Principles of Gynecologic Oncology Surgery

Principles of Gynecologic Oncology Surgery
Copyright
Dedication
Contributors
Foreword
Preface
1 - Introduction to Principles of Gynecologic Oncology Surgery
2 - Abdominal and Pelvic Anatomy
Pelvic Anatomy
Bony Pelvis
Ilium
Ischium
Pubis
Sacrum
Orientation of the Bony Pelvis
Anatomic Landmarks of the Bony Pelvis
Ischial Spine
Coccyx
Pubic Arch
Pectineal Line
Pelvic Ligaments
Sacrospinous Ligament
Sacrotuberous Ligament
Pelvic Muscles
Muscles of the Lateral Pelvis
Obturator Internus Muscle
Piriformis Muscle
Muscles of the Pelvic Floor
Levator Ani Muscle Complex
Arcus Tendineus Levator Ani
Puborectalis Muscle
Avascular Spaces
Retropubic Space (Space of Retzius)
Paravesical Spaces
Pararectal Space
Vesicovaginal Space
Rectovaginal Space
Presacral Space
Uterine Support Structures
Parametria
Round Ligaments
Broad Ligament
Pelvic Vasculature
Arterial Supply
Venous Drainage
Pelvic Lymphatic System
Pelvic Nerves (Fig. 2.30)
Somatic Nerves
Autonomic Nerves
Pelvic Viscera
Female Upper Genital Tract
Bladder
Ureters
Sigmoid Colon, Rectum, and Anus
Perineum
Perineal Membrane
Urogenital Triangle
Perineal Body
Anal Triangle
Ischiorectal Fossa
Vulva
Vagina
Urethra
The Retroperitoneum
Retroperitoneal Vasculature
Abdominal Aorta
Branches of the Abdominal Aorta
Inferior Vena Cava
Variations
Collateral Circulation
Lymphatic System
Retroperitoneal Nerves
Adrenal Glands
Arterial Supply
Venous Drainage
Lymphatic Drainage
Kidneys
Gerota Fascia
Anatomic Relations
Vascular Supply
Lymphatic Drainage
Ureters
Anatomy of the Upper Abdomen and Midabdomen
The Diaphragm
Diaphragmatic Attachments
Central Tendon of the Diaphragm
Diaphragmatic Apertures
Nerve Supply
Blood Supply
Lymphatic Drainage
The Stomach
Gastroesophageal Junction
Gastroduodenal Junction
Lesser Curvature
Greater Curvature
Anterosuperior Surface
Posteroinferior Surface
Segments of the Stomach
Lesser Omentum
Greater Omentum
Venous Drainage
Lymphatic Drainage
Nerves of the Stomach
Parasympathetic Nerve Supply
Sympathetic Nerve Supply
Duodenum and Pancreas
The Pancreas
Venous Drainage
Lymphatic Drainage
Nerves of the Duodenum and Pancreas
The Liver
Ligamentous Attachments
Perihepatic Organs
Hepatic Segmentation
Couinaud Classification
Hepatic Vasculature
Arterial Vasculature
Venous Vasculature
Lymphatic Drainage
Innervation
Intrahepatic Biliary Tree
Extrahepatic Biliary Tract
Cystic Duct
Gallbladder
Common Bile Duct
Hepatocystic Triangle and Triangle of Calot
Arterial Supply
Venous Drainage
Lymphatic Drainage
Spleen
Small Intestine
Blood Supply and Lymphatics of the Small Intestine
Large Bowel
Cecum and Appendix
Ascending Colon
Transverse Colon
Descending Colon
Sigmoid Colon
Rectum
Anal Canal
Blood Supply to the Large Bowel
Conclusion
Suggested Readings
3 - Enhanced Recovery After Surgery in Gynecologic Oncology Surgery
ERAS in Gynecologic Oncology
Elements of ERAS Program and Guidelines
Preoperative Components
Preoperative Counseling
Preoperative Optimization
Preoperative Mechanical Bowel Preparation
Preoperative Fasting and Carbohydrate Loading
Preanesthetic Medication
Thromboembolism Prophylaxis
Antimicrobial Prophylaxis
Intraoperative Components
Short-Acting Anesthesia
Multimodal Opioid-Sparing Regimens
Maintenance of Normothermia
No Routine Nasogastric Intubation or Drainage of the Peritoneal Cavity
Avoidance of Salt and Water Overload
Minimally Invasive Procedures
Postoperative Components
Postoperative Nausea and Vomiting Prophylaxis
Multimodal Analgesia
Avoidance of Salt and Water Overload
Early Oral Nutrition
Removal of Urinary Catheter
