Edward J. Tanner III, Fady Khoury-Collado, and Dennis S. Chi
Box 30-1 Master Surgeon’s Corner
The liver needs to be mobilized for the appropriate evaluation and treatment of right diaphragm disease.
If omental disease extends to the splenic and hepatic flexures, these need to be mobilized completely during omentectomy.
The retroperitoneal approach to resection of pelvic tumor often allows for easier access and removal of pelvic structures “en bloc” compared to a transperitoneal approach.
Ovarian cancer is one of the few solid tumors in which surgical cytoreduction is indicated for advanced metastatic disease. The most common indication for cytoreductive surgery is suspected or confirmed advanced-stage ovarian cancer. In selected cases, cytoreductive surgery is indicated for other advanced or recurrent gynecologic cancers. The goal of the cytoreductive surgery, defined in terms of the diameter of the largest residual implant, has evolved over the last 3 decades. Although leaving no residual tumor larger than 1 cm is currently defined as “optimal,” maximal survival benefit is associated with removal of all gross tumor. Therefore, the goal should be to attempt removal of all visible disease (complete cytoreduction). The available surgical techniques have similarly evolved during the same period to achieve this goal and now include upper abdominal procedures, tumor ablation techniques, and radical pelvic surgery.
Whether performed for primary or recurrent tumors or following neoadjuvant therapy, the same surgical principles and techniques of cytoreductive surgery discussed in this chapter are applicable.
Cytoreduction procedures are often lengthy and complex and carry the potential for significant intra- and postoperative morbidities. The patient needs to be evaluated thoroughly to assess whether she is able to tolerate such procedures, to optimize any underlying medical condition, and to plan postoperative care.
As in any patient assessment, the initial step is to take a detailed history, not only of the complaint that led to the suspicion or diagnosis of advanced ovarian cancer, but also of any associated symptoms that can indicate the existence or severity of associated comorbidities. Specifically, any respiratory symptoms should be investigated, because multiple etiologies can coexist. These can be related to the diagnosis of ovarian cancer (eg, pleural effusion, ascites) or simply denote the presence of a medical comorbidity (eg, chronic lung disease, cardiac disease) that either needs to be optimized prior to surgery or may contraindicate an extensive surgery. The presence of nausea and vomiting, abdominal distention, and difficulty with bowel movements may indicate bowel obstruction. A history of recent significant weight loss can point to potential malnutrition. If severe malnutrition is confirmed on laboratory evaluation, preoperative parenteral nutrition should be considered.
A detailed physical examination should specifically look for findings that denote the extent of disease or the underlying condition of the patient, or even suggest a different or coexistent primary malignancy (eg, breast examination, rectal examination). The abdomen is examined closely for ascites, which can cause significant abdominal distention, compromising the respiratory status of the patient and for which a simple paracentesis can provide immediate and significant relief. In the pelvis, a bimanual examination assesses the extent of pelvic disease and gives a reasonable idea about the likelihood of the requirement for a rectosigmoid colon resection.
Routine preoperative testing includes a complete blood count, coagulation studies, metabolic panel including albumin, renal and liver function tests, and an electrocardiogram. Tumor markers, although not mandatory, are commonly obtained as baseline values. Occasionally, they can suggest a different primary malignancy.
Imaging typically includes a computed tomography (CT) scan of the chest, abdomen, and pelvis. A chest radiograph is an acceptable alternative to chest CT. A CT scan of the chest, however, can determine the presence of enlarged mediastinal lymph nodes and pleural tumor deposits, in addition to moderate to large pleural effusions. If the CT demonstrates thoracic disease, an intrathoracic cytoreduction is attempted first.1 The CT of the abdomen and pelvis helps determine the extent of disease in the abdomen and will assist in the counseling and planning for the procedure.
The patient is informed about the main goal of the surgery and the potential procedures required to achieve complete or optimal cytoreduction. A realistic description of the length and complexity of the procedure, associated complications, need for intensive care monitoring, and expected recovery time is discussed, including the possibility of requiring a temporary or permanent stoma. Transfusion of blood and blood products is frequently needed, and any objections to their use on behalf of the patient should be clearly defined, because this can impact the safety of the planned procedure. At the same time, the possibility of aborting the debulking procedure based on intraoperative findings is discussed.
Patients are instructed to shower the night before or the morning of surgery. Mechanical bowel preparation is not mandatory but is given according to the surgeon’s preference. Prophylactic antibiotics are routinely given, typically cefotetan 2 g, within 1 hour prior to skin incision, with repeated doses given as needed (eg, prolonged surgeries, increased blood loss). Prophylactic antibiotics are discontinued within 24 hours of the operation. Required surgical instrumentation includes a fixed self-retaining retractor (eg, Bookwalter) and electrosurgical unit; automated gastrointestinal stapling devices, an argon beam coagulator, and a vessel-sealing cutting device are highly recommended.
Box 30-2 Caution Points
Avoid injury to the hepatic veins when mobilizing the liver.
Avoid injury to the transverse mesocolon and the middle colic artery during entry into the lesser sac during omentectomy.
Avoid excessive traction on the omentum at the splenic flexure, which can create splenic capsular tears.
Identify the ureters clearly (eg, tag with vessel loops) at all times during the pelvic part of the procedure.
Pneumatic compression devices must be in place and functioning prior to the induction of anesthesia. The dorsal lithotomy position, using Allen stirrups (Allen Medical Systems, Cleveland, OH), is preferred over the supine position because it allows for bimanual examination to determine the extent of tumor involvement in the posterior cul-de-sac and provides access and exposure to the pelvis when performing a rectosigmoid resection and reanastomosis (Figure 30-1). After positioning the patient, the stirrups are rotated into the position they will remain in during surgery to ensure that no undue pressure is exerted on the legs during prolonged periods.
FIGURE 30-1. Patient positioning.
Following positioning, a vertical midline incision is marked from above the xiphoid process to the pubic symphysis. The locations of possible chest tubes and intraperitoneal catheter reservoirs are marked, if anticipated. Antiseptic preparation of the skin follows and is applied from the nipple line to mid thighs. After draping the patient, a sterile catheter is placed in the bladder.
Entry into the abdominal cavity is best achieved through a midline vertical incision from the pubic symphysis to the xiphoid process. Abdominal entry may be hindered by adherence of omental disease to the anterior abdominal wall, although this can be excised without difficulty or bowel injury. If ascites is anticipated, the peritoneum is tented up and entered through a small opening. Fenestrated suction catheters can then be inserted and fluid evacuated in a controlled fashion. A fixed-arm, self-retaining retractor (eg, Bookwalter or Omni) is then placed, and a survey of the abdominal cavity is performed to determine the feasibility of resection. Lateral retractor blades should be placed carefully to avoid femoral nerve injury caused by psoas muscle compression.
