Pelvic Exenteration (AutoRecovered)

Pelvic Exenteration Ashley Butz San Joaquin Valley College Abstract The purpose of this paper is to inform the audience about a Pelvic Exenteration and what it in tales. Preparation for this procedure for the surgical team members along with the patient can be stressful due to set up along with what the patient must go through beforehand. This paper includes the equipment and supplies needed to set up the OR along with all the instruments being used. The explanation of this paper gives a clear understanding from start to finish as to what this procedure is all about including surgical technique, post-operative care, and the long-term prognosis of the patient and what they’ll have to go through after they leave the hospital. Pelvic ExenterationPelvic Exenteration was first reported by Alexander Brunschwig, a surgeon who specialized in oncology, in 1948. The procedure was described as “the most radical surgical attack so far described for pelvic cancer” and had a mortality rate of 23%. Since that time improvements in critical care, antibiotics, and advances in surgical technique have improved mortality rates related to this procedure (Teng, 2015). This procedure continues to be the only curative option for patients with recurring cervical, vaginal, or vulvular cancer. A total Pelvic Exenteration is defined as a surgical resection of all pelvic structures including the bladder, urethra, rectum, anus, colon, and all reproductive organs. There are also two other types of this procedure including an anterior pelvic exenteration and posterior pelvic exenteration. The anterior portion focuses on removing all the reproductive organs and the bladder, while the posterior focuses on removal of all reproductive organs and the bowel. This paper will mainly discuss the procedural steps and guidelines of a total pelvic exenteration. The purpose of this procedure is used for patients with recurrent cervical cancer that previous surgery and radiation or radiation alone could not cure. The expected outcome from this procedure is that patients will be free of cancer with a permanent colostomy and urostomy bag. PhysiologyAs explained previously, this procedure includes resection of all pelvic structures and its organs including the bladder, urethra, rectum, anus, colon, and all reproductive organs. The bladder is described as a hollow but muscular organ located in the anterior portion of the pelvis and lies posterior to the symphysis pubis. The bladder serves as a collecting point of urine and contracts to eliminate the urine through the urethra. The muscular coat of the bladder consists of three layers of smooth muscle. The inner mucosal lining of the bladder consists of transitional epithelium, which allows the bladder to expand as it fills with urine. When the bladder is empty the mucosa forms folds called rugae. One of the most important anatomic landmarks of the bladder is the vesical trigone which is located on the floor of the bladder and contains no rugae, this landmark helps with the process of urine transferring from the bladder to the urethra. The urethra is responsible for transporting urine from the bladder to outside of the body. The female urethra is approximately four centimeters long and travels anterior to the lower portion of the vagina. The urethra is in strict contact with the anterior wall of the vagina by a layer of fibrous tissue. The colon begins at the right side of the abdominal cavity traveling upward and across to the left, then downward to end at the opening of the anus. The colon is divided into seven portions including; the cecum, ascending colon, transverse colon, descending colon, sigmoid colon, rectum, and anal canal. The colon also has four coats including; serosa, muscular, submucosa, and mucosa. The submucosa layer contains a complex network of veins, arteries, lymph vessels, and nerve plexus of Meissner. The muscular layer consists of a series of circular rings. The primary functions of the colon are the absorption of water and electrolytes to condense the feces in preparation for expulsion, production of vitamin K by the bacteria and within the organ and expulsion of the feces. Lastly the uterus is a hollow, pear-shaped, muscular organ in which fertilized ovum is implanted and the embryo develops. The purpose of the uterus is to sustain and protect the development of the embryo. The broad ligament is the main structure that keeps the uterus in its position. The ligament extends laterally from the uterus to the pelvic walls and floor covering the top of the pelvic cavity. There are two other ligaments that help with positioning the uterus which includes the round ligament and cardinal ligament. The round ligament is a fold of peritoneum that extends from the anterior surface of the uterus through the inguinal canal and to the labium majus. The cardinal ligament is located within the inferior portion of the broad ligament on each side of the uterus and represents a continuation of the broad ligament. The wall of the uterus is composed of three layers including; the endometrium, myometrium, and the perimetrium. The uterus is innervated by the following 5 nerves: ovarian plexus, hypogastric plexus, first lumbar spinal segment, third and fourth sacral nerves, and the twelfth thoracic spinal segment. (Frey & Price, 2006). Equipment and Supplies For this procedure an abundance of specific equipment is needed including; a bair hugger to keep the patient from getting hypothermic, an antiembolotic hose and stockings to help with circulation in the patients’ legs, padded stirrups, padded shoulder