Joan L. Walker
INTRAPERITONEAL CATHETER AND PORT PLACEMENT
The placement of an intraperitoneal (IP) catheter and access port should ideally occur at the time of resection and staging for advanced-stage ovarian cancer confined to the peritoneal cavity. This requires the preoperative expectation that cancer will be found and subsequent consent for planned chemotherapy on a clinical trial or using chemotherapy delivered to the peritoneal cavity. The ease of removal of the device makes it a better choice to place an IP port at initial surgery rather than to have to schedule a second surgery to implant the device.
Alternatively, the device can be placed at an interval procedure using interventional radiologic techniques, laparoscopy, or a 2- to 4-cm laparotomy incision in the right or left lower quadrant. It is preferred to avoid the previous midline incision, when trying to introduce the catheter into the peritoneal cavity.
The location of the planned device port should not interfere with the patient’s undergarments or her sleeping position. The size of the port relative to the size of the patient may cause discomfort and require altering the choice of devices. The nursing staff must be able to palpate the port, and it must be secured to a platform, such as the fascia overlying the ribs, to prevent complications during insertion of the Huber needle. The operating room staff must have the device available, as well as 2-0 prolene sutures, Huber needles, and heparin 100 units/mL for flushing. The patient must be sterile and draped from the nipples to the middle thighs and laterally to the posterior axillary line.
The preferred device is a subcutaneously implanted port attached to a silicone catheter. Do not use products with Dacron cuffs. A Bardport silicone peritoneal catheter 14.3 French is the preferred device, and it has been Food and Drug Administration approved for use in IP therapy. The 9.6-French, single-lumen intravenous (IV) access device, also made of silicone, can be substituted if the peritoneal catheter is not available. The firmness of the catheter prevents kinking, and the silicone prevents adherence to peritoneal structures so the catheter can be withdrawn without difficulty.1,2
The port pocket is created by making a 5- to 6-cm incision 3 finger-breadths above the lower costal margin, at the midclavicular or anterior axillary line, and 4 prolene sutures are placed in the fascia overlying the ribs and through the port to stabilize the device to this platform (Figure 33-1). A long tonsil clamp is tunneled subcutaneously (just above the rectus fascia) to approximately the level of the umbilicus and then through the fascia, muscle, and peritoneum to grasp the nonfenestrated end of the catheter, which pulled it into the port pocket (Figure 33-2). The 2 ends of the catheter are trimmed so that approximately 15 cm of catheter is located within the peritoneal cavity and the tip is not long enough to reach the bladder or vagina. The catheter should not be left between the transverse colon and the abdominal wall, because it is likely to be entrapped in adhesions between those 2 structures due to the omentectomy. The catheter is attached to the port and fixed in place with 2-0 prolene sutured to fascia overlying ribs (Figure 33-3). The port pocket is closed in 2 layers with 3-0 absorbable suture and flushed with 100 units/mL of heparin to document that the system functions prior to leaving the operating room.
FIGURE 33-1. Intraperitoneal port placement: incision above left costal margin.
FIGURE 33-2. Intraperitoneal port placement: tunneling of catheter.
FIGURE 33-3. Intraperitoneal port placement: fixation of port reservoir.
An IP port can be placed as an interval procedure remote from the primary debulking operation via mini-laparotomy. The port pocket is created as described earlier. Entry into the peritoneal cavity should be away from previous midline wound and avoid areas of bowel resections or extensive dissection. Free peritoneal space is generally available overlying the cecum and is often the ideal site for incision to obtain entry into the peritoneal cavity. After identifying the peritoneal cavity, under direct visualization, the catheter is drawn through the full thickness of the peritoneum, muscle, and fascia into the subcutaneous tissue. The catheter is then pulled through the subcutaneous tissue layer above the fascia into the port pocket, trimmed to length, sutured, and positioned as described earlier. Every layer of the peritoneum, fascia, and skin should be closed individually at the mini-laparotomy site to avoid leakage. The device should not be used for at least 24 hours.
