Home / Site Map / Vulva and Introitus / Vagina and Urethra / Bladder and Ureter / Cervix / Uterus
Fallopian Tubes and Ovaries / Colon / Small Bowel / Abdominal Wall / Malignant Disease: Special Procedures

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

Subclavian Port-A-Cath

Oncology patients frequently require central venous access by catheter for chemotherapy, parenteral nutrition, and blood withdrawal. In some patients, after multiple surgical procedures and/or chemotherapy, venous access to the arms rapidly becomes unavailable. The same technique for Port-A-Cath can be used for Hickman and Gresbourg catheters required for total parenteral nutrition.

Physiologic Changes. Because there is greater blood flow through the central veins than through the peripheral veins, parenteral nutrition and chemotherapy can be administered through the central lines with less risk of causing chemical phlebitis.

Points of Caution. The patient must be placed in the Trendelenburg position. This increases the central venous pressure and avoids the possibility of an air embolism rising in the central venous system.

The guidewire or catheter should not be left in the atrium because its presence may cause arrhythmia.

The Silastic catheter should never be pulled back through the shaft of a needle. The tip of the needle can lacerate the catheter and release it as a foreign body within the venous system.

To prevent the development of a gas embolus, all syringes or catheters that are placed in the central venous system should be filled with a heparinized saline solution.


The patient is placed in a 15° Trendelenburg position to increase central venous pressure and thereby reduce the chances of air embolism. The subclavian vein has greater exposure if the shoulders are hyperextended over a rolled towel placed longitudinally between the scapula under the thoracic spine. The head should be turned to the opposite side. Under these conditions, the subclavian vein becomes more accessible. The skin over the neck and upper thorax is prepped in a routine fashion. Aseptic technique should be followed. A 2-inch, 14-gauge needle attached to a 10-mL syringe with 2-3 mL of heparinized saline solution in the syringe should be inserted through the skin with the bevel of the needle pointing down. The ideal site for the puncture is at the inferior border of the middle of the clavicle directed toward a fingertip pressed firmly into the suprasternal notch. The needle should be passed beneath the inferior margin of the clavicle in a horizontal plane and directed toward the anterior margin of the trachea at the level of the suprasternal notch. The needle and syringe are kept parallel to the surface of the patient's bed and adjacent to the anterior wall of the subclavian vein in the direction of its long axis. The accuracy of the placement into the subclavian vein can be demonstrated by a copious flow of blood into the barrel of the syringe with slight negative pressure. The syringe is removed from the hub of the needle, and the thumb is immediately placed over the hub.

A flexible guidewire is inserted through the hub of the needle and passes into the superior vena cava (SVC).

When the guidewire is securely in the superior vena cava, the needle is withdrawn over the guidewire and removed.

The guidewire is shown as it enters the skin under the clavicle. The ideal site for the Port-A-Cath chamber is selected; it is between two ribs, approximately 8cm from the point where the guidewire enters the skin. A 4-cm incision is made in this area, and a pocket is created under the subcutaneous fat on top of the pectoralis fascia. Hemostasis in this pocket is essential.

The subcutaneous pocket is demonstrated by placing the Port-A-Cath, with the catheter attached, into the pocket. At this point, the eyes on the Port-A-Cath flange are sutured to the fascia of the pectoralis muscle with 3-0 nylon sutures.

The Port-A-Cath and the catheter are filled with heparinized saline solution. This is achieved by inserting a Huber needle attached to a syringe of heparinized saline. The entire Port-A-Cath and catheter are filled with saline solution before any attempt is made to insert the catheter into the venous system.

A 1-cm incision is made adjacent to the guidewire underneath the clavicle. An alligator-mouth grasping forceps is tunneled through the small incision down to the larger subcutaneous pocket. The alligator-mouth jaws grasp the catheter and pull it through the subcutaneous pocket, out through the incision next to the guidewire in the subclavian vein.

The Port-A-Cath chamber is shown at the lower right. The skin incision over the Port-A-Cath is closed with fine suture or the skin stapler. At this point, a vein dilator sheath is inserted over the guidewire through the 1-cm skin incision under the clavicle and down into the subclavian vein. Note that the catheter exits the skin adjacent to the vein dilator sheath.

The guidewire is withdrawn through the vein dilator sheath and removed. A finger is inserted over the vein dilator to prevent air from entering the subclavian vein. The Port-A-Cath catheter is measured from the subcutaneous pocket up to the subclavian vein and down an estimated distance in the superior vena cava. The excess catheter is cut away with sharp scissors.

The catheter is threaded through the vein dilator sheath into the subclavian vein and, ultimately, into the superior vena cava.

The vein dilator sheath is constructed so that it will tear away as it is pulled out of the subclavian vein. This is achieved by placing the finger on each flange of the vein dilator sheath. An assistant threads the catheter farther into the superior vena cava. The sheath is withdrawn as it is split apart. The vein dilator sheath is removed entirely.

At this time an x-ray picture is taken (either by fluoroscopy or from the flat plate of the chest) to ascertain the position of the catheter. If it is in the right atrium, it is withdrawn 4-5 cm through the skin incision. When the catheter is in the appropriate position, the skin incision is closed with fine suture or skin staples. A heparinized saline solution in a 10-mL syringe with a Huber needle is placed through the skin into the Silastic diaphragm Port-A-Cath, and the entire system is flushed with 10mL of heparinized saline solution.

Copyright - all rights reserved / Clifford R. Wheeless, Jr., M.D. and Marcella L. Roenneburg, M.D.
All contents of this web site are copywrite protected.