In ovarian cancer, the omentum is a frequent site of tumor metastases, which can vary from microscopic implants to total replacement of the omentum by an “omental cake.” Therefore, omentectomy is part of staging and debulking procedures. An infracolic omen-tectomy is usually sufficient for staging purposes, whereas a supracolic omentectomy is performed when the gastrocolic omentum is involved with tumor. The omentectomy starts by reflecting the omentum cephalad and to the dorsal reflection onto the transverse colon (Figure 30-2). If the omentum is attached to the abdominal wall by tumor implants, it usually can be easily released bluntly or with electrocautery dissection.
FIGURE 30-2. Omental cake reflected cephalad.
The omental dissection starts in the avascular part of the posterior leaf, a few millimeters from the transverse colon serosa, at a level where omental tissue is not replaced by tumor. Using electrocautery, the posterior leaf of the omentum is incised, and with the use of traction and counter traction, the omentum is kept under tension as the incision is extended toward the splenic and hepatic flexures. Where the tumor is adherent to the bowel serosa, sharp dissection with Metzenbaum scissors is used. The lesser sac is entered and inspected for the presence of disease through the space between the anterior and posterior leafs of the omentum. The anterior leaf of the omentum can be taken at any time during the dissection, progressively detaching the omentum from the underlying transverse colon. If tumor implants on the omentum extend laterally to the hepatic and/or splenic flexures, these will need to be mobilized to be able to remove the disease in its entirety. As the omental dissection proceeds toward the splenic flexure, caution should be exercised when placing tension on the omentum, because excessive traction can lead to a splenic capsular tear and troublesome bleeding.
As the dissection proceeds, it is important not to lose the orientation and the direction of the dissection, which can easily happen due to the redundant layers of the omentum. In this context, frequent examination of the transverse mesocolon is critical to avoid an inadvertent injury to the middle colic vessels. When omental vessels are encountered, they can be secured with clamps and ties or using a vessel-sealing device. The right and left gastroepiploic vessels and the intervening gastroepiploic vessels are divided. In rare cases, the tumor densely infiltrates the transverse colon to a point where no plane of dissection can be created without entering the serosa of the bowel. In this case, removing the omental tumor requires a contiguous en bloc resection of involved segment of the colon. The decision whether to proceed with the resection depends on the overall spread of the disease, the extent of the colon segment to be resected, and the likelihood of achieving the cytoreductive goal.
If the supracolic omentum is involved with tumor, a gastrocolic omentectomy is performed. The gastrocolic omentum is divided from its attachment to the greater gastric curvature, and the vessels arising from the gastric arcade are systematically secured. Caution should be exercised at this level to avoid injury to the stomach. It is commonly recommended to decompress the stomach for 24 hours after surgery to avoid bleeding from the vessels secured along the greater curvature of the stomach. We have not routinely followed this practice and have not experienced any incidents of postoperative bleeding.
Right Upper Quadrant Cytoreduction
In patients with advanced ovarian cancer undergoing primary or secondary cytoreductive surgery, the right upper quadrant is a frequent site of disease. The right diaphragm frequently harbors metastatic disease, which can range from superficial peritoneal implants to full-thickness infiltrating tumors. Due to their proximity, the peritoneum covering Morrison’s pouch and Gerota’s fascia is also a frequent site of disease. Tumor implants can also involve the liver surface, the gallbladder, the porta hepatis, and less often, the liver parenchyma. Superficial disease on the liver can be ablated with the argon beam coagulator (ABC) or other ablative devices or superficially excised along with Glisson’s capsule. More extensive liver disease should not be considered an impediment to primary cytoreduction but will frequently require the assistance of an hepatobiliary surgeon (eg, partial liver resections, cholecystectomy, dissection of the porta hepatis). The details of these latter procedures will not be discussed in this chapter. We will instead focus on the procedures most commonly used in cytoreduction of disease in the right upper quadrant, which can be safely incorporated, with appropriate training, into the skill set of the gynecologic oncologist with interest in cytoreductive surgery. We will describe mainly the mobilization of the right lobe of the liver and removal of right diaphragm disease, because the right side is the most commonly affected. When the left diaphragm is involved, a similar approach can be used.
The liver is attached to the anterior abdominal wall by the falciform ligament. The free edge of the falciform ligament contains the round ligament—a remnant of the left umbilical vein. The bare area of the liver, located on its posterior surface in direct contact with the diaphragm, is limited by the coronary ligaments anteriorly and posteriorly and the triangular ligaments laterally.
Liver mobilization is an indispensable initial step in cytoreduction of the right upper quadrant. When omitted, the extent of diaphragm disease is often underestimated. In addition, regardless of the modality for cytoreduction used (eg, tumor ablation, peritonectomy, diaphragm resection), exposure is less than ideal if the liver is not mobilized. The patient, typically in the lithotomy position for the debulking procedure, is rotated to a “right upper quadrant up” position, which is a combination of a reverse Trendelenburg position with inclination of the operating table to the patient’s left side. Self-retaining retractors (eg, Bookwalter, Omni, Goligher) are used to elevate the ribs and expose the diaphragm. The primary surgeon stands either between the legs of the patient or to the patient’s left side.
For mobilization of the liver, the free edge of the falciform ligament containing the round ligament is divided first (Figure 30-3). A suture ligature placed on the lower edge can be used to aid in downward traction on the liver. The liver is separated from its attachment to the anterior abdominal wall as the falciform is divided, close to its liver attachment, in a cephalad direction until its peritoneal layers divide laterally to form the right and left anterior coronary ligaments (Figure 30-4). The dissection continues along the right coronary ligament (Figure 30-5). This dissection can be performed sharply or with electrocautery, the critical point being the identification and avoidance of injury to the right hepatic vein and inferior vena cava. Depending on the adequacy of exposure and the amount of disease present, the dissection of the coronary ligament may continue for a variable amount of length, until it becomes more appropriate to start the dissection laterally by dividing the right triangular ligament and proceed medially (Figure 30-6). The dissection proceeds on either side until the bare area of the liver is exposed. The mobilization of the right lobe of the liver is completed by freeing the right posterior coronary ligament. The different steps of the mobilization do not necessarily follow the same order in every case; the sequence of steps is dictated by the amount of disease and the ease of exposure. Once the bare area is exposed, the liver is gently retracted medially and inferiorly, exposing the entire right diaphragm, Morrison’s pouch, and Gerota’s fascia (Figure 30-7).
