A 1
1 Obliterated hypogastric artery B Grasping forceps retracts peritoneum medially Exposure of aortic caval bifurcation Interiliac-external iliac node removal
Sp
Carcinoma of the cervix, stage IVA. There is a large and exophytic adenocarcinoma of the cervix. On this -weighted sagittal image there is direct extension through the posterior wall of the bladder, outlined by high-signal urine arrow . There is also extension into the vagina white arrows and into the rectum curved arrows . B, bladder Colour flow Doppler studies may give some information regarding tumour vascularity, but again there is considerable overlap between the flow characteristics of...
Info Ibo
limiting factor for most patients is the bony confines of the operative field. For instance, a large patient may have a wide and shallow pelvis, making her an acceptable candidate for a radical hysterectomy. This may be determined before the incision by noting the distance between the anterior iliac crests in relation to the distance from the crest to the ischial tubercle. Similarly, for vaginal procedures, emphasis should be placed on the distance between the ischial tubercles and the angle of...
Preoperative management
Before epithelialization is complete an abnormal communication between viscera will tend to close spontaneously, provided that the natural outflow is unobstructed. Bypassing the sphincter mechanisms, for example by urinary catheterization or defunctioning colostomy may encourage closure. The early management is of critical importance, and depends on the aetiology and site of the lesion. If surgical trauma is recognized within the first 24 hours postoperatively immediate repair may be...
procedure
Pelvic side-wall recurrences of cervical cancer are generally considered to be inoperable. If patients suffering from this type of relapse have not been irradiated in the pelvis before, radiotherapy or chemoradiotherapy can lead to remission. However, in about 95 of patients with side-wall recurrences the disease is diagnosed after primary or adjuvant pelvic irradiation, or has not been controlled by radiotherapy. Thus for the majority of patients with side-wall recurrences of cervical cancer...
General principles of surgical treatment
The timing of surgical repair is perhaps the single most contentious aspect of fistula management. While shortening the waiting period is of both social and psychological benefit to patients who are always very distressed, one must not trade these issues for compromise to surgical success. The benefit of delay is to allow slough to separate, and inflammatory change to resolve. In both obstetric and radiation fistulas there is considerable sloughing of tissues, and it is imperative that this...
Contributors
Memorial Sloan-Kettering Cancer Center Department of Obstetrics and Gynaecology Department of Obstetrics and Gynaecology Obstetrics, Gynecology and Reproductive Science Plastic and Reconstructive Surgery Service Memorial Sloan-Kettering Cancer Center Obstetrics, Gynecology and Women's Health University of Minnesota Medical School Department of Gynecological Oncology Ohio State University College of Medicine 1654 Upham Drive, 5th Floor Means Hall University of Rochester Medical Center Department...
Radical abdominal hysterectomy
J Richard Smith Deborah CM Boyle Giuseppe Del Priore Radical abdominal hysterectomy is designed to remove the uterus, cervix, upper third of the vagina, either part or the whole of the parametrium, and the uterosacral and vesicouterine ligaments. In addition, the common iliac, internal iliac, external iliac, obturator, hypogastric and presacral lymph nodes are also removed, as may be the paraaortic nodes. This operation is used for management of Stage IA2 and IB 1 and 2 tumors of the uterine...
Operative procedure Xbd
The flap is dissected with the patient supine or in the lithotomy position. Skin islands may be designed in a wide variety of shapes and orientations as long as a significant portion of the skin and subcutaneous tissues are centered over the muscle. In most cases an elliptical skin island is oriented vertically over the muscle Figure 2 . For vaginal reconstruction, a more transversely oriented skin island may be designed above or below the level of the umbilicus, depending on the placement of...
T7
Omentum flap nourished by the left gastroepiploic vessels. After W.Hanns. H ckel M, Schlenger K, Hamm H, Knapstein PG, Hohenfellner R, R sler HP 1996 Five-year experience with combined operative and radiotherapeutic treatment of recurrent gynecologic tumors infiltrating the pelvic wall, Cancer 77 1918-33. Hurwitz DJ, Swartz WW, Mathes SJ 1981 The gluteal thigh flap a reliable sensate flap for the closure of buttock and perineal wounds, Plast Reconstr Surg 68 521-32. Konerding MA, Gaumann A,...
Bibliography 1
Cosin JA, Carter JR, Paley PJ et al 1997 A simplified method for detubularization in the construction of a continent ileocolic reservoir Miami pouch , Gynecol Oncol 64 436-41. Hartenbach EM, Saltzman AK, Carter JR et al 1995 Nonsurgical management strategies for the functional complications of ileocolonic continent urinary reservoirs, Gynecol Oncol 56 127-8. Kock NG, Nilson AE, Nilsson LO et al 1982 Urinary diversion via continent ileal reservoir clinical results in 12 patients, J Urol 128...