Either right or left upper quadrant entry techniques can be used for laparoscopic IP port placement. The stomach should be aspirated with an oral gastric tube or nasogastric tube prior to initiating the procedure. Open laparoscopic techniques or mini-laparotomy may prove to be more advantageous when adhesions are expected. Blind Veress needle technique in the left upper quadrant should only be undertaken if knowledge of the anatomy in that location indicates it is free of adhesions or if ascites is present and ultrasound guidance can be used. A 5-mm trocar is placed 2 to 3 finger-breadths below the costal margin in the midclavicular line. The laparoscope is inserted and used to guide placement of a second 5-mm port. The IP catheter is inserted through the lower trocar under direct visualization and the trocar removed over the catheter (Figure 33-4). The port pocket is then created overlying the fascia of the lower ribs as described earlier, and the catheter is pulled from the lower insertion site with a long tonsil up into the port pocket. The catheter is trimmed to proper length, attached to the port, and sutured to the fascia overlying the ribs with 2-0 prolene sutures. The port and catheter are flushed with 10 mL of heparin 100 units/mL using a Huber needle, and the port pocket is closed in 2 layers.
FIGURE 33-4. Laparoscopic intraperitoneal port placement.
Complications are categorized into port access problems, inflow obstruction, abdominal pain, infections, and leaking into wound, bowel lumen, or bladder or out of the vagina. The expected complication rate is 10%.
Difficulty accessing the port or inflow obstruction is evaluated by fluoroscopy with infusion of a small amount of dilute solution of IV contrast dye. Surgical correction of the device can be considered, but usually the device is removed and IV chemotherapy is given. Successful correction is dependent on the cause being a mechanical problem, rather than a patient-specific problem, such as adhesions.
A fever in an IP chemotherapy patient can be evaluated by irrigating and aspirating saline from the port to send to microbiology, for cell count and culture, to look for evidence of peritoneal or catheter infection. Cellulitis surrounding an IP port is rarely treated with antibiotics alone; the port and catheter are generally removed. Leaking around the port or subcutaneous tissues is often an indication of inflow obstruction or intra-abdominal adhesions surrounding the catheter with retrograde flow of fluid back into the port pocket. Fluoroscopy will usually be diagnostic.
The device leaking into the vagina, bladder, or bowel is generally corrected by percutaneous removal of the catheter. Fistulas do not always occur as a result, and a laparotomy is not generally needed, unless the patient appears to have peritonitis, free air, or a urinoma. Complaints of diarrhea or incontinence of urine with IP chemotherapy administration should be investigated with contrast dye to determine a potential communication between bowel, bladder, peritoneum, and infusion with the catheter.
INTRAPERITONEAL PORT REMOVAL
An IP port can be removed either in the operating room under sedation and local anesthesia or as an office procedure using only local anesthetic. It is best to remove these devices as soon as their useful life is over, so a complication will not interfere with the patient’s quality of life.
The patient should not be neutropenic or thrombocytopenic, and medications that inhibit platelet function should be withheld. A list of equipment needed for office removal is provided in Table 33-1.
Table 33-1 Equipment Needed for Intraperitoneal Port Removal
List of equipment needed:
Sterile field prep and drape
Mayo stand and sterile cover
3-0 Vicryl SH needle
4-0 Vicryl PS-2 needle
Electrocautery is optional
Sterile skin preparation is first, followed by placement of a disposable sterile drape with a perforation at the site of the port. The skin surrounding the port pocket is infiltrated with 1% lidocaine. A skin incision is made overlying the port through old scar. The adipose tissue is dissected down to the palpable port where the catheter is attached. A dense fibrinous sheath is found over the port and the catheter, and this sheath has to be incised without cutting the catheter itself. A hemostat is used to undermine the catheter and pull it up and out of the abdomen, and this is used for traction. The port is elevated, and the 4 prolene sutures are cut, while cutting through the fibrinous sheath surrounding the port, and the port and catheter are removed. The port pocket is closed in 2 layers.
A prescription for narcotics is often given, but nonsteroidal pain medications are generally adequate. Covering the incision for 24 hours is all that is required.
MANAGEMENT OF INTRAOPERATIVE HEMORRHAGE
The effective management of unexpected intraoperative hemorrhage includes the creation of an adequate incision, ensuring good retraction, and optimizing exposure and lighting. The identification of important landmarks and the use of reliable surgical dissection planes will help to minimize blood loss. Depending on the origin of blood loss, a variety of hemorrhage control techniques are at the surgeon’s disposal.
