Summer B. Dewdney and Matthew A. Powell
PROCEDURE OVERVIEW
Box 29-1 Master Surgeon’s Corner
Complete surgical staging including lymph node dissection, omentectomy, appendectomy, and staging biopsies should be performed for all patients with apparent early-stage epithelial ovarian carcinomas because nearly a third of patients will have metastatic disease that was not appreciated visually or by palpation.
The extent of surgical staging for endometrial carcinoma remains controversial as to when pelvic and/or para-aortic lymph nodes should be removed. Surgeons managing patients with endometrial carcinoma should be prepared for the possibility of performing these procedures in all cases.
Accurate and complete surgical staging is a crucial part of managing patients with gynecologic malignancies and allows for appropriate informed discussions regarding further interventions and accurate risk stratification of patients on clinical trials.
Indications
Currently, ovarian and endometrial carcinomas are recommended to be surgically staged cancers by the International Federation of Obstetrics and Gynecology (FIGO). This requires removal of the primary site and any area of spread or potential spread when possible. Surgical staging is a crucial portion of the treatment for these gynecologic malignancies. Accuracy and completeness of staging ensures objective data, which helps guide appropriate administration of adjuvant therapies and development of clinical trials.
Historical Perspective
For patients with ovarian cancer, Young et al1 established the importance of surgical staging. These investigators performed systematic restaging on 100 patients and showed a 31% rate of upstaging after patients were fully surgically staged, which included multiple peritoneal biopsies and removal of pelvic and para-aortic lymph nodes. In addition, 77% of these 31 patients actually had stage III disease. Prior to this study, the staging of ovarian cancer was either not performed or relied on bipedal lymphangiography, intravenous pyelography, barium enemas, and peritoneoscopy (laparoscopy). Today, in early-stage ovarian cancer, comprehensive staging as defined by the National Cancer Institute–sponsored Gynecologic Oncology Group (GOG) includes a systematic evaluation and biopsies to determine a need for adjuvant therapy. In advanced-stage ovarian cancer, an attempt at optimal cytoreduction is the standard of care and is addressed in detail elsewhere in this text.
Prior to 1988, endometrial cancer was clinically staged through uterine sounding and imaging to determine possible spread. It was treated with a combination of preoperative radiation followed by surgery. The GOG helped transition from clinical staging to surgical staging through a prospective cohort that underwent a staging surgery; the GOG found surgical staging to be more beneficial to patients.2 In 1988, FIGO changed the staging to a surgical-pathologic system which has not been changed until recently.3 In 2009, FIGO updated the staging of endometrial cancer. Most recently, a GOG prospective randomized controlled trial (LAP2) showed that a laparoscopic approach to endometrial cancer shows no difference in detecting advanced-stage disease compared with an open approach.4
Vulvar and vaginal cancer staging is discussed elsewhere in this text.
Expected Clinical Outcomes
The primary purpose of a staging procedure is to provide an accurate account of the extent of disease to determine the need for further therapy. In addition, a universal staging system allows comparison of the outcomes of patients between institutions and countries. Interpretable results from clinical trials evaluating adjuvant therapies rely on accuracy and completeness of the surgical staging of the enrolled patients. Thus, some patients can often be excluded from participation from clinical trials due to improperly performed cancer surgery.
PREOPERATIVE PREPARATION
Patient Evaluation and Work-Up
All patients who are undergoing a surgical evaluation need a preoperative work-up for their comorbidities as determined by the surgery team and anesthesia.
According to the National Comprehensive Cancer Network (NCCN), if a patient is suspected of having ovarian cancer, it is necessary to obtain a family history and, depending on results, consider family history evaluation with genetics. A complete physical examination including an abdominal/pelvic examination is performed, and evaluation of any gastrointestinal symptoms is pursued if clinically indicated. Imaging with an ultrasound and/or abdominal/pelvic computed tomography with chest imaging is usually indicated. Laboratory tests that are typically obtained include a CA-125 or other tumor markers as clinically indicated, complete blood count (CBC), and chemistry profile with liver function tests.5
For endometrial cancer, initial evaluation includes a pathology review of the endometrial sample. Patients who are less than 50 years old may need genetic counseling if they have a significant family history and/or selected pathologic risk features. This can occur after surgery as well. The NCCN also recommends a CBC, chest x-ray, and current cervical cytology.6
Consent Considerations
Consent is permission, granted by the patient to the surgeon, to make a diagnostic or therapeutic intervention on the patient’s behalf.7 To be valid, the patient must be informed. For all staging procedures, it is important that the patient is aware of risks, benefits, and alternatives to the procedure being done. The risk of most staging procedures is low, for example taking random peritoneal biopsies and washings, but higher risk may be associated with performing lymph node dissection (discussed in Chapter 28) for early-stage endometrial cancer. The risk of lymphedema and other adverse effects of lymph node removal should be discussed with the patient.