Anatomic considerations Sbk
The two hypogastric internal iliac arteries and the inferior mesenteric artery IMA together supply blood flow to the pelvis, including the buttocks, left colon, and terminal spinal cord. It is a near-absolute requirement that at least one of these three vessels be preserved. The IMA is frequently the least important source of pelvic blood flow every effort should be made, however, to preserve at least one hypogastric artery. Within these guidelines, essentially any other vessel can be ligated...
Operative procedure
Gastrostomy tubes can be placed percutaneously with endoscopic guidance or can be placed at the time of laparotomy. The stomach should be mobile enough to reach the anterior abdominal wall. At laparotomy, a specialized gastrotomy tube, or a Malecot, self-retaining flanged rubber urologic tube can be placed into the abdominal cavity via a left upper quadrant stab incision in the midclavicular line. Two concentric purse-string sutures of delayed absorbable material are placed in the anterior...
Postoperative management
Nursing care of patients who have undergone urogenital fistula repair is of critical importance, and obsessional postoperative management may do much to secure success. As a corollary, however, poor nursing may easily undermine what has been achieved by the surgeon. Strict fluid balance must be kept, and an adequate daily fluid intake should be maintained until the urine is clear of blood. Haematuria is more persistent following abdominal surgery than vaginal procedures, and intravenous fluid...
Info Wlh
1 Origin of connective tissue, detached at lateral pelvic wall 6 Arcus tendineus fasciae pelvis aorta immediately cephalad to the third part, and the inferior mesenteric artery, which leaves the aorta just caudad to this same duodenal section. The gonadal veins, on the other hand, are asymmetric, with the left vein emptying into the left renal vein. Lymphatic drainage parallels the course of the venous blood supply. However, drainage is not always as straightforward as the blood supply. Lymph...
Operative procedure Sai
The best procedure to follow in any unplanned vascular injury is first to control the bleeding with direct pressure this may be accomplished with a finger or by packing with a sponge. Once the bleeding is controlled, get help in terms of both additional staff and specialist advice, when needed and formulate a plan before anything further is done. When dealing with an arterial injury or planned resection and repair, proximal and distal control are vitally important this point cannot be...
Ivb
Distant metastasis or disease outside the true pelvis the tumour Table 1 . As outlined above, conization is suitable management for cervical intraepithelial neoplasia CIN and stage IA1 tumours. It is also probably adequate management for the majority of stage IA2 tumours. Table 2 shows the papers Table 2 Results of pelvic lymphadenectomy in microinvasive carcinomas adapted from Burghardt 1993 lt 5 mm invasion, early stormal invasion excluded Table 2 Results of pelvic lymphadenectomy in...
Pudendal Thigh Flap
Martello JY, Vasconez HC 1995 Vulvar and vaginal reconstruction after surgical treatment for gynecologic cancer, Clin Plast Surg 22 129-40. McCraw JB, Massey FM, Shanklin KD et al 1976 Vaginal reconstruction with gracilis myocutaneous flaps, Plast Reconstr Surg 58 176-83. Tobin GR, Day TG 1988 Vaginal and pelvic reconstruction with distally based rectus abdominis and myocutaneous flaps, Plast Reconstr Surg 83 62-73. Tobin GR, Pursell SH, Day TG Jr 1990 Refinements in vaginal reconstruction...
I
Palliative procedures often have an important part to play in the management of the preterminal stages of this disease and are usually concerned with relieving the effects of intestinal obstruction. The most common of these procedures is the bypass of obstructive loops of small bowel, in which circumstance an ileocolic bypass anastomosis is to be favoured over heroic attempts at mass resection see Chapter 17 . The use of such palliative and salvage surgery can provide a great degree of...
Info Xoq
whom U and M art iht ultrasound and menopausal scores, UItrasoLhnd was nssRsiifiri -for rtif fallowing features Suggestive 0f malignancy evidence of metastases presence of ascites A scars of 0 was giuun where nona of itiese was present t if one was present jnd a scofc of 3 lor two or more. A scorc uf 1 pr 3 was tfiven p pre- or postmenopausal patients respectively. An RM1 ol 200 had a sensitivity or 65 and a specificity of 97 for diagnosing ovarian cancel. The correct staging of ovarian cancer...
Anatomic considerations Ivm
Skin vascularization may be direct or indirect. Direct vessels travel along nerve fibers, between muscles and along fascial planes to enter the skin. Indirect vessels arise from named vessels as perforators of the fascia from the underlying muscle. Free flaps, which require microsurgical anastomoses, depend on the direct vascular supply. Peninsular flaps e.g. advancement flaps may have a well-defined blood supply or depend upon intrafascial and suprafascial blood flow through the preserved skin...
