Oncology Patients With Exploratory Laparotomy
Cylinders for Intracavitary
of Uterine Afterloading Applicators
for Intracavitary Radiation Therapy
Injection of Chromic Phosphate
Omental Pedicle "J"
With Bilateral Inguinal
Lymph Node Dissection
Vulva With Gracilis Myocutaneous Flaps
Flap and Vertical Rectus
Bilateral Pelvic Lymph
Node Dissection and With Extension of the Vagina
"J" Pouch Rectal
Omental "J" Flap
Continent Urostomy (Miami Pouch)
Gracilis Dynamic Anal
System Versus Skin Grafting
Pelvic Flap for
Augmentation of Continent Urostomy or Neovagina
of Hemorrhage in Gynecologic Surgery
of the Punctured
of a Lacerated
Internal Iliac Vein and
Suturing of a Lacerated Common Iliac Artery
Suspension of the Vagina
Not to Do in Case of Pelvic Hemorrhage
Associated With Abdominal Pregnancy
Staging of Gynecologic Oncology Patients With
Modern gynecologic oncology demands accurate staging of cancer patients
in order to determine the most effective method of treatment. The noninvasive
techniques formerly required for staging are being expanded to include
extensive exploratory laparotomy. A significant percentage of patients
may have more advanced disease than was noted with noninvasive clinical
Surgical staging as described in this section is of particular value
in ovarian and endometrial carcinoma. Its role in epidermoid carcinoma
of the cervix remains debatable at this time. The debate is not whether
additional information can be gained; it can. The question is whether
the overall end results warrant the additional morbidity associated
with total pelvic and aortic irradiation following this type of surgical
staging. Since it is particularly important for the surgeon to search
under the diaphragm and to explore the aorta up to the level of the
renal vessels, the Pfannenstiel incision is not advised.
The purpose of the operation is to gain detailed knowledge of the extent
of metastasis of the pelvic malignancy.
Physiologic Changes. The most significant physiologic
change is adhesion formation secondary to the procedure. This has an
adverse effect if one contemplates total pelvic and aortic irradiation
or intraperitoneal therapy. The adhesions fix the intra-abdominal structures,
such as the bowel, thereby giving them maximum irradiation. Adhesions
form pockets and block diffusion of intraperitoneal drugs to their
Points of Caution. It is difficult to perform this
procedure through a lower transverse incision because adequate exposure
to the upper abdomen is compromised.
To adequately expose the renal vessels, the ligament of Treitz and
the third portion of the duodenum frequently require mobilization.
The patient is placed in the supine position
or the dorsal modified lithotomy position with the hips slightly
abducted, the thighs parallel to the floor, and the knees flexed
in obstetric stirrups. The incision should extend from the symphysis
pubis to well above the umbilicus and, in many cases, up to the
initial exploration should start under the diaphragm. This
area should be visualized directly or with the aid of a laparoscope.
If studding is found under either the left or the right diaphragm,
biopsy of the small lesions should be done.
Washings should be obtained from five separate
areas in the abdominal cavity under each diaphragm, in each lateral
colonic gutter, and in the pelvis. These should be sent to the
laboratory for cytopathologic studies.
The exploration of the retroperitoneal space
is begun by excising the peritoneum in the area of the cecum
and terminal ileum.
The peritoneum is incised parallel to the
right common iliac artery. The incision is then advanced up the
aorta until the third portion of the duodenum is encountered.
At the third portion of the duodenum,
the ligament of Treitz is noted and mobilized along with duodenum
to allow adequate exposure to the renal vessels.
Lymph node excision is begun at the level
of the left renal artery and vein, the origin of the right and
left ovarian vessels. Adequate lymph sampling is performed along
the aorta. VC indicates vena cava.
The peritoneum overlying the aorta is closed
with 3-0 synthetic absorbable sutures.
At this point, the oncologic
procedure, whether it be a Wertheim hysterectomy for cervical
carcinoma, tumor debulking for ovarian carcinoma, or extra fascia
hysterectomy for uterine carcinoma, can begin.