Early Mobilization
Postoperative Glucose Control
Audit of Compliance and Outcomes
Summary
References
4 - Vulvar Surgery and Sentinel Node Mapping for Vulvar Cancer
Presentation, Diagnosis, and Workup
Presentation
Diagnosis
Preoperative Workup
Preoperative Considerations
Anatomy
Primary Surgical Treatment Versus Primary Radiation
Surgical Planning for Resection of Primary Tumor
Surgical Planning for Inguinofemoral Lymph Nodes
Sentinel Nodes in Vulvar Cancer
Surgical Procedures
Wide Local Excision
Wide Radical Excision
Complete Inguinofemoral Lymphadenectomy
Lymphatic Mapping and Sentinel Lymph Node Biopsy
Mapping Substances
Surgical Technique
Complications and Morbidity
References
5 - Conservative Surgery in Early-Stage Cervical Cancer
Radical Trachelectomy
Indications
Preoperative Evaluation
Surgical Approaches
Vaginal Radical Trachelectomy
Abdominal Radical Trachelectomy
Minimally Invasive Radical Trachelectomy
Intraoperative Schema
Pelvic Lymphadenectomy and Lymphatic Mapping
Obstetric Outcomes
Cervical Conization or Simple Hysterectomy in Low-Risk Patients
Rationale for Conservative Management of Cervical Cancer
Summary of Data From Retrospective Studies of Conservative Management
Prospective Trials of Conservative Surgical Management of Low-Risk Cervical Cancer
Conservative Surgery in Larger Cervical Tumors
Surgical Techniques
Abdominal (Robotic) Radical Trachelectomy
Step 1: Exploration of the Abdomen
Step 2: Exposure of the Retroperitoneum and Pelvic Spaces
Step 3: Uterine Artery Ligation and Ureteral and Parametrial Dissection
Step 4: Colpotomy and Cervical-Parametrial Amputation
Step 5: Placement of Uterine Cannula and Cerclage
Areas of Controversy
Complications of Radical Trachelectomy
Intraoperative Complications
Amenorrhea
Cerclage Erosion
Reoperation
Conversion to Radical Hysterectomy
Key Points
References
6 - The Application of Sentinel Lymph Node Biopsy in Cervical Cancer*
Lymph Node Involvement in Cervical Cancer
Cervical Cancer: A Candidate for Sentinel Lymph Node Mapping
Anatomy of the Cervix and Its Lymphatic Channels
Efficiency of Sentinel Lymph Node Technique
Methodologies
Radioactive Tracers, Lymphoscintigraphy, and SPECT-CT
Lymphoscintigraphy Versus SPECT-CT
Colorimetric Dye
Fluorescence
The Performance of the Detection Modalities
Impact of Size of Metastasis in the Sentinel Node
Morbidity
Typical and Unexpected Locations of Sentinel Lymph Nodes
Limitations of Sentinel Lymph Node Technique
Indications for Sentinel Lymph Node Detection
Impact of Neoadjuvant Chemotherapy on Sentinel Lymph Node Detection
Technical Application and Suggested Algorithm
Conclusion
References
7 - Abdominal Radical Hysterectomy
History of Radical Hysterectomy
Classification of Radical Hysterectomy
Type A Radical Hysterectomy
Type B Radical Hysterectomy
Type C Radical Hysterectomy
Lateral Parametria—Transverse (Horizontal) Resection Margins
Longitudinal (Deep Parametrial or Vertical) Resection Margins
Ventral Parametria—Transverse Resection Margins
Longitudinal Resection Margins
Dorsal Parametria—Transverse Resection Margins
Longitudinal Resection Margins
Type D Radical Hysterectomy
Indications for Radical Hysterectomy
Preoperative Evaluation
Surgical Approach
Laparoscopic-Assisted Radical Vaginal Hysterectomy
Abdominal Radical Hysterectomy
Laparoscopic Radical Hysterectomy
Robotic Radical Hysterectomy
Surgical Assessment and Technique
Type of Incision
Unexpected Nodal Disease
Step-by-Step Approach to Abdominal Radical Hysterectomy
Development of the Rectovaginal Space (Fig. 7.1)
Development of the Pelvic Spaces