Patient Preparation
In the past, bowel preparation has been used to decrease intraluminal fecal mass, presumably to decrease the bacteria load in the bowel. It has been used widely in general surgery and in gynecology oncology. Despite the widespread use of bowel preparation, there are limited data on its effectiveness. Multiple randomized controlled trials have shown no benefit of a mechanical bowel preparation. A Cochrane review analyzing 13 randomized controlled trials with 4777 participants found no difference in patient outcomes between patients who had a mechanical bowel preparation and patients who did not.8 We do not routinely use bowel preparations in our patients; there is no proven benefit with level I evidence, and bowel preparations are expensive, uncomfortable, and unpleasant for patients. There is still debate about the uses of bowel preparation in patients with planned left colon resections. Special considerations should also be made for patients with partial obstructions or chronic constipation.
Antimicrobial prophylaxis to reduce surgical site infection has been clearly established. For our endome-trial cancer cases that are unlikely to involve any bowel, we use cefazolin for prophylaxis as per the American College of Obstetrics and Gynecology (ACOG) recommendations for hysterectomies. For patients undergoing ovarian cancer staging, we often use cefoxitin, which is recommend for bowel surgeries and which may be more appropriate given ovarian cancer involvement of the bowel and need for bowel resections for cytoreduction.
According to American College of Chest Physicians guidelines, for gynecologic patients undergoing major surgical procedures for either benign disease or malignancy, venous thromboembolism (VTE) prophylaxis with chemical or mechanical prophylaxis is necessary.9 The duration of VTE prophylaxis for patients undergoing major gynecologic procedures is at least until hospital discharge, and one should consider extending prophylaxis for higher risk patients. Almost all patients undergoing surgical staging for a gynecologic malignancy are considered higher risk patients, especially if over age 60 years. The ENOXACAN II trial showed that 40 mg of enoxaparin preoperatively and continued for 4 weeks postoperatively significantly decreased VTEs.10 At our institution, we give postoperative, prolonged, prophylactic low molecular weight heparin to these patients after discharge for home administration.
Required Instrumentation
Instrumentation for staging procedures includes standard instruments. In addition, we have found electrosurgical vessel-sealing devices to be very useful for omentectomies and other surgical staging procedures. These electrosurgical devices have been shown to be safe and effective both in laparotomy and laparoscopic procedures.11-15
OPERATIVE PROCEDURE
Box 29-2 Caution Points
Appropriate patient positioning to allow for both planned and any possible additional procedures is crucial.
Access to the primary tumor and staging procedures can be performed via a laparoscopic approach or an open approach.
Positioning
The patient is placed in either supine or dorsal lithotomy position depending on surgeon preference and the need for access to the perineum, bladder, and/or rectum. If lithotomy position is used, it is very important to take extra caution in positioning to ensure no pressure points or hyperextension of joints. The risk of nerve injury is higher in this position. In robotic or laparoscopic cases when there is a need for steep Trendelenburg positioning, care must be taken if shoulder braces are used because there is a risk of brachial plexus injury. We recommend not using shoulder braces, but instead a gel pad and chest straps, all with appropriate padding.
Abdominal Entry
A midline vertical skin incision is made using the electrosurgical device or a scalpel. The subcutaneous fat and fascia are then incised with either instrument to match the overlying skin incision. The fascia then is gently dissected off the rectus muscle to identify the linea alba. Once identified, the underlying peritoneum is grasped and entered. It may be necessary to extend this incision depending on the malignant potential of the mass or if the surgery is for endometrial cancer and there is disease outside of the uterus. The incision will need to be extended to the umbilicus and, most of the time, around the umbilicus to gain adequate exposure for exploration and for a para-aortic lymph node dissection if indicated. The inferior facial and peritoneal incision needs to be to the pubic bone with avoidance of injury to the bladder. A retractor is then used for adequate exposure; we often use a Bookwalter or Balfour with a C-arm (or third arm).
Exploration
Exploration of the abdominopelvic cavity follows a stepwise progression based on the potential peritoneal and retroperitoneal patterns of dissemination of ovarian and endometrial cancers (Figure 29-1). All peritoneal surfaces including the paracolic gutters, the surface of both diaphragms, and the serosa and mesentery of the gastrointestinal tract should be visualized and palpated for evidence of metastatic disease. This includes “running” the entire length of the small bowel from the ileocecal junction to the ligament of Treitz and large intestine. Both diaphragms should be palpated in addition to the liver, gallbladder, spleen, and kidneys. The pelvic and para-aortic lymph node bed should be palpated for grossly enlarged nodes. Ideally, the palpation of lymph nodes should occur after the opening of the retroperitoneal spaces to directly identify the nodal tissue. The omentum should be carefully inspected.
