dilated to accommodate a
should be considered, including the Miami or Indiana 12–14F red rubber catheter.
pouch. In this section, a modification of the Penn pouch
will be described. For this technique, the ureters are
implanted into a segment of distal ileum approximately
10 cm from the ileocecal valve; the appendix serves as the
catheterizable limb and continence valve, and the
ascending colon functions as the reservoir. A longer
segment of terminal ileum can be used if additional length
is needed to replace excised or irradiated ureters. The
ureters are not tunneled, but implanting them proximal to
the ileocecal valve prevents reflux, which is more likely to
occur in a pouch that uses the ascending colon as both the
reservoir and the site of ureteral implantation. The appendix
is placed into a submucosal tunnel in situ to provide a short
efferent limb that is easy to catheterize. Traditional
ileocecal pouches that use the terminal ileum as the
efferent limb have demonstrated higher revision rates for
difficult catheterization or stomal incontinence.
110 Atlas of Procedures in Gynecologic Oncology
a b
c
Figure 5.29. Incising the taenia.
(a) The taenia leading toward the appendix is injected with
1% lidocaine with 1:100 000 epinephrine to create a wheal
from the appendix–cecal junction along the taenia for 4 cm.
(b) The seromuscular layer of the cecum is incised with a
#15 blade along the anterior taenia coli. (c) The length of the
incision should be 4–5 cm. Care should be taken not to enter
the cecal mucosa.
Pelvic exenteration 111
a b
a b
a b
c d
e
Figure 5.32. Tunneling the appendix.
Sutures of 3–0 silk are used to secure the appendix into the
submucosal trough. The appendix is flipped into the trough
created along the taenial incision. Initially, one side of the
cecal seromuscular incision is grasped close to the base of
the appendix. The tunnel is formed from the appendix–
cecal junction and works towards the distal end of the
appendix and along the cecal incision. (a) The suture is
passed through the seromuscular layer from lateral to
medial and (b) grasped with a fine forceps through the first
window. (c) The suture itself, not the needle, is grasped to
allow for easier mobility when it is brought through the
window beneath the appendix. (d) The suture is then
reloaded and passed through the seromuscular layer on the
opposite side from medial to lateral. (e) It is then regrasped
through the window to be brought back beneath the
appendix in the opposite direction. The appendix is
secured into the trough as this suture reopposes the serosa
of the cecal flaps.
Pelvic exenteration 113
a b
a b
a b
c d
1
2 1
2
3
3
References
1. Brunschwig A. Complete excision of pelvic viscera for 7. Shingleton HM, Soong SJ, Gelder MS et al. Clinical and
advanced carcinoma. Cancer 1948;1:177–83. histopathologic factors predicting recurrence and survival
2. Penalver MA, Angioli R, Mirhashemi R, Malik R. after pelvic exenteration for cancer of the cervix. Obstet
Management of early and late complications of ileocolonic Gynecol 1989;73:1027–34.
continent urinary reservoir (Miami pouch). Gynecol Oncol 8. Stanhope CR, Webb MJ, Podratz KC. Pelvic exenteration
1998;69:185–91. for recurrent cervical cancer. Clin Obstet Gynecol 1990;33:
3. Ramirez PT, Modesitt SC, Morris M et al. Functional 897–909.
outcomes and complications of continent urinary 9. Barakat RR, Goldman NA, Patel DA et al. Pelvic
diversions in patients with gynecologic malignancies. exenteration for recurrent endometrial cancer. Gynecol
Gynecol Oncol 2002;85:285–91. Oncol 1999;75:99–102.
4. Crozier M, Morris M, Levenback C et al. Pelvic 10. Gemignani ML, Alektiar KM, Leitao M et al. Radical
exenteration for adenocarcinoma of the uterine cervix. surgical resection and high-dose intraoperative radiation
Gynecol Oncol 1995;58:74–8. therapy (HDR-IORT) in patients with recurrent
5. Matthews CM, Morris M, Burke TW et al. Pelvic gynecologic cancers. Int J Radiat Oncol Biol Phys
exenteration in the elderly patient. Obstet Gynecol 2001;50:687–94.
1992;79:773–7. 11. Hockel M. Laterally extended endopelvic resection:
6. Morley GW, Hopkins MP, Lindenauer SM, Roberts JA. surgical treatment of infrailiac pelvic wall recurrences of
Pelvic exenteration, University of Michigan: 100 patients gynecologic malignancies. Am J Obstet Gynecol
at 5 years. Obstet Gynecol 1989;74:934–43. 1999;180:306–12.
6 Retroperitoneal lymph node
dissection
Oliver Zivanovic, Nadeem R Abu-Rustum, and Joel Sheinfeld
117
118 Atlas of Procedures in Gynecologic Oncology
2
3
1 2
5 6
3
4
6
1 – Precaval 6 – Ovarian
2 – Preaortic 7 – Presacral
3 – Intercaval 8 – Common iliac
4 – Paracaval 9 – External iliac
5 – Paraaortic
Figure 6.3. Insertion of the right ovarian vein into the left
renal vein.
Retroperitoneal lymph node dissection 119
1
1 2
3
Figure 6.6. The left renal vein crossing over the aorta.
1 – Right ureter
2 – Inferior vena cava
a b
1
1
2
3
4
2
c
Figure 6.16a–c. This completes the retroperitoneal lymph
node dissection exposing the left renal vein, the left renal
artery, the aorta, and the IVC.
7 Panniculectomy to facilitate
pelvic surgery
Eric L Eisenhauer, Babak J Mehrara, and Nadeem R Abu-Rustum
Surgical procedures in morbidly obese patients therefore, that the staging operation in obese patients
are technically challenging. The combination of a is not abbreviated. With the increasing incidence
prodigious anterior abdominal wall to gain access, of obesity in the US population, the necessity of
compromised exposure during the case, and an designing and standardizing surgical approaches
incision in which healing is hindered by increased that allow adequate staging with low morbidity is
dead space and poor blood supply can be daunting paramount.
even for seasoned surgeons. Increases in blood loss,
operative time, wound infection rates, and operative Panniculectomy to facilitate pelvic access is commonly
injuries are well-documented in obese patients performed in morbidly obese patients, and has been
and are probably related to compromised operative previously described in multiple reports.4,9–15 For
exposure.1–4 Contributing to these factors is the high gynecologic procedures confined to the pelvis and
incidence of co-morbid medical conditions in these lower abdomen, excising this portion of the abdomi-
patients that can further hinder recovery when nal wall provides excellent operative access while
complications occur. Preoperative planning, intraop- allowing a more uniform abdominal closure. Reported
erative technique, and close postoperative manage- benefits of panniculectomy in series comparing it to
ment can reduce the number of complications. standard laparotomy include decreased incisional
However, wound complications still represent a complications and increased lymph node count.16,17
significant cause of postoperative morbidity in
these patients. In this chapter we present our technique for perform-
ing panniculectomy. Details of the procedures for
Obese women are frequently seen by gynecologic which the panniculectomy is performed (hysterec-
oncologists for surgical care due to the direct relation- tomy, staging, etc.) are found elsewhere in this text.
ship between increasing body mass index (BMI) and Although we have performed panniculectomy most
endometrial cancer risk.5–7 Consistent with findings often in our patients with endometrial cancer, the
in normal-weight women, almost one-fourth of steps described are equally applicable to any surgical
morbidly obese women with endometrial cancer may procedures requiring access to the pelvis and lower
have evidence of extrauterine disease.8 It is essential, abdomen.
123
124 Atlas of Procedures in Gynecologic Oncology
Figure 7.1. Identify and mark the pannus. Figure 7.2. Abdominal incision.
Although the incision site is marked in the operating room, A scalpel is then used to make the skin incision, which is
it is essential to examine the patient while standing so that carried down to the anterior abdominal wall fascia. The
the dependent pannus can be accurately marked. entire resection is performed with the scalpel, and we
Generally, an infraumbilical panniculectomy provides avoid using cautery in this part of the operation to decrease
adequate access for pelvic and low paraaortic surgery, the amount of tissue and fat necrosis.
although in cases requiring a supraumbilical
panniculectomy, the skin around the umbilicus can be
incised and the umbilicus repositioned. The subcutaneous
tissue along the marked border is infiltrated with
epinephrine hydrochloride, 1 mg in 500 ml saline, for
added hemostasis. Approximately 1 L of this solution is
injected circumferentially along the marked incision using
a 60 cc syringe with a long 18-gauge needle.
Figure 7.3. Securing vascular perforators. Figure 7.4. Separating the specimen from the fascia.
Many perforating vascular branches will be identified as The incision has been beveled inward so that the specimen
the panniculectomy specimen is developed. These are at the fascia is narrower than the wider skin incision. The
carefully clamped, ligated, and divided, as cut vessels that base of the specimen often contains vascular perforators
retract into the surrounding adipose tissue can be difficult which can be successively clamped and divided to remove
to control. the pannus specimen. The surrounding fascia is not
completely cleared in order to not further devascularize it.
Panniculectomy to facilitate pelvic surgery 125
Figure 7.9. Fascial closure and subcutaneous irrigation. Figure 7.10. Drain placement and subcutaneous tissue
Once the resection and staging have been completed, the closure.
bowel is returned to its normal position, adhesion barriers Drainage of the subcutaneous dead space is accomplished
are placed, and the vertical incision is closed with a No. 1 by placing two closed-suction Jackson-Pratt (JP) drains
looped polydiaxanone suture. After fascial closure, along the fascia, one on each side of the incision. We
irrigation of the subcutaneous tissue is performed with 2 L prefer to bring the drains out in the midline below the
of dilute bacitracin solution with the Simpulse Solo incision to ensure that the medial part of the incision is
irrigation system (Davol, Cranston, RI). adequately drained. The remaining dead space is closed
with two to three layers of interrupted 2–0 polyglactin
sutures.
Figure 7.11. Subcuticular skin closure. Figure 7.12. Closed incision and dressing application.
The subcuticular layer is closed with either a running 4–0 Steri-strips are placed over the incision and a sterile
poliglecaprone suture or the INSORB subcuticular stapler dressing applied. JP drains are secured with stay sutures.
(Incisive Surgical, Inc., Plymouth, MN), as shown here.
Panniculectomy to facilitate pelvic surgery 127
References
1. Meyerowitz BR, Gruber RP, Laub DR. Massive abdominal undergoing gynecological surgery. Gynecol Oncol
panniculectomy. JAMA 1973;225(4):408–9. 1998;70(1):80–6.
2. Grazer FM, Goldwyn RM. Abdominoplasty assessed by 11. Micha JP, Rettenmaier MA, Francis L, Willenberg R,
survey, with emphasis on complications. Plast Reconstr Brown JV. ‘Medically necessary’ panniculectomy
Surg 1977;59(4):513–17. to facilitate gynecologic cancer surgery in
3. Pitkin RM. Abdominal hysterectomy in obese women. morbidly obese patients. Gynecol Oncol 1998;
Surg Gynecol Obstet 1976;142(4):532–6. 69(3):237–42.
4. Voss SC, Sharp HC, Scott JR. Abdominoplasty combined 12. Pearl ML, Valea FA, Chalas E. Panniculectomy and
with gynecologic surgical procedures. Obstet Gynecol supraumbilical vertical midline incisions in morbidly
1986;67(2):181–5. obese gynecologic oncology patients. J Am Coll Surg
5. Tretli S, Magnus K. Height and weight in relation to 1998;186(6):649–53.
uterine corpus cancer morbidity and mortality. A 13. Powell JL, Kasparek DK, Connor GP. Panniculectomy to
follow-up study of 570,000 women in Norway. Int J Cancer facilitate gynecologic surgery in morbidly obese women.
1990;46(2):165–72. Obstet Gynecol 1999;94(4):528–31.
6. Parazzini F, La Vecchia C, Bocciolone L, Franceschi S. 14. Hopkins MP, Shriner AM, Parker MG, Scott L.
The epidemiology of endometrial cancer. Gynecol Oncol Panniculectomy at the time of gynecologic surgery in
1991;41(1):1–16. morbidly obese patients. Am J Obstet Gynecol
7. Tornberg SA, Carstensen JM. Relationship between 2000;182(6):1502–5.
Quetelet’s index and cancer of breast and female genital 15. Tillmanns TD, Kamelle SA, Abudayyeh I et al.
tract in 47,000 women followed for 25 years. Br J Cancer Panniculectomy with simultaneous gynecologic oncology
1994;69:358–61. surgery. Gynecol Oncol 2001;83(3):518–22.
8. Everett E, Tamimi H, Greer B et al. The effect of body mass 16. Wright JD, Powell MA, Herzog TJ et al. Panniculectomy:
index on clinical/pathologic features, surgical morbidity, improving lymph node yield in morbidly obese
and outcome in patients with endometrial cancer. patients with endometrial neoplasms. Gynecol Oncol
Gynecol Oncol 2003;90(1):150–7. 2004;94(2):436–41.
9. Cosin JA, Powell JL, Donovan JT, Stueber K. The safety 17. Eisenhauer EL, Wypych KA, Mehrara BJ et al. Comparing
and efficacy of extensive abdominal panniculectomy at the surgical outcomes in obese women undergoing
time of pelvic surgery. Gynecol Oncol 1994;55(1):36–40. laparotomy, laparoscopy, or laparotomy with
10. Blomfield PI, Le T, Allen DG, Planner RS. panniculectomy for the staging of uterine malignancy.
Panniculectomy: a useful technique for the obese patient Ann Surg Oncol 2007;14(8):2384–91.
8 Fertility-sparing radical
abdominal trachelectomy
for cervical cancer
Sharyn N Lewin and Nadeem R Abu-Rustum
The traditional surgical management for women The eligibility criteria for a radical vaginal trachelec-
with early-stage cervical carcinoma has been radical tomy, as described by Professor Dargent, are high-
abdominal hysterectomy and pelvic lymphadenec- lighted in Chapter 14 and include women ≤40 years
tomy. While high cure rates and favorable quality of age who desire fertility preservation, lesion size
of life endpoints may be achieved, loss of future ≤2 cm, Stages IA–IBI, negative lymph nodes, and
reproductive capacity occurs in nearly all cases. The no involvement of the upper endocervical canal.6
rare exception is seen when modern assisted- Although these criteria also apply to the radical
reproductive techniques are used. With such tech- abdominal approach, it is noteworthy that many cen-
niques, the patient’s oocytes may be used to generate ters perform radical abdominal hysterectomies for
embryos carried by a surrogate mother. Recent data Stage IBI tumors ≤4 cm or even Stage IB2 lesions <6 cm
suggest approximately 40% of Stage I cervical cancers in size.6 The radical abdominal trachelectomy, there-
are diagnosed before 40 years of age.1 Many of these fore, may be a viable option for selected patients with
women may be eligible for a fertility-sparing larger Stage IB lesions: namely, 2–4 cm. Ungar et al
approach.2 reported the largest series of radical abdominal
trachelectomies to date. Of the 30 patients described,
The concept of conserving the uterine fundus 5 (17%) had Stage IB2 tumors.7 Thus, the radical
through a radical abdominal trachelectomy was abdominal trachelectomy may be employed in the
first described by Aburel.3 This innovative approach treatment of larger tumors or in patients not amenable
mirrors trends found in the surgical management to vaginal surgery due to anatomic factors or from
of other solid tumor types aimed at favorable scarring due to prior procedures.6
oncologic outcomes with preservation of organ
function.4 This technique only recently gained notori- With relatively short-term follow-up, the pooled
ety, many years after the description of the radical published recurrence and death rates (4.2% and 2.8%,
vaginal trachelectomy by Professor Daniel Dargent respectively) following radical vaginal trachelectomy
in 1987.5 Since that time, several authors have appear comparable to the traditional radical abdomi-
described their surgical technique as well as the nal hysterectomy.10 Moreover, a 70% pregnancy rate
resultant oncologic outcomes.6–9 Furthermore, these has been described in women trying to conceive.10
reports describe normal menstrual function and With a radical abdominal trachelectomy, the param-
successful pregnancies, illustrating that preserved etrial resection is identical to the traditional Type III
uterine function is possible after bilateral uterine radical hysterectomy. Oncologic outcomes should
artery ligation as long as the utero-ovarian blood also be comparable; however, longer follow-up with a
supply is maintained.6,7 larger patient population is needed.
129
130 Atlas of Procedures in Gynecologic Oncology
a b
Figure 8.4. Anterior colpotomy using a Wertheim clamp. Figure 8.5. Measuring the lower uterine segment.
Alternatively, a Wertheim clamp can be placed at the The lower uterine segment is then estimated and clamps
desired length of the vagina and the specimen separated. are placed at the level of the internal os.
a b
c d
a b
a b
c
Figure 8.9. Reconstructing the uterine corpus to
upper vagina.
(a) The detached uterine corpus and residual upper vagina
prior to reconstruction. (b) The uterus is then reconstructed
to the upper vagina with six to eight #2–0 absorbable
sutures in a circumferential manner. (Reproduced with
permission from Sloan Memorial Sloan-Kettering Cancer
Center, 2006.) (c) The reconstructed uterine corpus to the
upper vagina prior to securing the sutures.
An alternative approach would be to separate the fun- cervix, and perform the radical trachelectomy. The
dus from the cervix prior to the colpotomy, pack the role of cystourethroscopy with bilateral temporary
fundus with the intact utero-ovarian blood supply ureteral catheterization in fertility-sparing radical
in the upper pelvis, place retraction clamps on the surgery for cervical cancer is optional.11
References
1. Plante M, Renaud MC, Francois H, Roy M. Vaginal radical technique and review of the literature. Gynecol Oncol
trachelectomy: an oncologically safe fertility-preserving 2006;103(3):807–13.
surgery. An updated series of 72 cases and review of the 7. Ungar L, Palfalvi L, Hogg R et al. Abdominal radical
literature. Gynecol Oncol 2004;94:614–23. trachelectomy: a fertility-preserving option for women
2. Sonoda Y, Abu-Rustum NR, Gemignani ML et al. with early cervical cancer. BJOG 2005;112:366–9.
A fertility-sparing alternative to radical hysterectomy: 8. Smith JR, Boyle DCM, Corless DJ et al. Abdominal radical
how many patients may be eligible? Gynecol Oncol trachelectomy: a new surgical technique for the
2004;95(3):534–8. conservative management of cervical carcinoma. BJOG
3. Aburel E. Colpohisterectomia largita subfundica. 1997;104:1196–200.
In: Sirbu P (ed.). Chirurgica gynecologica. Bucharest, 9. Abu-Rustum NR, Su W, Levine DA et al. Pediatric radical
Romania: Editura Medicala, 1981:714–21. abdominal trachelectomy for cervical clear cell carcinoma:
4. Covens A, Shaw P, Murphy J et al. Is radical trachelectomy a novel surgical approach. Gynecol Oncol 2005;97:
a safe alternative to radical hysterectomy for patients with 296–300.
stage IA-B carcinoma of the cervix? Cancer 10. Dursun P, Leblanc E, Nogueira MC. Radical vaginal
1999;86(11):2273–9. trachelectomy (Dargent’s operation): a critical
5. Dargent D, Martin X, Sacchetoni A, Mathevet P. review of the literature. Eur J Surg Oncol 2007;33(8):
Laparoscopic vaginal radical trachelectomy: a treatment to 933–41.
preserve the fertility of cervical carcinoma patients. Cancer 11. Abu-Rustum NR, Sonoda Y, Black D et al. Cystoscopic
2000;88:1877–82. temporary ureteral catheterization during radical vaginal
6. Abu-Rustum NR, Sonoda Y, Black D et al. Fertility-sparing and abdominal trachelectomy. Gynecol Oncol
radical abdominal trachelectomy for cervical carcinoma: 2006;103(2):729–31.
9 Extended pelvic resection
John P Diaz, Patrick J Boland, Dennis S Chi, and Nadeem R Abu-Rustum
Tumor persistence or local recurrence in a previously sidewall muscle, and major nerves in those women
irradiated pelvis usually indicates a dismal prognosis. undergoing surgery for recurrent gynecologic malig-
Until now, salvage was only possible in a few nancies. We hope these advances will translate into
selected patients with centrally located disease who increased utilization of surgical resection of pelvic
had undergone a successful pelvic exenteration. recurrences in these highly selected cases.