FIGURE 30-3. Division of round ligament of liver.
FIGURE 30-4. Division of falciform and coronary ligaments.
FIGURE 30-5. Division of right coronary ligament.
FIGURE 30-6. Division of right triangular ligament.
At this time, optimal exposure of the right diaphragm is achieved and the extent of disease is inspected and palpated to assess for the depth of invasion of tumor implants into the diaphragm muscle.
FIGURE 30-7. Exposure of bare area of the liver after liver mobilization.
Several reports have demonstrated the feasibility and improved outcome associated with cytoreduction of disease of the diaphragm.2,3 After inspection of the diaphragm peritoneum, the area to be excised is outlined. The peritoneal incision usually starts at the level of the costal margin and proceeds posteriorly until all the area involved with tumor is released from the underlying diaphragm muscle (Figure 30-8). During this part, the peritonectomy will alternate between lateral and medial progress, depending on the situation.
FIGURE 30-8. Diaphragm peritonectomy incision.
Several techniques to separate the peritoneum from the underlying muscle have been described, and the surgeon can use whichever technique he or she feels is the most appropriate in each situation. The simplest form is to grasp and put under tension the incised peritoneal edge with several clamps (eg, ring forceps or Allis clamps) and to separate the underlying muscle bluntly by exerting pressure posteriorly and cephalad using a sponge stick. This technique works well when the tumor implants do not infiltrate deeply. In areas where the peritoneal layer is adherent to the muscle (central tendon of the diaphragm, deeper implants), blunt dissection may not be appropriate, and other forms of dissection need to be used. Electrocautery or the ABC can be used to aid in the dissection (Figure 30-9).
FIGURE 30-9. Diaphragm peritonectomy dissection in subperitoneal plane.
The detachment of the involved diaphragm peritoneum will proceed in this way, alternating techniques and direction until all the involved peritoneum is removed (Figure 30-10). Small-vessel bleeding from branches of the phrenic artery and vein often occurs during this dissection and can be controlled with electrocautery, the ABC, or a vessel-sealing device. Once the peritonectomy is completed, the integrity of the diaphragm is verified with a “bubble test”—the right upper quadrant is filled with saline, and the patient is given a maximal inspiration. Bubbles indicate a connection with the pleural cavity. The site of bubbling is identified, and interrupted sutures are placed. The technique for repair of larger defects is described in the following section.
FIGURE 30-10. Diaphragm peritonectomy exposure of muscle.
Tumor implants firmly adherent to the diaphragm muscle are indicative of muscle invasion or full-thickness involvement and require partial diaphragm resection to clear the tumor. In patients who undergo video-assisted thoracic surgery, full-thickness diaphragm involvement and the presence of pleural implants can be directly visualized and the extent of diaphragm resection planned accordingly. Occasionally, preoperative imaging can point to full-thickness diaphragm involvement. The right phrenic nerve innervates the right diaphragm, entering on the superomedial surface and branching immediately in a radial fashion. Therefore, resections that extend medially carry a higher risk of nerve injury and postoperative diaphragm paralysis.
From the abdominal side, which is by far the most common approach to diaphragm resection, palpation of the involved area can help in identifying the area to be resected. The anesthesiologist is notified about imminent entry into the pleural space with the resultant pneumothorax. When the pleural cavity is entered, the lung is visualized and avoided. The area involved with tumor is outlined and can be resected using electrocautery or an Endo GIA stapler (Figures 30-11 and 30-12). An advantage of the Endo GIA stapler is better delineated edges, which are easier to approximate and suture, with a lesser likelihood of the suture pulling through the muscle because the staple line provides a resistant line of support. The Endo GIA or TA stapling devices (both from Covidien, Mansfield, MA) can occasionally be used in a single step to excise a small lesion while tenting down the diaphragm. Even diaphragm defects as large as 10 cm can be primarily closed without undue tension using interrupted figure-of-eight permanent sutures (1-0 polypropylene) (Figures 30-13 and 30-14). A single or looped running suture has also been used successfully.4,5 When the defect is too extensive for a tension-free primary closure, a polytetrafluoroethylene patch can be sutured in place with a running suture, starting at the medial edge.
FIGURE 30-11. Full-thickness diaphragm resection using the electrosurgical unit.
FIGURE 30-12. Full-thickness diaphragm resection using the Endo GIA stapler.
FIGURE 30-13. Diaphragm closure with interrupted stitches.
FIGURE 30-14. Completed diaphragm closure.
To prevent postoperative pneumothorax and pleural effusion, air and fluid need to be evacuated from the pleural cavity as the diaphragm defect is closed. A commonly used technique includes passing of a 14- to 16-French red Robinson catheter through the diaphragm defect into the pleural cavity as the closure of the defect is coming to an end (final 1-2 cm). A purse-string or figure-of-eight suture is placed loosely through the diaphragm muscle to surround this remaining connection with the pleural space. As the patient is given several maximal inspirations followed by a Valsalva maneuver, the Robinson catheter, while placed under gentle suction or under a water seal, is removed as the suture is tightened. Persistent pneumothorax is evaluated using the previously described “bubble test.” Alternatively, a chest tube can be placed in the pleural cavity, with minimal morbidity, under direct visualization of the pleural space through the diaphragm opening, and it will effectively drain air and fluid from the pleural space for the first few postoperative days (Figure 30-15).
FIGURE 30-15. Chest tube placed under direct visualization.
Left Upper Quadrant
The left upper quadrant is a frequent site of metastatic disease in advanced ovarian cancer, with disease involving the spleen, stomach, distal pancreas, and transverse colon. Recent retrospective evidence suggests that even in the setting of extensive upper abdominal disease, optimal cytoreduction improves survival, and this can be achieved with acceptable morbidity.6
Adequate exposure to the left upper quadrant requires a vertical midline incision. Exposure can be further enhanced by initially addressing extensive omental disease to facilitate visualization of important vascular structures and viscera in the left upper quadrant. The posterior leaf of the omentum is initially divided, allowing access to the lesser sac. Once the lesser sac is entered, the omental cake and stomach can be reflected anteriorly so that a thorough exploration of the distal pancreas, splenic hilum, porta hepatis, and celiac trunk can be performed. This allows for a more accurate estimation of disease resectability.
