San Joaquin Valley College
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 has to 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 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 Pelvic Exenteration is defined as a surgical resection of all pelvic structures including the uterus, cervix, vagina, bladder, and rectum. 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.
As explained previously, this procedure includes resection of all pelvic structures and it’s organs including the uterus, cervix, vagina, bladder, and rectum. The uterus’ main function is to sustain and protect the development of the embryo during pregnancy. The cervix is designed to dilate in preparation for delivery of the fetus while the vagina serves as a birth canal during labor. The bladder is a collecting point or urine and contacts the eliminate toxins from the body, and the rectum is used for a temporary storage unit for feces. (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 to help with circulation in the patients legs, padded stirrups, padded shoulder braces, electrosurgical unit, suction, an 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 over and over again while supplies are considered to be 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)
In order to perform this 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 surgeon may request to have a vascular procedure tray, gastrointestinal tray, along with gastrointestinal staplers on standby in case complications occur during surgery. As a surgical tech in the scrub role, the surgical tech 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).
Anesthesia and Positioning
General 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 trendelenberg, trendelenberg 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 prevent neurologic damage, electrosurgical unit dispersive pad, 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)
Before the patient can enter the operating room, the patient must sign surgical procedure consent along with sterilization procedure consent and has to be documented into the patients chart. Extra blood should be on standby along with confirmation of correct blood type. Pathology should also be contacted beforehand for possible frozen sections taken during the procedure. Lastly all instruments must be accounted for during counts pre-operation and intra-operation.
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 symphsis pubis and down to the urethra. The ureters are indentified 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 liagted. In the perineal phase the surgeon isolates the internal pudendal vessels on both sides, liagtes them, and then cuts them. The prarvesical 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 and the ureters are anastomosted 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 skins edges. Hemostasis is assessed and controlled and 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 Complications
Once dressings are applied, the patient is transferred to the ICU which is where they will be monitored. Patient can expect to stay in the hospital for up to a week 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. 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 patients 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).
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