Patients with a pelvic sidewall recurrence, represent-
ing a more common situation of local failure, are
traditionally considered ineligible for curative surgi-
cal therapy. Pelvic sidewall involvement, suggested SURGICAL TECHNIQUES
by the clinical triad of hydronephrosis, leg edema,
and sciatic nerve pain, has been considered a
contraindication to pelvic exenteration.1 The scope of Laterally extended endopelvic
pelvic exenteration is changing. Advances in imaging resection (LEER)
enable us to select more appropriate surgical
candidates, and the definition of a radical surgical
Proper exposure is achieved with a vertical midline
resection has expanded, allowing us to offer pelvic
laparotomy circumventing the umbilicus. All perito-
exenteration to patients previously deemed inopera-
neal adhesions are lysed, and the abdominal and
ble. Resection of nerve, muscle, and bone has been
pelvic intraperitoneal compartment is systematically
incorporated in an attempt to obtain clear resection
explored by inspection and palpation. Biopsy speci-
margins. Patient selection is of paramount impor-
mens are taken from all suspected intraperitoneal
tance. For selected patients with gynecologic tumors
sites. The bowel contents are removed from the field
fixed at the pelvic sidewall, a laterally extended
by placement and use of a self-retaining retractor.
endopelvic resection (LEER) may be considered if the
Following exposure of the entire tumor area, the
following four criteria are met:
retroperitoneal pelvic and midabdominal compart-
1. R0 resection of the tumor is achievable. ments are opened. On both sides the paracolic gutters
2. Local tumor control can lead to cure or at least and pelvic parietal peritoneum along the psoas
prolongation of life. muscles are incised and the round ligaments are
3. The patient’s general performance status is separated. The anterior visceral peritoneum of the
compatible with the extensive operation and its bladder is incised, and the space of Retzius is opened.
consequences. Both paravesical and pararectal spaces and the
4. No equally effective alternative treatment is presacral space are developed. Similarly, the space
available. between the external iliac vessels and the medial
aspect of the psoas muscle is opened. Based on
With extended endopelvic resections involving the the location of the recurrent tumor, these spaces
resection of pelvic sidewall muscles and major may be only partially opened. Gross intralesional
vessels in the lesser pelvis, Hockel included 24 of his dissection must be avoided. Bilateral uterolysis is
patients with recurrent cervical cancer and found a performed. Selective periaortic and pelvic lymph
5-year disease-free and overall survival of 41% and node dissection may be performed as required, taking
44%, respectively.2 This approach enables those into consideration prior operations and intraoperative
women with pelvic sidewall disease a chance of cure, findings.
with an acceptable associated morbidity.
If needed, the infundibulopelvic ligaments are divided
The objective of this chapter is to illustrate the and the ureters are cut as low as possible in the
techniques utilized in resections of pelvic bone, pelvis. Biopsy specimens of the distal ureters are
137
138 Atlas of Procedures in Gynecologic Oncology
examined by frozen sections in selected cases. The wall and urethra are transected along strong curved
mesosigmoid is skeletonized and the blood vessels clamps. The anal canal is mobilized from the poste-
are ligated at the rectosigmoid transition. The bowel rior vaginal wall, which is divided after clamping as
continuity is interrupted at the site by the use of the well. The anorectal transition is separated with a sta-
GIA instrument. pling instrument. Now the complete specimen of the
laterally extended resection, consisting of the urethra,
At the tumor-free pelvic wall, the visceral branches of bladder, vagina, uterus, adnexa, and rectum at the left
the internal iliac vessels, the pelvic autonomic nerve side, en bloc with the complete endopelvic urogenital
plexus, the cardinal and pubocervical ligaments, and mesentery and the coccygeus, iliococcygeus, pubo-
the paracolpium are completely divided between coccygeus, and obturator internus muscles, can be
clamps. removed and examined with multiple frozen sections
for tumor margins.
The internal iliac artery at the side of the pelvic side-
wall lesion is ligated and divided at the site of branch- Depending on the location of the recurrent tumor at
ing off from the common iliac artery. Thereafter, all the pelvic sidewall, the extent of visceral and parietal
parietal branches of the iliac vessel system are transected resection can be reduced in comparison with the
between ligatures or clips: the ascending lumbar vein, maximum version described herein. Infrailiac sacro-
superior gluteal artery and vein, inferior gluteal artery coccygeal recurrence may allow the bladder and
and vein, and internal pudendal artery and vein. The the obturator internus muscle to be spared. With
internal iliac vein can now be divided at the bifurcation infrailiac ischiopubic relapse, the rectum and the
as well. The left lumbosacral plexus and the piriformis coccygeus muscle may remain in situ.
muscle are exposed by this maneu ver.
If the pelvic sidewall recurrence has been resected
Ventral incision of the obturator internus muscle with clean margins by laterally extended endopelvic
is carried out with the Bovie tip at the site of the resection, as demonstrated with multiple frozen
obturator nerve, which is either elevated or divided sections, the ablative part of the operation is finished.
if it is incorporated from the acetabulum and the To improve wound healing in the irradiated pelvis,
obturator membrane by use of a periosteal dissector. the surgeon elevates an omentum majus flap nour-
Below the level of the ischial spine, the obturator ished by the ipsilateral gastroepiploic gutter, and
muscle, which is leaving the endopelvis through the fixes it to the pelvic surface. The inclusion of the anus
smaller sciatic foramen, is divided again and the and anal canal into the laterally extended pelvic
muscle stump is ligated. The separated endopelvic evisceration necessitates the reconstruction of the
part of the obturator muscle, in continuity with pelvic floor to avoid a perineal hernia. This can be
the attached iliococcygeus and pubococcygeus mus- done by means of a transversus and rectus musculo-
cles, is retracted medially to expose the ischiorectal peritoneal flap, which may also be used for vaginal
fossa. reconstruction. For supravesical urinary diversion,
either a conduit or a continent pouch is constructed
A superior incision below the sacral plexus, between from non-irradiated colon segments (ascending, trans-
the ischial spine and the fourth sacral body and verse, or descending colon) with the Mainz technique.
the elevation of the coccygeus muscle from the Bowel continuity is accomplished with a stapled
sacrospinous ligament, is performed with a periosteal deep colorectal anastomosis; otherwise, an end
dissector. colostomy is made for fecal diversion. If microscopic
tumor extends to the lateral resection margins, the
Medially to the ischiorectal fossa, the lateral vaginal combined operative and radiation treatment is
wall is identified and incised. The anterior vaginal applied.
Extended pelvic resection 139
a b
c d
References
1. Barber HR. Relative prognostic significance of preoperative 4. Akasu T, Yamaguchi T, Fujimoto Y et al. Abdominal
and operative findings in pelvic exenteration. Surg Clin sacral resection for posterior pelvic recurrence of rectal
North Am 1969;49:431–47. carcinoma: analyses of prognostic factors and recurrence
2. Hockel M. Laterally extended endopelvic resection. Novel patterns. Ann Surg Oncol 2007;14:74–83.
surgical treatment of locally recurrent cervical carcinoma 5. Yamada K, Ishizawa T, Niwa K et al. Pelvic exenteration
involving the pelvic side wall. Gynecol Oncol and sacral resection for locally advanced primary
2003;91:369–77. and recurrent rectal cancer. Dis Colon Rectum
3. Brunschwig A, Barber HR. Pelvic exenteration combined 2002;45:1078–84.
with resection of segments of bony pelvis. Surgery
1969;65:417–20.
10 Myocutaneous flap
reconstruction
Anuja K Antony, Douglas A Levine, and Babak J Mehrara
The management of patients with gynecologic cancer using myocutaneous flaps decrease wound healing
is complex and requires careful planning. Vaginal complications following pelvic exenteration com-
and pelvic floor reconstruction is most commonly pared with those patients who did not have any
performed as a coordinated approach involving gyne- reconstruction.1–3
cologic surgical oncologists, radiation oncologists,
and reconstructive surgeons. In recent years, these Soper et al in 2007 compared gracilis flaps vs VRAM
procedures have become more commonplace as the flaps after total pelvic exenteration and found similar
techniques have become more reliable to allow for rates of vaginal stenosis and no significant difference
improved closure and healing after radical, disabling in donor site complications. The gracilis patients
gynecologic cancer surgery. Familiarity with these experienced 31% of any degree of flap loss (skin or
procedures may help guide operative resection and muscle loss of 50% requiring operative debridement
understanding of the methods utilized to carry out occurred in only 14% of patients) compared with 5%
reconstruction. of VRAM patients. They reported similar rates of
vaginal coitus in both patient groups.4
The most common types of reconstruction employ
flaps composed of regional muscle and soft tissue Cordeiro et al in 2002 proposed a classification
into the area of the defect. Larger defects may require scheme for partial or total vaginal defects.5 In general,
free tissue transfer with microsurgical techniques; VRAM flaps were used for partial large-volume defects
however, with the wide array of regional options avail- involving the posterior wall of the vagina (most com-
able, these procedures are rarely necessary. The most monly rectal cancers invading the vagina and treated
common flaps in the plastic surgeon’s armamentarium with abdominal perineal resection). In addition, the
include the rectus flap with the overlying vertically VRAM flap is useful for coverage of partial vaginal
oriented skin and soft tissue (VRAM or vertical rectus defects involving circumferential resections of the
abdominis flap) and the gracilis myocutaneous flap. cervix and upper vagina. In contrast, bilateral gracilis
flaps are most useful for complete circumferential
Vaginal or pelvic reconstruction is indicated for vaginal resections (e.g. pelvic exenteration). Both flaps
achieving stable skin closure, obliterating dead are most useful in patients with small to moderate
space, transferring vascularized healthy tissues to amounts of subcutaneous fat, as excessive flap bulk
the wound bed to accelerate healing, isolating small and wound healing complications at the donor site
bowel from the perineum, and restoring sexual func- can occur in morbidly obese patients. Decisions with
tion/genital anatomy. Such reconstructions can also regards to flap choice typically are based on viability
provide psychological benefit by restoring body of available tissues and its associated blood supply,
image and sexual function for the patient. Many previous operations or co-morbidities, defect size and
studies have demonstrated that pelvic reconstruction location, and personal experience.
145
146 Atlas of Procedures in Gynecologic Oncology
The distal incision is made first and the gracilis muscle is the muscle. The dissection proceeds proximally rapidly
identified posterior to the sartorius muscle. The distal until the pedicle is identified underneath the adductor
portion of the muscle is tendinous and traction on the longus muscle. Oftentimes, an accessory pedicle is iden-
muscle will highlight its course, thereby enabling the sur- tified distally in the leg and care should be taken not to
geon to confirm placement of the proposed skin paddle injure this pedicle until the proximal, dominant pedicle is
centered directly over the gracilis muscle. The muscle definitively identified. The proximal muscle dissection is
tendon is encircled with a Penrose drain and the assistant performed and adductor longus muscle is retracted.
applies gentle pressure while the surgeon makes the Perforating vessels from the gracilis pedicle to the adduc-
anterior incision through the skin, subcutaneous tissues, tor longus muscle are dissected and ligated and the pedi-
and fascia overlying the adductor magnus and sartorius cle dissection is continued proximally to the vessel origin.
muscles. The dissection is initiated from distal to proximal Once the anterior dissection is performed and the muscle
while staying deep to the gracilis muscle to prevent dam- is completely encircled, the posterior skin incision is
age to the perforating vessels to the skin that wrap around made and the flap is circumferentially elevated.
Myocutaneous flap reconstruction 147
Figure 10.2. Tunneling the flaps. Figure 10.3. Creating the neovagina.
A subcutaneous tunnel is made in the medial thigh The edges of the two flaps are then sutured together to form
between the upper portion of the skin incision used to a tube and the neovagina is placed in the pelvis. Generally,
harvest the gracilis muscle and the vagina. The tunnel no tacking sutures are required, as fibrosis occurs rapidly
should measure at least 4 finger breadths in width and and prevents herniation of the newly formed vagina.
should allow comfortable transfer of the flap. In most cases
the gracilis muscle is disinserted proximally to allow
rotation of the flap into the vaginal defect. This should be
performed with extreme care, as it results in an 180°
rotation of the pedicle vessels. For this reason, the vessels
should be completely dissected in most cases to prevent
venous or arterial kinking during flap transposition. The flap
is passed through the tunnel and the portion of the skin
paddle that is necessary for vaginal reconstruction is
marked. The excess skin (i.e., skin that is in the
subcutaneous tunnel) is de-epithelialized and thinned
carefully. The contralateral gracilis flap is harvested in an
identical fashion and tunneled into the vaginal defect.
a b
a b
a b
References
1. Jurado M, Bazan A, Elejabeitia J et al. Primary vaginal and 4. Soper JT, Secord AA, Havrilesky LJ et al. Comparison of
pelvic floor reconstruction at the time of pelvic gracilis and rectus abdominis myocutaneous flap
exenteration: a study of morbidity. Gynecol Oncol neovaginal reconstruction performed during radical pelvic
2000;77:293–7. surgery: flap-specific morbidity. Int J Gynecol Cancer
2. Carlson JW, Soisson AP, Fowler JM et al. Rectus 2007;17:298–303.
abdominis myocutaneous flap for primary vaginal 5. Cordeiro PG, Pusic AL, Disa JJ. A classification system and
reconstruction. Gynecol Oncol 1993;51:323–9. reconstructive algorithm for acquired vaginal defects.
3. de Haas WG, Miller MJ, Temple WJ et al. Perineal wound Plast Reconstr Surg 2002;110:1058–65.
closure with the rectus abdominis musculocutaneous flap
after tumor ablation. Ann Surg Oncol 1995;2:400–6.
11 Laparoscopic staging
procedures
Yukio Sonoda and Richard R Barakat
Surgical staging remains the gold standard by validate the place of laparoscopy in the management
which spread of malignant gynecologic tumor is of gynecologic malignancies. If these two approaches
measured. Surgical staging relies on the evaluation of prove to be equal, the skills required to perform
the pelvic and paraaortic lymph nodes. Due to the laparoscopic staging should become part of the gyne-
close proximity of these nodes to the underlying cologic oncologist’s armamentarium. This chapter
vascular structures, surgical removal can be techni- illustrates the different components of the laparo-
cally challenging. The ability to perform such an scopic staging procedure.
evaluation using minimally invasive surgery has
opened the door for the acceptance of laparoscopy in The procedures described in this chapter are
the gynecologic oncology community. those used for the comprehensive staging of ovarian
and endometrial cancers. Patients with cervical
Professor Daniel Dargent can be credited for much of cancer are currently staged clinically, and the laparo-
the laparoscopic movement in gynecologic oncology. scopic management for this disease is described in
His first use of laparoscopy to evaluate the pelvic Chapter 12 (Laparoscopic radical hysterectomy). The
nodes1 soon prompted others like Querleu et al2 to techniques described in this chapter are intended
incorporate this new staging technique into the for use in patients who have organ-confined disease.
management of cervical cancer. Although laparoscopy may be appropriate in
selected circumstances where disease has spread
Reports of the use of laparoscopic staging for the out of the pelvis, the procedures described within
management of endometrial cancer and ovarian are not meant for that purpose. There are differences
cancer soon followed.3,4 The use of minimally inva- in the staging procedures performed for primary
sive surgery for the management of gynecologic malig- ovarian and endometrial cancer, but the overwhelm-
nancies seems ideal for surgical staging. Avoiding the ing similarities warrant them to be presented together.
morbidity associated with traditional laparotomy in The general outline of this chapter applies to the
the early-stage patient is the primary goal of the comprehensive laparoscopic staging of ovarian
laparoscopic staging procedure. Yet, this must be per- cancer. This laparoscopic staging procedure includes
formed without a loss of accuracy. The comparable a thorough survey of the abdomen and pelvis, bilat-
precision of the two approaches to staging has been eral pelvic and paraaortic lymph node dissections,
demonstrated in terms of lymph node counts in both an infracolic omentectomy, pelvic and peritoneal
humans and porcine models.5,6 Additional benefits to washings, random biopsies, a hysterectomy, and
the laparoscopic approach include decreased length bilateral salpingo-oophorectomy. For endometrial
of stay, overall costs, and postoperative adhesions.5–7 cancer, a similar procedure is conducted except
Recently, the results from the largest randomized trial that the paraaortic lymph node dissection is termi-
comparing traditional open surgery to laparoscopy for nated at the level of the inferior mesenteric artery
early-stage endometrial cancer has demonstrated instead of continuing to the level of insertion of the
improved quality of life in the initial 6-month post- ovarian veins, and an omentectomy is only performed
operative period.8 in selected cases. An omentectomy is indicated for
patients with serous or clear-cell histologic subtypes
The potential value of operative laparoscopy in the of endometrial cancer. Some practitioners perform
surgical staging of gynecologic malignancies has an omentectomy for any high-grade endometrioid
become apparent. Feasibility has been demonstrated endometrial cancer, as these tumors are part of the
and prospective randomized trials are now starting to spectrum of high-risk lesions that include serous and
153
154 Atlas of Procedures in Gynecologic Oncology
clear-cell histologies. The lymphadenectomy depicted peer-reviewed literature suggest a therapeutic advan-
in this chapter is the standard way that the authors tage to performing a complete lymphadenectomy in
perform a lymph node dissection for all early-stage patients with early-stage disease. Additionally, it is
ovarian and endometrial cancers. Some practitioners often less complicated to remove all lymphatic tissue,
may elect to perform a more limited lymph node rather than only selected packages, since these nodal
sampling; however, there are no specific criteria to packets are frequently adherent and laden with small
determine the adequacy of a lymph sampling vs blood vessels. Thus, a formal lymphadenectomy is
formal dissection. A number of reports in the demonstrated in this chapter.
5-12
5-12 5-12
5-12
a b
a b
Paraaortic lymphadenectomy.
2
3
1 – Aortic bifurcation
2 – Left common iliac artery Figure 11.9. Insertion of a gauze sponge.
3 – Right common iliac artery Prior to beginning the lymph node dissection, a radiopaque
Figure 11.8. Preparation of the paraaortic lymph node gauze sponge can be inserted into the abdominal cavity.
dissection. Unfolding the gauze completely will permit it to be placed
We typically perform the paraaortic dissection before the through a 10-mm trocar. It can be used to blot the
pelvic dissection since this is the more challenging portion operative field or to tamponade any bleeding in a similar
of the staging procedure. In preparation for the paraaortic fashion to that in which a laparotomy pad is used for open
lymph node dissection, the small bowel should be packed cases. It is important to keep track of these sponges, so that
into the left upper quadrant to expose the aortic one does not inadvertently remain in the patient
bifurcation. Meticulous packing of the bowel will facilitate postoperatively.
the dissection.
a b
a b
a b
a b
Figure 11.16. Removing interaortocaval lymph nodes. Figure 11.17. Beginning the left paraaortic dissection.
The interaortocaval lymph nodes are removed in similar The left-sided dissection can be more challenging. This is
fashion. They are grasped and elevated off the aorta. The in part due to the presence of the inferior mesenteric artery.
aorta is visualized, and the nodes are removed using a Prior to beginning, it is helpful to assure that the posterior
combination of blunt dissection and coagulation. The parietal peritoneum is well incised to allow for added
surgeon must be aware of the lumbar vessels and right mobility when retracting the sigmoid laterally. The left
renal artery which lie deep to the lymphatic tissue and ureter should initially be identified in similar fashion by
may be difficult to visualize. elevating all structures off the left psoas muscle. After
identifying the ureter, it can be retracted laterally away
from the nodal tissue.
a b
1 1
2
3
2
3
Figure 11.19. Superior aspect of the dissection. Figure 11.20. Removing the subaortic lymph nodes.
The lymph nodes should be removed to the level of the The subaortic lymph nodes can be removed using a similar
inferior mesenteric artery (IMA) for cases of endometrial technique. This nodal package overlies the left common
cancer. The IMA is usually surrounded by lymphatic tissue iliac vein. There may be some vascular connections to the
and should be cleared to unmistakably identify the IMA nodal package and, thus, this area must be approached
in order to avoid injuring this vessel, and to ensure that with caution. The lymph nodes should be fully freed from
the dissection is carried high enough. In cases of the vein to prevent tearing during nodal removal. The
ovarian cancer, the upper limit of the dissection is the dissection should be performed carefully so that the
left renal vein. underlying vascular structure is not punctured or lacerated.