Bladder Dissection
Uterine Artery Ligation and Unroofing of Ureter
Parametrial Resection
Pelvic Node Dissection
Complications of Radical Hysterectomy
Intraoperative Complications
Postoperative Complications
Summary
Key Points
References
8 - Surgical Staging for Treatment Planning
Anatomic Considerations
General Instrumentation
Extraperitoneal Laparoscopic Paraaortic Node Dissection
Patient and Staff Positioning
Technical Description
Entry Into Extraperitoneal Space and Placement of Trocars
Development of Extraperitoneal Space
Mobilization of Nodal Tissue Along the Lateral Portions of the Left Common Iliac Artery and Aorta
Mobilization of Nodal Tissue Along the Anterior Portion of the Aorta and Vena Cava
Removal of Detached Nodal Bundles
“Preventive Marsupialization” and Completion of the Procedure
Additional Considerations
Complete Inter-aortocaval Dissection
Gonadal Pedicle Resection
Nerve-Sparing Dissection
Technical Difficulties
Fixed Nodes
Intraoperative and Postoperative Complications
Lymphatic Complications
Lower Extremity Lymphedema
Hemorrhage
Bowel Injury and Ureteral Injuries
Anatomic Variations
Renal Artery and Vein Anomalies
Congenital Anomalies of Inferior Vena Cava
Ureter Variations
Potential Limitations
Alternative Approaches
Single-Port Extraperitoneal Approach
Robotic Extraperitoneal Approach
Other Considerations
Surgical Radioprotection in Locally Advanced Cervix Cancer
Revision of the Patterns of Dissection
Revision of Indications of Paraaortic Lymph Node Dissection
References
9 - Hysterectomy With Pelvic and Paraaortic Lymphadenectomy
Role of Lymphadenectomy
Therapeutic Value of Lymphadenectomy
Sentinel Nodes in Endometrial Cancer
Indications for Lymphadenectomy
Complications of Pelvic and Paraaortic Lymphadenectomy
Vascular Anatomic Variations in the Paraaortic Area
Tips and Tricks to Avoid Vascular Injuries During Lymphadenectomy
Role of Oophorectomy at the Time of Hysterectomy
Preoperative Evaluation
Perioperative Management
Surgical Technique
Hysterectomy
Open Abdominal Approach
Step 1: Exploration of the Abdomen
Step 2: Exposure of the Retroperitoneal Spaces and Ureteral Identification
Step 3: Adnexal Removal or Sparing
Step 4: Development of the Vesicouterine Fold and Caudal Reflection of the Bladder
Step 5: Division of the Cardinal and Uterosacral Ligaments
Step 6: Colpotomy and Vaginal Closure
Landmarks for Pelvic and Paraaortic Lymphadenectomy
Pelvic Lymphadenectomy
Paraaortic Lymphadenectomy
Lymphadenectomy: Pelvic Phase
Access to the Retroperitoneum
Lymph Node Dissection
Lymphadenectomy: Paraaortic Phase
Left Paraaortic Lymph Node Removal
Summary
Key Points
References
10 - Sentinel Lymph Node Mapping for Endometrial Cancer
Importance of Lymph Node Assessment
Sentinel Lymph Node Mapping Techniques
Colored Dye Injection
Sentinel Lymph Node Mapping Algorithm
Sentinel Lymph Node Ultrastaging
Summary
References
11 - Indications for Laparoscopic Assessment of Cytoreduction
Background
Imaging Tools for Preoperative Evaluation
Serum Biomarkers
Preoperative Imaging Modalities
Combination Predictive Models
Rationale for Laparoscopic Evaluation
History of Laparoscopy to Assess Feasibility of Cytoreduction
Indications for Laparoscopic Evaluation
Method of Laparoscopic Assessment
Parietal Peritoneum
Diaphragmatic Disease
Omentum
Bowel Infiltration
Stomach, Spleen, and Lesser Omentum
Liver Metastases
Technique for Laparoscopic Assessment
Incomplete Evaluation
Clinical Implications
Laparoscopic Evaluation at Interval Cytoreductive Surgery
Prospective Trial Results
Summary
References