Most patients undergoing surgery for gynecologic cancer should be considered a potential risk for major hemorrhage. Anticipation of such situations and proper preparation are key to effective management. An emergency vascular surgical tray of standard topical hemostatic agents (Table 33-2) should be readily available, as well as vessel loops and long hemoclip appliers; for obese patients, an extra long lighted retractor set (St. Mark Deep Pelvic Lighted Retractor), extra long suction, and a laparoscopic clip applier are helpful. Rapid notification plans for anesthesia, nursing, blood bank and surgical assistance from trauma, and vascular or general surgery should be in place. Coagulopathy, hypothermia, and dilutional problems, due to the use of excessive crystalloid for blood pressure support when blood is not available, should be avoided.
Table 33-2 Hemostatic Agents for Topical Application
Standard trauma surgery practice is to put a dry lap in all quadrants and work from the most likely site of hemorrhage outward, applying manual pressure on the bleeding site until proper exposure and isolation can be obtained.
Rapid decision making is often the key to successful outcomes. Considerations include adequacy of the incision, measures necessary to obtain proximal and distal control of a vascular injury, need for temporary compression of the aorta, and need for additional personnel (eg, vascular surgeon). Significant vascular injuries encountered during laparoscopy should be tamponaded while preparations are made for laparotomy. Ideally, laparotomy equipment is available in the room for every laparoscopic surgery.
Control of Abdominal Hemorrhage
Bleeding from left para-aortic dissection may require a modified Mattox maneuver (Figure 33-5) in which mobilization of the left colon and splenic flexure toward the midline and separation of the colon mesentery from Gerota fascia exposes of the aorta, left kidney, ureter, and renal vessels. Anatomic identification of all structures is most efficient by following the left ureter and left ovarian vein cephalad to their insertions into the kidney and the renal vein on the left and vena cava on the right.
FIGURE 33-5. Modified Mattox maneuver. Mobilization of the left colon and spleen allows visualization of the left renal vessels and aorta.
Vena cava lacerations should be adequately exposed before repair is attempted, and the Cattell-Braasch maneuver (Figure 33-6), which mobilizes the right colon with the cecum, ascending colon, and hepatic flexure at the white line of Toldt and reflects the colon and the base of the mesentery medially and superiorly, may be necessary. This maneuver allows excellent exposure of the vena cava, aorta, right ureter, right kidney, and renal vessels. If the laceration is more cephalad, the Kocher maneuver should be performed, which mobilizes the duodenum and posterior aspect of the head of the pancreas. Compression proximal and distal to the injury allows for a controlled closure of the laceration. Small injuries to the vena cava may be controlled with the application of 1 or 2 vascular hemoclips. Alternatively, an Allis or Satinsky clamp can be used to approximate the laceration, while a 4-0 or 5-0 prolene continuous running suture is used to reapproximate the vascular edges.
FIGURE 33-6. Cattell-Braasch maneuver: dissection of the cecum, ascending colon, and hepatic flexure at the white line of Toldt and reflecting the colon and the base of the mesentery medially and superiorly to achieve exposure of vena cava, aorta, right ureter, right kidney, and renal vessels.
Lacerations of the splenic capsule during omen-tectomy can be controlled with thrombin-soaked gel foam, fibrin glue, or Floseal and Surgicel. Splenectomy is an alternative when these maneuvers fail.
Control of Pelvic Hemorrhage
Pelvic hemorrhage is one of the most difficult areas of bleeding to control, particularly if bleeding is multifocal and exposure is limited. Packing with tamponade is usually the best initial strategy for unanticipated major pelvic blood loss. Anesthesia should be notified and the institutional massive hemorrhage protocol initiated. Once adequate resources have been mobilized, the packs are removed, and a systematic approach is undertaken to explore IP structures and the retroperitoneal spaces to locate and control the source of bleeding. The ureters should always be clearly identified and mobilized away from the field of dissection. Development of the pararectal and paravesical spaces facilitates exposure of the major retroperitoneal vasculature. Bleeding sites should be controlled individually; hemoclips or sutures should never be placed blindly into the pelvic sidewall.