Not being aware of this anatomic relationship can result in
serious injury to the left common iliac vein, resulting in
potential life-threatening hemorrhage.
a b
3
4
a b
Pelvic lymphadenectomy
Figure 11.24. Beginning the pelvic lymph node dissection.
The dissection for the laparoscopic staging procedure
1 begins with the pelvic lymph node dissection. We perform
these staging procedures with the argon-beam coagulator;
however, other forms of energy (bipolar, monopolar, and
2 ultrasonic) can be used. The pelvic lymph node dissection
begins by identifying the round ligament. This is grasped
3 with a forceps to tent the posterior leaf of the broad
ligament. A uterine manipulator may also be used to retract
4 the uterus and create tension on the broad ligament.
a b
1
2
a b
a b
1
2 2
3
3
a b
Figure 11.30. Removing nodal tissue from the external iliac vein.
After identifying the external iliac vein, the surrounding nodal tissue can be grasped and dissected free using the argon-
beam coagulator (a). Since the wall of the vein is pliable, it can easily be damaged if one is not careful during the
dissection. Additionally, carbon dioxide gas that has been used to insufflate the peritoneum often compresses the vein.
Care should be taken when using any form of energy around the delicate vascular structures (b).
a b
3
4
2
3
4
5
6
a b
a b
1 2
2 3
3 4
4
Laparoscopic omentectomy
a b
c
Figure 11.37. Freeing the transverse colon.
(a) The omentum is elevated and spread out to visualize the
posterior leaf and the transverse colon. (b) The posterior
leaf is incised to enter the lesser sac and separate the
omentum from the transverse colon. (c) The avascular
portion of the omental attachment to the transverse colon is
removed with the argon-beam coagulator (ABC) or similar
instrument. Other areas may be transected with the cautery,
but more energy will be required to adequately coagulate
the small blood vessels that course through the omentum.
The ABC should be activated a few millimeters away from
the colon, as some degree of thermal spread does occur.
170 Atlas of Procedures in Gynecologic Oncology
a b
c
Figure 11.38. Transecting the gastrocolic ligament.
Once the omentum has been freed from the transverse
colon, the gastrocolic ligament can be transected. This has
a rich anastomosis of blood vessels and should be
thoroughly cauterized. A number of different techniques
may be employed to divide the gastrocolic ligament.
(a) Ultrasonic energy can be used to sequentially coagulate
and cut across the gastrocolic ligament. (b) The ultrasound
waves cause the tissue to be desiccated, which not only
results in coagulation and cautery but also in the release of
water as a byproduct. (c) Alternatively, a vascular stapler or
vessel-sealing device that uses bipolar energy may be used
to transect the gastrocolic ligament, or to separate the
omentum from the transverse colon.
Laparoscopic staging procedures 171
1 – Right ovary
2 – Right infundibulopelvic ligament
3 – Right ureter
172 Atlas of Procedures in Gynecologic Oncology
a b
3
4
c d
1 – Right ovary
2 – Right fallopian tube
3 – Right infundibulopelvic ligament
4 – Window in medial leaf of broad ligament
5 – Right ureter
a b
a b
a b
a b
c
Figure 11.50. Circumscribing the vagina.
(a) An initial incision is made anteriorly in the vaginal
mucosa just below the level of the bladder. (b) The incision
is extended laterally in both directions. This can either be
performed with the electrocautery (as illustrated) or a
scalpel. (c) The incision is continued posteriorly until the
anterior and posterior incision meet. Once the initial
incision is made, it is carried through the endopelvic fascia
until a white and fibrous layer is reached. If the incision is
not made deep enough, difficulty will be encountered
while trying to enter the anterior or posterior cul-de-sac. To
facilitate the dissection and achieve a natural separation of
the tissue planes, strong traction is placed on the tenacula
and the vaginal retractors to create countertraction.
Laparoscopic staging procedures 177
a b c
a b
a b
References
1. Dargent D, Salvat J. L’Envahissement ganglionnaire 6. Lanvin D, Elhage A, Henry B et al. Accuracy and safety of
pelvien. Paris: McGraw-Hill, 1989. laparoscopic lymphadenectomy: an experimental
2. Querleu D, Leblanc E, Castelain B. Laparoscopic pelvic prospective randomized study. Gynecol Oncol
lymphadenectomy in the staging of early carcinoma of the 1997;67(1):83–7.
cervix. Am J Obstet Gynecol 1991;164(2):579–81. 7. Gemignani ML, Curtin JP, Zelmanovich J et al.
3. Childers JM, Surwit EA. Combined laparoscopic and Laparoscopic-assisted vaginal hysterectomy for
vaginal surgery for the management of two cases of endometrial cancer: clinical outcomes and hospital
stage I endometrial cancer. Gynecol Oncol charges. Gynecol Oncol 1999;73(1):5–11.
1992;45(1):46–51. 8. Kornblith A, Walker J, Huang H, Cella D. Quality of life
4. Querleu D, LeBlanc E. Laparoscopic infrarenal paraaortic (QOL) of patients in a randomized clinical trial of
lymph node dissection for restaging of carcinoma of the laparoscopy (scope) vs. open laparotomy (open) for the
ovary or fallopian tube. Cancer 1994;73(5):1467–71. surgical resection and staging of uterine cancer: a
5. Scribner DR Jr, Mannel RS, Walker JL, Johnson GA. Gynecologic Oncology Group (GOG) study. Presented at
Cost analysis of laparoscopy versus laparotomy for the Society of Gynecologic Oncologists 37th Annual
early endometrial cancer. Gynecol Oncol Meeting, Palm Springs, CA, March 22–26, 2006.
1999;75(3):460–3. Abstract #46.
12 Laparoscopic radical
hysterectomy
Douglas A Levine and Richard R Barakat
Laparoscopic radical hysterectomy is an alternative in 1992.8 Since that time many reports have appeared
method to radical hysterectomy via laparotomy for in the peer-reviewed literature regarding the outcomes
the treatment of early invasive cervical cancer and, to of patients undergoing laparoscopic radical hysterec-
a lesser extent, endometrial cancer. Patients with tomy for early invasive cervical cancer. One of the
Stage IA2 and IB1 cervical cancers should be treated largest series to date was published by Spirtos et al in
by radical hysterectomy and pelvic lymphadenec- 2002.9 They reported on 78 patients with Stage IA2 or
tomy with or without adjuvant radiation therapy IB cervical cancers who had negative paraaortic nodes,
based upon pathologic findings.1,2 Patients with Stage clinically normal pelvic nodes, and no evidence of
IA1 tumors and lymph–vascular space invasion (LVSI) extracervical disease. The operative time, estimated
should also undergo radical hysterectomy. The blood loss, and intraoperative complications compare
management of patients with Stage IB2 lesions is very favorably to reports on radical hysterectomy via
more controversial. Standard management had been laparotomy. A more recent report from China confirms
either radical hysterectomy or radiation therapy, with that this procedure can be performed safely.10 Whereas
the understanding that the two treatments were the identical surgical procedure can be performed
equally effective. With the discovery that chemoradi- laparoscopically, there are no randomized data to
ation is superior treatment for patients with cervical prove the equivalence of laparoscopic and open
cancer than radiation alone, there is a bias toward radical hysterectomy. Future studies will need to
chemoradiation for Stage IB2 lesions instead of radi- determine if this procedure results in the similarly
cal surgery.3 Nonetheless, chemoradiation has never high cure rates seen when early-stage cervical cancer
been directly compared to radical surgery for Stage is treated by conventional radical surgery. The recur-
IB2 tumors and definitive recommendations will have rence rates reported to date suggest that the two proce-
to await the results of randomized trials. Several dures have similar efficacy.
recent studies have reported that radical hysterec-
tomy for the treatment of Stage II endometrial cancer In this chapter, the technique of laparoscopic radical
is associated with improved long-term survival.4,5 hysterectomy will be described in detail. One of the
Radical hysterectomy should be considered for benefits for gynecologic oncologists wishing to learn
endometrial cancer patients with preoperatively these techniques is that the same procedure already
known cervical involvement. performed via laparotomy is tailored to laparoscopic
instrumentation. The laparoscopic procedure requires
The benefits of laparoscopic radical hysterectomy a mastery of the standard radical hysterectomy
instead of traditional radical hysterectomy reflect the followed by an adaptation to laparoscopic techniques
general benefits of laparoscopy. In particular, laparo- in order to accomplish the required surgical objec-
scopic procedures for gynecologic malignancies result tives. There are variations in technique, and illustrated
in decreased hospitalization, reduced blood loss, here is the use of the argon-beam coagulator for dissec-
faster recovery, diminished overall hospital charges, tion and hemostasis, along with the endoscopic stapler
and less postoperative pain.6,7 The additional magni- and hemostatic clips. The argon-beam coagulator is set
fication of the laparoscope can be useful when on 70 W of energy with a gas flow of 2–4 L/min. The
performing complex parts of the procedure, such as endoscopic stapler is always used with vascular loads,
ligating the uterine artery at its origin and dissecting and hemoclips can be placed with a 5- or 10-mm clip
the ureter from the parametrial tunnel. Nezhat et al applier. Other cautery instrumentation such as the
first described the laparoscopic radical hysterectomy LigaSure or ultrasonic energy devices can also be used.
181
182 Atlas of Procedures in Gynecologic Oncology
As mentioned above, this procedure is intended for would be for any woman undergoing a hysterectomy
patients with early invasive cervical cancer (Stage IA1 for benign indications. However, recent reports sug-
with LVSI, Stage IA2, and Stage IB1). The treatment of gest a higher incidence of ovarian metastases in
Stage IB2 lesions is controversial and a full discus- women with adenocarcinoma of the uterine cervix. In
sion, outside of what has already been mentioned, is these cases, the benefits of oophorectomy must be
beyond the scope of this text. Large lesions may be carefully weighed against the risks.13,14 If the ovaries
difficult to extract while following the strict principles are left in situ, they may be transposed out of the pel-
of cancer surgery. Gross lesions <2 cm in greatest vis in an attempt to reduce the exposure to postopera-
dimension should be readily amenable to tive radiation. However, only 40–50% of patients who
laparoscopic radical hysterectomy, but larger lesions undergo ovarian transposition and receive postopera-
should be carefully evaluated for resectability via the tive radiation therapy retain ovarian function.15,16
laparoscopic approach. An abdominal procedure may Approximately 20% of patients with transposed ova-
be more successful for patients with large lesions or ries will require additional surgery to manage symp-
lesions involving the upper vagina. The laparoscopic tomatic adnexal masses.17,18 Furthermore, in those
procedure may be contraindicated in patients with patients who underwent ovarian transposition and
severe pulmonary disease or other co-morbid condi- did not receive postoperative radiation therapy, the
tions in which steep Trendelenburg position, increased average age of menopause occurred 5 years earlier.
intraabdominal pressure, or extended operative time Therefore, the decision to perform ovarian transposi-
would not be well tolerated. Other relative contraindi- tion should be carefully considered as it does not pro-
cations to laparoscopy include multiple prior abdom- tect ovarian function after radiation in the majority of
inal procedures, previous pelvic irradiation, abdominal patients, can increase the risk for subsequent adnexal
wall defects, or bleeding diatheses. There are no weight surgery, and can reduce overall endocrine function.
restrictions for performing a laparoscopic radical Finally, it was once thought that pelvic drains should
hysterectomy, but many practitioners will not offer be placed at the time of radical hysterectomy. Multiple
this approach to patients with a Quetelet index >35. studies have established that pelvic drains do not
alter the incidence of postoperative lymphocyst
The management of the ovaries at the time of radical formation.19,20 In fact, febrile morbidity may actually
hysterectomy has been the subject of many reports. be increased in patients who have had pelvic drains
The incidence of ovarian metastases is low enough placed. Standard practice does not include the place-
that oophorectomy is not a standard part of the ment of pelvic drains to reduce lymphocyst formation
procedure.11,12 The ovaries should be managed as they or febrile morbidity.
Laparoscopic radical hysterectomy 183
Cystoscopy
a b
a b
1
2
a b
1 1
2
2
3
4
5
a b
Pelvic lymphadenectomy
a b
a b
a b
c
Figure 12.12. External iliac lymph nodes.
Additional nodes are removed along the external iliac artery
and vein as described. (a) Nodal tissue being removed from
the right external iliac artery. (b) Lymphatic tissue being
removed from the left external iliac artery. In contrast with
adipose tissue, the nodal tissue is more ‘sticky’ and does not
come away from the vessels as easily. Blunt dissection alone
will lead to bleeding from small perforating vessels and
result in unnecessary leakage of lymphatic fluid. This can
result in postoperative lymphocyst formation. (c) Thus,
coagulation or hemostatic clips should be used as part of
the lymph node dissection to minimize bleeding and
lymphatic leakage. Generally, coagulation is used for small
perforators and clips are reserved for larger pedicles.
a b
1 1
2
a b
1 1
3
3
4
a b
1
2
a b
2 1
3
2
a b
c
Figure 12.17. Obturator lymph nodes.
Obturator lymphatic tissue is grasped with a forceps and
elevated. Blunt dissection is used initially until the
obturator nerve is clearly identified. The nodes are not
cauterized or transected until the nerve is readily apparent.
(a, b) The nodal tissue is dissected bluntly since the nerve
has not yet been seen. (c) The nerve has been visualized
and cautery can be carefully used to transect the base of
the nodal packet. Typically, the obturator fossa will yield a
greater number of lymph nodes than the external iliac
dissection.
Laparoscopic radical hysterectomy 191
a b
2
1
3 2
4
a b
a b
1
2
4
5
6
a b
2
3
a b
1 1
2 2
a b
Uterosacral ligament
a b
1
2
a b
a b
2
2
a b
1
2
Parametrial dissection
1
a b
c d
Specimen removal
Figure 12.36. Preparing the vagina.
Once the bladder has been fully mobilized and the ureters
are directly entering the bladder, the vagina is ready to be
incised. A rectal probe or similar device (i.e. sponge stick,
ColpoProbe) is placed into the vagina to provide traction
and distend the vaginal tube. The anterior wall of the
vagina is displaced ventrally with the vaginal/rectal probe
in preparation for the vaginal incision.
a b
1 – Right ureter
2 – Inferior vena cava Figure 1.59. Left peritoneal incision.
3 – Right common iliac artery
The left paraaortic lymph nodes can be approached
Figure 1.58. Low paraaortic nodal dissection. laterally or medially. More commonly in laparoscopy, the
The lower right paraaortic nodes have been removed to the left side is approached by extending the peritoneal incision
level of the inferior mesenteric artery, seen later. This level for the right-sided dissection across the midline, superiorly
of dissection provides an adequate sampling for patients and inferiorly. At laparotomy, a lateral approach is often
with endometrial cancer. For ovarian cancer, the lymphatic more simple due to the origin of the inferior mesenteric
drainage follows the course of the ovarian veins, and nodal artery from the left anterior aspect of the aorta. The lateral
sampling needs to be continued to the renal vessels. The approach can be performed as a continuation of the
ureter is retracted laterally from the vena cava and aorta. left-sided pelvic node dissection or de novo lateral to the
sigmoid colon.
200 Atlas of Procedures in Gynecologic Oncology
a b
a b
a b
c
Figure 12.41. Specimen removal.
The specimen is grasped by the cervix or lower uterine
segment with a laparoscopic forceps. (a) The cervical os is
seen rotated toward the laparoscope. (b) The second
assistant, who stands between the patient’s legs, places a
single-tooth tenaculum through the vagina. (c) The
specimen is then grasped at or near the cervix and drawn
through the vagina. Once removed, the specimen is sent
for routine pathologic analysis. Frozen section is not
necessary unless there is concern for a close vaginal
margin, and an additional portion of the upper vagina
could be resected if need be.
202 Atlas of Procedures in Gynecologic Oncology
a b
c d
a b
d
Figure 12.44. Tying the first knot.
Passing the suture through the slipknot that was made
extracorporeally creates the first knot. The slipknot is
grasped with a forceps (a) and the needle is placed through
the loop in the suture (b). After being brought through the
loop, it is cinched down by pulling on the free end of the
suture (c).
204 Atlas of Procedures in Gynecologic Oncology
a b
c d
a b
a b
1
2 1
1 – Suture that has been passed through the vaginal cuff 1 – Suture that has been rotated over the empty jaw of
2 – Suture being held to create a loop the EndoStitch
a b
c
Figure 12.48. Passing the suture.
(a, b) The loop is then brought in between the jaws of the
instrument and the needle is passed beneath the suture
loop. (c) The needle is then withdrawn on the other side
and brought out through an internal loop, which creates a
flat knot.
a b
1 – Vaginal cuff
2 – Left ureter
Figure 12.50. Irrigation. 3 – Right ureter
At the completion of the procedure, the pelvis is copiously 4 – Right ovary
irrigated and suctioned to assess hemostasis. All vascular
pedicles are closely examined and hemostasis may be Figure 12.51. Completed procedure.
achieved with a combination of coagulation, hemostatic Both ureters can be seen directly entering the urinary
clips, and sutures as necessary. bladder, and the vaginal cuff has been closed
laparoscopically. If the ovaries have not been removed,
they are restored to their normal anatomic location and
may be sutured to the pelvic peritoneum at the discretion
of the operator. Some practitioners will transpose the
ovaries out of the pelvis in a premenopausal patient, but
this decision should be individualized as discussed
previously.
Laparoscopic radical hysterectomy 207
a b
References
1. Sedlis A, Bundy BN, Rotman MZ et al. A randomized trial 8. Nezhat CR, Burrell MO, Nezhat FR et al. Laparoscopic
of pelvic radiation therapy versus no further therapy in radical hysterectomy with paraaortic and pelvic node
selected patients with stage IB carcinoma of the cervix dissection. Am J Obstet Gynecol 1992;166:864–5.
after radical hysterectomy and pelvic lymphadenectomy: a 9. Spirtos NM, Eisenkop SM, Schlaerth JB, Ballon SC.
Gynecologic Oncology Group Study. Gynecol Oncol Laparoscopic radical hysterectomy (type III) with
1999;73:177–83. aortic and pelvic lymphadenectomy in patients with
2. Peters WA 3rd, Liu PY, Barrett RJ 2nd et al. Concurrent stage I cervical cancer: surgical morbidity and
chemotherapy and pelvic radiation therapy compared with intermediate follow-up. Am J Obstet Gynecol 2002;
pelvic radiation therapy alone as adjuvant therapy after 187:340–8.
radical surgery in high-risk early-stage cancer of the 10. Xu H, Chen Y, Li Y et al. Complications of laparoscopic
cervix. J Clin Oncol 2000;18:1606–13. radical hysterectomy and lymphadenectomy for invasive
3. Keys HM, Bundy BN, Stehman FB et al. Cisplatin, cervical cancer: experience based on 317 procedures. Surg
radiation, and adjuvant hysterectomy compared with Endosc 2007;21:960–4.
radiation and adjuvant hysterectomy for bulky stage IB 11. Sutton GP, Bundy BN, Delgado G et al. Ovarian metastases
cervical carcinoma. N Engl J Med 1999;340:1154–61. in stage IB carcinoma of the cervix: a Gynecologic
4. Mariani A, Webb MJ, Keeney GL et al. Role of wide/radical Oncology Group study. Am J Obstet Gynecol 1992;
hysterectomy and pelvic lymph node dissection in 166:50–3.
endometrial cancer with cervical involvement. Gynecol 12. Natsume N, Aoki Y, Kase H et al. Ovarian metastasis in
Oncol 2001;83:72–80. stage IB and II cervical adenocarcinoma. Gynecol Oncol
5. Sartori E, Gadducci A, Landoni F et al. Clinical behavior 1999;74:255–8.
of 203 stage II endometrial cancer cases: the impact of 13. Landoni F, Zanagnolo V, Lovato-Diaz L et al; Cooperative
primary surgical approach and of adjuvant radiation Task Force. Ovarian metastases in early-stage cervical
therapy. Int J Gynecol Cancer 2001;11:430–7. cancer (IA2-IIA): a multicenter retrospective study of 1965
6. Gemignani ML, Curtin JP, Zelmanovich J et al. patients (a Cooperative Task Force study). Int J Gynecol
Laparoscopic-assisted vaginal hysterectomy for endometrial Cancer 2007;17:623–8.
cancer: clinical outcomes and hospital charges. Gynecol 14. Shimada M, Kigawa J, Nishimura R et al. Ovarian
Oncol 1999;73:5–11. metastasis in carcinoma of the uterine cervix. Gynecol
7. Malur S, Possover M, Michels W, Schneider A. Oncol 2006; 101:234–7.
Laparoscopic-assisted vaginal versus abdominal surgery in 15. Feeney DD, Moore DH, Look KY et al. The fate of the
patients with endometrial cancer – a prospective ovaries after radical hysterectomy and ovarian
randomized trial. Gynecol Oncol 2001;80:239–44. transposition. Gynecol Oncol 1995;56:3–7.