12 - Radical Upper Abdominal Surgery: Liver, Diaphragm, and Spleen
Anatomic Considerations
Liver
Liver Surface
Liver Segments
Porta Hepatis
Hepatic Veins
Diaphragm
Muscular Components
Apertures and Visceral Relations
Innervation and Vascular Supply
Ligaments of the Liver and the Bare Area
Spleen
Pancreas
Cytoreductive Surgery
Cytoreduction of Hepatic Disease
Mobilization and Exposure
Surface Liver Disease
Parenchymal Liver Disease
Nonanatomic Wedge Resection
Total Inflow Occlusion
Major and Minor Hepatic Resections
Microwave Ablation
Cryoablation
Porta Hepatis Disease
Cytoreduction of Diaphragmatic Disease
Exposure
Liver Mobilization
Diaphragm Peritonectomy
Full-Thickness Diaphragm Resection
Spleen
Exposure
Splenectomy
Posterior Approach
Anterior Approach
Laparoscopic Splenectomy
Splenic Injury
Distal Pancreatectomy
Radical en Bloc Left Upper Quadrant Resection
Conclusion
References
13 - Radical Pelvic and Retroperitoneal Ovarian Cancer Surgery
Pelvis
Retroperitoneum
Retroperitoneal Node Dissection
Pelvic Lymphadenectomy: Surgical Technique
Step 1: Dissection of the Avascular Spaces of the Pelvis
Step 2: Separation of the Nodal Tissue From the Iliac Vessels
Step 3: Removal of the Common Iliac Nodes
Aortic Node Dissection
Anatomic Considerations
Transperitoneal Technique by Laparotomy
Step 1: Peritoneal Incision and Exposure of the Area of Dissection
Step 2: Removal of the Paracaval Nodes
Step 3: Removal of the Paraaortic Nodes
Step 4: Removal of the Node Specimen Between the Aorta and the Vena Cava
Pelvic Surgery for Advanced Ovarian Cancer: Surgical Technique
Surgical Technique
Type I Radical Oophorectomy
Type II Radical Oophorectomy
Bowel Anastomosis
Type III Radical Oophorectomy
References
14 - Complications and Management of Radical Cytoreduction
Complication Classification Systems
Preoperative Risk Assessment for Complications
Surgical Complexity Scores
Surgical Procedures as Predictors of Perioperative Complications
Selection of Patients for Surgery
Preoperative Care Planning and Prevention of Complications
Thromboembolic Prophylaxis
Nutritional Support
Smoking and Alcohol Cessation
Preoperative Antibiotics
Postoperative Care Planning
Intensive Care Unit Hospitalization
Glycemic Control
Fluid Management
Maintenance of Electrolyte Homeostasis
Nutritional Support
Correction of Anemia
Pain Management
Respiratory Management
Postoperative Thromboembolism Prophylaxis
Ambulation and Discharge
Perioperative Complications
Hemorrhage
Infection
Surgical Site Infection
Digestive Tract Fistula
Other Infectious Complications
Gastrointestinal Tract Complications
Gastric Distention
Ileus
Ascites Reaccumulation and Abdominal Compartment Syndrome
Hematologic Disorders
Thromboembolic Complications
Respiratory Complications
Pulmonary Infection
Pleural Effusion
Other Respiratory Complications
Cardiac and Neurovascular Complications
Renal Failure
Mortality
Conclusion
References
15 - Pelvic Exenteration for Gynecologic Cancers
History
Indications
Classification
Preoperative Imaging
Prognostic Factors and Contraindications
Prognostic Factors
Surgical Margins
Histologic Type
Lymph Node Status
Time to Recurrence
Other Factors
Contraindications
Surgical Technique
Development of Pelvic Spaces
Ureteral Dissection
Ligament (Parametria) Detachment
Endopelvic Fascia and Levator Ani Muscle Resection
Vaginectomy
Perineal Resection
Oncologic Outcomes
Combined Treatment
Intraoperative Radiotherapy
Preoperative Chemotherapy
Extension of Radicality
Lateral Pelvic Side Wall Excision
Resection of Large Vessels, Nerves, and Bones