braces, electrosurgical unit, suction, and a scale to weigh sponges which helps calculate the patients complete blood loss during surgery. Along with specific equipment that is needed for this surgery there is also general equipment including; the OR bed, back table, mayo stand, ring stand, an anesthesia cart which also includes the anesthesia machine as well. In correlation to equipment, many supplies are needed for this procedure as well. The difference between supplies and equipment is that equipment is considered as a long-term asset that can be used repeatedly while supplies are a current asset which most supplies used are discarded after the procedure. Supplies include; drapes, several gowns, masks, several pairs of gloves, a laparotomy set, a basin set, laparotomy pads, towels, saline for irrigation, a penrose drain, umbilical tape, and vascular loops used for retraction, hemoclips in a variety of sizes, pouches for colostomy and urostomy, and a Robinson catheter used for drainage of the bladder. (Goldman, 2008) Instruments In order to perform a Pelvic exenteration surgery, many instruments are needed for this procedure including a major surgical tray along with a long instrument tray since the surgeon will need more leverage to be able to reach each organ within the abdominal cavity, a variety of self-retaining retractors, and hemoclips appliers. The major tray consists of these instruments below: Major Tray: Metal Ruler Rochester-Pean forceps curved Russian tissue forceps Richardson retractor medium #3 Knife handle Rochester-Pean forceps straight Mayo-Hegar Needle holder Richardson retractor large #4 knife handle Rochester-Ochsner forceps straight Babcock forceps Deaver retractor Yankauer suction Rochester-Ochsner forceps curved Allis tissue forceps Zalkind ribbon retractor Mayo scissors straight Crile forceps straight Adson brown tissue forceps Senn retractor double end sharp and blunt Mayo scissors curved Crile forceps curved Backhaus towel clamps Metzenbaum scissors curved Mosquito forceps straight Dressing forceps Metzenbaum scissors straight Foerster sponge forceps straight serrated Mosquito forceps curved Tissue forceps US Army retractor Forester sponge forceps curved serrated The surgeon may request to have a vascular procedure tray, gastrointestinal tray, along with gastrointestinal staplers on standby in case complications occur during surgery. The vascular tray will most likely be opened due to amount of vasculature that is involved with this type of case. As a surgical technologist in the scrub role, the surgical technologist will need to be able to take into consideration to keep the dirty and clean instruments separated. Dirty instruments are only used once and then discarded. (Goldman, 2008). The following instruments below are included in the Vascular and Gastrointestinal trays: Vascular Tray: Dandy nerve hook Wylie hypogastric clamp curved Knife handle #7 Debakey multi-purpose clamp Aortic Debakey vascular clamp 26cm Mayo scissors straight Kalman Ryder needle holder Aortic Debakey vascular clamp 31cm Metzenbaum scissors curved Potts-smith scissors Hartman-Mosquito forceps Castroviejo needle holder straight with lock Crile Forceps curved Castroviejo needle holder straight without lock Gastrointestinal Tray: Metzenbaum Lahey curved Adson tissue forceps Crile forceps curved Foerster sponge forceps serrated Metzenbaum standard scissors curved Allis tissue forceps Rochester-pean forcpes curved Knife handle #3 Mayo dissecting scissors straight Babcock forceps Doyen forceps straight Knife handle #3 long Serrated dressing forceps Halstead mosquito forceps straight Doyen forceps curved Metzenbaum Lahey straight Potts-smith forceps Halstead mosquito forceps curved Crile wood & Mayo hegar needle holder Mayo guyon kidney clamp Lahey gall duct forceps Kelly retractor Allen forceps Anesthesia and PositioningGeneral and regional anesthesia will be used for this procedure; the type of anesthesia used is based on the surgeon’s preference. For this surgery the patient will be placed in the lithotomy position with slight Trendelenburg, Trendelenburg is used to help push the abdominal contents that are not being worked on out of the way for better visualization. Supplies and aids that are needed for positioning of the patient include; arms boards with arms straps, padding for bony prominences and to prevent neurologic damage, electrosurgical unit dispersive pad which will be placed on either thigh of the patient, and shoulder pads. (Goldman, 2008). Skin Preparation and Draping The most common type of skin preparation used for this procedure is iodine. The circulator will start at the midline, extending from nipples to knees from bedside to bedside, then cleansing the anus last and discarding each sponge after use. Two skin preparation trays are needed. Draping starts with the under the buttocks drape, then the leggings, and lastly the laparotomy drape in applied starting with extending the drape down to the feet and then the head. (Goldman, 2008)Practical Considerations Before the patient can enter the operating room, the patient must sign a surgical procedure consent along with a sterilization procedure consent and must be documented into the patient’s chart prior to entering the operating room. Extra blood should be on standby along with confirmation of correct blood type and cross. Pathology should also be contacted beforehand for possible frozen sections taken during the procedure, the Surgical technologist should also be ready for many possible frozen sections taken, specimens can be labeled with a marking pen on a label attached to a towel. All