Indications 1
In gynecology, most urinary diversions are performed as part of the reconstructive phase of a pelvic exenteration or because of severe irradiation injury to the bladder. The type of diversion employed depends on the surgeon's preference, the patient's overall health, the prognosis and the patient's ability to perform the tasks necessary to catheterize a continent pouch. The ileal conduit is the simplest diversion to perform. Care must be exercised in patients who have undergone radiotherapy as...
Laparoscopy
This chapter describes the procedures of appendectomy, hysterectomy both standard and radical , omentectomy, palliative end colostomy and lymphadenectomy encompassing both para-aortic and pelvic lymph nodes . Whole textbooks have been devoted to laparoscopic surgery but in line with the 'cookbook' approach of this volume, we believe these procedures are more than adequately described in the following text. Since the first use of laparoscopy for appendectomy by Kurt Semms in Germany and Nezhat...
Operative technique
Two main types of closure technique are applied to the repair of urinary fistulas the classical saucerization technique described by Sims in 1852, and the much more commonly used dissection and repair in layers. Figures 3-7 demonstrate the latter form of repair in a posthysterectomy vault fistula. Tissue forceps or traction sutures are applied to bring the fistula more clearly into view, and obtain optimal access for repair. Infiltration with 1 in 200 000 adrenaline helps to reduce bleeding,...
V
Most vulvar incisions can be approximated primarily. Skin grafts or rotational flaps may be indicated if there is inadequate mobilization to allow for a tension-free closure see Chapter 21 . Obliteration of resultant dead space is important, as well as the use of suction drainage. Superficial and deep inguinal lymph node dissection For the superficial node dissection, groin incisions are first introduced 1-2 cm below Poupart's ligament. The superficial inguinal fat pad is then removed,...
Info Bgx
NS Not stated CLS Capillary-like space NS Not stated CLS Capillary-like space published relating to extracervical spread of microinvasive tumours, suggesting that the majority will be adequately managed by conization. Most gynaecologic oncologists would qualify this, depending on whether lymphovascular permeation was present. If it was, they might proceed to a radical hysterectomy and pelvic lymphadenectomy. As can be seen from the table, this practice is not based strictly on evidence. It...
surgery
The procedure of pelvic exenteration was first described in its present form by Brunschwig in 1948. Over the years it has been used mainly in the treatment of advanced and recurrent carcinoma of the cervix. Its primary role at the present time is the management of the numerous patients who develop recurrent cancer of the cervix following primary radiotherapeutic treatment. It has been estimated that between one third and one half of patients with invasive carcinoma of the cervix will have...
W
A stapler is used to transect the round ligament, ovarian ligament and fallopian tube A stapler is used to transect the round ligament, ovarian ligament and fallopian tube The anterior leaf of the broad ligament is dissected Omentum frequently is involved with metastatic lesions whenever there is intra-abdominal spread of cancer. Omentectomy is part of the staging of ovarian cancer and is often performed in treating or staging other gynecologic cancers such as uterine papillary serous...
Interventional techniques in gynaecological malignancy
Where standard routes of analgesic administration have failed, the epidural route using a percutaneous epidural catheter can provide optimal analgesia. The benefits of opioid administration by the spinal route have been acknowledged for some time and there is clear evidence that some patients find epidural analgesia of a higher quality with a diminished incidence of unwanted side effects such as nausea, drowsiness and constipation. Epidural catheters can be inserted percutaneously and brought...
Info Lxb
Right-angle clamps are applied to the vagina far enough caudally to allow removal of the upper third of the vagina Figure 25 . As described above in cases of Stage 2a tumor, the vagina may have been marked with diathermy at the start of the procedure to ensure adequate resection margins are obtained. The vagina is then incised and the uterus with parametrium and upper vagina is then removed. The upper edges of the vagina may be oversewn circumferentially with a locked-on suture to achieve...
Operative procedure Qfq
Preoperative preparation should include a mechanical and antibiotic bowel preparation using a bowel cleansing solution such as Golytely Schwarz Pharma, Inc., Milwaukee, WI, USA , and oral neomycin, erythromycin and an antifungal such as fluconazole. Perioperative antibiotics may also be required. A The flap is then 'unrolled' towards the undamaged ureter and the anastomosis performed. Care must be exercised not to perform the anastomosis too close to the cut edge of the bladder The flap is then...
Radical vaginal trachelectomy
Radical vaginal trachelectomy RVT is a new conservative surgical procedure for the treatment of selected cases of early-stage cervical cancer. It has the advantage of preserving the uterine body, which in turns allows the preservation of childbearing potential. This procedure has been described by Professor Daniel Dargent from Lyon, France. Among the group of more than a hundred women who have undergone this operation, more than 20 healthy babies have been born so far, the majority by elective...