Resection of External Iliac or Common Iliac Vessels
Large Pelvic Nerve Resection
Composite Exenteration
Counseling
References
16 - Complications of Pelvic Exenteration
Medical Complications
Febrile Morbidity
Thromboembolic Events
Incidence and Guidelines
Signs and Symptoms
Evaluation of Thromboembolic Events
Treatment of Thromboembolic Events
Acute Renal Events
Initial Evaluation After Diagnosis
Patient Evaluation
Urinalysis
Urine Sodium Excretion
Urine Volume
Volume Depletion
Volume Overload
Hyperkalemia
Prognosis
Surgical Complications
Dehiscence and Evisceration
Necrotizing Fasciitis
Urinary Diversion Complications
Bowel-Related Complications
Postoperative Ileus
Bowel Obstruction
Signs and Symptoms
Diagnosis
Treatment
Anastomotic Leaks
Management
Stomal Complications
Skin Irritation
Retraction
Prolapse
Parastomal Hernia
Necrosis
Mucocutaneous Separation
Fistulas
Signs and Symptoms
Evaluation
Treatment
Pelvic Reconstruction Complications
Modified Rectus Abdominis Flap
Gracilis Myocutaneous Flap
References
17 - Small Bowel and Large Bowel Resection and Anastomosis
Regional Vascular Anatomy of the Small Bowel and Large Bowel
Anatomy of the Small Intestine
Anatomy of the Large Intestine
Surgical Techniques
General Principles of Intestinal Surgery
Intestinal Anastomosis
Techniques of Bowel Anastomosis
Hand-Sewn Anastomoses
Stapled Anastomosis
Types of Bowel Anastomoses
End-to-End Anastomosis
End-to-Side Anastomosis
Side-to-Side Functional End-to-End Anastomosis
Small Bowel Resection
Ileocecal Resection
Transverse Colectomy
Right Hemicolectomy in Conjunction With Omental Disease
Left Hemicolectomy in Conjunction With Omental Disease
Rectal Resection
References
18 - Management of Bowel Surgery Complications
Special Anatomy
Splenic Flexure
Ureteric Injury
Vascular Anatomy
Vascular Hemorrhage
Iatrogenic Injuries During Minimally Invasive Surgery
Deep Space Surgical Site Infections
Anastomotic Complications
Acute Complications
Enterocutaneous Fistulas
Blind Loop Syndrome and Intestinal Bacterial Overgrowth
Postsurgical Nutritional Deficiencies and Short Gut Syndrome
Obstructions
References
19 - Management of Urologic Complications in Gynecologic Oncology Surgery
Ureteral Injuries and Management
Primary Ureteral Repair
Ureteroneocystostomy
Advanced Reconstructive Procedures
Bladder Injuries and Management
Fistula Complications
Neurogenic Bladder
Conclusion
References
20 - Pelvic Reconstruction in Gynecologic Oncology Surgery
Indications
Preoperative Evaluation and Patient Selection
Procedures
Secondary Intention and Complex Primary Closure
Procedure Details
Skin Grafting and Skin Substitutes
Procedure Details
Local Flaps
Procedure Details
Procedure Details
Regional Flaps: Abdomen
Vertical Rectus Abdominis Myocutaneous Flap
Pearl: Ways to Spare Fascia During Vertical Rectus Abdominis Myocutaneous Flap Harvest
Pearl: Raising Vertical Rectus Abdominis Myocutaneous Flap
Rectus Abdominis Muscle With Peritoneum
Extended Vertical Rectus Abdominis Myocutaneous Flap
Closure of Vertical Rectus Abdominis Myocutaneous Flap Donor Site
Procedure Details
Omental Flap
Procedure Details
Regional Flaps: Thigh and Buttock
Gracilis Flap
Procedure Details
Anterolateral Thigh Flap
Procedure Detail
Gluteal Flaps
Conclusion
References
21 - Urinary Diversion in Gynecologic Oncology
Historical Perspective of Urinary Diversions
Indications for Urinary Diversion
Preoperative Management
Tumor Restaging
Medical Optimization
Gastrointestinal Evaluation
Previous Radiotherapy Dosages
Psychological Consultation
Ostomy Nurse or Wound Care Consultation
Mechanical Bowel Preparation