Partial Transverse Colectomy
If no plane between the involved omentum and transverse colon can be achieved, en bloc transverse colectomy and omentectomy may be required. To perform an en bloc resection of the transverse colon and omentum, the lesser sac is first entered superiorly by dividing the gastrocolic ligament. The gastrocolic ligament is transected with a vessel-sealing device along the entire length of the greater curvature of the stomach. The surgeon must ensure that this dissection does not extend into the underlying transverse colon mesentery because this may compromise blood supply to the anastomosis site. The transverse colon is fully mobilized by dividing the hepatocolic and splenocolic ligaments, with care to avoid avulsing the blood supply to the spleen. The location of the bowel resection is then determined (Figure 30-16). The integrity of the marginal artery of Drummond should be confirmed by transillumination prior to completing the resection. This will ensure that the reapproximated ends of proximal and distal transverse colon will have an adequate blood supply. Otherwise, the distal end of the anastomosis should occur distal to the splenic flexure in the descending colon. After dividing the colon with a GIA (gastro-intestinal anastomosis) stapling device, the transverse colon mesentery is transected with a vessel-sealing device, and the specimen is removed en bloc (Figure 30-17).
FIGURE 30-16. Partial transverse colectomy: delineation of extent of resection.
FIGURE 30-17. Partial transverse colectomy specimen with “wedge” of mesentery.
Once the specimen has been excised, the colon can be further mobilized by incising the peritoneum overlying the paracolic gutters (white line of Toldt) and reflecting both limbs of the proposed anastomosis medially. Once the proposed anastomosis is mobilized adequately to ensure the absence of tension, a side-to-side (Figure 30-18) or end-to-end bowel anastomosis can be performed, as stated elsewhere in the chapter; however, the remainder of the upper abdomen dissection should be performed prior to completion of the anastomosis. If an anastomosis cannot be achieved due to tension, a diverting ascending colostomy can be performed, although in our experience, this is rarely necessary.
FIGURE 30-18. Side-to-side, functional, end-to-end stapled anastomosis of transverse colon.
Splenectomy is required to achieve optimal cytoreduction in approximately 10% of patients with advanced ovarian cancer.7 Splenic involvement can occur due to direct tumor extension or hematogenous metastasis, although the former is more likely. An anterior or posterior approach can be performed; the choice of approach depends on the distribution of disease in the left upper quadrant, and a combination of techniques may be required in some cases.
The anterior approach to splenectomy is most useful if the anterior attachments of the spleen are free from tumor, as often occurs when the splenic hilum is involved by tumor without direct extension of disease from the omentum. After entering the lesser sac, the stomach is retraced medially so that the gastrosplenic ligament and associated vessels can be sequentially divided with a vessel-sealing device. The gastrosplenic ligament is divided carefully to avoid including the posterior gastric wall in the specimen. If the spleen is free from adhesions laterally, a posterior approach may be initiated prior to dividing the splenic vessels. If the lateral attachments are involved by tumor, the splenic vessels are controlled first. To do so, the spleen can be gently lifted anteriorly so that the demarcation between the tail of the pancreas and splenic hilum is identified. This step prevents inadvertent resection of the pancreatic tail in the splenectomy specimen. The splenic artery is isolated and double ligated with nonresorbable silk sutures. The splenic vein is then ligated separately to allow for drainage of the venous reservoir in the organ following arterial ligation and to prevent formation of arteriovenous fistula (Figure 30-19). Anterior and medial mobilization of the spleen allows for division of the posterior and lateral lienorenal ligament. If the left hemidiaphragm is involved by tumor, the spleen can be resected en bloc with the diaphragm specimen.
FIGURE 30-19. Splenectomy: anterior approach.
If there is extensive omental infiltration of the splenic hilum, a posterior approach to splenectomy may be preferable (Figure 30-20). The patient is placed “left side up” to allow the surgeon operating from the patient’s right side easier access to the left upper quadrant. The spleen is then retracted medially, and the lienorenal ligament is divided. The splenic vessels should be visible medially, although division of the splenophrenic ligaments may be required to allow for additional medial and anterior retraction of spleen and improved visualization. After identifying the tail of the pancreas, the splenic vessels are sequentially isolated and ligated, as stated previously (Figure 30-21). After dividing these vessels, the lesser sac can be accessed and the spleen rotated medially out of the incision. This should allow for posterior visualization of the gastrosplenic ligament and short gastric vessels, which can now be more easily skeletonized and divided.
FIGURE 30-20. Splenectomy: hilar tumor requiring posterior approach.
FIGURE 30-21. Splenectomy: posterior approach.
Once the spleen has been removed, the splenic vascular pedicles are inspected and reinforced as necessary. If the tail of the pancreas is injured inadvertently, this area can be reinforced with a continuous layer of delayed resorbable 3-0 sutures. Following a splenectomy, a closed-suction drain is placed in the splenic bed prior to closure of the abdomen to assess for postoperative pancreatic leaks.
The distal pancreas may occasionally be involved in patients with advanced ovarian cancer. This most often occurs when omental disease extends posteriorly past the splenic hilum. Access to the tail of the pancreas requires full exposure of the lesser sac. The gastrosplenic ligament and short gastric vessels are sequentially incised along the greater curvature of the stomach so that the posterior borders of the lesser sac, including the pancreas and splenic hilum, are visualized. The peritoneum overlying the inferior border of the pancreas is incised from just proximal to the involved portion toward the splenic hilum, with care to avoid the underlying inferior mesenteric vein. The splenic artery is then identified on the superior border of the pancreas, ligated, and transected, as previously described. The previously identified splenic vein can then be ligated and transected separately. A vascular load (2.5-mm) Endo GIA stapler is then used to transect the pancreas (Figure 30-22). We frequently place a 2-0 delayed-resorbable running suture layer along the entire length of the transected pancreas. A closed-suction drain should be placed in the left upper quadrant to monitor for pancreatic leak.
FIGURE 30-22. Distal pancreatectomy using an Endo GIA stapler.
When omental metastasis involves the supracolic omen-tum, the tissue plane between the greater curvature of the stomach and omentum usually remains intact. Occasionally, there is direct extension into the gastric body. If optimal cytoreduction is achievable, a partial gastrectomy should be considered. To do so, involved portions of the gastrocolic and gastrosplenic ligaments are ligated with a vessel-sealing device to allow for better access to the posterior gastric body within the lesser sac. Once the posterior border of the gastric body is freely mobilized, a large TA or GIA stapling device can be passed above the involved portion of the greater curvature, and the involved portion is removed (Figure 30-23). The suture line is then reinforced with a second layer of 3-0 silk interrupting imbricating sutures, and the stomach is decompressed by nasogastric tube placement for at least 24 hours postoperatively.
FIGURE 30-23. Partial gastrectomy using a TA stapler.
