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Malignant Disease:
Special Procedures

Staging of Gynecologic
Oncology Patients With
Exploratory Laparotomy

Subclavian Port-A-Cath 

Peritoneal Port-A-Cath

Application of Vaginal
Cylinders for Intracavitary
Radiation Therapy

Application of Uterine Afterloading Applicators
for Intracavitary Radiation Therapy  

Pelvic High-Dose Afterloader

Abdominal Injection of Chromic Phosphate

Supracolic Total Omentectomy

Omental Pedicle "J" Flap

Tube Gastrostomy

Total Vaginectomy

Radical Vulvectomy
With Bilateral Inguinal
Lymph Node Dissection

Reconstruction of the
Vulva With Gracilis Myocutaneous Flaps

Transverse Rectus
Abdominis Myocutaneous
Flap and Vertical Rectus
Abdominis Myocutaneous

Radical Wertheim
Hysterectomy With
Bilateral Pelvic Lymph
Node Dissection and With Extension of the Vagina

Anterior Exenteration

Posterior Exenteration

Total Pelvic Exenteration

Colonic "J" Pouch Rectal

Kock Pouch Continent Urostomy

Omental "J" Flap Neovagina

Ileocolic Continent Urostomy (Miami Pouch)

Construction of Neoanus
Gracilis Dynamic Anal

Skin-Stretching System Versus Skin Grafting

Gastric Pelvic Flap for
Augmentation of Continent Urostomy or Neovagina

Control of Hemorrhage in Gynecologic Surgery

Repair of the Punctured
Vena Cava

Ligation of a Lacerated
Internal Iliac Vein and
Suturing of a Lacerated Common Iliac Artery

Hemorrhage Control in
Sacrospinous Ligament
Suspension of the Vagina

Presacral Space
Hemorrhage Control

What Not to Do in Case of Pelvic Hemorrhage

Packing for Hemorrhage

Control of Hemorrhage
Associated With Abdominal Pregnancy

Construction of Neoanus Gracilis
Anal Myoplasty

In cases where the anal sphincter has become incompetent or when both the anus and anal sphincter have been removed (as in sublevator total pelvic exenteration or abdominoperineal resection), the surgeon may perform a neoanus dynamic anal myoplasty. The operation has been performed in Europe for 8 years and will come to the United States, pending Food and Drug Administration (FDA) approval.

Physiologic Changes.  The dynamic anal myoplasty operation attempts to restore the anus so that normal defecation can occur by using the gracilis muscle and a modified cardiac pacemaker. The anus and anal sphincter are rebuilt with the gracilis muscle, and a pacemaker is attached to the muscle. When the muscle is electronically stimulated, it produces an anal pressure that is greater than the colonic pressure, allowing the patient to maintain continence. When the electrical current is withdrawn, however, the gracilis muscle relaxes, the anal pressure falls to a level below that of the colon, and the patient pushes down and defecates. The on-and-off switch for the modified cardiac pacemaker is a simple magnet.

Points of Caution.  The integrity of the neurovascular bundle of the gracilis muscle must be carefully preserved, as it is dissected from the leg. Adjustment of the cardiac pacemaker for voltage and frequency can be made externally.


The patient is shown having had a laparotomy following abdominal perineal resection. With the patient in the dorsal supine modified lithotomy position with the leg extended and knee flexed, the gracilis muscle is palpated. An incision is made of approximately 30 cm, extending from the pubis ramus to the tubercle on the knee.

The adductor longus, the gracilis, and the adductor magnus muscles are identified. The vital neurovascular bundle of the gracilis muscle is located and dissected. The gracilis muscle is transected at the so-called "goose foot" as it inserts on the knee and is transected proximally, adjacent to the ramus of the ischium. Care must be taken to identify the sartorius muscle and not confuse this with the gracilis muscle. The stump of the distal gracilis muscle tendon is seen adjacent to the knee.

A tunnel is made under the posterior fourchette of the vagina, under the perineal body, and around the anus with sharp and blunt dissection. If it is a case of anal sphincter incompetence or a pull-through procedure from a previously existing abdominal perineal resection, the muscle is pulled through, with the gracilis neurovascular muscle kept intact.

The entire gracilis muscle is pulled through the tunnel and wrapped around the colon or defective anal sphincter and is fixed in place with interrupted sutures. The margin of the anal skin incision is shown for those cases where the anus and the anal sphincter have been completely removed. The wire leads from the modified cardiac pacemaker are attached to the gracilis muscle at the junction of the neurovascular bundle to the muscle and confirmed in this position by electronically stimulating the device while the incision is open.

The neoanus is shown with the sigmoid colon anastomosed to the border of the anus or perianal skin. The gracilis muscle is shown ghosted underneath.

The wire leads are brought through the subcutaneous tunnel to a site that is selected for the modified cardiac pacemaker on the abdominal wall. The wound in the left leg has been repaired over Jackson-Pratt suction drains.

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