GYN-Onc Considerations for Complex and Multivisceral Colorectal Disease
Mariam Alhilli
Robert Debernardo
Perioperative Considerations
Background: Gynecologic Organ Involvement by Colon Cancer
Potential organs involved the vagina, uterus/cervix, ovaries, rectocervical junction, or vulva/perineum.
Complete tumor resection has a strong impact on prognosis.
Tumor involvement is difficult to distinguish from tumor-associated inflammation.
En bloc resection (modified posterior exenteration) is advocated to avoid tumor dissemination.
Preoperative Considerations
Symptom assessment
Pelvic pain
Vaginal bleeding
Dyspareunia
Postcoital bleeding
Obstructive symptoms
Clinical examination
Thickening and obliteration of rectovaginal septum
Fixation, retroversion, and immobility of the uterus
Speculum examination: vaginal mass
Biopsy suspicious areas of disease
Consider pelvic examination under anesthesia, cystoscopy, and sigmoidoscopy
Imaging
Magnetic resonance imaging—determine transmural tumor involvement and lymph node involvement (Fig. 33-1)
Positron emission tomography/computed tomography: rule out metastatic disease
Colonoscopy/sigmoidoscopy
Bowel preparation
Stoma marking
Venous thromboembolism prophylaxis
Antibiotics
Preparation for bilateral ureteral stent placement/cystoscopy
Type and crossmatch of packed red blood cells
 FIGURE 33-1 ▪ Magnetic resonance imaging pelvis (rectal tumor invading vagina). Recurrent rectal carcinoma forming a large tumor mass with involvement of proctectomy bed, vagina, bilateral labia, and mons pubis. A. Sagital image. B. Axial image. |
Intraoperative Considerations
Equipment
Vessel loops to identify ureters
Cystoscopy and ureteral stents
End-to-end anastomosis (EEA) sizers
Surgical clips
Surgical staplers
Proctoscopy or flexible sigmoidoscopy
Vessel sealing device
Bookwalter retractor
Positioning
Low lithotomy position with legs in stirrups
Surgical preparation from the nipple line to the knees
Anatomic considerations (Fig. 33-2)
FIGURE 33-2 ▪ Pararectal (A) and paravesical (B) spaces.
Avascular spaces
Pararectal
Paravesical
Presacral
Pelvic lymph node dissection boundaries
From mid-common iliac vessels to circumflex iliac vein laterally and from midportion of psoas to ureter medially (hypogastric artery and vein) and obturator fossa anterior to obturator nerve
Para-aortic lymph node dissection boundaries
From the inferior mesenteric artery to the mid-common iliac vessels
Pelvic exenteration types (Fig. 33-3)
FIGURE 33-3 ▪ A. Posterior vs. B. Total exenteration. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2019. All Rights Reserved.)
Anterior: removal of the uterus, bladder, urethra, and anterior vagina and sparing of the rectum
Posterior: removal of the uterus, cervix, posterior vagina, and rectosigmoid colon
Total: removal of all pelvic viscera
Extent of surgical resection (Fig. 33-4)
FIGURE 33-4 ▪ Classification of pelvic exenteration: (A) Supralevator exenteration; (B) infralevator exenteration; and (C) infralevator exenteration with vulvectomy. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2019. All Rights Reserved.)
Infralevator:
Resection of levator ani and coccygeus muscles (pelvic diaphragm)
Anus and/or vulva may require removal.
Supralevator:
Performed if tumor does not involve the lower posterior one-third of vagina and distance between tumor and levator muscles is 2 cm or greater
Technique
En bloc resection of uterus, cervix, and rectosigmoid
A generous midline incision is made, and a self-retaining (Bookwalter) retractor is placed.
The abdomen and pelvis are assessed. Suspicious lesions are biopsied and sent for frozen section.
Retroperitoneal space is accessed, and the avascular spaces developed (Fig. 33-5).Related posts:
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