Staging of Gynecologic Oncology Patients With Exploratory Laparotomy

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Staging of Gynecologic Oncology Patients With Exploratory Laparotomy

Modern gynecologic oncology demands accurate staging of cancer patients in order to determine the most effective method of treatment. The noninvasive techniques formerly required for staging are being expanded to include extensive exploratory laparotomy. A significant percentage of patients may have more advanced disease than was noted with noninvasive clinical staging procedures.

Surgical staging as described in this section is of particular value in ovarian and endometrial carcinoma. Its role in epidermoid carcinoma of the cervix remains debatable at this time. The debate is not whether additional information can be gained; it can. The question is whether the overall end results warrant the additional morbidity associated with total pelvic and aortic irradiation following this type of surgical staging. Since it is particularly important for the surgeon to search under the diaphragm and to explore the aorta up to the level of the renal vessels, the Pfannenstiel incision is not advised.

The purpose of the operation is to gain detailed knowledge of the extent of metastasis of the pelvic malignancy.

Physiologic Changes. The most significant physiologic change is adhesion formation secondary to the procedure. This has an adverse effect if one contemplates total pelvic and aortic irradiation or intraperitoneal therapy. The adhesions fix the intra-abdominal structures, such as the bowel, thereby giving them maximum irradiation. Adhesions form pockets and block diffusion of intraperitoneal drugs to their targets.

Points of Caution. It is difficult to perform this procedure through a lower transverse incision because adequate exposure to the upper abdomen is compromised.

To adequately expose the renal vessels, the ligament of Treitz and the third portion of the duodenum frequently require mobilization.

Technique

The patient is placed in the supine position or the dorsal modified lithotomy position with the hips slightly abducted, the thighs parallel to the floor, and the knees flexed in obstetric stirrups. The incision should extend from the symphysis pubis to well above the umbilicus and, in many cases, up to the xiphoid.

The initial exploration should start under the diaphragm. This area should be visualized directly or with the aid of a laparoscope. If studding is found under either the left or the right diaphragm, biopsy of the small lesions should be done.

Washings should be obtained from five separate areas in the abdominal cavity under each diaphragm, in each lateral colonic gutter, and in the pelvis. These should be sent to the laboratory for cytopathologic studies.

The exploration of the retroperitoneal space is begun by excising the peritoneum in the area of the cecum and terminal ileum.

The peritoneum is incised parallel to the right common iliac artery. The incision is then advanced up the aorta until the third portion of the duodenum is encountered.

At the third portion of the duodenum, the ligament of Treitz is noted and mobilized along with duodenum to allow adequate exposure to the renal vessels.

Lymph node excision is begun at the level of the left renal artery and vein, the origin of the right and left ovarian vessels. Adequate lymph sampling is performed along the aorta. VC indicates vena cava.

The peritoneum overlying the aorta is closed with 3-0 synthetic absorbable sutures.

At this point, the oncologic procedure, whether it be a Wertheim hysterectomy for cervical carcinoma, tumor debulking for ovarian carcinoma, or extra fascia hysterectomy for uterine carcinoma, can begin.