208 Atlas of Procedures in Gynecologic Oncology
16. Buekers TE, Anderson B, Sorosky JI, Buller RE. Ovarian 19. Jensen JK, Lucci JA 3rd, DiSaia PJ et al. To drain or
function after surgical treatment for cervical cancer. not to drain: a retrospective study of closed-suction
Gynecol Oncol 2001;80:85–8. drainage following radical hysterectomy with
17. Chambers SK, Chambers JT, Holm C et al. Sequelae of pelvic lymphadenectomy. Gynecol Oncol 1993;
lateral ovarian transposition in unirradiated cervical 51:46–9.
cancer patients. Gynecol Oncol 1990;39:155–9. 20. Lopes AD, Hall JR, Monaghan JM. Drainage following
18. Anderson B, LaPolla J, Turner D et al. Ovarian transposition radical hysterectomy and pelvic lymphadenectomy:
in cervical cancer. Gynecol Oncol 1993;49:206–14. dogma or need? Obstet Gynecol 1995;86:960–3.
13 Laparoscopically assisted
vaginal radical hysterectomy
Michel Roy, Marie Plante, and Marie-Claude Renaud
The vaginal radical hysterectomy was first described an abdominal incision, shorter hospital stay, and
by Schauta1 at the beginning of the 20th century. It lower morbidity.5 Studies have shown that the
had the advantage of a significantly lower mortality specimen removed after an LAVRH is satisfactory.
rate than the abdominal radical hysterectomy Furthermore, if positive lymph nodes are identified
championed by Wertheim; however, a few years later, at laparoscopy, one has the option of offering
Wertheim2 reported a better survival rate with his patients combined chemotherapy and radiation ther-
abdominal approach. Thus, the vaginal route fell into apy without having submitted them to a major laparo-
disfavor. In the 1940s, pelvic lymphadenectomy tomy. Lastly, and perhaps more importantly, since
became part of the standard of care in the surgical there is a definite learning curve before one becomes
treatment of cervical cancer. Obviously, the vaginal comfortable with vaginal radical surgery,6 the skills
approach alone could not accommodate that new gained in LAVRH help the surgeon to offer selected
standard. This changed when Mitra3 proposed the use young patients the more conservative fertility-
of bilateral flank incisions to perform a retroperito- preserving vaginal radical trachelectomy,7,8 which is a
neal lymph node dissection, followed by the vaginal modification of the Schauta–Amreich procedure (see
radical hysterectomy. However, the technique was Chapter 14). In this chapter, we will review the
more complicated than the abdominal approach alone technique for LAVRH.
and was not esthetically appealing; therefore, it did not
gain popularity in North America. With the subsequent Vaginal radical surgery requires the surgeon to master
development of laparoscopic techniques to perform a laparoscopic surgery in order to conduct a complete
complete pelvic and paraaortic lymph node dissection,4 laparoscopic lymph node dissection. At the comple-
and the experience of vaginal surgery specialists, tion of the lymphadenectomy, the paravesical and
particularly Professor Daniel Dargent in France, the pararectal spaces are defined laparoscopically. This
Schauta operation suddenly enjoys a renewed interest dissection is helpful to facilitate the transection of the
in the gynecologic oncology community and has uterine artery, after clipping or cauterization, at its
regained acceptance as an attractive and efficient origin from the internal iliac artery. The distal para-
alternative to the standard abdominal approach. metrial tissue, potentially bearing lymph nodes, is also
removed to reduce the extent of the parametrectomy
Advantages of the laparoscopically assisted vaginal required vaginally.
radical hysterectomy (LAVRH) include the absence of
209
210 Atlas of Procedures in Gynecologic Oncology
Laparoscopic preparation
1
2
3
4
5
6
7
8
1 – Obliterated left umbilical artery Figure 13.2. Laparoscopic ligation of the uterine artery.
2 – Left paravesical space The uterine artery is transected at its origin from the
3 – Left external iliac vessels internal iliac artery. This can be performed with bipolar
4 – Left superior vesical artery
electrocautery (as shown in the figure), hemoclips, staplers,
5 – Left obturator nerve
or suture ligatures.
6 – Left uterine artery
7 – Left internal iliac artery
8 – Left pararectal space
1
2 1
2
3
3
4
4 5
6
1 – Left obturator nerve 3 – Left obturator artery 1 – Left obturator nerve 4 – Left ureter
2 – Parametrium 4 – Left internal iliac artery, 2 – Left obturator artery 5 – Left internal iliac artery
retracted medially 3 – Left uterine artery 6 – Left external iliac artery
4
1
1 – Bladder
2 – Uterus
3 – Parametrium
4 – Ureter
5 – Uterine artery
a b
Figure 13.11. Incision of the vaginal mucosa – lateral Figure 13.12. Closing the vaginal cuff.
incision. Chrobak clamps (Lépine, France), applied side by side, are
The incision is made only superficially through the lateral used to close the vaginal cuff in front of the cervix. This
vaginal mucosa, so as not to enter the underlying tissues. A maintains important anatomic relationships and assists with
sidewall retractor toed in laterally is useful to retract the the en-bloc removal of the specimen.
vaginal mucosa as it is incised.
214 Atlas of Procedures in Gynecologic Oncology
Pelvic spaces
1 – Vesicouterine space
2
3 1 – Vesicouterine space
Triangle – Area of entry
1
2 2
1 – Right ureter
2 – Posterior bladder pillars Figure 13.23. Posterior bladder pillars.
Figure 13.22. Mobilization of the ureter. The remaining posterior and anterior attachments are
Mobilization upwards of the ureter is accomplished by transected, enabling the surgeon to elevate the ureter
grabbing the base of the bladder and the distal portion of outside the parametrium. Medial and superior dissection of
the ureter with a Babcock clamp. Placing this connective the ureter should be avoided because of the risk of injury to
tissue on tension exposes the posterior bladder pillars. the bladder base.
Without releasing these attachments, further mobility of the
ureter is limited.
Laparoscopically assisted vaginal radical hysterectomy 217
1 1
2
2
1 – Right ureter
1 – Right ureter 2 – Right uterine artery
2 – Right uterine artery
Figure 13.25. Manipulation of the uterine artery.
Figure 13.24. Identification of the uterine artery. Gentle traction can be placed on the uterine artery with a
After the posterior fibers are fully transected, the uterine small clamp or other instrument in order to gain additional
artery can be visualized beneath the knee of the ureter. mobility. This will help to ultimately transect the uterine
artery as close to its origin as possible. Often, remaining
fibers between the ureter and the parametria can be
identified and transected.
Parametrium
Figure 13.27. Opening of the pouch of Douglas. Figure 13.28. Excision of the paracolpos.
After both ureters have been dissected and pushed up, the The connective tissue between the vaginal mucosa and
peritoneum is entered by opening the posterior cul-de-sac lower part of the cervix, the paracolpos, is clamped,
with scissors while the uterus is pulled upwards. transected, and suture ligated.
1 – Right ureter
2 – Second clamp
3 – First clamp
1 – Anterior peritoneum
References
1. Schauta F. Die erwierte vaginale totalexstirpation des 6. Sardi J, Vidaurreta J, Bermudez A, Di Paola G.
uterus beim kollumkarzinome. Vienna-Leipzig: Laparoscopically assisted Schauta operation: learning
J. Safar, 1908. experience at the Gynecologic Oncology Unit, Buenos
2. Werteim E. Die erweirte abdominale Operation bei Aires University Hospital. Gynecol Oncol 1999;75:361–5.
Carcinoma Colli Uteri. Berlin: Urban and 7. Roy M, Plante M, Renaud MC, Tetu B. Vaginal radical
Schwarzenberg, 1911. hysterectomy versus abdominal radical hysterectomy in
3. Mitra S. Extraperitoneal lymphadenectomy and radical the treatment of early-stage cervical cancer. Gynecol Oncol
vaginal hysterectomy for cancer of the cervix (Mitra 1996;62:336–9.
technique). Am J Obstet Gynecol 1959;78:191–6. 8. Roy M, Plante M. Pregnancies after radical vaginal
4. Possover M, Krause N, Plaul K et al. Laparoscopic trachelectomy for early-stage cervical cancer. Am J Obstet
paraaortic and pelvic lymphadenectomy: experience with Gynecol 1998;179:1491–6.
150 patients and review of the literature. Gynecol Oncol 9. Plante M, Roy M. Radical vaginal trachelectomy.
1998;71:19–28. In: Smith JR, Del Priore G, Curtin J, Monaghan JM (eds).
5. Dargent D, Kouakou F, Adeleine P. L’opération de Schauta An atlas of gynecologic oncology, investigation and
90 ans après. Lyon Chir 1991;87:323–9. surgery. London: Martin Dunitz, 2001.
14 Vaginal radical
trachelectomy
Marie Plante, Marie-Claude Renaud, Yukio Sonoda, and Michel Roy
221
222 Atlas of Procedures in Gynecologic Oncology
aPersonal communication.
T-1, first trimester; T-2, second trimester; T-3, third trimester; TAB, therapeutic abortion.
Vaginal radical trachelectomy 223
Figure 14.3. Marking of 12 o’clock. Figure 14.4. Incision of the vaginal mucosa.
A small vertical incision is made with the scalpel A circumferential incision is made with the scalpel just
at 12 o’clock as a landmark for future reference. This helps above the Kocher clamps. The mucosa and submucosal
to maintain proper orientation throughout the procedure. layers are incised, but care is taken not to go too deep to
avoid tearing the mucosa.
224 Atlas of Procedures in Gynecologic Oncology
1 – Vesicovaginal space
2
(b)
3
1
(a) 2
4
(c)
1 – Bladder pillars
2 – Left paravesical space
Figure 14.12. Palpation of the left ureter.
Figure 14.11. Opening the left paravesical space.
Pulling the Chrobak clamps to the right side of the patient,
If entered correctly, the space should be avascular and the
the surgeon’s left index finger is placed in the vesicovaginal
scissors should slide inside easily. Once entered, the space
space while a Breisky retractor (or the back of a forceps) is
is widened by rotating the scissors under the pubic bone in
placed in the left paravesical space. By pulling downward
a semicircular rotating motion to the patient’s contralateral
and pressing the finger and instrument together, the
side (not shown).
surgeon should feel the characteristic snap of the ureter
rolling under the finger. This maneuver orients the surgeon
to the location of the ureter in relation to the bladder
pillars.
226 Atlas of Procedures in Gynecologic Oncology
2
3
1 1
2
3
2
1 – Left ureter
2 – Babcock clamp
1
2
1 – Cervix
2 – Left paracolpos
Figure 14.18. Opening the posterior cul-de-sac. Figure 14.19. Excision of the left paracolpos.
The Chrobak clamps are sharply angulated anteriorly and With the Chrobak clamps rotated to the right, the left
the posterior cul-de-sac is opened using Metzenbaum paracolpos is clamped using a curved Heaney
scissors. clamp, excised and suture ligated with 2–0 Vicryl
(polyglactin 910).
228 Atlas of Procedures in Gynecologic Oncology
1
1
2
1 – Cervix
2 – Left uterosacral ligament
1 – Cervix
2 – Left pararectal space Figure 14.21. Excision of the left uterosacral ligament.
The proximal part of the left uterosacral ligament is
Figure 14.20. Opening the left pararectal space. clamped with a curved Heaney clamp, excised, and suture
Metzenbaum scissors are used to open the left pararectal ligated with 2–0 Vicryl (polyglactin 910). The identical
space, which is located lateral to the peritoneum and procedure is then performed on the patient’s right side.
medial to the uterosacral ligament, not yet seen.
1
2
2
3
1
2
1 – Uterine isthmus
2 – Right uterine artery
3 – Endocervix
4 – Right and left parametrium
230 Atlas of Procedures in Gynecologic Oncology
2 2
Figure 14.26. Transection of the cervix. Figure 14.27. Excision of the trachelectomy specimen.
The cervix is amputated with a scalpel held perpendicular As the specimen is excised, the cervical os appears. Care is
to the specimen about 1 cm distal to the isthmus. taken not to angulate the scalpel in order to avoid
removing too much cervix posteriorly.
1 – Endocervix
2 – Left parametrium
3 – Right parametrium
4 – Vaginal mucosa
Vaginal radical trachelectomy 231
1 – Cervix
2 – Posterior cul-de-sac
3 – Posterior peritoneum
a b
1 – Cervix
2 – Posterior isthmus
1 – Uterine probe
2 – Cervical os
3 – Cerclage suture
1
1
2 2
Figure 14.33. Anterior vaginal closure. Figure 14.34. Lateral vaginal closure.
Starting anteriorly, the edges of the vaginal mucosa are Laterally, due to the excess vaginal mucosa, it is preferable
sutured to the residual exocervical stroma with interrupted to place a separate figure-of-eight suture through the
figures-of-eight sutures using 2–0 Vicryl (polyglactin 910). vaginal mucosa only. Then, a separate suture is placed to
Sutures should not be placed too close to the new cervical reapproximate the vaginal mucosa to the new exocervix.
os in order to avoid burying the cervix, which may make
follow-up examinations more difficult.
Vaginal radical trachelectomy 233
1
2
1 – Vaginal mucosa
2 – Cervix
3 – Lateral vaginal suture Figure 14.36. Posterior vaginal closure.
The vaginal closure is completed posteriorly in a similar
Figure 14.35. Contralateral vaginal closure. fashion. If needed, additional sutures can be placed in
An identical procedure is performed on the opposite side. between the previous ones. Sometimes, excess vaginal
Beginning laterally, the vaginal mucosal sutures are placed. mucosa may need to be removed with cautery to facilitate
The anterior vaginal mucosa is then sutured to the new the closure (not shown here).
exocervix.
Figure 14.38. Trachelectomy procedure. Figure 14.39. Trachelectomy specimen – anterior view.
The procedure is conducted in a similar fashion for the The anterior/exocervical aspect of the specimen
patient with a macroscopic lesion. Here, it is equally demonstrates the cervix with an exophytic lesion and a rim
important to completely cover the cervix during the of vaginal mucosa.
preparatory phase in order to minimize the risk of tumor
dissemination. The cervix of a patient with a macroscopic
exocervical squamous lesion confirmed by a cervical
biopsy is shown.
1
2
3
1
1.3 cm
3
4
Conclusion
Based on the available oncologic and obstetrical out-
comes, the vaginal radical trachelectomy procedure is
considered a valuable fertility-preserving alternative
for young women with early-stage cervical cancer.
References
1. Plante M. Fertility preservation in the management of radical hysterectomy (LARVH). Gynecol Oncol
gynecologic cancers. Curr Opin Oncol 2000;12:497–507. 2007;106:132–41.
2. Dargent D, Brun JL, Roy M, Mathevet P, Remy I. La 7. Plante M, Renaud MC, Harel F, Roy M. Vaginal radical
trachélectomie élargie (T.E.). Une alternative à trachelectomy: an oncologically safe fertility-preserving
l’hystérectomie radicale dans le traitement des cancers surgery. An updated series of 72 cases and review of the
infiltrants développés sur la face externe du col utérin. literature. Gynecol Oncol 2004;94:614–23.
J Obstet Gynecol 1994;2:285–92. 8. Hertel H, Köhler C, Grund D et al; German Association of
3. Sahdev A, Sohaib SA, Wenaden AE, Shepherd JH, Gynecologic Oncologists (AGO). Radical vaginal
Reznek RH. The performance of magnetic resonance trachelectomy (RVT) combined with laparoscopic pelvic
imaging in early cervical carcinoma: a long-term lymphadenectomy: prospective multicenter study of 100
experience. Int J Gynecol Cancer 2007;17:629–36. patients with early cervical cancer. Gynecol Oncol
4. Plante M, Lau S, Brydon L et al. Neoadjuvant 2006;103:506–11.
chemotherapy followed by vaginal radical trachelectomy 9. Covens A. Preserving fertility in early cervical cancer with
in bulky stage IB1 cervical cancer: case report. radical trachelectomy. Contemp Ob Gyn 2004;2:460–6.
Gynecol Oncol 2006;101:367–70. 10. Alexander-Sefre F, Chee N, Spencer C, Menon U,
5. Shepherd JH, Spencer C, Herod J, Ind TE. Radical vaginal Shepherd JH. Surgical morbidity associated with radical
trachelectomy as a fertility-sparing procedure in women trachelectomy and radical hysterectomy. Gynecol Oncol
with early-stage cervical cancer-cumulative pregnancy rate 2006;101:450–4.
in a series of 123 women. BJOG 2006;113:719–24. 11. Plante M, Renaud MC, Hoskins IA, Roy M. Vaginal radical
6. Marchiole P, Benchaib M, Buenerd A et al. Oncological trachelectomy: a valuable fertility-preserving option in the
safety of laparoscopic-assisted vaginal radical management of early-stage cervical cancer. A series of 50
trachelectomy (LARVT or Dargent’s operation): a pregnancies and review of the literature. Gynecol Oncol
comparative study with laparoscopic-assisted vaginal 2005;98:3–10.
15 Second-look laparoscopy
with intraperitoneal
catheter placement
Christopher S Awtrey and Nadeem R Abu-Rustum
A common approach to the patient with advanced disease. Hoskins et al reported that complete resection
epithelial ovarian cancer involves initial staging of visible disease at the time of second-look laparo-
and attempted optimal cytoreduction followed by tomy was associated with an improved survival.3
platinum-based chemotherapy. For most patients Laparoscopy appears to be an acceptable alternative
with advanced-stage epithelial ovarian cancer this to laparotomy and is associated with less morbidity,
approach leads to a period of clinical remission or, shorter operating time, shorter hospital stay, and
for a minority, complete cure of disease. Physicians lower hospital charges.4 With current technology, lap-
monitor patients for disease recurrence by clinical aroscopy should not be associated with a decreased
examination, imaging studies, and tumor markers. sensitivity of the procedure.4,5
Even in combination, these are not always highly
sensitive for disease persistence or recurrence. The The second-look procedure can be divided into three
ability to detect tumor deposits <1 cm with currently separate components. As with the initial surgical
utilized techniques, such as computed tomography evaluation, the first step is abdominal entry, restora-
(CT), sonography, and magnetic resonance imaging tion of normal anatomy, and evaluation of the perito-
(MRI), are limited.1 Furthermore, tumor markers that neal cavity. Unlike primary evaluation, adhesions
are initially elevated and normalize after primary often markedly hinder this process. Indeed, in some
therapy do not always guarantee a biopsy-proven cases the adhesions can be so dense that incidental
remission. In patients with no clinical evidence of enterotomy may occur upon attempted abdominal
tumor after primary surgery and adjuvant chemother- entry. Adhesions can be due to either postoperative
apy, persistent disease is noted in 60% of surgically changes or to microscopic tumor deposits. Biopsies
evaluated patients.2 A secondary surgical evaluation should be taken from the adhesions and sent for
is the most accurate method for assessing the status of pathologic evaluation. Upon abdominal entry, wash-
disease. ings are also taken to be assessed for microscopic
cytologic evidence of disease.
