TABLE 28.1 ENHANCED RECOVERY AFTER SURGERY PROTOCOL
The medial umbilical ligaments
The peritoneal folds overlying the ureters close to the bladder
The vasa on each side
The posterior cul-de-sac of the rectovesical pouch
The iliac vessels
important that the peritoneotomy across the cul-de-sac be created distally, such that it is only 1 to 2 cm anterior to the surface of the rectum. Often, there is a subtle transverse peritoneal fold at this location (we refer to it as the “second peritoneal fold”). This plane is now developed between the vasa and seminal vesicles anteriorly and the anterior surface of the rectum posteriorly. The vessels supplying the seminal vesicles are controlled, and bilateral vasa and vesicles are maintained en bloc with the bladder. Continued dissection brings the posterior layer of Denonvilliers fascia into view, which is incised with cold Shears (monopolar curved scissors) to reveal the yellow prerectal fat posterior to the prostate. This is an important landmark guiding the posterior dissection; the plane must remain between the prostate anteriorly and the prerectal fat posteriorly toward to the prostate apex, thus minimizing chance of rectal injury (Fig. 28.2).
two clips on the bladder end of the transected juxtavesical ureters serve as critical landmarks for the anteromedial limit of resection; the laparoscopic stapler is deployed just posterolateral to these clips. Usually, two or three stapler cartridge firings are necessary on each side to control the entire width of the lateral pedicles down to the endopelvic fascia on either side.
FIGURE 28.2 Dissection of the rectovesical space. The bladder is retracted anteriorly by the fourth arm, and a plane between the prostate (anterior) and prerectal fat (posterior) is developed toward the apex of the prostate. SV, seminal vesicles.
FIGURE 28.3 Ligation of the left bladder pedicle during cystoprostatectomy (A) and of the right bladder pedicle during anterior pelvic exenteration (B), with the use of a vascular stapler.
pelvic fascia is incised high on the prostate to drop the bundles posteriorly. The DVC is then divided as previously described. The bundles on either side are released from the prostate apex using cold Shears, and the urethra is divided. The remainder of the operation proceeds in the usual fashion.
catheter (22Fr Couvelaire) (Fig. 28.10). The anastomosis is completed when the left and right running sutures reach the midline. This is followed by the anterior folding of the lateral edge of the intestine, performed by a running suture using barbed 2-0 V-Loc on a CT-1 needle to create a spherical configuration for the neobladder. A small opening is left in the anterior suture line to allow passage of bilateral ileoureteral stents.