Bleeding from the external iliac vein is usually easily controlled by grasping with a Satinsky or bulldog clamp or Allis clamp. Proximal and distal control can also be achieved by occlusion with sponge sticks (Figure 33-7). Alternatively, the vessel can be systematically approached by surrounding the vein distally and proximally with a Potts loop (wrapping a vessel loop twice around the vein and applying gentle elevation). The vein may have a laceration on top by avulsion of the circumflex iliac or on the underside by the accessory obturator vein. Suturing the defect is less likely to decrease the lumen diameter compared with using a hemoclip; however, the clip applied parallel to the vein is faster when feasible. Small defects can be grasped with smooth forceps, elevated, and controlled with a single hemoclip or 2 hemoclips placed in the shape of a “V.” Alternatively, a series of figure-of-eight stitches with 4-0 or 5-0 prolene suture on a vascular needle should be adequate. If the defect is long, a running 5-0 prolene suture is used. Deep venous thrombosis is common after intimal injury and repair and should be prevented with anticoagulation as soon as feasible; early diagnosis postoperatively with Doppler imaging is recommended.3
FIGURE 33-7. Occlusion of external iliac vein to localize and repair vascular injury.
The obturator space under the external iliac vein may be a site of bleeding during the dissection of lymph nodes from this region. This space may be approached from between the psoas muscle and the external iliac vessels to visualize the obturator nerve and vessels while the source of bleeding is secured. Alternatively, the medial approach using the paravesical space can be used to identify the obturator nerve and the hypo-gastric artery and vein. Bleeding from veins retracting into obturator foramen should stop with pressure or Gelfoam soaked in thrombin or the use of Floseal. An accessory obturator vein is present in 24% of patients and is located on the inferior surface of the external iliac vein. Control of bleeding from this vessel requires that the external iliac vein be rotated laterally for adequate exposure.
Hypogastric vein bleeding and lateral pelvic hemorrhage constitute another very difficult surgical dilemma. The preferred approach is to achieve adequate visualization of the bleeding vessel and control it with hemoclips or sutures. Use of hemostatic agents and pressure is secondary.
Bleeding from the presacral space and associated venous plexus can be life threatening. Hemostatic agents such as thrombin, Nu Knit and Fibrillar Surgicel, and Floseal with manual pressure are usually effective in controlling bleeding unless a large laceration has occurred. Suturing in the presacral space is notoriously unsuccessful. A bleeding friable vein can be coated with Floseal; then Fibrillar Surgicel is applied on top of Floseal and pressure is held for 10 to 15 minutes. In the event of failure of hemostatic agents and pressure, sterile thumb tacks placed into the sacrum on top of the Gelfoam or Surgicel may be considered. The indication for sterile thumb tacks is for control of localized severe hemorrhage from the presacral area. This technique should only be used when other techniques are ineffective. The bleeding can only be effectively controlled by this technique if it can be localized by manual compression with a surgeon’s fingers or sponge stick. Contraindications include bleeding greater than 2 cm from the midline and bleeding that appears to originate from the sacral neural foramina or ureter, rectum, or vagina. The above techniques are unlikely to control presacral bleeding in the face of systemic coagulation disorder. In such circumstances, packing the pelvis and using the guiding principles of “damage control surgery” with temporary closure, resuscitation in the intensive care unit, and reoperation are more likely to be life saving. Interventional radiology is also helpful in many of these situations. Return to the operating room is planned in 24 to 48 hours to remove the packing after resuscitation and stabilization.
Hypogastric Artery Ligation (Ligation of the Anterior Division of the Internal Iliac Artery)
Hypogastric artery ligation can be used to control hemorrhage from any gynecologic surgery complicated by bleeding from the central pelvis or parametria due to small vessel injury. The procedure is effective for arterial bleeding from the vaginal apex and in the broad ligament. It is not effective for venous oozing anywhere in the pelvis. Bilateral hypogastric artery ligation was first performed by Howard A. Kelly at the Johns Hopkins Hospital in 1894 as an emergency measure to control pelvic bleeding in a patient undergoing hysterectomy for cervical cancer.4 The effectiveness of hypogastric artery ligation is predicated on the resulting decrease in arterial pulse pressure distal to the site of ligation and is dependent on successful prevention of collateral circulation beyond the ligature via branches of the posterior division of the hypogastric artery (iliolumbar, lateral sacral, and superior gluteal arteries).5 The posterior division arises within 5 cm of the common iliac artery bifurcation in 95% of cases.6 As such, the point of ligation should be at least 5 cm distal to the common iliac artery bifurcation.