Sigmoidoscopy cystoscopy and stenting
Sigmoidoscopy forms part of the routine examination of patients who complain of colorectal symptoms. Patients presenting with rectal bleeding or a change in bowel habit should undergo either a rigid Sigmoidoscopy followed by a barium enema, or a colonoscopy. In addition, patients presenting with vulval carcinoma extending to the perineum should have anal and rectal assessment. Flexible Sigmoidoscopy can be used to confirm lesions in the distal colon and rectum, to obtain material, and in the...
Radical vaginal hysterectomy
The vaginal approach was first used when surgeons considered treating cancers of the cervix in ways other than by cauterization or similar palliative tools Recamier 1829 . However, at the turn of the nineteenth century the abdominal approach became prevalent, as a consequence of two simultaneous changes. First, even if it was more risky than vaginal surgery, abdominal surgery was no longer a death sentence. Second, the concept of radical surgery, introduced by Halsted in the field of breast...
Investigations
If there is suspicion of a fistula, but its presence is not easily confirmed by clinical examination with a speculum, further investigation will be necessary to confirm or exclude the possibility fully. Even where the diagnosis is clinically obvious, additional investigation may be appropriate for full evaluation prior to deciding treatment. The main principles of investigation therefore are to confirm that the discharge is urinary faecal to establish that the leakage is extraurethral rather...
Info Bim
Established as an independent prognostic indicator Reflects clinical course in gt 90 of CA125 positive tumours recurrence with a sensitivity of 8494 and a false positive rate of lt 2 Initial serum Postoperative levels serum levels As part of the risk of malignancy index a sensitivity of 7185 with a specificity of 9697 is achieved positive predictive value 89 High-risk population annual screening with CA125 and ultrasound is widely advocated but is not yet validated Median lead time compared to...
Bowel surgery
The intestine is vulnerable to injury and obstruction as a result of involvement by gynecologic malignancies. Intestinal injury may also complicate the successful surgical or radiotherapeutic treatment of these diseases. This chapter focuses on common surgical procedures performed by gynecologic oncologists on the gastrointestinal tract during the management of gynecologic malignancies. Small bowel resection is often necessary to remove obstructed, perforated or tumor-infiltrated intestine....
Anatomic considerations 1
The bladder receives its blood supply mainly from the superior and inferior vesical arteries, both of which are branches of the anterior division of the hypogastric artery. The obturator, uterine and vaginal arteries may all also send branches to the bladder. The ureter takes its blood supply from branches of major vessels which it courses near. This includes the aorta as well as the renal, ovarian, iliac common and internal , vesical and uterine vessels. The bladder is innervated by the...
Inferior Gluteal Artery
2 Superficial epigastric artery 3 Superficial circumflex iliac artery extended arm. During vaginal procedures, an assistant unfamiliar with the course of the femoral nerve might rest an arm on the patient's medial anterior thigh and compress the femoral nerve. This nerve may also be injured by an abdominal retractor placed too deeply over the psoas muscle. Finally, some of the smaller nerves, such as the genital femoral nerve, may be transected during the removal of suspicious lymph nodes....
Radical vulvar surgery
Radical vulvectomy and groin node dissection have been the standard treatment for cancer of the vulva since 1912 when this procedure was first described by Basset. Because carcinoma of the vulva is rare, accounting for only 0.4 of all cancers in women, scientific comparisons of variations on this operation have often been limited by studies with small or heterogeneous samples. Traditionally, an en bloc radical resection of the entire vulva and bilateral inguinal nodes through the trapezoid or...
Anatomy
Werner Lichtenegger Giuseppe Del Priore Physicians are familiar with general human anatomy and expert in their own regions of specialization. Since gynecologic oncologists are often called upon to perform unique and sometimes infrequent procedures in a variety of regions, a review of the different anatomic areas can be helpful. Of course, gynecologic oncologists will usually be operating in the pelvis or called upon as a consultant to other pelvic surgeons. Therefore, a detailed understanding...
An Atlas of Gynecologic Oncology
MB ChB, MD, FRCOG Consultant and Honorary Senior Lecturer in Gynaecology Co-Director of Gynaecologic Oncology Imperial College School of Medicine Chelsea and Westminster Hospital London, UK Visiting Associate Professor of Gynecology New York University School of Medicine New York, USA Giuseppe Del Priore MD, MPH, FACOG Assi Chief of Gynecologic Oncology Bellevue Hospital stant Director of Gynecological Oncology New York University School of Medicine New York, USA John Curtin, FACOG, MD...