Venous Thromboembolism Prophylaxis
Preoperative Antibiotics
Blood Products
Surgical Techniques for Urinary Diversion
Incontinent Urinary Conduits
Ileal Conduit Surgical Technique (see Fig. 21.1)
Surgical Steps
Step 1
Step 2
Step 3
Step 4
Step 5
Step 6
Step 7
Step 8
Step 9
Sigmoid and Transverse Conduit Surgical Technique
Surgical Steps
Step 1
Steps 2 Through 9
Continent Urinary Reservoirs Versus Incontinent Diversions
Surgical Technique: Miami Pouch
Surgical Steps
Step 1
Step 2
Step 3
Step 4
Step 5
Step 6
Step 7
Step 8
Step 9
Minimally Invasive Approach to Urinary Diversion
Orthotopic Bladder
Postoperative Care and Management of Postoperative Complications
Immediate Postoperative Care
Intensive Care Unit Admission
Foley Catheter
Drains
Electrolytes
Postoperative Antibiotics
Venous Thromboembolism
Nephroureteral Stents
Management of Postoperative Complications
Urinary Tract Infection or Pyelonephritis (13% to 42%) (see Table 21.2)
Difficulty With Catheterization (Continent Diversions) (12% to 54%) (see Table 21.2)
Ureteral (Anastomotic) Stricture (4% to 22%)
Incontinence (7% to 13.3%)
Urinary Stone Formation (7% to 18%)
Neobladder-Related Anastomotic Leaks and Cutaneous Fistulas
Gastrointestinal and Pouch-Related Fistulas (2% to 15%)
Quality of Life
Key Points
References
22 - Management of Vascular Complications
Vascular Anatomy in Gynecologic Oncology Surgery
Gynecologic Malignancy Involving Major Vessels
Preoperative Vascular Imaging
Acute Major Intraoperative Vascular Injuries
Prevention of Vascular Injuries
Principles of Vascular Repair
Surgical Techniques for Major Vascular Reconstruction
Primary Repair and Patch Angioplasty
Arterial Reconstruction
Venous Reconstruction
Vascular Anastomosis and Anticoagulation
Soft Tissue Coverage for Vessels and Grafts
Postoperative Care and Surveillance
Other Major Vascular Complications
Venothromboembolic Complications
Pseudoaneurysm
Radiation-Induced Vasculopathy
Summary
Acknowledgment
References
23 - Complications of Radiation Oncology
Radiation Oncology
Fractures
Necrosis
Rectal Proctitis
Urologic Complications
Radiation Cystitis
Ureteral Stenosis
Sexual Function and Quality of Life
Fistulas
Vesicovaginal Fistulas
Bowel Fistulas
Conclusion
References
24 - Laparoendoscopic Single-Site Surgery in Gynecologic Oncology
Postoperative Pain
Incisional Morbidity
Cosmesis
Incisional Utility
Challenges of Laparoendoscopic Single-Site Surgery
Maintenance of Pneumoperitoneum
Prevention of Hand Collision
Triangulation
Perspective in Field of View
Learning Curve
Patient Selection
Orientation to Equipment
Instrument, Hand, and Body Position
Robotic-Assisted Laparoendoscopic Single-Site Surgery
Procedures in Detail
Laparoendoscopic Single-Site Surgery Adnexectomy
Laparoendoscopic Single-Site Surgery Hysterectomy
Laparoendoscopic Single-Site Surgery Staging Lymphadenectomy
Pelvic Node Dissection
Paraaortic Node Dissection
Robotic-Assisted Laparoendoscopic Single-Site Hysterectomy and Bilateral Salpingo-oophorectomy
Conclusion
Conflicts of Interest
Acknowledgment
References
25 - Laparoscopic Approach to Gynecologic Malignancy
Patient Selection for Laparoscopic Surgery
Preoperative Evaluation
Tumor Manipulation, Tissue Extraction, and Port-Site Metastasis
Patient and Operating Room Setup
Trocar Placement
?Abdominal Exploration (Video 25.1)
?Total Laparoscopic Hysterectomy (Video 25.2)
Exposure of the Retroperitoneum
Salpingectomy and/or Adnexectomy
Posterior Leaf and Uterosacral Ligament Section
Vesicouterine Space Dissection
Transection of Uterine Vessels
Colpotomy and Uterine Extraction
