The patient is placed on the operating table in the modified dorsal lithotomy position with the hips abducted approximately 30°, exposing the perineum. The entire abdominal wall, vulva, perineal area, and vagina are surgically prepared. A Foley catheter is inserted in the bladder.

The abdomen is opened through a large lower midline incision that is extended around the umbilicus. The abdomen is thoroughly explored for tumor.

The bowel is packed off, exposing the pelvic brim. The peritoneum below the cecum and terminal ileum is opened, and the common iliac artery and aorta are exposed. The aorta is explored all the way to the renal vessels, and any suspicious lymph nodes are removed.

The peritoneum has been opened from the bifurcation of the aorta to the femoral canal, and suspicious lymph nodes have been dissected off the common iliac artery. The ureter crosses the common iliac artery on the right side, medial and inferior to the ovarian vessels.

The round ligaments on each side are cut at the pelvic wall, and the posterior and anterior leaves of the broad ligament are completely opened.

The external iliac vein is deviated laterally, exposing the obturator fossa from which all lymph nodes suspected of bearing tumor are removed. The ovarian vessels are clamped and doubly tied at the pelvic brim.

The ureter, with a generous portion of its peritoneal attachment left intact, is transected below the common iliac artery.

The ureter has been transected, and the distal ureter has been ligated. The obturator fossa has been cleaned of all contents. The hypogastric artery is cross-clamped, transected, and tied with 2-0 suture. The distal portion of the artery is elevated, and its branches are identified, clamped, and tied.

Attention is directed to the space of Retzius where the bladder is separated from the rectopubic space. Fine adhesions to the pelvic wall can be lysed with Metzenbaum scissors; and any small vessels in the plexus of Santorini can be clamped and tied with suture, or hemoclips may be applied.

This view illustrates the pelvic spaces. In an anterior exenteration, both the paravesical spaces (PVS) and the pararectal spaces (PRS) are seen. The lateral extent of the cardinal ligament (the web) is demonstrated with countertraction from the first two fingers of the surgeon's hand. The web is clamped, incised, and tied at the pelvic wall. B, bladder; PSS, presacral space; R, rectum; RVS, rectovaginal space; SR, space of Retzius; and VVS, vesicovaginal space.

The stumps of the ureterosacral ligament are seen transected adjacent to the pelvic wall, which includes the hypogastric venous plexus. Successive bites on the web at the pelvic wall are made with clamps and incised down to the levator ani muscles. The rectum remains intact.

The hypogastric vein and artery have been cut and tied. The stumps of the web are seen on the pelvic wall. The specimen has been completely freed down to the levator sling and is retracted medially. The ureterosacral ligaments have been cut and tied at the pelvic wall. The peritoneum of the cul-de-sac of Douglas has been transected, and the posterior vaginal wall has been dissected off the rectum.

The same procedure is carried out on the opposite side. The ligated ureter is seen. The specimen (bladder, uterus, tubes, ovaries, and vagina) has been freed from the anterior lateral pelvic wall.

The specimen is now retracted cephalad. A scalpel is used to transect the urethra at the meatus.

The vagina is transected across the introitus below the level of the levator sling. Any remaining rectal stalks attaching the posterior vaginal wall to the rectum are lysed, and the specimen is removed.

The vaginal cuff has been closed with an interrupted 0 absorbable suture. The ureters are seen below the pelvic brim. The urethra has been transected at the meatus. Maximum attention at this stage is turned toward hemostasis within the pelvis.

A continent urinary diversion (Kock pouch) will be made from small bowel. The terminal ileum with the respective links in centimeters for construction of the pouch is shown (see the Kock Pouch Continent Urostomy).

The Kock pouch continent urostomy with afferent and efferent nipples has been completed. The letters A to A', B to B', C to C' delineate the order of suture that produces a spherical pouch.

The continent pouch has been completed. The stoma is sutured to the subcuticular layer of the skin of the umbilicus with 3-0 polyglycolic acid (PGA) sutures.  A No. 30 French Medena catheter has been placed through the stoma down the efferent limb and exits the efferent nipple into the pouch. This Medena catheter has been securely sutured in place with No. 1 nylon suture that includes the margins of the skin, the entire intestinal wall of the stoma, the opposite intestinal wall, and the opposite margin of skin; it is securely tied around the Medena catheter with multiple half-hitch knots to hold the catheter in the pouch without slippage for 3 weeks. A second suture of No. 1 nylon is placed on the opposite side.

A Jackson-Pratt closed suction drain has been placed adjacent to the Kock pouch and is brought out through the abdominal wall. It is sutured with a 3-0 PGA suture to prevent removal for 3 weeks. Note that the afferent limb of the bowel and the afferent nipple have the ureters sutured in a mucosa-to-mucosa fashion with No. 8 French Finney "J" Silastic stents in place. The abdomen is closed. The Medina catheter is irrigated every 2-4 hours for the next 3 weeks to prevent mucus obstruction.

An omental vascular pedicle "J" flap is created.

The omental "J" flap is brought into the pelvis and sutured around the ileopectineal line and across the rectosigmoid colon as a pelvic lid. The abdomen is closed in layers. A sump nasogastric tube or a feeding gastrostomy tube is inserted in the stomach.