A second-look laparotomy is defined as a compre-
hensive diagnostic surgical evaluation performed in Evaluation of the abdominal cavity involves visual-
patients with a history of epithelial ovarian cancer izing and palpating the bowel and its mesentery, the
who are deemed clinically free of disease by physical liver edge and diaphragmatic surfaces, as well as the
examination, imaging studies, and tumor markers. pelvic peritoneal surfaces. If there is no evidence of
The procedure consists of a thorough evaluation of disease, the second portion of the procedure is to
the peritoneal cavity and obtaining biopsies of any obtain multiple random biopsies from these perito-
suspicious nodules or adhesions. In the absence of neal surfaces. The paracolic gutters, diaphragmatic
gross disease, biopsies and washings of normal- surfaces, entire abdominopelvic peritoneum, and
appearing surfaces are taken in a systematic manner to remaining omentum are all biopsied. The third
be evaluated for microscopic involvement. The proce- portion of the procedure is to evaluate the nodal
dure also permits resection of any gross disease and basins. Again, this is done by palpation and biopsy
the placement of an intraperitoneal catheter to infuse from the pelvic and paraaortic regions. In general,
chemotherapy as consolidation treatment in patients patients who had advanced disease and did not
who have no evidence or microscopic evidence of undergo lymph node sampling at the time of initial
237
238 Atlas of Procedures in Gynecologic Oncology
cytoreductive surgery are candidates for lymph node recurrent disease, several consolidation strategies have
sampling at the time of second-look laparoscopy. been designed to improve survival. Intraperitoneal
(IP) chemotherapy offers many theoretical advantages
The substitution of video laparoscopy for laparotomy over intravenously administered agents, including
clearly benefits the patient with respect to postopera- the ability to deliver extremely high concentrations of
tive recovery; however, it does present the surgical drug to the IP compartment. Barakat et al recently
team with a unique set of challenges. Due to the high described the long-term follow-up of patients
frequency of intestinal adhesions to the previous treated at Memorial Hospital with IP chemotherapy.6
midline abdominal incision, blind introduction of a Patients treated with IP therapy after a negative
Veress needle in the periumbilical area is dangerous. second-look evaluation had a median survival of
The preferred method of abdominal entry is an open 8.7 years, and in those with microscopic disease
laparoscopic technique, away from the prior incision the median survival was 4.8 years. Although never
site. This reduces, but does not eliminate, the risk of studied in a prospective randomized manner, the use
bowel injury upon entry. A shortcoming with the of IP chemotherapy as a consolidation technique
application of minimally invasive techniques to this appears promising. Placement of the IP catheter at
procedure is the limited tactile sensation available to the time of second-look laparoscopy is simple and
palpate the peritoneal and diaphragmatic surfaces safe. The criteria for placing an IP port at the time of
and nodal basins. To a certain extent, this can be second look include a lack of significant adhesions,
overcome by close visual inspection with the laparo- so as not to interfere with IP drug distribution, and
scope and use of a straight, blunt probe. For the patient disease of no greater than 5 mm in any dimension.
needing nodal sampling, this is performed in the same The use of laparoscopy in second-look procedures is
manner as in an open procedure. Laparoscopic lymph likely to expand as gynecologic oncologists become
node sampling is described elsewhere in this text. more familiar and comfortable with these techniques.
Moreover, minimally invasive technology continues
Since approximately half of the patients found to be to advance, and operative gynecologic oncology will
disease free at second-look evaluation go on to develop benefit from these developments.
Second-look laparoscopy with intraperitoneal catheter placement 239
c
Figure 15.1. Open laparoscopy.
The procedure begins by placing a Hassan cannula via the
open technique. Abdominal access is typically obtained
through a periumbilical incision; however, an alternative
location is chosen if it is distant from the previous
abdominal scar. (a, b) After the incision in the skin is made,
dissection is carried down to the level of the fascia with
narrow curved retractors. Once the fascia is identified, it is
grasped and incised. The peritoneum is then entered under
direct vision. (c) After the intraabdominal location is
confirmed with the laparoscope, two stay sutures are
placed through the fascia and secured to the cannula.
a b
c
Figure 15.3. Washings.
With the patient in steep Trendelenburg position, the bowel
is mobilized out of the pelvis. Copious irrigation is used in
a systematic fashion, starting from the pelvis and working
clockwise along the peritoneal surfaces. Important areas to
include are (a) the pelvis, (b) bilateral paracolic gutters, and
(c) bilateral diaphragmatic surfaces. Washings may be
sampled separately from each of these surfaces or
combined together, as long as all sites have been included.
The washings are collected into a trap attached to the
suction tubing.
a b
c
Figure 15.9. Hemostasis.
Dense adhesions may contain moderate-sized blood
vessels. If bleeding is encountered, several techniques can
be used to obtain hemostasis, including coagulation,
sutures, or clips. (a) Bleeding is seen coming from the site of
a dense omental adhesion. (b) The bleeding vessel is
grasped with a forceps and the clip applier is introduced
through a 5-mm trocar. (c) The clip is then applied to
control the bleeding. Suction and irrigation are used as
needed to clear the surfaces of blood and to look for
additional sites of bleeding.
a b
a b
a b
c d
a b
a b
c
Figure 15.17. Subcutaneous tunneling.
(a) A long fine-tipped clamp is advanced from the pocket
inferiorly through the subcutaneous tissues to the lower
quadrant port site. The tip of the clamp should be oriented
superiorly to assist in grasping the catheter. If a suitable
clamp is not available, a laparoscopic grasper may be used
as an alternative. (b) Once the lower quadrant port site is
reached with the tip of the clamp, the end of the catheter is
securely grasped. (c) The catheter is then pulled through
the subcutaneous tunnel.
246 Atlas of Procedures in Gynecologic Oncology
Figure 15.18. Connecting the reservoir. Figure 15.19. Inserting the port.
The catheter tubing is connected to the port and the The port is then advanced into the pocket to ensure that it
catheter lock is applied; the clear end of the lock is placed will fit correctly. Adjustments can be made at this point if
against the hub. Once attached, heparinized saline is the pocket is not the correct size.
infused through the catheter. The attachment between the
tubing and the port must be secure to prevent inadvertent
infusion of chemotherapeutic agents into the subcutaneous
tissues.
a b
a b
a b
References
1. Ozols RF, Rubin SC, Thomas G, Robboy S. Epithelial laparotomy on survival of patients with epithelial ovarian
ovarian cancer. In: Hoskins WJ, Perez CA, cancer. Gynecol Oncol 1989;34:365–71.
Young RC (eds). Principles and practice of gynecologic 4. Abu-Rustum NR, Barakat RR, Siegel PL et al. Second-look
oncology, 3rd edn. Philadelphia: Lippincott-Raven, operation for epithelial ovarian cancer: laparoscopy or
2000: 1025. laparotomy? Obstet Gynecol 1996;88:549–53.
2. Rubin SC, Hoskins WJ, Hakes TB et al. Serum CA 125 5. Hussain A, Chi DS, Prasad M et al. The role of laparoscopy
levels and surgical findings in patients undergoing in second-look evaluations for ovarian cancer. Gynecol
secondary operations for epithelial ovarian cancer. Oncol 2001;80:44–7.
Am J Obstet Gynecol 1989;160:667–71. 6. Barakat RR, Sabbatini P, Bhaskaran D et al. Intraperitoneal
3. Hoskins WJ, Rubin SC, Dulaney E et al. Influence of chemotherapy for ovarian carcinoma: results of long-term
cytoreductive surgery at the time of second look follow-up. J Clin Oncol 2002;20:694–8.
16 Extraperitoneal lymph
node dissection
Yukio Sonoda, Denis Querleu, and Eric Leblanc
The laparoscopic extraperitoneal approach for be comfortable managing possible vascular injuries
dissecting the paraaortic nodes combines the benefits either by laparoscopy or by laparotomy.
of laparoscopy with those of an extraperitoneal
dissection. It has been most commonly used for the Prior to undertaking the procedure, the surgeon
surgical staging of patients with locally advanced should obtain a radiological study – i.e. a computed
cervical cancer, but can be applied to other circum- tomography (CT) scan – to evaluate the retroperitoneal
stances when the paraaortic nodes require thorough structures and rule out any vascular abnormalities.
evaluation. For patients who are going to be treated Careful identification of the major landmarks is cru-
with radiation, traditional transperitoneal paraaortic cial for the success of this dissection. The remainder
lymph node sampling via laparotomy has been of this chapter illustrates the technical steps for this
associated with increased radiation-induced gastro- procedure.
intestinal toxicity secondary to resulting bowel adhe-
sions. An extraperitoneal approach has been shown
to decrease toxicity, owing to the decreased incidence
of bowel adhesions. Transperitoneal laparoscopy has
also been employed, with good success, to sample
the paraaortic nodes. Benefits of the laparoscopic
extraperitoneal approach compared to a laparoscopic
transperitoneal approach include operative feasibility
in spite of previous abdominal surgery, decreased risk
of direct bowel injury, and decreased bowel adhesion
formation. Benefits over an extraperitoneal laparo-
tomy include decreased wound complications and
possibly decreased hospital stay and treatment
delays.
249
250 Atlas of Procedures in Gynecologic Oncology
a b
2
3
4
5
1 – Peritoneum
2 – Aorta
3 – Left ureter
4 – Extraperitoneal space
5 – Psoas
a b
a b
1 1
2
3
2
4 3
4
a b
1
1
2
2
3
3
4
5
6
4
7
1 – Right ureter
2 – Right common iliac artery 8
3 – Aorta 9
4 – Left common iliac artery
1 – Right external iliac artery
Figure 16.11. Right common iliac artery. 2 – Right common iliac artery
Prior to removing the lymph nodes from the right common 3 – Right internal iliac artery
iliac artery, the right ureter should be visualized. As it is 4 – Left common iliac vein
still attached to the peritoneum, it can be swept laterally 5 – Left common iliac artery
and away from the dissection. 6 – Left internal iliac artery
7 – Left external iliac artery
8 – Left genitofemoral nerve
9 – Left psoas muscle
a b
1 Fellow’s vein
2
3
a b
1
1
2
2
3
4 4
2
3
Tube thoracostomy refers to the placement of a tube effusions develop as a result of tumor metastasis to
into either hemithoracic cavity for drainage purposes. the parietal or visceral pleura, which then hinders
Drainage can be of blood (hemothorax), pus (empy- the normal reabsorption of the fluid. Patients who
ema), air (pneumothorax), or fluid (pleural effusion). present with pulmonary complaints, including dysp-
In gynecologic oncology, some patients with advanced nea on exertion and pleuritic chest pain, should have
ovarian cancer will present with pleural effusions, a chest radiograph performed to include the postero-
some of which may contain cancer cells and are anterior as well as upright and lateral decubitus
termed malignant effusions. Malignant pleural views.
257
258 Atlas of Procedures in Gynecologic Oncology
a b
a b
c d
a b
Figure 17.15. Introducing the thoracoscope. Figure 17.16. One port site technique.
Once the chest cavity is entered, the thoracoscope can be Additional ports can be used to insert instruments into the
introduced. The scope, with the video, allows the lung and chest in order to proceed with the biopsy or resection.
pleura to be explored by the surgeon. However, removing the trocar in the initial incision allows
for a second instrument to be inserted adjacent to the
thoracoscope, eliminating the need for a second incision.
Figure 17.17. Inspection of the entire lung and Figure 17.18. Biopsy of pleural lesions.
pleural cavity. All suspicious lesions can be biopsied. A pleurodesis can
With the lung deflated, the parietal and pleural layers can be performed through the scope by inserting talcum
be inspected for disease. powder or doxycycline into the chest. These materials
cause an inflammatory reaction and cause the lung to
adhere to the pleural wall. The goal of the pleurodesis is to
prevent future reaccumulation of fluid into this space. At
the end of the procedure, a chest tube is placed, as
described above for continued drainage.
Chest tube placement and video-assisted thoracoscopic surgery 265
References
1. Cerfolio RJ, Bryant AS, Singh S, Bass CS, Bartolucci AA. ovarian cancer and moderate to large pleural effusions.
The management of chest tubes in patients with a Gynecol Oncol 2004;94:307–11.
pneumothorax and an air leak after pulmonary resection. 3. Juretzka MM, Abu-Rustum NR, Sonoda Y et al. The
Chest 2005;128:816–20. impact of video-assisted thoracic surgery (VATS) in
2. Chi DS, Abu-Rustum NR, Sonoda Y et al. The benefit of patients with suspected advanced ovarian
video-assisted thoracoscopic surgery before planned malignancies and pleural effusions. Gynecol Oncol
abdominal exploration in patients with suspected advanced 2007;104(3):670–4.
18 Hand-assisted laparoscopic
splenectomy
John P Diaz and Dennis S Chi
267
268 Atlas of Procedures in Gynecologic Oncology
Procedure
Figure 18.3. Mobilization of the splenic flexure. Figure 18.4. Exposure of the lesser sac.
Traditional laparoscopic instruments are used to mobilize A nasogastric tube inserted into the stomach can be used as
the splenic flexure of the colon from the spleen. Division a handle to lift the stomach up while using the hand
of these attachments allows the spleen to now be retracted inserted through the hand port to assist in dividing the
medially, exposing the lienorenal ligament. The ligament is greater omentum to expose the lesser sac.
then divided with the aid of the Ligasure. The ligament is
divided only as far as it can be clearly seen, leaving the rest
until after division of the vessels in the splenic hilum.
Hand-assisted laparoscopic splenectomy 269
References
1. Gemignani ML, Chi DS, Gurin CC, Curtin JP, Barakat RR. ovarian and fallopian tube cancers. Am J Obstet Gynecol
Splenectomy in recurrent epithelial ovarian cancer. 2005;192:1614–19.
Gynecol Oncol 1999; 72:407–10. 4. Chi DS, Abu-Rustum NR, Sonoda Y et al. Laparoscopic
2. Abu-Rustum NR, Barakat RR, Siegel PL et al. and hand-assisted laparoscopic splenectomy for recurrent
Second-look operation for epithelial ovarian cancer: and persistent ovarian cancer. Gynecol Oncol
laparoscopy or laparotomy? Obstet Gynecol 1996; 2006;101:224–7.
88:549–53. 5. Howdieshell TR, Heffernan D, Dipiro JT. Surgical infection
3. Chi DS, Abu-Rustum NR, Sonoda Y et al. The safety and society guidelines for vaccination after traumatic injury.
efficacy of laparoscopic surgical staging of apparent stage I Surg Infect (Larchmt) 2006;7:275–303.
19 Robotically assisted
laparoscopic surgery for
gynecologic malignancies
Mario M Leitao Jr and Ginger J Gardner
Surgery is the cornerstone of treatment for most car-building industry. The use of robotic technology
patients diagnosed with gynecologic malignancies. in surgery, however, is relatively new. Rather than
Surgery has traditionally involved large laparotomy resembling the human form or being programmed in
incisions that are associated with significant pain and advance, robotic technology in medicine is a tool
prolonged recovery periods. The advent of minimally entirely under the real-time, continuous control of the
invasive procedures has allowed gynecologic oncolo- primary operating surgeon. The design of the robot
gists to perform the same procedures through 3–5 allows the surgeon to complete a broad range of surgi-
small incisions, all less than 1 inch (2.5 cm), using cal procedures with a minimally invasive approach,
laparoscopic techniques. This has resulted in much while avoiding many of the challenges of a traditional
less postoperative pain, improved cosmetic results, laparoscopic technique.
and faster recovery for patients. Advanced laparo-
scopic procedures have not been uniformly adopted The only commercially available robotic system in
by all gynecologic oncologists, and only a limited the world is the daVinci Surgical System manufac-
number routinely perform advanced procedures.1 tured by Intuitive Surgical in Sunnyvale, California,
This is probably owing to the need to acquire new with the most recent updated platform, the da Vinci S
surgical skill sets, the non-complementary move- Surgical System. It consists of a patient cart, which is
ments of the laparoscopic instruments compared to often referred to as the ‘robot.’ This cart has one arm
the surgeon’s movements, and the limited range of dedicated for the camera and three additional arms to
motion of the currently available instruments. which various surgical instruments are attached. The
Furthermore, traditional laparoscopy only provides surgeon controls the patient cart (‘robot’) from the
the surgeon with two-dimensional images, limited console. The console is positioned away from the
ergonomics for lengthy procedures, and on many patient, and the surgeon is unscrubbed during this
occasions requires both an abdominal and vaginal time. The surgeon places his hands in the console
approach. Complex procedures can therefore be dif- controls and the instruments on the ‘robot’ move in
ficult to complete in a minimally invasive fashion. the exact manner that the surgeon’s hands move. The
The advent of robotic technology has addressed and complete system also consists of a video tower, so
overcome many of these limitations. that the entire procedure can be visualized by the
other members of the surgical team in the operating
The American Heritage Dictionary defines ‘robot’ as room.
‘a mechanical device that sometimes resembles a
human and is capable of performing a variety of often The robotic system provides the surgeon with a
complex human tasks on command or by being pro- three-dimensional view of the operative field in the
grammed in advance’.2 The word ‘robot’ comes from surgical console. During procedures, the movements
the Czech word ‘robota,’ a derivative of ‘rab’ (slave), of the robotic instruments complement the movement
which is defined as servitude or forced labor.2 Robots of the surgeon’s hands and are therefore similar to
are often associated with popular science fiction the steps and motions used during open surgery.
novels and thus sound futuristic and exciting. In Furthermore, the robotic instruments have a wrist-
reality, robotic technology has been used in a variety like movement that allows for a broader range of
of industries for many years, most notably in the motion and easier suturing compared with traditional
271
272 Atlas of Procedures in Gynecologic Oncology
laparoscopy. All of these technical advancements is often placed on the side opposite to the fourth
have made it much easier for surgeons to adapt mini- robotic arm.
mally invasive approaches from their open approaches
in a much more ergonomic surgical setting. The The first report of robotically assisted surgery in
robotic techniques enable both novice and expert humans for a gynecologic indication was of a tubal
laparoscopic surgeons to complete simple and reanastomosis in 1999.4 The first series of robotically
complex skills much faster.3 assisted hysterectomies was published in 2002.5
Additional gynecologic reports have described suc-
Trocar placement for robotically assisted procedures cessful completion of robotically assisted ovarian
differs from traditional laparoscopy and is described transposition, myomectomies, vesicovaginal fistula
below. All procedures can be completed using 4–5 repair, and sacrocolpopexy.6–10 These studies do not
trocars. The need for a vaginal approach is also elimi- directly compare their outcomes to laparoscopic
nated, except to remove the specimen after colpotomy approaches, but provide acceptable results. The first
is completed abdominally. Proper positioning of the robotically assisted gynecologic oncology procedures
patient is important. Steep Trendelenburg position is were reported in 2005, with the first radical hysterec-
necessary, so the patient must be secured to the oper- tomy reported in 2006.11,12
ating table using various methods. We routinely place
the patient into steep Trendelenburg position prior to The largest series in gynecologic oncology have only
scrubbing to ensure that there is no upward slippage been presented in abstract form at the Society of
of the patient and to test the patient’s ability to with- Gynecologic Oncology’s 38th Annual Meeting on
stand this position. The robotic system is a fixed sys- Women’s Cancer in 2007.13,14 This single institution’s
tem that does not have a feedback mechanism to alert experience demonstrates similar operative times for
the surgeon that the patient has moved against the robotically assisted radical hysterectomies compared
patient cart. Such movement may result in damage to with laparotomies, with significantly less blood loss
the abdominal wall. and length of hospital stay.13 In addition, shorter mean
operative times were seen for robotically assisted
Uterine manipulators of the surgeon’s preference are endometrial staging procedures compared with tradi-
placed, except in cases of gross cervical malignancies. tional laparoscopic staging procedures.14 Higher mean
We prefer the use of the ZUMI with the KOH lymph node counts were also seen in patients who
Colpotomizer system and Colpo-Pneumo Occluder, or had undergone a robotically assisted procedure com-
the VCare Uterine Manipulator. These manipulators pared with a traditional laparoscopic approach.14 Both
allow for excellent delineation of the vaginal fornices series demonstrated lower complication rates for
and facilitate the colpotomy and maintenance of the robotically assisted procedures compared with both
pneumoperitoneum during a total laparoscopic hys- laparotomy and laparoscopy.
terectomy whether using traditional or robotic tech-
nique. For patients with gross cervical malignancies, The field of robotics in gynecology is new and will
a blunt vaginal probe may be used. require additional investigation. The advent of robotics
must not lead to the performance of unindicated pro-
To begin the procedure, abdominal entry is performed cedures simply because they can now be performed
in the surgeon’s preferred manner for laparoscopy. with smaller incisions by more surgeons. However,
An extra long 12-mm trocar should be used for the robotics holds great promise. Robotics has many of the
camera site. Abdominal inspection is performed using technical advantages of traditional laparoscopy and is
the robotic camera free from the robot. Alternatively, the natural evolution of minimally invasive surgery.
a laparoscope can be used. The additional trocars are Some of the key aspects of robotically assisted proce-
then placed under direct visualization – three 8-mm dures are shown below. The described techniques
robotic trocars and one assistant 10–12 mm trocar in may be different or modified based on individual sur-
the left or right upper quadrant. This assistant trocar geon experience and robotic platform version.