The pelvis is often obliterated by multiple and/or confluent tumor nodules in patients with advanced epithelial ovarian cancer, such that removal of the pelvic viscera and surrounding peritoneum is often necessary to achieve a minimal residual disease state. Over the last 40 years, these en bloc resections have been referred to in a number of ways (ie, radical oophorectomy, modified posterior exenteration, low anterior resection), but essentially, all refer to en bloc excision of the uterus, cervix, bilateral fallopian tubes and ovaries, rectosigmoid colon, and pelvic peritoneum. Several recent analyses have shown that these procedures can be performed safely while increasing the rate of optimal cytoreduction.8 Patients who undergo modified posterior exenteration for advanced ovarian cancer have a low rate of complications related to the procedure. Overall, the rate of colorectal anastomotic leak/fistula is 2.1%, and the mortality rate is only 0.8%.9
The first step in the modified posterior exenteration is a circumscribing peritoneal incision around the pelvic viscera and extending cranially along the psoas muscles (Figure 30-24). If a rectosigmoid resection is required, the left lateral incision may be extended along the line of Toldt as far as the splenic flexure to allow for adequate mobilization of the descending colon in anticipation of a tension-free rectal anastomosis. All pelvic disease should be incorporated into the specimen, if possible; thus, a lateral peritoneal incision is preferred. If the round ligaments are obscured by peritoneal implants, they can be identified retroperitone-ally after the lateral peritoneal incision has been made (Figure 30-25). The pararectal space is then developed, and the ureter and ovarian vessels are identified. After dissecting the ureters off of the medial leaf of the broad ligament, vessel loops are passed under the ureters to allow for future identification and lateral traction, as necessary. The ureters are then skeletonized from the pelvic brim to the tunnel of Wertheim. The infundibulopelvic ligaments can then be transected and ligated with suture or a vessel-sealing device (eg, LigaSure vessel sealer; Covidien).
FIGURE 30-24. Modified posterior exenteration: circumscribing pelvic peritoneal incision.
FIGURE 30-25. Modified posterior exenteration: ligation of round ligament.
The round ligaments are then divided as close to their attachment along the pelvic sidewall as possible, and the anterior pelvic peritoneum is incised along the pubic symphysis to the midline. The paravesical space is then developed down to the cardinal ligaments. The anterior pelvic peritoneum is grasped with Allis clamps along the midline and retracted cranially to allow for electrocautery dissection between this layer and the bladder dome (Figure 30-26). This dissection is then carried inferiorly to the pubocervical fascia (Figures 30-27 and 30-28). Occasionally, bladder wall invasion is encountered and may require full-thickness bladder resection. In this event, careful consideration must be taken to avoid unrecognized resection of the bladder trigone, because this requires a more complex bladder reconstruction, with possible ureteral reimplantation.
FIGURE 30-26. Modified posterior exenteration: anterior pelvic peritoneum grasped with Allis clamp.
FIGURE 30-27. Modified posterior exenteration: anterior peritoneum raised.
FIGURE 30-28. Modified posterior exenteration: pubocervical fascia exposed. LUS, lower uterine segment.
The uterine pedicles are skeletonized, ligated, and divided at the level of the ureters (Figure 30-29). The ureters are then unroofed from the bladder pillars, allowing lateral reflection away from the specimen. The bladder is then dissected off of the vagina approximately 2 to 3 cm distal to the cervical junction, and an anterior colpotomy is performed 1 to 2 cm distal to the cervical junction using electrocautery. This location can be better identified by performing a bimanual examination or inserting a sponge-stick or end-to-end anastomosis sizer into the anterior vagina. The colpotomy is then extended laterally, using Heaney clamps to secure and suture ligate the vaginal angles (Figure 30-30). Alternatively, a vessel-sealing device (eg, LigaSure) can be used to easily divide the vagina, with excellent hemostasis. The posterior wall of the vagina is then incised with electrocautery and the rectovaginal septum entered (Figure 30-31). At this point, the extent of surgical resection is dependent on the amount of tumor involvement in the posterior cul-de-sac (type I vs. type II modification).
FIGURE 30-29. Modified posterior exenteration: uterine artery ligation.
FIGURE 30-30. Modified posterior exenteration: vaginal angles secured with Heaney clamps.
FIGURE 30-31. Modified posterior exenteration: posterior vaginal entry.
In the type I modification, the rectum can be spared if uninvolved by tumor. The posterior cul-de-sac peritoneum is incised at the level of the previously ligated infundibulopelvic ligaments and extended along the lateral pelvic gutters. This incision is carried caudally and toward the midline so that the peritoneum of the posterior cul-de-sac and paraovarian fossa can be included in the specimen. Tumor and underlying peritoneum may require sharp dissection to be separated from the underlying rectal serosa (Figure 30-32). If a small rectal defect (< 2 cm) is inadvertently created or required to resect limited tumor implants, the colotomy can be repaired with a single layer of inverting interrupted 3-0 polypropylene sutures. Excision of the posterior cul-de-sac is extended toward the rectovaginal septum incision created anteriorly, allowing for the specimen to be removed en bloc.
FIGURE 30-32. Modified posterior exenteration: type I modification.
In the type II modification, the rectosigmoid colon is removed with the uterus and ovaries due to complete obliteration of the posterior pelvis or extensive serosal implants along the rectosigmoid (Figure 30-33). The rectosigmoid colon can be divided with a GIA stapling device at any location from the pelvic brim to the splenic flexure, as required, to achieve optimal cytoreduction; however, 2 to 3 cm of uninvolved colon should be available proximal to the planned transection site. Following colon transection, the peritoneum of the mesentery is incised laterally to join the pelvic peritoneal incision of the pelvic dissection, with care to avoid the underlying ureters. The sigmoid mesentery is then incised and transected with suture ligation or a vessel-sealing device perpendicular to the long axis of the sigmoid for several centimeters prior to passing caudally and parallel to the long axis of the sigmoid at the pelvic brim to ensure removal of involved mesenteric lymph nodes (Figure 30-34). The superior rectal artery and vein are identified and ligated during this dissection. Care must be taken to avoid transection of the left colic artery during any part of the procedure so that adequate blood supply to the descending colon is maintained.
FIGURE 30-33. Modified posterior exenteration: type II modification.
FIGURE 30-34. Transection of rectosigmoid colon mesentery.
The pararectal space is then entered at the pelvic brim, and the rectum is dissected off of the underlying presacral fascia with a combination of blunt dissection and a vessel-sealing device. The rectal pillars that represent the posterior and lateral borders of the presacral space are divided with a vessel-sealing device. At this point, the posterior cul-de-sac and the rectum should be completely freed posteriorly to the level of rectovaginal septum incision created anteriorly. The specimen can be lifted ventrally and the remaining mesorectal fat cleared off of the site of rectal resection (Figure 30-35). The rectal resection is most easily performed with a TA stapler 2 to 3 cm distal to the most distal extent of rectal tumor involvement (Figure 30-36). Prior to firing the TA stapler, the surgeon must ensure that the ureters are not incorporated into the resection. Following rectal transection, the specimen should be completely detached and can be passed off the field.