FIGURE 29-1. Abdominal exploration proceeds in a stepwise fashion and follows the peritoneal and retroperitoneal pattern of dissemination.
Cytologic Washings
The volume of any free peritoneal fluid (ascites) should be noted and sent for cytology. If there is no free fluid present, then washings will be obtained from the pelvis, paracolic gutters, and infradiaphragmatic area for ovarian cancer staging using approximately 50 to 100 mL of normal saline. In endometrial cancers, peritoneal washings for cytologic examination are obtained by irrigating the pelvis with warm saline (Figure 29-2). Washings for endometrial cancer are no longer part of the surgical staging criteria per the new FIGO 2009 guidelines, but they are still recommended to be obtained and results reported.
FIGURE 29-2. Pelvic washings to obtain cytologic specimen.
Peritoneal Biopsies
If there is no evidence of disease beyond the ovary, peritoneal biopsies must be performed for ovarian cancer. In addition, peritoneal biopsies should be done for high-grade endometrial cancer. These can be done by grasping the peritoneal surface with an Allis clamp and using Metzenbaum scissors or electrocautery to remove a sampling of the peritoneal surface (Figure 29-3). The following areas should be biopsied:
FIGURE 29-3. Pelvic peritoneal biopsy.
1. Posterior cul-de-sac
2. Anterior cul-de-sac (vesical peritoneum)
3. Right and left pelvic sidewalls
4. Right and left paracolic gutters
5. Right diaphragm peritoneum
Biopsy or scraping of the right diaphragm is done in the setting of early-stage ovarian cancer and high-grade endometrial cancer staging. This can be done with a spatula to send for cytology or direct biopsy of the serosal covering of the diaphragm.
Omentectomy
An avascular plane between the transverse colon and the infracolic omentum is identified and entered (Figure 29-4). The omentum is detached from the transverse colon, usually only requiring electrocautery. It is then detached from the gastrocolic omentum usually with serial pedicles, clamping with Kelly clamps, and then cutting and tying these pedicles. In addition, a bipolar electrosurgical sealing device can be used and is safe and efficient in performing this procedure. An infracolic omentum is sufficient for early-stage ovarian cancer and high-grade endometrial cancer.
FIGURE 29-4. Infracolic omentectomy: clamp demonstrating avascular plane.
Extended Omentectomy (Gastrocolic Omentectomy)
If there is any suspicious area within the gastric omen-tum (area between stomach and transverse colon), then the entire gastrocolic omentum should be removed (Figure 29-5).
FIGURE 29-5. Complete gastrocolic omentectomy.
Bilateral Pelvic and Para-Aortic Lymphadenectomy
Lymphadenectomy is discussed in detail in Chapter 28.
Appendectomy
At times during an ovarian cancer staging surgery or an endometrial cancer staging surgery, the appendix may be removed. It can be removed for a variety of reasons including possible tumor involvement or inflammation. In addition, when a primary ovarian tumor is found to be a mucinous subtype on frozen section pathology, it is important to remove the appendix to exclude a primary appendiceal neoplasm. Often, the mucinous histology seen in the ovary will be a metastasis from an appendiceal origin (or a gastrointestinal origin).
A Babcock is used to grasp the appendix atraumatically to lift it up on tension. Next, the mesoappendix is identified, which holds the blood supply to the appendix, the appendiceal artery. The mesentery including the artery is then isolated, doubly clamped, and suture ligated.
The appendix is then free of its attachments and can be freely lifted up to identify the base. The base is then clamped with a straight hemostat, crushed, and then moved up a few millimeters toward the specimen. A free tie (delayed-absorbable or permanent) can then be used to ligate the crushed portion. Once this is done, a knife is used to transect below the clamp, which ensures no spillage of bowel contents into the operative field (Figure 29-6). The appendiceal stump can be buried with a Z-stitch or a purse-string suture. Some surgeons will cauterize the stump, and some do not bury it; no method has been shown to be more beneficial than the others.
FIGURE 29-6. Appendectomy.
Closure and Final Steps
At the conclusion of the surgery, the fascia is closed using #1 loop polydioxanone (PDS) in a mass closure fashion including all of the abdominal wall layers. Prior to closure, all pedicle sites should be reinspected to ensure hemostasis.
POSTOPERATIVE CARE
Box 29-3 Complications and Morbidity
Patients with gynecologic malignancies are in the highest risk category of having a pulmonary embolism or deep vein thrombosis.
