The abdomen is entered through a low midline incision that is extended around the umbilicus. A thorough exploration of the upper abdomen is made, particularly along the aorta and common iliac arteries. The peritoneum below the terminal ileum and cecum is opened. The right common iliac artery and vein are identified. The incision into the peritoneum is extended along the aorta until the renal vessels are located. Occasionally, the third portion of the duodenum requires mobilization for exposure. The aortic lymph nodes are palpated, and any suspicious lymph node is removed for pathologic analysis.

The peritoneal incision is extended caudad along the external iliac vessels to the femoral canal. All lymphatic tissue is dissected from the common and external iliac arteries and veins.

The round ligaments are cut and tied at the pelvic wall, and the broad ligaments are opened.

All lymphatic tissue is removed from the obturator fossa. The infundibulopelvic ligaments with the ovarian vessels are clamped, cut, and tied at the pelvic brim.

The right ureter is transected below the pelvic brim. Steps 1-5 are then repeated on the left side.

The obturator fossa external iliac and common iliac artery and veins have been cleaned of all lymphatic tissue. The hypogastric artery and vein are clamped and tied at the bifurcation of the common iliac vessels. The ureter has been cut, the distal segment has been tied, and the proximal segment is left open and free.

The peritoneum of the mesentery of the rectosigmoid colon is opened. A soft Silastic drain is placed through an avascular opening in the mesentery and used for retraction of the colon.

The peritoneum of the mesentery on the medial side of the rectosigmoid colon is opened.

The vascular tissue in the mesentery is cross-clamped in successive pedicles, incised, and tied with 2-0 suture.

The rectosigmoid colon is clamped and transected with the gastrointestinal anastomosis (GIA) automatic surgical stapler. This transects the colon and seals the distal and proximal segments.

The remaining mesentery of the rectosigmoid colon is clamped and incised down to the sacrum.

The rectum is dissected off the sacrum and coccyx by blunt dissection. This is performed by retracting the uterus and distal segment of the rectum anterior and cephalad, inserting a hand behind the rectum in the presacral space, and freeing the rectum down to the coccyx.

It is important to allow the blunt dissection to proceed laterally, since the presacral veins may then be lacerated and may retract in to the presacral foramen, causing copious bleeding.

The rectal stalks on each side are clamped, incised, and tied with 2-0 sutures down to the levator muscles.

The specimen should now be free posteriorly.

The bladder is separated from the pubic symphysis where the dotted line appears.

The space of Retzius is entered, and the bladder and proximal two-thirds of the urethra are freed. The lateral attachments of the bladder are clamped and incised on both sides. The entire specimen can now be freed laterally, forming one large lateral attachment of bladder, rectum, and uterine parametria to the pelvic wall.

The first and second fingers have been inserted into the paravesical and pararectal spaces, identifying both sides of the large lateral attachment to the pelvic wall. The anterior wall of the paravesical and the posterior wall of the pararectal space have been removed with dissection of the rectal stalks and bladder attachments. The large pedicle contains the plexus of hypogastric veins. No attempt is made to isolate each vein individually. The pedicle is clamped, incised, and tied on the pelvic wall. Several successive bites are required to transect the pedicle to the levator ani muscle.

This is a posterior view of the same step performed on the opposite side.

The lateral attachment of the specimen is transected in successive bites. It is helpful for the assistant to retract the specimen medially during this maneuver.

All lateral wall attachments have been clamped, incised, and ligated on each side. The specimen has been freed posteriorly, laterally, and anteriorly. The remaining attachments are the urethra, vagina, and rectum.

By cephalad retraction on the specimen, the urethra can be exposed and transected at the level of the levator sling.

The vagina is transected.

The rectum is transected at the level of the levator muscles or higher if an adequate margin from the tumor can be achieved.

The exenterated pelvis is shown with the urethra transected near its meatus. The vagina has been transected and closed with 0 absorbable suture. The rectum is available for anastomosis for the descending colonic J pouch. A continent urostomy Kock pouch (see Kock Pouch Continent Urostomy) will be constructed.

Both afferent and efferent nipples have been completed. Note that the two strips of the polyglycolic acid (PGA) mesh pass through the windows of Deaver in the mesentery of both the efferent and afferent bowel limbs adjacent to the nipples. The letters A to A', B to B', C to C' delineate the order of suture placement that will produce a spherical rather than tubular pouch shape.

The continent pouch has been completed. The stoma is sutured to the subcuticular layer of the skin with 3-0 PGA sutures. The stoma is sutured to the subcuticular skin of the umbilicus with 3-0 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 catheter has been securely sutured in place with a No. 1 nylon suture that includes the margin 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 spillage for 3 weeks. A second No. 1 nylon suture is placed on the other side.

A Jackson-Pratt closed suction drain has been placed adjacent to the Kock pouch and 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 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 Medena catheter is irrigated every 2-4 hours for the next 3 weeks to prevent mucus obstruction.

A sagittal view is shown. The rectal J pouch has been stapled to the rectum with the EEA stapler. A diversionary loop colostomy has been performed.

A pelvic view shows the rectal J pouch anastomosed to the rectum. The vagina is shown closed with suture.

An omental J flap is initiated by transecting the omentum off the greater curvature of the stomach. The gastroepiploic artery is preserved.

The omental J flap is sown into the pelvis as a lid.

This sagittal view shows the omental J flap as a lid for the pelvis. It contains the small intestine and displaces it out of the pelvis in a sling made from omentum.

The colonic J pouch reservoir is anastomosed to the rectum. V, vagina.

This shows the loop diversion colostomy placed in the transverse colon. The urine has been diverted into a continent Kock pouch. The colonic J pouch has been anastomosed to the rectum. K, kidney.