Robotically assisted laparoscopic surgery for gynecologic malignancies 273
a b
1
4
m
Camera 8c 8 cm
8–10 cm 8–10 cm
2
15° 15°
8–10 cm
1 2
3
4
20–25 cm 3
5
6
Patient feet
a b
a b
c
Figure 19.12. Left paraaortic lymphadenectomy.
The peritoneum overlying the aorta is grasped (a) to start
1
the dissection of the left paraaortic nodal space. The left
paraaortic space is dissected under the inferior mesenteric
artery (IMA). The left ureter is seen in the ‘roof’ of this
space (b). The dissection continues to the left psoas major
2 muscle (c). This dissection can safely be performed in a
blunt fashion or with monopolar cautery. The Maryland
forceps has bipolar energy and can be used to coagulate
small vessels as needed.
3
a b
1 – Aortic bifurcation
a b
2
3
4
5
1 – Round ligament
2 – Broad ligament
3 – Fallopian tube
4 – External iliac artery
5 – IP ligament
c
Figure 19.15. Start of the hysterectomy.
The hysterectomy is initiated by entering and developing
the retroperitoneal space. (a) The pertinent anatomic
structures are identified. (b) The retroperitoneum is entered
by starting the peritoneal incision in an avascular area of
the anterior leaf of the broad ligament. (c) This incision is
then carried cephalad and parallel to the infundibulopelvic
(IP) ligament.
1
2
1 – Paravesical space
2 – Obliterated umbilical artery
280 Atlas of Procedures in Gynecologic Oncology
1
2
3 3
4
5
a b
2
3
1 – Uterine artery
2 – Ureter
3 – IP ligament
a b
c
Figure 19.20. Transection of the infundibulopelvic
ligament.
(a) The infundibulopelvic (IP) ligament is cauterized with
the bipolar Maryland forceps. Alternatively, any other
robotic bipolar instrument, PK Dissecting Forceps or
Harmonic curved shears, can be used. (b, c) The IP
cauterized IP ligament is then transected with the
monopolar hot shears.
a b
a b
c d
a b
1 – Bladder
2 – KOH ring
3 – Uterine vessels
c
Figure 19.23. Transection of uterine vessels for simple
hysterectomy.
(a) The uterine vessels are well skeletonized and can be
clearly identified as they enter the uterus at the level of the
internal os of the cervix. The value of developing the bladder
flap well and incising the posterior broad ligament is now
evident in this image. (b) The uterine vessels are coagulated
using the bipolar Maryland forceps or equivalent instrument.
(c) The vessels are then transected using the monopolar hot
shears. This may need to be done in multiple steps,
depending on the caliber of this pedicle. The uterine vessel
pedicle is further developed away from the uterus by
progressively cauterizing medially to the prior points of
cauterization and taken to the level of the KOH ring.
a 1 b
2 1
2
3
a b
1 – Bladder
2 – KOH ring
c
Figure 19.27. Continuation of colpotomy.
The colpotomy incision is continued to the right (a,b) and
left (c) circumferentially using the KOH ring as a guide.
1 – Fallopian tubes 1
286 Atlas of Procedures in Gynecologic Oncology
a b
a b
c d
Figure 19.30. Suture tying and continuation of the vaginal cuff closure.
The tail is kept short after the suture is placed at the right vaginal angle. This will ensure that there is enough suture to
complete the closure. The suture is wrapped twice around the right arm using the left arm (a). The tail is then grasped with
the right arm (b), pulled through, and secured (c). There is no feedback on the robotic system, and the suture can be easily
broken if pulled too tight. The closure is then continued in a running manner and locking each time (d).
Robotically assisted laparoscopic surgery for gynecologic malignancies 287
2
3
a b
1
2
1 3
2
References
1. Frumovitz M, Ramirez PT, Greer M et al. Laparoscopic 8. Melamud O, Eichel L, Turbow B, Shanberg A.
training and practice in gynecologic oncology among Laparoscopic vesicovaginal fistula repair with robotic
Society of Gynecologic Oncologists members and reconstruction. Urology 2005;65:163–6.
fellows-in-training. Gynecol Oncol 2004;94:746–53. 9. Elliott DS, Krambeck AE, Chow GK. Long-term results of
2. The American Heritage Dictionary of the English robotic assisted laparoscopic sacrocolpopexy for the
Language, 4th edn. Boston: Houghton Mifflin Company, treatment of high grade vaginal vault prolapse. J Urol
2004. http://dictionary.reference.com/browse/robot 2006;176:655–9.
(accessed: August 1, 2007). 10. Sundaram BM, Kalidasan G, Hemal AK. Robotic repair of
3. Sarle R, Tewari A, Shrivastava A et al. Surgical robotics vesicovaginal fistula: case series of five patients. Urology
and laparoscopic training drills. J Endourol 2004;18: 2006;67:970–3.
63–7. 11. Reynolds RK, Burke WM, Advincula AP. Preliminary
4. Falcone T, Goldberg J, Garcia-Ruiz A et al. Full robotic experience with robotic-assisted laparoscopic staging of
assistance for laparoscopic tubal anastomosis: a case gynecologic malignancies. JSLS 2005;9:149–58.
report. J Laparoendosc Adv Surg Tech A 1999;9:107–13. 12. Sert BM, Abeler VM. Robotic-assisted laparoscopic radical
5. Diaz-Arrastia C, Jurnalov C, Gomez G, Townsend C Jr. hysterectomy (Piver type III) with pelvic node dissection –
Laparoscopic hysterectomy using computer-enhanced case report. Eur J Gynaec Oncol 2006;27:531–3.
surgical robot. Surg Endosc 2002;16:1271–3. 13. Shafer A, Boggess JF, Gehrig P et al. Type III radical
6. Molpus KL, Wedergren JS, Carlson MA. Robotically hysterectomy for obese women with cervical
assisted endoscopic ovarian transposition. JSLS 2003;7: carcinoma: robotic versus open. Gynecol Oncol
59–62. 207;104:S14 (abstract).
7. Advincula AP, Song A, Burke W, Reynolds RK. 14. Boggess JF, Fowler WC Jr, Gehrig P et al. Robotic
Preliminary experience with robot-assisted laparoscopic assistance improves minimally invasive surgery for
myomectomy. J Am Assoc Gynecol Laparosc 2004;11: endometrial cancer. Gynecol Oncol 2007;104:S52
511–18. (abstract).
20 Sentinel lymph node
identification for early-stage
cervical and uterine cancer
Nadeem R Abu-Rustum and Mary L Gemignani
289
290 Atlas of Procedures in Gynecologic Oncology
a b
The 4 ml of blue dye can be divided into four separate Adverse effects of isosulfan blue include allergic reac-
injections, one into each quadrant of the cervix (1 ml tions (<1% of patients) such as localized swelling and
each). Alternatively, the injections can be given at the pruritus of the hands, feet, abdomen, and neck. Severe
3 and 9 o’clock positions, which correspond more to reactions, including edema of the face and glottis,
the parametria and avoid blue dye staining of the respiratory distress, and shock, have been occasion-
bladder flap secondary to the 12 o’clock injection. ally reported with other similar compounds. In rare
After the injection, the patient is prepped and draped instances, isosulfan blue can cause a transient drop in
in the usual sterile fashion. The procedure continues oxygen saturation, as measured by pulse oximetry.
as planned, either through laparoscopy or laparotomy. Isosulfan blue will turn the urine blue-green for up
The sentinel node identification and removal is per- to 24 hours following injection. Contraindications
formed first. If no blue nodes are noted, a second include known hypersensitivity to phenylethane
injection of 2 ml of blue dye can be injected directly compounds.
into the cervix.
Sentinel lymph node identification for early-stage cervical and uterine cancer 291
a b
c d
Figure 20.5. Removing the blue or hot nodes. (Continued on next page)
292 Atlas of Procedures in Gynecologic Oncology
Figure 20.8. Cervical and fundal injection. Figure 20.9. Laparoscopic fundal injection.
A combination of a cervical and fundal injection can be The fundal injection of Lymphazurin (isosulfan blue) can
utilized. This figure shows a fundal injection of 2 ml of also be performed via laparoscopy, using a long needle.
Lymphazurin (isosulfan blue) given to a patient with Here, the blue dye can be seen immediately dissipating in
endometrial cancer; the patient also has a large fundal the subserosal lymphatics.
myoma.
21 Paracentesis
Douglas A Levine
Both gynecologic oncologists and medical oncologists vessels (most seriously the inferior epigastric vessels),
frequently perform paracentesis in the management or the introduction of infection. If a large volume of
of patients with ovarian cancer. This simple bedside ascites is removed, hemodynamic parameters should
or office procedure can be employed for diagnostic or be closely monitored. Usually, large-volume paracen-
therapeutic purposes (Table 21.1). It is usually associ- tesis is well tolerated in patients without significant
ated with minimal discomfort and a low rate of pre-existing cardiac or pulmonary disease. Intravenous
complications. Among the many indications for a fluids should be given throughout the procedure and
paracentesis, the most common are to confirm the colloids can be added for symptomatic management
diagnosis of cancer prior to definitive treatment or to as needed. Rarely does hemodynamic instability
relieve symptoms related to increased intraabdominal result, even when >10 L of ascites are removed.2
pressure. While seeding of the paracentesis tract has
been reported in the literature,1 and is a potential con-
cern, no impact on survival has been shown. This
may be due to the high response rate seen with
currently available combination chemotherapy.
Nonetheless, unnecessary paracentesis should be
avoided. In general, if a patient has clinical and radio- Table 21.1 Indications for paracentesis in
graphic signs of advanced ovarian cancer, a para- gynecologic malignancies.
centesis for the sole purpose of confirming a cancer
Diagnostic Therapeutic
diagnosis is not required prior to surgery. A more
appropriate indication for paracentesis would be to Advantages Confirm cancer Relief of
confirm a cancer diagnosis prior to initiating neoadju- diagnosis symptomatic ascites
vant chemotherapy in a patient medically unfit to tol- Differentiate from Improve cardio-
erate surgery. In this setting, definitive surgery would benign ascites pulmonary function
be delayed until several courses of cytotoxic chemo-
Determine general Reduce intra-
therapy had been given.
histologic subtype abdominal pressure
295
296 Atlas of Procedures in Gynecologic Oncology
1
2
3
4
5
6
1
2
3
a b
References
1. Kruitwagen RF, Swinkels BM, Keyser KG et al. Incidence 2. Gotlieb WH, Feldman B, Feldman-Moran O et al.
and effect on survival of abdominal wall metastases at trocar Intraperitoneal pressures and clinical parameters of total
or puncture sites following laparoscopy or paracentesis in paracentesis for palliation of symptomatic ascites in ovarian
women with ovarian cancer. Gynecol Oncol 1996;60:233–7. cancer. Gynecol Oncol 1998;71:381–5.
22 Percutaneous endoscopic
gastrostomy tube placement
Mark Schattner and Moshe Shike
In patients with advanced gynecologic malignancies, PEG placement is a safe procedure, with a mortality
bowel obstruction is a cause of significant morbidity rate of 1% and a major complication rate of 3%.3 Major
and mortality. Often, there is complete intestinal complications include peritonitis due to inadvertent
obstruction involving multiple segments of bowel, tube removal prior to maturation of the fistulous tract
making surgical correction difficult or impossible. or hemorrhage. Traversing a tumor, the colon, or even
Palliation of nausea, vomiting, and abdominal pain the liver by PEG tubes being placed for drainage has
in inoperable patients requires gastric decompression. not resulted in clinically significant difficulties.4,5
A modification of the percutaneous endoscopic
gastrostomy (PEG) tube can safely provide effective
drainage of gastrointestinal contents.
A review1 reported success rates of gastrostomy tube Figure 22.1. Preparing the abdomen.
placement of 83–100% in patients with inoperable Ascites is not a contraindication to percutaneous
bowel obstruction. Post-procedure survival in this endoscopic gastrostomy placement; however, it may make
series ranged from 2 to 600 days. After PEG place- transillumination from the stomach more difficult and
ment, 88% of patients are able to drink and eat soft therefore as much ascites as possible should be removed.
foods, which are then drained through the PEG.2 The abdomen is then cleaned in the usual sterile fashion,
Care of the PEG is easy and requires only flushing of after which the Betadine (povidone-iodine) solution is
the tube, care of the ostomy site, and emptying of the removed with an alcohol wash to facilitate
drainage bag. transillumination.
303
304 Atlas of Procedures in Gynecologic Oncology
a b
a b
a b
Figure 22.8. Grasping the thread. Figure 22.9. Retrieving the thread.
The endoscopist grasps the thread in the stomach with While maintaining a firm grip on the thread, the endoscope
standard endoscopic biopsy forceps. is withdrawn out of the patient. As the thread exits the
patient’s mouth, an assistant grabs it.
Percutaneous endoscopic gastrostomy tube placement 307
a b
c d
Figure 22.12. Confirming placement. Figure 22.13. Applying the external bumper.
A repeat endoscopy is performed to confirm the position of An external bumper is passed over the tapered end of the
the tube and the internal bumper. PEG tube and into position against the skin wall. The
bumper should be left 0.5–1.0 cm above the skin to avoid
placing excessive pressure on the mucosa under the
internal bumper. If the external bumper is pulled tightly
against the skin, it will cause the internal bumper to erode
through the gastric wall and cause a ‘buried-bumper
syndrome’. The tapered end of the PEG tube should now
be cut off and that end attached to a drainage bag. The
patient can now drink and eat soft foods, which will be
drained out of the tube.
References
1. Campagnutta E, Cannizzaro R. Percutaneous endoscopic gastroenterology, 3rd edn. New York: Lippincott,
gastrostomy (PEG) in palliative treatment of non-operable Williams & Wilkins, 1999:2825–33.
intestinal obstruction due to gynecologic cancer: a review. 4. Stellato TA, Gauderer MW. Percutaneous endoscopic
Eur J Gynaecol Oncol 2000;21:397–402. gastrostomy for gastrointestinal decompression. Ann Surg
2. Herman LL, Hoskins WJ, Shike M. Percutaneous 1987;205:119–22.
endoscopic gastrostomy for decompression of the stomach 5. Picus D, Marx MV, Weyman PJ. Chronic intestinal
and small bowel. Gastrointest Endosc 1992;38:314–18. obstruction: value of percutaneous gastrostomy
3. Ponsky J, Dunkin B. Percutaneous endoscopic gastrostomy. tube placement. AJR Am J Roentgenol 1988;150:
In: Yamada T, Alpers DH, Laine L et al (eds). Textbook of 295–7.
23 Central venous catheter
placement
Michelle Montemarano and Douglas A Levine
Central venous catheter placement plays an important approaches less desirable. Relative contraindications
role in the diagnosis, management, and treatment of to central venous catheter placement include marked
the patient with a gynecologic malignancy. Central coagulopathy, patient refusal, and bacteremia. Of note,
venous catheter monitoring is frequently employed in coagulopathic states, femoral vein cannulization can
in the perioperative setting. Indications for central result in fewer bleeding complications.
venous catheter placement include pressure monitor-
ing, infusion of large-volume or hypertonic solutions, The figures in this chapter illustrate the technique of
inaccessible peripheral veins, or hemodialysis. Central central venous catheterization via the left internal
venous catheters are placed in the superior vena cava, jugular (IJ) vein. The IJ approach is common because
inferior vena cava, or one of their major branches. of its well-defined landmarks. The three common
The subclavian, internal jugular, and external jugular approaches for cannulation of the IJ vein are poste-
veins are frequently employed when access to the rior, central, and anterior. Here, the left IJ vein via the
central venous circulation is required, or when central approach (between the two heads of the
peripheral sites are unavailable. sternocleidomastoid muscle belly) is depicted, but
the figures are applicable to all central venous access
The risks associated with central venous access include approaches. The IJ runs medial to the sternocleido-
pneumothorax, puncture of arteries or lymphatics, air mastoid (SCM) muscle in its upper part, posterior to
embolus, infection, or thrombus formation. The sub- it in the triangle between the two inferior heads of the
clavian and internal jugular veins lie close to the SCM in its middle part, and behind the anterior por-
carotid and subclavian arteries, the apical lung, nerves, tion of the clavicular head of the muscle in its lower
and other key structures. These structures must be rec- part, terminating above the medial clavicle where it
ognized as one is accessing the central venous system. enters the subclavian vein.
The most commonly recognized risk, pneumothorax,
is apparent when air, instead of blood, is aspirated The Seldinger technique is frequently used in the
during location of the vessel. For this reason, all placement of central venous catheters. This technique
patients undergo a post-procedure chest radiograph to involves puncturing the vein with a small-bore needle
rule out pneumothorax and evaluate line placement. through which a guidewire is introduced into the
While advantages and disadvantages of the various vein. The needle is then withdrawn and a catheter is
approaches to central venous access exist, the clinician introduced over the guidewire, which is subsequently
should choose the technique based on clinical consid- removed. Most commercially available central venous
erations and familiarity with the approach (see access trays provide all of the equipment necessary to
Table 23.1). Some patients may have had prior head place a central venous catheter, including needles,
and neck surgery, or venous thrombi, making certain guidewires, and dilators (Figure 23.1).
309
310 Atlas of Procedures in Gynecologic Oncology
Long-term venous access is important in the treatment compatible, and connect to valved or open-ended sili-
and management of patients with gynecologic malig- cone or polyurethane catheters (Figure 24.1). Routine
nancies. There are several central venous access devices maintenance requires only that the port be flushed
to choose from, which are characterized by catheter with heparinized saline (normal saline for valved
size, type (implantable versus external), number of catheters) every 4–6 weeks, and after each use.
lumens, and longevity (‘permanent’ versus temporary).
Like many medical devices, implantable ports con-
In determining the type of catheter to place in a given tinue to evolve. Power-injectable ports, when accessed
patient, several factors should be considered, includ- with power-injectable Huber needles, can be used for
ing the intended use of the catheter, frequency of computed tomography (CT) arteriography, including
access, physician preferences, and patient lifestyle. pulmonary arteriography. Ports with an antibiotic or
heparin coating of the catheter, which promise to
Implantable ports are ideal for long-term, intermittent further decrease infection rates, will be available in
central venous access. Compared to external tunneled the near future.
central venous catheters, implantable ports require
less maintenance and have a lower rate of infection. The role of the interventional radiologist in the place-
Because implantable ports are completely contained ment of central venous access has increased drama-
under the skin when not accessed, there is no limita- tically in the past decade. By using ultrasound,
tion on range of motion or patient lifestyle. This is an fluoroscopy, intravenous contrast, and specialized
important feature for patients who swim, lift weights, catheters with guidewires, interventional radiologists
or have small children at home (who may pull on are able to negotiate venous occlusions, deal with vas-
external catheters.) cular anomalies, and provide alternative puncture sites
not previously accessible. The lower complication rate
Implantable ports are most often titanium or plastic, and almost 100% success rate may fuel the movement
both of which are magnetic resonance imaging (MRI) of venous access into the angiography suite.
a b
315
316 Atlas of Procedures in Gynecologic Oncology
a b
a b
a b
a b
a b
a b
a b
hospitalization or radiation precautions. Typically, typically placed at the time of first fraction and
four to seven treatments are delivered at one or two sutured in place for use with subsequent fractions.
fractions per week, either during external radiation or This obviates the need for subsequent cervical dilata-
following. In view of the multiple fractions and the tions in order to place the tandem, allowing ease in
outpatient nature, an indwelling cervical sleeve is multiple outpatient placements.
a b
1 – Right ovoid
2 – Flange
3 – Tandem
328 Atlas of Procedures in Gynecologic Oncology
1
Figure 25.13. Fluoroscopy. 2
The vaginal canal is then packed anteriorly and posteriorly.
This secures the tandem and ovoids in place, while 3
displacing the bladder and rectum away from the apparatus
to decrease dose to these structures. Alternatively, with an 4
HDR insertion, a rectal retractor, which is placed posterior 5
to the tandem, may be utilized to limit dose. Fluoroscopy
may be utilized to ensure proper positioning. If 6
repositioning is needed, it can be accomplished while the
patient is still under anesthesia. The anterior and posterior
packing soaked with Betadine (povidone-iodine), above
and below the intracavitary device, has been preliminarily
packed into position.