The technique is safest after development of the pararectal and paravesical spaces to visualize the entire pelvic vasculature and ureter. The common iliac, external iliac, and hypogastric vasculature should be visually confirmed and a point on the hypogastric artery at least 5 cm distal to the common iliac artery bifurcation selected for placement of the ligature. The hypogastric vein lies lateral and deep to the hypogastric artery and should be carefully avoided. The hypo-gastric artery is carefully dissected by passing a right angle clamp beneath it, working from lateral to medial without injuring the underlying vein. This is accomplished by pushing the artery medially and ventrally as the tips are advanced from lateral to medial around the artery toward the midline. The tips must not be pushed laterally into the vein. The hypogastric artery is ligated with a 1-0 or 2-0 silk suture (Figure 33-8). There is no need to place a transfixion stitch or to divide the artery once ligated.
FIGURE 33-8. Hypogastric artery ligation.
At the conclusion of the procedure, one must be cautious to evaluate the remainder of the abdomen for unsuspected injuries or bleeding and removal of all instruments and packing. If the patient cannot be adequately resuscitated, rapid abdominal closure after packing for tamponade of bleeding may be the best decision. Damage control surgery is, on occasion, the best choice with the expectation that reoperation in 24 to 48 hours is the safest plan.
WOUND MANAGEMENT AND VACUUM-ASSISTED CLOSURES
Primary Abdominal Closure (Clean and Clean/Contaminated)
The patient factors and surgical factors affecting the risk of wound infection, seroma, hernias, fascial dehiscence, and evisceration should be considered for every gynecologic oncology procedure. Obesity, advanced age, diabetes, cancer, and poor nutrition are common comorbidities that compromise wound healing.
The mass closure of fascia can be performed as an interrupted technique (Smead-Jones) or a modified continuous running suture. Monofilament delayed-absorbable suture in a continuous or interrupted mass closure (#1 polydioxanone or Maxon) has become the technique preferred by most surgeons, but it may be appropriate to use permanent monofilament suture (#2 nylon) in very high-risk individuals or when a hernia is already present.7-9
Alternative Abdominal Wall Closures
Intra-abdominal sepsis and contaminated wounds are indications for alternative strategies for abdominal wall closures. Primary routine fascial closure is appropriate for the stable patient defined as follows: normothermic; without coagulopathy or bleeding; not acidotic; and the source of the infection has been isolated and permanently treated. In these circumstances, the wound should be irrigated, a closed suction drainage system is placed, the abdominal wall is approximated using a mass closure, and a wound vacuum device is applied to the adipose layer for secondary closure. The risk of fascial necrosis and unseen infections can be eliminated by leaving the adipose and skin open and frequently evaluated.
Uncontrollable hemorrhage requiring packing and the presence of gross abdominal sepsis are indications for damage control surgery or open abdomen management.10 Phase I in damage control surgery is control of the hemorrhage and/or the contamination. The unfinished surgery may require packing to be left in place to control bleeding, or delay of the hysterectomy that did not get performed or the tumor that was not removed. In the case of intra-abdominal sepsis, the bowel injury or perforation may have been temporarily stapled across without completing the anastomosis or bringing up a stoma. Hemorrhage, once under control, or packed, requires a rapid running mass closure suture of the abdominal wall and covering the wound. This approach prevents retraction of the fascia and thus provides a better opportunity for complete abdominal wall closure in 24 hours when the patient is completely resuscitated. Intra-abdominal sepsis may result in intra-abdominal compartment syndrome, and the open abdomen approach has become recognized as an alternative to abdominal wall closure under certain circumstances, including lactic acidosis, coagulopathy, and hypothermia. Isolation of the source of infection, warm irrigation, drainage, and an open abdomen dressing for 24 hours constitute the operative plan. Retraction of the fascia is a major complication of this approach, and therefore, rapid (< 48 hours) return to the operating room for fascial closure is required.