FIGURE 30-35. Division of mesorectum using vesselsealing device.
FIGURE 30-36. Transection of proximal rectum using TA stapler.
Rectal reanastomosis is most easily performed using an end-to-end stapling technique, to be described in detail later in this chapter. Successful rectal reanastomosis requires an adequate blood supply in the absence of tension. If these conditions do not exist, anastomotic leak may occur. Management of this complication will be discussed later in this chapter. To avoid anastomotic leaks, mobilization of the sigmoid colon is often required. Several techniques may be used to aid in this process, including the following:
1. Transect the attachments between transverse colon and the infracolic omentum or splenic flexure.
2. Mobilize the descending colon and associated mesentery medially.
3. Open the lesser sac and divide the gastrocolic ligament to allow for mobilization of the splenic flexure.
4. Open the descending colon mesentery and ligate individual vessels of the descending colon including the left colic artery. This procedure is not feasible if collateral circulation from the marginal artery of Drummond has previously been ligated or is functionally absent, as is the case in approximately 5% of the population.
5. Ligate the inferior mesenteric vein inferior to the pancreas, allowing for greater descent of the mesentery.
If an adequate blood supply cannot be ensured or any degree of tension is suspected in the anastomosis, diverting loop ileostomy or colostomy should be considered. Although diversion will not prevent the formation of an anastomotic leak, it will usually prevent peritonitis caused by dissemination of stool throughout the abdominal cavity. This risk must be weighed against the inconvenience of a temporary ostomy for the patient and potential for exclusion for clinical trials in patients who desire early reversal of their anastomosis.
Cytoreductive surgery for ovarian cancer requires resection of all large-volume disease. Because ovarian cancer may involve any peritoneal surface, small bowel and colon implants are frequently encountered. Although full-thickness bowel wall invasion is uncommon, it can be difficult to remove tumor implants on the bowel wall without injuring underlying tissues. Thus, bowel resection is often required to achieve optimal cytoreduction. In our experience, approximately 35% of patients with stage III or IV disease will require large bowel resection, and 5% will require small bowel resection during primary cytoreductive surgery.7 Although there are no prospective data, most retrospective analyses suggest that bowel resections can be performed safely and may improve survival in patients with advanced-stage disease if resection results in optimal cytoreduction.9 If optimal cytoreduction cannot be safely achieved, bowel resection should only be performed at time of exploratory laparotomy if impending bowel obstruction is encountered. In this section, we will review the intestinal procedures frequently encountered during ovarian cancer surgery.
There are several techniques for bowel resection and anastomosis. The incorporation of surgical stapling devices has greatly decreased the time required to perform these procedures without a negative impact on patient safety. In general, any intestinal anastomosis should: (1) be tension free, with an adequate blood supply; (2) have an adequate lumen to allow for passage of intestinal contents; and (3) be hemostatic and secure. Surgical techniques used for bowel resection depend on the location of disease (ie, ileum, right colon, or rectosigmoid) and the lumen of the bowel to be reanastomosed (ie, distal ileum, colon, or rectum). The most commonly performed procedures involve the resection of the distal ileum, cecum, and ascending colon or of the sigmoid and rectum. Due to the unreliable blood supply to the distal 10 cm of ileum, resection of this segment requires incorporation of the cecum to facilitate adequate blood supply of the anastomotic site. Regardless of the type of bowel resected or anastomosis required, this can generally be achieved with either hand-sewn or stapled techniques.
Bowel transection is most easily achieved with a GIA stapling device. The advantage of this device is the simultaneous transection and closure of the bowel lumen. In the case of small bowel resections, the bowel wall is transected at a slight angle, allowing a greater length of the mesenteric edge of the bowel segment to be retained to ensure adequate transmural blood supply to the antimesenteric border of the anastomosis. A wedge of the associated mesentery is then divided, with care to avoid the distal branches of the superior mesenteric artery supplying the distal small bowel segments. This is facilitated with the use of a vesselsealing device. Resection of underlying bulky (diameter > 1 cm) mesenteric adenopathy must be considered if optimal cytoreduction is to be achieved.
Bowel Anastomosis Techniques
Given the simplicity and speed of using bowel stapling devices, hand-sewn anastomoses are usually reserved for small bowel resections in which the length of adjacent uninvolved bowel is not adequate for the use of a stapling device or if there is significant bowel wall edema. A 2-layer closure, using 3-0 silk or polypropylene for both layers, is generally preferred for the hand-sewn technique. To accommodate the discrepancy in bowel lumen between the distal ileum and ascending colon, a Cheatle incision may be made in the antimesenteric surface of the small bowel to increase its diameter prior to reanastomosis. The transected bowel ends are first reapproximated with bowel clamps, and a row of interrupted imbricating Lambert sutures is placed in the posterior wall of the seromuscular layer. The bowel clamps are removed, and the staple line is excised. A continuous full-thickness stitch is then passed close to the posterior mucosal edges. Once the corner of the posterior edge has been reached, the needle is passed to the outside of the anterior bowel wall, and the remaining anterior inner layer is closed by passing the needle full thickness outside-in and then inside-out (Connell stitch). The anterior seromuscular layer is then closed with interrupted sutures similar to the outer posterior layer and the mesenteric defect repaired with care to avoid ligation of the underlying mesenteric vessels. Although a single-layer closure can be used for both small bowel and colonic anastomoses, this technique is generally reserved only for colonic reanastomosis at the time of obstruction and has not been shown to be beneficial over stapling techniques.
Stapled anastomoses can be performed quickly and safely under most circumstances. The 3 primary techniques are the end-to-end, end-to-side, and side-to-side anastomoses. The decision to use hand-sewn versus stapled techniques is often based on cost, time, and surgeon preference.
A stapled end-to-end anastomosis (EEA) is generally performed to reapproximate 2 ends of colon, as is often encountered following rectal resection at the time of posterior exenteration, or, less commonly, to reapproximate the right and left colon following en bloc resection of the transverse colon and omen-tum. After both limbs of bowel have been transected with a stapling device, the anvil of an EEA stapler is inserted into one end of the colon. During rectal resection, this is usually the proximal loop of sigmoid. The anvil is secured with a polypropylene purse-string suture placed by hand or with the assistance of a purse-string applicator. The EEA stapler is then inserted into the distal bowel segment through colotomy (made several centimeters away from the proposed anastomosis) or by passing the stapler into the rectum in the case of a rectal resection (Figure 30-37). The EEA trocar is then passed through the prior staple line and the anvil attached. The EEA stapler is then fired and removed, creating a new bowel lumen. If a colotomy was performed to accommodate the EEA stapler, this may be closed with a TA stapling device, with care to avoid narrowing the bowel lumen by creating a staple line perpendicular to the bowel lumen. Following the completion of the anastomosis, an adequate seal can be confirmed by filling the pelvis with water and distending the rectum with air. A proctoscope can be used to directly visualize the intraluminal staple line, if desired.