1 – Tandem
2 – Rectal marker
3 – Marker seeds
4 – Flange
5 – Right ovoid
6 – Urinary catheter balloon
1
2
1 – Rectal marker
2 – Tandem
3 – Ovoids
1 – Bladder
2 – Ring
3 – Tandem
4 – Rectum
330 Atlas of Procedures in Gynecologic Oncology
a b
a b
a b
a b
1
2
1
3
2
3 4
4 5
Intraoperative radiation therapy electron beams. Care must be taken when administer-
ing radiation using this method. The treatment field
must be well exposed, with the adjacent structures
IORT is utilized for a variety of different sites and
moved out of the path of the electron beam. This may
malignancies. Typically, IORT is used to deliver
not be possible with tumors that are deep seated in
focal high doses of radiation to patients who have
the pelvis or retroperitoneum, for example. In addi-
previously received treatment or to supplement the
tion, the electron cone should be set up so that the
dose beyond that which would be safely permissible
head of the treatment machine is perpendicular to
using external-beam therapy alone. The use of IORT
the surface of the tumor bed. When an electron deliv-
allows delivery of high doses of radiation to an
ers radiation over a sloped or irregular surface, the
operative tumor bed while sparing the adjacent
dose delivery would be inhomogeneous with varying
normal tissues. The purpose of IORT is to improve
treatment depths. In addition, larger fields may require
the local control following a surgical resection. In
that it be split and treated with two separate abutting
gynecologic malignancies, it is typically used in the
electron fields, which must be matched carefully.
recurrent setting. Overall, IORT has had acceptable
tolerance with favorable local control rates in patients A second method of administering IORT is with
with recurrent disease following complete surgical a high-dose-rate brachytherapy unit. A Harrison–
resection. There are two methods for delivering Anderson–Mick (HAM) applicator, composed of flex-
IORT. ible silastic material with catheters running parallel
through it and spaced 1 cm apart, is used to deliver
The first method provides treatment delivery using treatment. The distance from each catheter to the
electrons produced by a linear accelerator. This treat- treating surface is 0.5 cm. The number of catheters
ment is undertaken either with a dedicated linear and the length along each catheter that is employed to
accelerator in the operating room or by transferring treat a field can be tailored to the size and dimensions
the patient from the operating room to a radiation of the tumor bed. The advantage of this form of IORT
treatment room. The electron beam is focused on the over that of electrons is seen when treating deep-
tumor bed, and the field shape and size is adjusted to seated tumors in the pelvis or in regions where the
encompass the treatment field. The critical normal normal tissues cannot be moved easily away from the
structures are moved away from the field and the path of an electron beam. With the use of a HAM
patient is subsequently treated. This technique allows applicator, small lead blocks can be placed directly
delivery of radiation to a prescribed superficial depth, against critical adjacent structures to block them from
which can be varied by utilizing different energies of the intraoperative treatment.
334 Atlas of Procedures in Gynecologic Oncology
a b
References
1. Tod M, Meredith W. A dosage system for use in the 2. Tod M, Meredith W. Treatment of cancer of the cervix
treatment of cancer of the uterine cervix. Br J Radiol uteri – a revised ‘Manchester method’. Br J Radiol
1938;11:809–24. 1953;26:252–7.
26 Cystourethroscopy and
ureteral catheterization
Siobhan M Kehoe and Nadeem R Abu-Rustum
Cystourethroscopy is often used in gynecologic filled with approximately 200–250 ml of fluid to avoid
oncology for staging to assess the extent of disease overdistention. Patients who have received prior
progression into the bladder. In most gynecologic radiation may have less elasticity of their bladder;
malignancies, bladder involvement will upstage the therefore, less fluid should be used to distend the
disease and will often change the treatment plan. At bladder.
the same time, cystoscopy can be used intraopera-
tively for ureteral catheter or stent placement to aid in The bladder is inspected in a uniform fashion. A
identifying the pelvic ureter in advanced dissection. non-distended bladder wall has ruggae, whereas the
Cystoscopy can also be used to evaluate for bladder distended bladder is smooth and has a grid pattern
or ureteral injury that may occur during a difficult due to the detrusor muscle fibers. We recommend to
dissection, allowing for early identification of injury start with identifying the trigone, which is directly
and immediate repair. above the urethra. The ureteral orifices, which are
small slit-like openings, are located on the inter-
The patient is placed in the dorsal lithotomy ureteric ridge at the lateral corners of the trigone. They
position, and preparation and draping is performed can be visualized by gently rotating the cystoscope.
in the same fashion as for gynecologic procedures. The flow from the ureteral orifices can be visualized
A rigid cystourethroscope is made up of a sheath, easier by using indigo carmine: 5 ml of indigo
a bridge, and a telescope. The lubricated curved carmine is injected intravenously and, as this dye is
sheath is placed over the cystoscope. It is introduced excreted into the urine, flow from the ureteral orifice
into the urethra and passed through into the bladder can be confirmed. Lack of flow from one ureteral
under direct visualization while inspecting the orifice after several minutes may suggest ureteral
urethra. A light source attaches to the scope to allow obstruction. Flow will still be present if there is
for visibility. The telescope that is placed into the partial obstruction, but comparing the ureteral jets
sheath has an ocular lens that magnifies the image. between the two orifices may help determine if there
The common viewing angles of the telescope are 0°, is ureteral compromise on one side.
30°, and 70°. For gynecologic applications, a 30°
rigid cystoscope is most often used for diagnostic After identifying both ureteral orifices, the rest of the
procedures. bladder can be inspected. Cystoscopy is often per-
formed to detect direct invasion of malignant disease
With a 30° scope, the urethra, which is approximately into the bladder. With the rotation of the scope, the
4 cm in women, can be inspected as the cystoscope is lateral walls can be inspected. The dome of the blad-
being passed into the bladder. The size range of the der is then visualized. The dome may be identified by
cystoscope for gynecologic procedures is from 17 to the air bubbles within the bladder. The scope is then
24F. Initially, the telescope can be removed, and urine rotated 90° to visualize completely the anterior wall.
drained and collected from the sheath and sent for The normal urothelium of the bladder is yellow and
cytology. It is often better to drain the bladder, as submucosal blood vessels are visible. The bladder
concentrated urine can hinder the view. The sheath walls are inspected for gross lesions or for areas of
has inflow and outflow ports. Irrigation fluid is irregularity in the wall. Invasive malignant tumors
also attached to the cystoscope and used to fill and appear usually sessile or nodular. Invasive cancers
distend the bladder. The fluid can be normal saline or can also cause ulceration of the mucosa. Superficial
a non-conductive fluid such as glycine when electro- primary bladder tumors are more exophytic. A biopsy
cautery is being used. The bladder should only be of the irregular lesion should be performed. With a
337
338 Atlas of Procedures in Gynecologic Oncology
non-conducting solution, cautery can be used to trachelectomy, and radical parametrectomy. Ureteral
obtain hemostasis at the biopsy site, if needed. stent placement prior to a laparoscopic or vaginal
radical hysterectomy can facilitate the dissection of
Cystoscopy is also used for intraoperative catheter or the ureter and may decrease the rate of ureteral injury.
stent placement before certain procedures. These pro- The cystoscopic bridge has ports to allow for the
cedures include laparoscopic radical hysterectomy, introduction of a catheter or forceps.
a b
a b
Figure 26.5. Technique of tunneling the ureteral catheter into the same opening of the Foley catheter.
The ends of the ureteral catheters extend out through the urethra. A transurethral Foley catheter is inserted into the bladder,
with the ureteral catheters lying adjacent to the Foley catheter. The ends of the ureteral catheters can be tunneled into the
end of the Foley catheter tube to allow for only one drainage bag. A 14G angiocath vascular access device can be inserted
into the Foley tube from inside to out. The needle is removed, leaving the catheter through the tube, which is then used to
guide the ureteral catheter into the urine drainage bag. A separate 14G angiocath vascular access device should be used for
the right and left ureteral catheter. The ureteral catheters are removed at the end of the operative case while leaving the
Foley catheter in place. At the end of the procedure, the irrigating fluid should be removed from the bladder through the
cystoscope. The cystoscope is then removed slowly, with care not to damage the urethra.
Appendix: staging systems
FIGO staging classification: vulva IA1 Stromal invasion no greater than 3 mm in depth
and 7 mm or less in horizontal spread
IA2 Stromal invasion more than 3 mm and not more
0 Carcinoma in situ; preinvasive carcinoma
than 5 mm in depth, with a horizontal spread of
I Tumor confined to vulva or vulva and perineum;
7 mm or less
2 cm or less in greatest dimension; nodes are
IB Clinically visible lesion confined to the cervix
negative
or microscopic lesion greater than IA2
IA Stromal invasion no greater than 1 mm
IB1 Clinically visible lesion 4 cm or less in greatest
IB Stromal invasion greater than 1 mm
dimension
II Tumor confined to vulva or vulva and perineum;
IB2 Clinically visible lesion more than 4 cm in great-
more than 2 cm in greatest dimension; nodes are
est dimension
negative
II Tumor invades beyond cervix but not to pelvic
III Tumor of any size with adjacent spread to the
wall or to lower third of the vagina
lower urethra, vagina, or the anus and/or with
IIA Without parametrial invasion
unilateral regional lymph node metastasis
IIB With parametrial invasion
IVA Tumor invades upper urethra, bladder mucosa,
III Tumor extends to pelvic wall and/or involves
rectal mucosa, or pelvic bone and/or bilateral
the lower third of the vagina and/or causes
regional node metastases
hydronephrosis or nonfunctioning kidney
IVB Distant metastasis
IIIA Tumor involves lower third of vagina; no exten-
sion to pelvic wall
IIIB Tumor extends to pelvic wall and/or causes
FIGO staging classification: vagina hydronephrosis or nonfunctioning kidney
IV Carcinoma has extended beyond the true pelvis
or has clinically involved the mucosa of the
0 Carcinoma in situ; intraepithelial carcinoma
bladder or rectum
I Tumor confined to vaginal wall
IVA Tumor invades mucosa of bladder or rectum
II Tumor involves subvaginal tissues but does not
and/or extends to adjacent organs
extend to pelvic wall
IVB Distant metastasis
III Tumor extends to pelvic wall
IVA Tumor invades mucosa of bladder or rectum
and/or extends beyond the true pelvis
IVB Distant metastasis FIGO staging classification:
corpus uteri
FIGO staging classification: I Tumor confined to corpus uteri
IA Tumor limited to endometrium
cervix uteri IB Tumor invades up to or less than one half of the
myometrium
0 Carcinoma in situ; intraepithelial carcinoma IC Tumor invades more than one half of the
I Carcinoma confined to the cervix (extension to myometrium
corpus should be disregarded) II Tumor invades cervix but does not extend
IA Invasive carcinoma diagnosed only by micros- beyond uterus
copy (all macroscopically visible lesions—even IIA Endocervical glandular involvement only
with superficial invasion—are Stage IB) IIB Cervical stromal invasion
341
342 Appendix
III Local and/or regional spread IB Tumor limited to both ovaries; capsule intact,
IIIA Tumor involves serosa and/or adnexa (direct no tumor on ovarian surface; no malignant cells
extension or metastasis) and/or cancer cells in in ascites or peritoneal washings
ascites or peritoneal washings IC Tumor limited to one or both ovaries with any
IIIB Vaginal involvement (direct extension or of the following: capsule ruptured, tumor on
metastasis) ovarian surface; malignant cells in ascites or
IIIC Metastasis to pelvic and/or paraaortic lymph peritoneal washings
nodes II Tumor involves one or both ovaries with pelvic
IVA Tumor invades bladder mucosa and/or bowel extension
mucosa IIA Extension and/or implants on uterus and/or
IVB Distant metastasis (including intraabdominal tube(s)
and/or inguinal lymph nodes) IIB Extension to other pelvic tissues
IIC Pelvic extension with any of the following:
capsule ruptured, tumor on ovarian surface;
FIGO staging classification: malignant cells in ascites or peritoneal
washings
fallopian tube III Tumor involves one or both ovaries with
peritoneal metastasis outside the pelvis and/
0 Carcinoma in situ or retroperitoneal or inguinal lymph node
I Tumor confined to fallopian tube(s) metastasis
IA Tumor limited to one tube, without penetrating IIIA Microscopic peritoneal metastasis beyond
the serosal surface pelvis
IB Tumor limited to both tubes, without penetrating IIIB Macroscopic peritoneal metastasis beyond pelvis
the serosal surface 2 cm or less in greatest dimension
IC Tumor limited to one or both tube(s) with exten- IIIC Peritoneal metastasis beyond pelvis more than
sion onto or through the tubal serosa, or with 2 cm in greatest dimension and/or positive
malignant cells in ascites or peritoneal washings retroperitoneal or inguinal lymph nodes
II Tumor involves one or both fallopian tube(s) IV Distant metastasis (excludes peritoneal metasta-
with pelvic extension sis) including liver parenchyma or malignant
IIA Extension and/or metastases to uterus and/or pleural effusion, which must be cytologically
ovaries positive
IIB Extension to other pelvic structures
IIC Pelvic extension with malignant cells in ascites
or peritoneal washings
III Tumor involves one or both fallopian tube(s)
with peritoneal implants outside the pelvis and/
FIGO staging classification:
or positive retroperitoneal or inguinal nodes gestational trophoblastic disease
IIIA Microscopic peritoneal metastasis outside the
pelvis I Disease confined to uterus
IIIB Macroscopic peritoneal metastasis outside the II Disease outside of uterus but is limited to the
pelvis 2 cm or less in greatest dimension genital structures—vagina, ovary, broad ligament,
IIIC Peritoneal metastasis more than 2 cm in greatest and fallopian tube—by metastasis or direct
dimension and/or positive retroperitoneal or extension
inguinal lymph nodes III Disease extends to the lungs with or without
IV Distant metastasis (excludes peritoneal metasta- known genital tract involvement
sis) including liver parenchyma or malignant IV All other metastatic sites
pleural effusion, which must be cytologically
positive
Substages assigned for each stage as follows:
A. No risk factors present
FIGO staging classification: ovary B. One risk factor
C. Both risk factors
I Growth limited to the ovaries
IA Tumor limited to one ovary; capsule intact, no Risk factors used to assign substages:
tumor on ovarian surface; no malignant cells in 1. Pretherapy serum hCG >100,000 mIU/ml
ascites or peritoneal washings 2. Duration of disease >6 months
Appendix 343
Score
Prognostic factor 0 1 2 4
Note: The identification of an individual patient’s stage and risk score will be expressed by allotting a Roman numeral to the stage and
an Arabic numeral to the risk score, separated by a colon. Total score is interpreted as follows: low risk, 0–4; intermediate risk, 5–7;
high risk, ≥8.