Phase II in damage control surgery is a rapid transfer to the intensive care unit for resuscitation and allowing time for patient warming, correction of acidosis, correction of coagulopathy, ventilation, blood pressure, and fluid management. Monitoring of intra-abdominal pressure and careful attention to the early diagnosis of abdominal compartment syndrome will help determine the timing of future abdominal explorations and wash out procedures.
Phase III in damage control surgery is a return trip to the operating room in 24 to 48 hours for completion of previously postponed surgical steps, including removal of packing, control of bleeding, reanastomosis of bowel, maturation of stomas, intra-abdominal wash out, placement of drains, and exploration for viable versus necrotic tissue and unrecognized injuries. A major goal of the second operation should be closure of the abdominal fascia, and when not feasible, traction on the fascia must be instituted to allow for future closure when there is a reduction of intra-abdominal swelling and edema. A wound vacuum is generally applied to the adipose layer. Postoperatively, the patient needs to be observed for development of intra-abdominal compartment syndrome.
Open Abdomen Wound Management Systems
The basic concept of open abdomen wound management systems is to provide closed-suction drainage to the intra-abdominal compartment, protect the intra-abdominal contents with a thin plastic sheet, cover the wound with sterile towels or sponges, and then apply an adhesive dressing over the entire abdomen. A commercially available kit, the ABThera (Kinetic Concepts, Inc., San Antonio, TX), provides the prepackaged materials to manage this situation (Figure 33-9). The missing component is the traction on the fascia. The fascia must be primarily closed, closed within 24 hours, or have continuous traction on it to prevent the permanent retraction, which makes future abdominal closure impossible. Closure of the fascia is generally attempted daily or the wound may never reapproximate.11 The ABRA abdominal wall closure device (Canica Design, Inc., Almonte, Ontario, Canada) was developed to assist with fascial closure when edematous bowel and increased intra-abdominal pressure require fascial closure to be delayed over a number of days (Figures 33-9 and 33-10).
FIGURE 33-9. ABThera open wound management system and ABRA fascial closure system (incision open).
FIGURE 33-10. ABRA fascial closure system (incision closed).
Vacuum-Assisted Closure Device (Negative-Pressure Wound Therapy)
Negative-pressure wound technology protects the surrounding skin while assisting with control of moisture and promoting granulation tissue development and wound closure in the adipose tissue below the skin level. Indications in gynecologic oncology for negative-pressure wound therapy (vacuum-assisted closure [VAC]) include planned secondary closure of open wounds in contaminated or septic cases and secondary closure of wounds opened after seroma or wound infections. In the setting of necrotizing fasciitis of the abdominal wall or vulva (Figure 33-11), the wound VAC device can be a valuable tool after all necrotic tissue has been debrided. Wound assessments every 24 hours must occur for a few days after the initial debridement, and then less frequent changes can occur. Contraindications include settings where there is devitalized tissue, tumor in the wound, potential fistula underlying wound, vascular graft, vessels, nerves, or exposed organs. Infection should be controlled prior to application of the device.
FIGURE 33-11. Necrotizing fasciitis of the vulva.
The surrounding skin must be clean and dry, and Mastisol liquid adhesive is applied to the skin prior to sealing the wound. The negative-pressure wound therapy systems (wound VAC devices) include a sponge that is cut to fit to the depth, width, and length of the wound and an adhesive barrier that covers the sponge and provides and air-tight seal to the skin (Figure 33-12). The vacuum tubing is attached to the foam, which is attached to the provided collection device and vacuum control for the fluids produced by the wound. Sponge consists of an open-pore polyurethane ether foam sponge, which is then covered with a semiocclusive adhesive cover and attached to the fluid collection system and the suction pump. The dressings are changed at least every 3 days and whenever the vacuum seal is lost.
FIGURE 33-12. Wound vacuum system.
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11. Pliakos I, Papavramidis TS, Mihalopoulos N, et al. Vacuum-assisted closure in severe abdominal sepsis with or without retention sutured sequential fascial closure: a clinical trial. Surgery. 2010;148(5):947-953.