FIGURE 30-37. Stapled circular end-to-end anastomosis (CEEA) of colon to rectum.
An end-to-side stapled anastomosis is usually performed to reapproximate 2 loops of bowel of different diameter, as is the case after an ileocecal resection. After both limbs of bowel have been transected with a stapling device, the anvil of an EEA stapler is inserted into the proximal loop of ileum, and a purse-string suture is placed, as previously described. The lumen of the distal loop of colon is then opened to accommodate the EEA stapler. The EEA trocar is then advanced through the antimesenteric wall of the colon and the anvil attached. The EEA stapler is then fired and removed, creating the new bowel lumen. The open end of colon is then closed with a TA stapling device, and the mesenteric defect is reapproximated. As an alternative to the end-to-end technique for rectal reanastomosis following modified posterior exenteration, a rectal “J-pouch” can be created by anastomosing the distal rectum to a detubularized loop of sigmoid colon, with the sigmoid anastomosis performed at the bottom of the “J” of the detubularized loop. To allow for adequate evacuation of stool, the length of pouch should be limited to 5 cm or less.
Under most circumstances, a side-to-side (functional end-to-end) stapled technique is preferred for reanastomosis of 2 small bowel segments or to re-approximate the distal ileum to ascending colon if an end-to-side technique is not performed. Following bowel resection, the antimesenteric edges of the transected bowel are placed side by side, and the antimesenteric corners are incised. Stay sutures may be placed along the antimesenteric surface of the planned anastomosis to prevent misalignment of the bowel segments and prevent tension along the staple line. The 2 arms of the GIA stapling device are inserted into the holes created in the staple line, and the GIA stapler is fired to create a new intestinal lumen (Figure 30-38). Prior to firing the stapler, the surgeon must ensure that the mesenteric edges of the bowel are not incorporated into the staple line to avoid devascularization. The stapler is removed and the remaining defect closed with a TA stapler. Prior to closure of the luminal defect, the staple lines of the new intestinal lumen are offset to prevent intraluminal adhesions or devascularization that may occur at an area incorporating multiple staple lines. Regardless of the technique used, patency of the bowel lumen must be confirmed by pinching the anastomosis between the thumb and index finger following completion of the anastomosis.
FIGURE 30-38. Small bowel anastomosis.
Intraoperative tumor ablation techniques are commonly used in ovarian cancer surgery and play an important role in achieving the cytoreductive goal while reducing the need for major organ resections. Ovarian cancer commonly presents with innumerable tumor implants in the abdominal cavity, and achieving complete cytoreduction requires their meticulous removal. In this setting, the most commonly used ablative tools are the ABC and the Cavitron Ultrasonic Surgical Aspirator (CUSA).
Argon Beam Coagulator
Electrosurgical ablation of tumor implants using the ABC is especially useful to eradicate tumors from areas where the alternative would have involved extensive resections, in which the morbidity and long-term consequences can be significant (eg, diffuse small bowel mesenteric implants, diaphragm) (Figure 30-39). In addition to tumor ablation, the ABC has a hemostatic effect, and its utility has been demonstrated in surgeries associated with extensive blood loss.10
FIGURE 30-39. Argon beam coagulator for tumor ablation.
The ABC uses a beam of inert argon to conduct unipolar current in a noncontact, directed fashion. The energy transmitted (40-150 W) is in the same range as standard monopolar electrocautery. The electrical current is initiated only when the tip is within 10 mm of the target tissue. The current spreads out on the tissue surface with a more homogeneous distribution of energy than standard electrocautery. In addition to tissue destruction, the argon displaces the blood and debris from the immediate operative field and coagulates vessels up to 2 to 3 mm in diameter; therefore, good visibility is maintained while it is used.11
A consistent finding in experimental animal models is that both power setting and interaction time increase the amount of tissue damage. Application to the bowel serosa should be avoided; in a canine model, a 40-W application for 1 second reached the muscularis propria in 50% of cases. At 3 seconds, damage extended into the submucosa, and at 5 seconds, full-thickness injury had occurred in all cases. In addition, delayed (5-7 days after the injury) bowel perforation at 50% of the application sites occurred with 3-second applications.12 Therefore, if the ABC is applied inadvertently for a period longer than 1 second, the area of bowel injured should be oversewn or resected, and the patient should be closely monitored in the postoperative period for signs and symptoms suggesting bowel perforation.
The depth of destruction produced by the ABC is composed of 3 distinct zones of tissue injury: vaporization (immediate tissue/current interface), carbonized eschar, and coagulative necrosis (deepest layer).11 It increases from 1.7 mm to 5.5 mm as the power setting of the ABC (60, 80, and 100 W) and the interaction time between the ABC and the tissue (1, 3, and 5 seconds) increase. An important finding is that at all power settings and interaction intervals, the ratio between the depth of coagulative necrosis and the depth of carbonized eschar is relatively constant and close to 1. This means that for any thickness of visible tumor destroyed (the carbonized eschar part), there is an equivalent amount of deeper tissue also destroyed (coagulative necrosis part), even if it appears grossly normal.