Vaginal Cuff Suture
Laparoscopic Radical Hysterectomy
Laparoscopic Type A Radical Hysterectomy (Extrafascial Hysterectomy)
?Laparoscopic Type B Radical Hysterectomy (Video 25.3)
Pelvic Lymphadenectomy
Posterior Leaf of the Broad Ligament, Uterosacral Ligament, and Rectovaginal Space Dissection
Mobilization of the Bladder
Ureteral Tunnel Dissection
Uterine Pedicle Section and Paracervical Tissue Dissection
Colpotomy and Uterine Extraction
Ovarian Transposition (Oophoropexy)
?Laparoscopic Type C Radical Hysterectomy (Video 25.4)
Uterine Pedicle Section and Paracervical Tissue Dissection
Surgery Completion Survey
Postoperative Care After Laparoscopic Radical Hysterectomy
?Laparoscopic Radical Trachelectomy (Video 25.5)
Technique of Laparoscopic Radical Trachelectomy
Vesicovaginal Space Dissection, Rectovaginal Space Dissection, and Uterosacral Resection
Uterine Artery Ligation and Paracervical Resection
Colpotomy
Cervical Transection and Margin Evaluation
Cervical Cerclage and Uterine Repositioning
?Laparoscopic Pelvic Lymphadenectomy (Video 25.6)
Technique
Lateral Identification of the Obturator Nerve and Dissection of the Lumbosacral Lymph Nodes
Detaching the Lymph Nodes from the Iliac Vessels
Lymphadenectomy of the Obturator Fossa
Retroperitoneal Exposure
Paracaval Dissection and Ovarian Vessel Resection
Presacral and Intercavoaortic Dissection
Paraaortic Inframesenteric Dissection
Paraaortic Supramesenteric Dissection
Laparoscopic Surgery for Ovarian Neoplasms
?Adnexectomy for Suspected Ovarian Cysts (Video 25.8)
Technique
Adnexectomy
Cyst Extraction
Placement of Endobags in the Surgical Field
?Laparoscopic Omentectomy and Peritoneal Biopsies (Video 25.9)
Omentectomy: Standard Technique
Omentectomy: Reverse Technique
Key Points
References
26 - Robotic Surgery
Advantages and Disadvantages of Robotic Surgery
Preoperative Evaluation
Perioperative Management—Enhanced Recovery Pathways
Surgical Techniques—Pelvic Procedures
Indications
Surgical Technique
Step 1: Room Setup
Step 2: Patient Positioning
Step 3: Sentinel Lymph Node Dye Injection
Step 4: Placement of a Uterine Manipulator
Step 5: Abdominal Entry
Step 6: Trocar Placement
Step 7: Examination of the Upper Abdomen
Step 8: Docking
Step 9: Instrument Selection
Step 10: Procedure
Step 11: Specimen Removal
Step 12: Vaginal Cuff Closure or Cerclage Placement—Instrument Selection
Step 13: Removing the Trocars
Step 14: Abdominal Incision Closure
Surgical Techniques—Upper Abdominal Procedures
Indications
Surgical Technique
Step 1: Room Setup
Step 2: Patient Positioning
Step 3: Abdominal Entry
Step 4: Trocar Placement
Step 5: Docking
Step 6: Instrument Selection
Step 7: Procedure
Step 8: Specimen Removal
Steps 9 and 10: Trocar Removal and Abdominal Incisional Closure
Surgical Techniques—Multiquadrant Procedures
Trocar Placement
Docking
Special Considerations
Pelvic Exenteration
Obesity and Robotic Surgery
Cost of Robotic Surgery in Gynecologic Oncology
Conclusion
Suggested Readings
References
27 - Complications of Minimally Invasive Surgery
Complications During Abdominal Entry
Vascular Injuries at Abdominal Entry
Bowel Injuries at Abdominal Entry
Laparoscopic Bowel and Urinary Tract Injuries
Mechanism of Thermal Injuries
Preventing Gastrointestinal Tract Injuries
Laparoscopic Repair of Gastrointestinal Tract Injuries
Preventing Urinary Tract Injuries
Detection of Urinary Tract Injuries
Laparoscopic Repair of Urinary Tract Injuries
Subcutaneous Emphysema
Gas Embolism
Port-Site Hernias
Port-Site Metastasis
Vaginal Evisceration
Conclusion
Key Points
References