Index
ABC see argon-beam coagulator bowel securing 261
abdominal distention 62, 297 adhesions see adhesions clitoris, base of 46
abdominal inspection anastomosis 72–3, 82–3, 138 colon
laparoscopic procedures 156, 240–1, 272 carcinomatosis 61 mobilization 75
open surgical procedures 2–4, 59–62 distention 59 opening 72, 78, 113
abdominal sacral resection 141, 142 nodules, second-look laparoscopy 241 transection 75, 98
accessory obturator vein (anastomotic obstruction see intestinal obstruction see also sigmoid colon; transverse colon
pelvic vein) 18, 168, 191 resection 57, 60, 61, 67–86 colorectal anastomosis 72–3, 138
adductor longus muscle 50 see also large intestine; small intestine colostomy, end 74–9, 138
adhesions brachytherapy 321–35 completion 79
advanced ovarian cancer 61 high-dose-rate (HDR) 323, 324–5, 330, fashioning 76–8
second-look laparoscopy 237, 241–2 335 site positioning 62, 74, 76
sigmoid, laparoscopic lysis 162, 184 interstitial 321, 331, 331–3 sizing 77
anastomotic pelvic vein 18, 168, 191 intravaginal (IVRT) 321, 321–4 Colpo-Pneumo Occluder 272, 274
anterior exenteration 93 low-dose-rate (LDR) 324 colpotomy
anterior longitudinal ligament 122 tandem intracavitary 321, 324–5, 325–30 laparoscopic staging 177
anterior rectus fascia 76 broad ligament radical abdominal trachelectomy 131–2
anterior spinous ligament 88, 121 laparoscopic staging 163, 172, 173, 179 robotically assisted laparoscopic
antibiotic prophylaxis, robotically assisted laparoscopic surgery 284–5
panniculectomy 126, 127 surgery 279, 281 common femoral vein 51
aorta 117, 118 Brunschwig, Alexander 93 common iliac artery 117
extraperitoneal lymph node extraperitoneal lymph node
dissection 252, 255 Camper’s fascia 50 dissection 252, 253, 255
retroperitoneal lymph node carcinomatosis 61, 240 radical abdominal hysterectomy 37
dissection 120, 121, 122 carcinosarcoma, endometrial 1 retroperitoneal lymph node
robotically assisted lymph node cardinal ligaments 10, 179 dissection 120
dissection 275, 276, 277 carotid artery 311 staging procedures 19, 157, 162
see also paraaortic lymph node cecum, continent urinary diversion 110–11 common iliac lymph nodes 96, 118
dissection central venous access, long-term 315, common iliac node dissection
appendectomy 1, 28–32 315–20 extraperitoneal laparoscopic 253
appendiceal artery 29 central venous catheter placement 309, laparoscopic radical hysterectomy 188
appendix 28 310–14 surgical staging 18, 19
continent urinary conduit 109, 111–15 cerclage, cervical 133, 231–2 common iliac vein
tunneling 112 cervical cancer extraperitoneal lymph node
argon-beam coagulator (ABC) 181 brachytherapy 321, 324, 331 dissection 253
laparoscopic radical hysterectomy 184, chemoradiation 33, 181 laparoscopic staging 161
186, 192, 193, 198 extended pelvic resection 137 surgical staging 19, 23
laparoscopic staging 160, 162, 163, 164, extraperitoneal lymph node computed tomography (CT) 249, 329, 333
166, 167 dissection 249–55 cribriform fascia 51
ascending colon, continent urinary laparoscopic radical hysterectomy C-Trak laparoscopic sentinel lymph node
diversion 109, 113–14 181–208 probe 291
ascites 62–3 pelvic exenteration 93–4, 94 cul-de-sac see pouch of Douglas
abdominal distention 62, 297 radical abdominal hysterectomy 33–43 cystoscopes 337, 338
drainage at laparotomy 63 radical abdominal trachelectomy 129–35 cystourethroscopy (cystoscopy) 337–8, 338
paracentesis 295, 295–300 radiotherapy 33, 34, 181, 249 laparoscopic radical hysterectomy 183–4
PEG tube placement 303 robotically assisted laparoscopic ureteral catheterization 338, 338–9
Avitene 91 surgery 272, 273 cytoreduction
azygos vein 252 sentinel lymph node mapping 130, intrathoracic 262
289–90, 289–92 surgical see surgical cytoreduction
Balfour retractor 4 staging 153, 341
biopsies vaginal radical hysterectomy 209–20 Dargent, Daniel 129, 153, 209, 221
second-look procedures 237, 240–3 vaginal radical trachelectomy 221–35 Dargent operation see vaginal radical
staging procedures 27, 171 cervicovaginal artery, vaginal radical trachelectomy
video-assisted thoracoscopic surgery 264 trachelectomy 229 daVinci S Surgical System 271, 273
bladder cervix deep circumflex iliac vein
cystoscopic inspection 337–8 dilators 326 pelvic exenteration 96
laparoscopic radical hysterectomy 185, injection, vaginal hysterectomy 175 radical hysterectomy 37, 38, 189
186 posttrachelectomy 235 staging procedures 18, 165
laparoscopic staging 174–5 vaginal radical trachelectomy 224, 230 descending colon, reflection 21
pelvic exenteration 100 chemoradiation, cervical carcinoma 33, diaphragm
radical abdominal hysterectomy 33, 39 181 biopsy, second-look laparoscopy 243
robotically assisted laparoscopic chemotherapy ovarian tumor implants 62, 64
surgery 282 intraperitoneal 237, 238, 243–8 stripping 64–6
surgical staging 8 surgical cytoreduction and 57 dilators, cervical 326
vaginal radical hysterectomy 214–15, chest radiographs dorsal pancreatic artery 267
216 central venous catheters 309, 314 ‘doughnuts’ 73
vaginal radical trachelectomy 225–7 chest tube drainage 262, 262 drains, surgical
blue dye lymph node mapping malignant pleural effusions 257–8 laparoscopic radical hysterectomy 182
cervical cancer 290, 290 chest tube 257–62 panniculectomy 126, 127
vulvar cancer 54, 55 management 262, 262 radical abdominal hysterectomy 34
Bookwalter retractor 4, 125 placement 258–60 duodenum, mobilization 120, 276
346 Index
endocervix, length of residual 232 radical vaginal trachelectomy 34, 129, iliacus muscle, resection 139
endometrial carcinoma 221–35 immunizations 267
brachytherapy 321, 324, 331 FIGO staging systems 341–2 implantable venous access ports,
laparoscopic radical hysterectomy 181 Fletcher–Suit applicator 324 placement 315, 315–20
laparoscopic staging 153 fluid administration, during incisions
panniculectomy for morbid obesity 123 paracentesis 295, 300 hand-assisted laparoscopic
pelvic exenteration 94 fluoroscopy, during brachytherapy 322, splenectomy 268
radical abdominal hysterectomy 33 324, 328, 332 inguinofemoral lymphadenectomy 50
robotically assisted laparoscopic free tissue transfer 145 panniculectomy 124
surgery 275 frozen section, trachelectomy pelvic exenteration 101
sentinel lymph node mapping 292, specimen 234 radical abdominal hysterectomy 33
292–3 retroperitoneal lymph node
staging classification 341–2 gamma probe 53, 291 dissection 119
surgical cytoreduction for recurrent 58 gastrocolic ligament second-look laparoscopy 239
surgical staging 1, 2–32 ovarian cancer involving 60 stoma site 76
endometrium splenectomy 88 surgical cytoreduction 58, 62–3, 74
assessing, uterine specimen 13 transection 25, 170 surgical staging 2
curettage 133 gastroepiploic artery 26, 267, 269 vaginal hysterectomy 176
endoscope, robotic 273 gastrointestinal anastomosis (GIA) vaginal radical hysterectomy 213
endoscopy, gastrostomy tube stapler 75 vaginal radical trachelectomy 223
placement 304 gastrosplenic ligament 89 video-assisted thoracoscopic surgery 263
EndoStitch device 202–6 gastrostomy (PEG) tube placement 303–8, vulvectomy 45, 48
endotracheal tube, double lumen 263 303–8 Indiana pouch 93, 109
end-to-end anastomosis (EEA) stapler 73 gauze sponge, laparoscopic indigo carmine 337
enteromesenterotomy 80 procedures 157, 195 inferior epigastric artery 149, 154, 189
enterotomy 106 genitofemoral nerve inferior gluteal vessels 142
epinephrine 124, 213, 223 laparoscopic procedures 187, 253, 287 inferior mesenteric artery (IMA)
exenteration, pelvic see pelvic exenteration laparotomy procedures 15, 37 extraperitoneal lymph node
extended pelvic resection 137–43 Gerota’s fascia 66 dissection 252
abdominal sacral resection 141, 142 gestational trophoblastic disease (GTD) laparoscopic staging 160, 161, 162
iliacus muscle and femoral nerve 139 staging classification 342 retroperitoneal lymph node
superior pubic rami resection 139–41, WHO prognostic index score 343 dissection 117, 119, 120, 121–2
139–41 gluteus maximus muscle 142 robotically assisted laparoscopic
external iliac artery gracilis myocutaneous flap 145 surgery 277
extraperitoneal lymph node indications 102, 145 surgical cytoreduction 67
dissection 253 technique 146, 146–7 surgical staging 20, 21, 23
laparoscopic radical hysterectomy 185, great saphenous vein 51, 52 inferior vena cava (IVC)
187 GTD see gestational trophoblastic disease anatomy 117
laparoscopic staging 164, 165, 167, 168 duplicated 18, 37
pelvic exenteration 96, 98 hand-assisted laparoscopic extraperitoneal lymph node
robotically assisted laparoscopic splenectomy 267–70, 268–9 dissection 254, 255
surgery 279, 287, 288 Harrison–Anderson–Mick (HAM) laparoscopic staging 158–9
vaginal radical hysterectomy 210 applicator 333, 334–5 retroperitoneal lymph node
external iliac lymph node dissection Hartmann pouch 77 dissection 120
laparoscopic radical hysterectomy 187–9 hemoclips 40, 181 robotically assisted laparoscopic
laparoscopic staging 164–6 Henschke applicator 324, 328 surgery 277
radical abdominal hysterectomy 37 hepatectomy, partial 58 surgical cytoreduction 66
surgical staging 14–15 hepatorenal recess 66 surgical staging 20
external iliac lymph nodes 118 high-dose-rate (HDR) brachytherapy 323, vascular pitfalls 20
sentinel 291–2 324–5, 330, 335 infundibulopelvic (IP) ligament
external iliac vein hypogastric lymph nodes, sentinel 291–2 extended pelvic resection 137–8
laparoscopic radical hysterectomy 185 hypogastric vessels 97, 194 laparoscopic radical hysterectomy
laparoscopic staging 165–6, 167, 168 hysterectomy 192, 193
pelvic exenteration 96, 98 classification 34 laparoscopic staging 163, 172–3
external oblique aponeurosis 50 class II (modified radical) 33, 34, 41 radical abdominal trachelectomy 131
external pudendal artery 51 class III (radical) 33, 34, 41 robotically assisted laparoscopic
extraperitoneal lymph node laparoscopic see laparoscopic surgery 279, 280–1
dissection 249–55 hysterectomy surgical staging 5, 6, 7
marking lower limits 255 laparoscopic radical see laparoscopic inguinofemoral lymphadenectomy 45,
marsupialization of peritoneum 255 radical hysterectomy 50–2
paraaortic nodes 252–5 modified posterior exenteration 67–73 inguinofemoral lymph nodes, sentinel
psoas muscle 251 panniculectomy to facilitate 123, 125 biopsy 53–6
trocar/port placement 249–51 radical abdominal see radical abdominal interaortocaval lymph node dissection
hysterectomy 88, 121
falciform ligament 119 robotically assisted 272, 278–85 extraperitoneal approach 254
fallopian tube surgical staging 5–13 laparoscopic 160
cancer, staging classification 342 intercaval lymph nodes 118
laparoscopic radical hysterectomy 193 ileal conduit 93, 94, 105–8 internal iliac artery
laparoscopic staging 163, 172, 173 ileocecal valve, continent urinary extraperitoneal lymph node
robotically assisted laparoscopic diversion 109 dissection 253
surgery 279, 285 ileostomy 79–86 robotically assisted laparoscopic
‘fellow’s vein’ 20, 120, 159 checking stoma patency 86 surgery 280
femoral artery 51, 52 completed 85 vaginal radical hysterectomy 210
femoral nerve 51, 139 creation 84–5 internal iliac node sampling 18
femoral triangle 52 ileum internal iliac vein, laparoscopic radical
femoral vein 51, 52 continent urinary diversion 109, 114 hysterectomy 186
fertility-sparing surgery defunctionalized segment 105 internal iliac vessels
radical abdominal trachelectomy 129–35 opening 106 extended pelvic resection 138
Index 347
pelvic exenteration 96, 97 see also rectum; sigmoid colon; laparoscopic staging 167–8
radical abdominal hysterectomy 39 transverse colon radical abdominal hysterectomy 38
internal jugular (IJ) vein lateral aortic lymph nodes 117, 118 robotically assisted laparoscopic 288
central venous catheter placement 309, extraperitoneal approach 253 surgical staging 16–17
310–14 lateral caval lymph nodes 159, 254 obturator lymph nodes, sentinel 291–2
Mediport placement 315–20 laterally extended endopelvic resection obturator nerve
internal pudendal vessels 46 (LEER) 137–8 laparoscopic radical hysterectomy 185,
intestinal obstruction LAVRH see laparoscopically assisted 190, 191
end colostomy 74, 79 vaginal radical hysterectomy laparoscopic staging 167, 168
gastrostomy tube placement 303 left colic artery 67, 98 laparotomy procedures 16, 38
recurrent ovarian cancer 58, 59, 61 lesser sac 268 robotically assisted laparoscopic
intestine see bowel lidocaine 259 surgery 288
intraoperative radiation therapy lienorenal ligament 268 vaginal radical hysterectomy 210
(IORT) 321, 333 LigaSure device 26, 102 obturator space 16, 17, 166–8, 190
intraperitoneal (IP) catheter placement 237, linear accelerator 333 obturator vein 167
238, 243–8 liver, mobilization 64, 66 omental ‘cake’ 59, 60
intravaginal brachytherapy (IVRT) 321, local anesthesia omental pedicle flap 108, 138
321–4 chest tube placement 259 omentectomy 24–7
intravenous fluids, during paracentesis 295, paracentesis 298 gastrocolic 59
300 PEG tube placement 305 infracolic 24–6
ischiorectal fossa 138 low anterior resection 67–73 laparoscopic 153–4, 169–71
isodose curves 330 low-dose-rate (LDR) brachytherapy 324 omentum
isosulfan blue lower uterine segment, measuring 132 infracolic 24
adverse effects 290 lumbar arteries 117, 118, 121 ovarian cancer involving 59–60
cervical cancer 290, 290 lumbar veins 117, 118, 120 oophorectomy see salpingo-oophorectomy
vulvar cancer 54, 55 Lymphazurin see isosulfan blue osteotome 140
lymph node disease ovarian arteries 117
KOH Colpotomizer System 272, 274, 278 radical abdominal trachelectomy 130 extraperitoneal lymph node
recurrent 86–8 dissection 253, 254
laparoscopically assisted vaginal radical lymph node dissection retroperitoneal lymph node
hysterectomy (LAVRH) 209–20 extraperitoneal 249–55 dissection 120, 121
anatomical relationships 211 laparoscopic staging 153, 154, 157–68 ovarian cancer
dissection of right ureter 216–17 radical abdominal hysterectomy 34, 37–8 abdominal survey 59–62
laparoscopic preparation 210 recurrent ovarian cancer 86–8 chest tube placement 257, 258–62
parametrium 218–19 retroperitoneal 117–22 hand-assisted laparoscopic
pelvic spaces 210, 214–15 second-look laparoscopy 237–8 splenectomy 267–70, 268–9
specimen 220 surgical staging 1, 13–23 intraperitoneal catheter placement 237,
specimen removal and closure 219–20 vulvar cancer 45, 50–2 238, 243–8
vaginal portion 211–14 see also paraaortic lymph node laparoscopic staging 153
laparoscopic extraperitoneal lymph node dissection; pelvic lymphadenectomy malignant pleural effusions 257, 257–8,
dissection 249–55 lymphoceles 255 262
laparoscopic hysterectomy lymphoscintigraphy mucinous tumors 1
robotically assisted 272, 278–85 cervical cancer 289, 289 palliation of persistent/recurrent 58
surgical staging 171–80 vulvar cancer 53–6 paracentesis 295, 295–300
laparoscopic radical hysterectomy 34, pelvic mass 2
181–208 magnetic resonance imaging (MRI) 221 second-look laparoscopy 237–8,
cystoscopy 183–4 marsupialization, peritoneal 255 239–43
opening the spaces 184–6 medial circumflex femoral artery 146 staging classification 342
parametrial dissection 197–9 medial umbilical ligament 185, 280 surgical cytoreduction 57–8, 59–91
pelvic lymphadenectomy 187–92 Mediport placement 315, 315–20 surgical staging 1, 2–32
robotically assisted 272, 283–4 Mega needle driver 273 video-assisted thoracoscopic surgery
specimen 207 mesentery (VATS) 262, 263–4
specimen removal 199–201 appendiceal 28 ovarian veins
uterine artery and adnexa 192–5 colonic 75 anatomy 117, 118
uterosacral ligament 195–7 small bowel 80, 81 extraperitoneal lymph node
vaginal cuff closure 202–6 mesh, delayed absorbable 108 dissection 255
laparoscopic splenectomy, hand- mesorectal excision 99 laparoscopic staging 159
assisted 267–70, 268–9 methylene blue 290, 290 lymph nodes 118
laparoscopic staging 153–80 Miami pouch 93, 109 retroperitoneal lymph node
entering abdomen, survey and middle sacral artery 117 dissection 121
washings 154–6 mucinous ovarian tumors, surgical staging 20, 22, 23
laparoscopic portion of appendectomy 1, 28–32 ovaries
hysterectomy 171–5 mucous fistula 77, 79 laparoscopic radical hysterectomy 182,
paraaortic lymphadenectomy 153, 154, myocutaneous flap reconstruction 102, 192–3, 206
157–62 145–51 laparoscopic staging 173
pelvic lymph node dissection 163–8 surgical removal see salpingo-
robotically assisted 275 needle drivers 273 oophorectomy
vaginal portion of hysterectomy neovagina construction see vaginal transposition out of pelvis 34,
175–80 reconstruction 182, 206
laparotomy
cytoreduction see surgical cytoreduction obesity, morbid 123, 182 Paget’s disease of vulva 48
second look 237 obstetric outcome, vaginal radical palliative surgery 58, 93
surgical staging see surgical staging trachelectomy 221, 222, 222 pancreas, retroperitoneal lymph node
large intestine obturator artery 167, 210 dissection 120
carcinomatosis 61 obturator internus muscle 95, 138, 167, pancreatectomy, distal 90, 91
obstruction 74 168, 191 panniculectomy 123–7
resection 67–79 obturator lymph node dissection infraumbilical 124
laparoscopic radical hysterectomy 190–1 supraumbilical 124
348 Index
paraaortic lymph node dissection 117, laparoscopic radical vaginal radical trachelectomy 227, 231
120–2 hysterectomy 187–92 preaortic lymph nodes 117, 118, 254
extraperitoneal (laparoscopic) 249–55 laparoscopic staging 163–8 precaval lymph nodes 118, 159, 254
laparoscopic staging 153, 157–62 radical abdominal hysterectomy 34, 37 pregnancy, after vaginal radical
radical abdominal trachelectomy 130 radical abdominal trachelectomy 130 trachelectomy 221, 222, 222
recurrent ovarian cancer 87–8 robotically assisted laparoscopic 287–8 presacral lymph nodes 118
robotically assisted laparoscopic 276–8 surgical staging 13–18 presacral space
surgical staging 1, 19–23 pelvic mass pelvic exenteration 99, 100
paraaortic lymph nodes pelvic exenteration 95 surgical cytoreduction 67, 68
anatomy 117, 118 surgical cytoreduction 61, 74 psoas muscle
inspection/sampling 33, 96 surgical staging 2, 4–5 extraperitoneal lymph node
recurrent disease 86–7 pelvic sidewall dissection 251, 253
paracaval lymph nodes 20, 118 extended pelvic resection 137, 138 laparoscopic radical hysterectomy 187
paracentesis 295–301 pelvic exenteration 94, 95, 96 robotically assisted laparoscopic
equipment/kits 296 surgical staging 5 surgery 277
indications 295, 295 vaginal radical hysterectomy 210 staging procedures 18, 168
technique 297–300 pelvic spaces pubic bone, resection 139–41, 139–41
paracolpos laparoscopic radical hysterectomy 184–6
radical abdominal trachelectomy 131 pelvic exenteration 96 radiation therapy 321
vaginal radical hysterectomy 218 radical abdominal hysterectomy 33, cervical carcinoma 33, 34, 181, 249
vaginal radical trachelectomy 227 35–6 extraperitoneal lymph node dissection
parametrium robotically assisted laparoscopic and 249
hysterectomy classification and 33, 34 surgery 280 intraoperative (IORT) 321, 333, 334–5
laparoscopic radical vaginal radical hysterectomy 210, pelvic exenteration and 94
hysterectomy 197–9, 207 214–15 see also brachytherapy
radical abdominal hysterectomy 33, 35, vaginal radical trachelectomy 224–6 radical abdominal hysterectomy 33–43
41, 42 pelvic vein, anastomotic 18, 168, 191 advanced ovarian cancer 61
radical abdominal trachelectomy 131, pelvis, laparoscopic inspection 155 alternatives to 34, 129, 209
132 Penn pouch, modified 93, 94, 109–15 anatomic relationships 211
robotically assisted laparoscopic percutaneous endoscopic gastrostomy bladder mobilization 33, 39
surgery 284 (PEG) tube placement 303–8, 303–8 developing pelvic spaces 33, 35–6
sentinel lymph node mapping 292 perineum division of vagina 41
vaginal radical hysterectomy 210, pelvic exenteration 101–3 incisions 33
218–20 reconstruction see pelvic floor lymph node dissection 34, 37–8
vaginal radical trachelectomy 228, 229 reconstruction pelvis after specimen removal 42
pararectal space peritoneal carcinomatosis 240 rectovaginal space 40
laparoscopic radical hysterectomy 186 peritoneal washings specimen 42
pelvic exenteration 96, 97 second-look procedures 237, 240 unroofing ureter 33, 36, 40
radical abdominal hysterectomy 35, 36 staging procedures 3, 156 uterine artery 33, 36, 39–40, 42
radical abdominal trachelectomy 131 peritonectomy, diaphragm 64 uterosacral ligaments 33, 41
robotically assisted laparoscopic peritoneum radical abdominal trachelectomy 129–35
surgery 280 laparoscopic entry 157 extent of surgery 130
vaginal radical hysterectomy 210, 218 marsupialization 255 sentinel lymph node mapping 291–2
vaginal radical trachelectomy 228 nodules, second-look laparoscopy 240 technique 131–4
paravesical space pelvic 6, 13 radical laparoscopic hysterectomy see
laparoscopic radical hysterectomy 185 rectovaginal 40 laparoscopic radical hysterectomy
pelvic exenteration 96, 97 surgical entry 63 radical vaginal hysterectomy see vaginal
radical abdominal hysterectomy 35–6 vesicouterine see vesicouterine radical hysterectomy
radical abdominal trachelectomy 131 peritoneum radical vaginal trachelectomy see vaginal
robotically assisted laparoscopic pleural effusions, malignant 257 radical trachelectomy
surgery 279, 280 chest radiographs 257–8 radiographs
vaginal radical hysterectomy 210, 215 chest tube drainage 257, 258–62 brachytherapy 328–9, 332
vaginal radical trachelectomy 225, 228 video-assisted thoracoscopic surgery see also chest radiographs; fluoroscopy
PEG see percutaneous endoscopic (VATS) 262, 263–4 reconstructive procedures see pelvic floor
gastrostomy pleurodesis 262, 264 reconstruction; vaginal reconstruction
pelvic exenteration 93–115, 137 pleuroscopy see video-assisted rectal sizers 72
anterior 93 thoracoscopic surgery rectosigmoid resection
continent urinary diversion 93, pneumothorax 262, 309 pelvic exenteration 98–9
109–15 positioning, patient surgical cytoreduction 67–73
indications 93, 94 brachytherapy 323 rectouterine pouch see pouch of Douglas
infralevator 93 central venous catheter placement 310 rectovaginal septum, laparoscopic radical
lateral approach 95 hand-assisted laparoscopic hysterectomy 196
non-continent urinary diversion 93, splenectomy 268 rectovaginal space, radical abdominal
105–8 inguinofemoral lymphadenectomy 50 hysterectomy 40, 41
pelvic defect 103 radical vaginal hysterectomy 212 rectum
pelvic phase 96–100 retroperitoneal lymph node distal stump 77
perineal phase 101–3 dissection 119 extended pelvic resection 138
posterior 67–73, 93 robotically assisted laparoscopic low anterior resection 67–73
reconstruction after 93, 102, 145–51 surgery 272, 275 rectus abdominis flap 102, 145, 148–51
specimen 104 surgical cytoreduction 58 rectus abdominis muscle, stoma
supralevator 93, 99 video-assisted thoracoscopic surgery 263 creation 76, 108
total 93 posterior exenteration 93 renal arteries
see also extended pelvic resection modified 67–73 accessory 20
pelvic floor reconstruction 102, 145–51 posterior femoral cutaneous nerve 95 anatomy 117, 119
extended pelvic resection 138 pouch of Douglas (cul-de-sac) extraperitoneal lymph node
gracilis flap 146, 146–7 laparoscopic radical hysterectomy 195 dissection 252
vertical rectus abdominis flap 148–51 vaginal hysterectomy 177 retroperitoneal lymph node
pelvic lymphadenectomy vaginal radical hysterectomy 218 dissection 121, 122
Index 349