instruments must be accounted for during counts pre-operation and intra-operation. Extra gowns and gloves should be on stand-by when the time comes for the surgeon to start closing the abdomen, he or she will need to re-gown, re-glove, re-drape, and use a whole new basic/minor tray. During the procedure the circulating nurse must weigh sponges and keep an accurate record of the amount of irrigation used to help correct fluid imbalance. Lastly, everyone involved in the procedure should be mentally and physically prepared for a long case ahead, this procedure can take eight to thirteen hours to perform. Procedural Steps The surgeon begins the surgery by making a long vertical midline incision from symphysis pubis to the umbilicus, and the abdomen is opened. The surgeon then explores the peritoneal cavity for metastasis to the liver, the nodes of the celiac axis, the superior mesenteric artery, and the para-aortic tissues. The surgeon then explores the pelvis and the peritoneum along with the brim of the pelvis is examined for lymph node involvement. Frozen sections may be taken at this time to indicate negative margins. When findings of margins are negative, retractors are placed, and the small bowel is isolated with moist laparotomy pads. The surgeon then frees the sigmoid colon and sections it with clamps and blade or stapling device. The promixal end is exteriorized through an opening on the left side of the abdomen and is left clamped until later when the colostomy is permanently secured to the patient. The remaining sigmoid mesentery is then clamped, cut, and ligated. The distal sigmoid colon is then closed with an inverting suture. The surgeon will use a handheld vessel sealing device throughout the procedure to clamp, cut, and ligate vessels. The surgeon then incises the peritoneum over the dome of the bladder with a #7 knife handle with a #15 blade and separates the bladder from the symphysis pubis and down to the urethra. The ureters are identified and divided two to three centimeters below the brim of the pelvis. The proximal end is left open to allow urinary drainage, and the distal end is ligated. Before the Perineal Phase can be started, everyone who had scrubbed that case will need to re-gown, re-glove, and help re-drape the patient along with having a new basic/minor procedure tray opened. In the perineal phase the surgeon isolates the internal pudendal vessels on both sides, ligates them, and then cuts them. The paravesical and paravaginal tissues are then resected from the periosteum. The specimen is completely freed and removed from the pelvis. After bleeding of vessels is controlled, the surgeon starts closing the subcutaneous tissue with interrupted suture. A drain is placed in the wound and the skin is closed. The ileal or colonic segment is then fashioned, and the ureters are anastomosed to it. The external stoma is placed on the right side of the abdomen. The colostomy stoma is then prepared by removing the clamp from the sigmoid colon, opening the colon and then sutured to the stoma to the skin’s edges. Hemostasis is assessed and controlled, dressings are applied to the abdominal wound, drains, and tube sites. This procedure can take anywhere from eight to thirteen hours to perform. (Rothrock, 2015) Postoperative Care and ComplicationsOnce dressings are applied, the patient is transferred to the ICU by the circulating nurse and the anesthesia provider which is where they will be monitored. Patients can expect to stay in the hospital for up to a seven to ten days after surgery. It may take up to twelve weeks before the body gets used to the changes made and it make take six months to a whole year for the body to fully heal. Early walking and deep breathing will be encouraged by the staff to prevent blood clots and pneumonia. Since in this case a total pelvic exenteration was performed and vaginal reconstruction was done, the patient will only be able to lie on their back, side, or if they wish to stand, they can, for a total of six to eight weeks. Once the patient is discharged from the hospital, the patients’ healthcare provider will talk to them about any restrictions while the patient is at home and typically a nurse will visit the patient’s home to discuss and teach the patient about proper stoma, drain, and incisional care. Some complication relating to the surgery include; surgical site infection, urinary tract infection, hemorrhaging, deep vein thrombosis, blood loss, sepsis, wound dehiscence, and anastomotic breakdown. The wound classification for this procedure is considered a class ll, clean-contaminated. (Teng, 2015) Long Term Prognosis If no complications are present, patients will be able to resume most of their normal activities. The hardest part for patients after having this procedure is accepting the changes made to their body. Depending on the person, coping with the adjustments and changes to the patient’s overall life can be very hard to grasp for some and may take others a little longer to accept what has happened. (Memorial Sloan Kettering Cancer Center, 2017). References Frey, K., & Price, P. (2006). Surgical Anatomy and Physiology for the Surgical Technologist. Delmar: Cengage Learning.Goldman, M. (2008). Pocket Guide to the Operating Room, (3rd ed). Philadelphia: F.A. Davis Company. Memorial Sloan Kettering Cancer Center. (2017). About Your Total Pelvic Exenteration Surgery. New York: Memorial Sloan Kettering Cancer Center. Rothrock, J. (2015). Alexander’s Care of the Patient in Surgery, (15th ed). Missouri: Elsevier Mosby Teng, N. (2015). Pelvic Exenteration. California: Stanford University School of Medicine