Bowel obstruction from adhesions may occur in the first 7 to 21 days postoperatively.
Unrecognized serosal bowel injury can present as peritonitis in the first 72 hours postoperatively.
Diet and activity after a surgical staging depend on the extent of surgery performed and will need to be adjusted to the individual patient. In the majority of patients, it is important to have them ambulating the day of surgery or the first day after surgery. Traditionally, many surgeons will delay oral fluids and/or food immediately postoperative. However, the evidence does not fully support this style of management. A Cochrane review of 14 randomized controlled trials including 1224 patients undergoing gastrointestinal surgery indicates that earlier feeding may reduce the risk of postsurgical complications, and the authors found no obvious advantage of keeping patients NPO (nothing by mouth).16 In addition, another Cochrane review showed that early feeding after major abdominal gynecologic surgery is safe but associated with an increased risk of nausea and reduction in the length of hospital stay.17
Discharge planning is an important part of a patient’s hospital stay. It is necessary to evaluate for possible needs at home after discharge. Discharge planning and optimizing home health care will become increasingly important to contain costs of hospital stays and surgeries for gynecologic cancer patients.
REFERENCES
1. Young RC, Decker DG, Wharton JT, et al. Staging laparotomy in early ovarian cancer. JAMA. 1983;250:3072-3076.
2. Creasman WT, Morrow CP, Bundy BN, et al. Surgical pathologic spread patterns in endometrial cancer: a Gynecologic Oncology Group study. Cancer. 1987;60:2035-2041.
3. Mutch DG. The new FIGO staging system for cancer of the vulva, cervix, endometrium and sarcomas. Gynecol Oncol. 2009; 115:325-328.
4. Walker JL, Piedmonte MR, Spirtos NM, et al. Laparoscopy compared with laparotomy for comprehensive surgical staging of uterine cancer: Gynecologic Oncology Group study LAP2. J Clin Oncol. 2009;27:5331-5336.
5. National Comprehensive Cancer Network guidelines version 2.2011. Epithelial ovarian cancer/fallopian tube cancer/primary peritoneal cancer. Accessed June 29, 2011.
6. National Comprehensive Cancer Network guidelines version 2.2011. Uterine neoplasms. Accessed June 29, 2011.
7. Carson RA. Ethics in surgery. In: Townsend CM, Beauchamp RD, Evers BM, Mattox KL, eds. Sabiston Textbook of Surgery. 18th ed. Philadelphia, PA: Saunders; 2008.
8. Guenaga KF, Matos D, Wille-Jorgensen P. Mechanical bowel preparation for elective colorectal surgery (review). Cochrane Database Syst Rev. 2009;1:CD001544.
9. Geerts WH, Bergqvist D, Pineo GF, et al. Prevention of venous thromboembolism: American College of Chest Physicians evidence-based clinical practice guidelines (8th edition). Chest. 2008;133:S381-S453.
10. Bergqvist D, Agnelli G, Cohen AT, et al. Duration of prophylaxis against venous thromboembolism with enoxaparin after surgery for cancer. N Engl J Med. 2002;346:975-980.
11. Hefni MA, Bhaumik J, El-Toukhy T, et al. Safety and efficacy of using the LigaSure vessel sealing system for securing the pedicles in vaginal hysterectomy: randomised controlled trial. BJOG. 2005;112(3):329-333.
12. Cronje HS, de Coning EC. Electrosurgical bipolar vessel sealing during vaginal hysterectomy. Int J Gynaecol Obstet. 2005; 91:243-245.
13. Hagen B, Eriksson N, Sundset M. Randomised controlled trial of LigaSure versus conventional suture ligature for abdominal hysterectomy. BJOG. 2005;112:968-970.
14. Slomovitz BM, Ramirez PT, Frumovitz M, et al. Electrothermal bipolar coagulation for pelvic exenterations. Gynecol Oncol. 2006;102(3):534-536.
15. Kriplani A, Garg P, Sharma M, et al. A review of total laparoscopic hysterectomy using LigaSure uterine artery-sealing device: AIIMS experience. Lower extremity neuropathies associated with lithotomy positions. Anesthesiology. 2000;93(4): 938-942.
16. Andersen HK, Lewis SJ, Thomas S. Early enteral nutrition within 24h of colorectal surgery versus later commencement of feeding for postoperative complications. Cochrane Database Syst Rev. 2006;4:CD004080.
17. Charoenkwan K, Phillipson G, Vutyavanich T. Early versus delayed oral fluids and food for reducing complications after major abdominal gynaecologic surgery. Cochrane Database Syst Rev. 2007;4:CD004508.