Typically, 60- to 80-W settings are used for small nodules and implants on the bowel mesentery. Higher power settings (100-110 W) can safely be used for larger tumor plaques and for disease located on the diaphragm, liver, and abdominal peritoneum.11
Cavitron Ultrasonic Surgical Aspirator
The ultrasonic surgical aspirator consists of a hand-piece with a high-frequency (23,000 Hz) ultrasonic vibrator, which destroys tissue by cavitation, and an irrigation and aspiration system, which cleans the operative field and cools the tip of the instrument.13 The tip is hollow, and broken pieces of tumor are aspirated with saline through the handpiece. Cavitation induces selective tissue fragmentation: Tissue with a high water content (eg, fat, muscle, carcinoma) is destroyed easily, whereas tissue with a high content of collagen and elastic fibers (eg, blood vessels, nerves, ureters, serosa) is more difficult to damage. The amplitude of vibration controls the excursion of the instrument tip and the depth of tissue disruption. The amplitude setting most commonly used for tumor resection is 0.7 to 0.8 (210-240 µm). The tissue removed can be used to establish a histologic diagnosis.14,15
The CUSA has been used to remove tumor nodules from the diaphragm, liver surface, major vessels, ureters, and bowel and bladder serosa.13,16 It does not seem to be associated with a higher incidence of operative complications. However, the dissection and removal of tumor can be tedious and time consuming. Increased operative time may be offset if extensive dissection and reconstruction required by standard techniques are avoided by using the CUSA.15
An increased risk of coagulopathy with extended use of the CUSA has been suggested, but this was not confirmed by other studies, and this is probably related to the surgery itself rather than the use of the CUSA.13,17 Ultrasonic cell destruction, combined with continuous irrigation, causes a cloud of fine droplets above the surgical field,18 which has been shown to carry tumor cells. Although this may not be a concern in advanced cases with widely disseminated disease, the CUSA should be used with caution when resecting isolated tumors (eg, isolated recurrence).18,19
Final Steps and Closure
After the completion of optimal cytoreductive surgery, an intraperitoneal catheter may be inserted prior to incision closure (see Chapter 33). Prior to closure, the abdominal cavity is irrigated copiously with warm saline, and a meticulous survey of all operative surfaces to ensure hemostasis is performed. Antiadhesion barriers (eg, hyaluronic acid–carboxymethylcellulose barrier; Seprafilm, Genzyme, Cambridge, MA) may be placed in the pelvis and along the anterior abdomen at this point. These products should not be placed near bowel anastomoses due to an increased risk of anastomotic leak. Suction drains, though not mandatory, can be placed according to the surgeon’s preference and extent and type of surgery.
Careful attention during abdominal wall closure is necessary to reduce the already high risk of ventral hernia and wound infection in patients undergoing laparotomy for cytoreductive surgery. Closure of the abdominal fascia is performed using a continuous delayed-absorbable monofilament suture (Polydioxa-none [PDS]), with a suture-to-wound length of at least 4:1. Randomized data support the placement of fascial sutures close to the fascial edge (5-8 mm), with care to avoid inclusion of extra fat and muscle that may devascularize and increase the risk of ventral hernia and infection.20 Subcutaneous fat is then irrigated and reapproximated with polyglactin sutures if greater than 2 cm in depth.
Box 30-3 Complications and Morbidity
Monitor patients for development of pleural effusion if diaphragm peritonectomy/resection is performed; obtain chest radiograph in postanesthesia care unit and daily, as needed.
Acute shortness of breath in the postoperative setting is not uncommon, and a quick diagnosis is essential because treatment is different according to the etiology and can be lifesaving. Among the common etiologies, the differential diagnoses include pulmonary embolism, large pleural effusion, and hospital-acquired pneumonia.
Anastomotic leaks should be ruled out in cases of unexplained persistent febrile morbidity or leukocytosis.
Patients who have undergone extensive cytoreductive surgery require close monitoring, especially during the first 24 hours postoperatively. Many patients will have received large quantities of crystalloid, colloid, and blood products intraoperatively. In the setting of malnutrition, ascites, and pre-existing medical comorbidities, the management of postoperative fluid shifts often requires the close attention of the intensive care unit (ICU) or a step-down unit. Elderly patients, patients with medical comorbidities, and patients having undergone intestinal surgery are more likely to require ICU care.21
To ensure rapid return of bowel function, early refeeding should be encouraged in patients who have not undergone bowel resection or those who have undergone a diverting loop ileostomy. In patients who have undergone colon resection, we generally begin feeding clear liquids on the second postoperative day and advance to a low-residue diet as tolerated. In cases with concern for a tenuous anastomosis, conservative refeeding with solid food initiated at the onset of flatus can be considered, although data regarding its benefit are lacking.
Postoperative ileus is also a common complication in patients who have undergone extensive abdominal surgery and can occur as late as several days after the patient has resumed bowel function. Delayed onset of nausea and vomiting is suspicious of ileus/small bowel obstruction as well as abdominal abscess even in the absence of fever or leukocytosis. Usually, postoperative ileus can be managed with bowel rest and nasogastric decompression if nausea and vomiting are persistent with bowel rest.
Early ambulation is an important part of the recovery process following cytoreductive surgery, potentially reducing the rates of postoperative ileus and thromboembolic events. Regional anesthesia results in improved pain control and facilitates early ambulation. Physical therapy may be necessary to assist patients in the early postoperative period and assess the need for additional rehabilitation after discharge. This is especially important in elderly patients.
Most patients will have a bladder catheter placed for several days after surgery to monitor urine output. Urine output should be monitored closely as an indicator of intravascular fluid status. In the author’s experience, failure to begin spontaneous diuresis within 7 days of surgery is suggestive of a postoperative infection or anastomotic leak as most patients will begin to have reduction in the “stress response” that results in salt retention by the kidneys. In patients with resection of bladder peritoneum implants, we recommend leaving the Foley catheter in place for 5 to 7 days after surgery, and even longer if bladder resection is required. In these patients, a trial of void is generally recommended after catheter removal. Although urinary retention occurs in less than 10% of patients with epidural anesthesia to control laparotomy pain, we generally do not remove the Foley catheter until the epidural is removed, which usually occurs when the patient has tolerated a regular diet for 24 hours.
In patients who have intraperitoneal drains placed along the splenic bed following splenectomy with or without distal pancreatectomy, drain output should be measured daily, and if it increases or persists, it should be checked for amylase to evaluate for an unrecognized pancreatic leak. Amylase levels 3-fold higher than found in the serum may be suggestive of an unrecognized pancreatic leak. Management should include drain placement (if not already present) and close monitoring for signs of sepsis. If drain output and leukocytosis improve, the patient can resume a regular diet. Somatostatin can decrease fistula output but has not been shown to shorten the time to closure of the fistula.
Most patients should receive prophylactic anticoagulation with low molecular weight heparin starting on the first day after surgery if there are no concerns about active bleeding. This should continue throughout the hospitalization and should be considered for the first month after surgery in an outpatient setting to reduce the risk of postoperative thromboembolic events.
Patients who are scheduled to undergo cytoreductive surgery for suspected advanced ovarian cancer should be counseled by the operating surgeon about a number of short- and long-term complications that may affect their ability to care for themselves after surgery. This should include the potential for discharge with unanticipated stomas, urinary catheters, peritoneal drains, and wound infections. Discharge planning should begin several days prior to discharge, with a thorough assessment of all potential homecare needs. Patients occasionally require placement in rehabilitation facilities. Elderly patients and those who have enduring immobilization during a prolonged intensive care unit stay are most at risk for needing rehabilitation placement.
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