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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

Peritoneal Port-A-Cath

Recent data indicate that some forms of intraperitoneal chemotherapy for ovarian malignancies with small volume disease may be more efficacious than intravenous chemotherapy.

Physiologic Changes. Intraperitoneal chemotherapy allows a greater dose of drug to come into direct contact with tumor cells and, at the same time, secondary to the large molecular weight of the chemical, facilitates a delayed absorption across the peritoneum into the vascular space. Therefore, a smaller dose of the drug arrives at sensitive target organs, such as kidney, nerve, and heart, per unit of time.

The length of time the cancer cells spend under the curve of the ultimate dose of chemotherapy is important. After an appropriate time under the "curve," the adjacent normal cells receive no further damage from the drug because the chemotherapy can then be withdrawn. Withdrawal reduces the time that the drug is administered to the systemic circulation. This reduces the toxicity associated with chemotherapy.

Points of Caution. A Port-A-Cath intraperitoneal chemotherapy devices should not be inserted if there is bacterial contamination of the peritoneal cavity.

The Port-A-Cath system should be flushed frequently with heparinized saline solution. Ideally, it should be flushed once a week to prevent clogging of the system with peritoneal fluid. It should always be flushed thoroughly after any infusion of chemotherapy.


The patient is placed in the supine position. The surgeon selects a site for the Port-A-Cath by penetrating the abdominal wall with a 17-gauge Tuohy needle. A saline syringe is attached to the needle, and assessment is made for easy flow into the peritoneal cavity to ascertain when the point of the needle is free in the peritoneal cavity and when it is in an intraperitoneal organ or trapped between adhesions.

Another technique used to locate a site for the Port-A-Cath is to attach the hub of the needle to a pneumoperitoneum device, such as the laparoscopy carbon dioxide gas machine. If the needle is free in the peritoneal space, the flow pressure will be no higher than 10 mm Hg.

Several attempts are often required for placement of the needle several weeks after radical cytoreductive surgery.

When the appropriate spot has been located, a 6-cm "minilaparotomy" longitudinal incision is made in that area.


The incision is carried down to the peritoneum, and the peritoneal cavity is entered. Dissection of bowel and adhesions may be required to achieve complete flow into the intraperitoneal space.

A subcutaneous pocket of 6-7 cm is created on top of the rectus fascia. The Port-A-Cath is placed on top of the rectus fascia and secured with interrupted 3-0 nylon suture. At this point, the Port-A-Cath and its catheter are filled with heparinized saline solution.

The incision in the rectus fascia peritoneum remains open, and the catheter from the Port-A-Cath is brought near that incision. A clamp is inserted through the fascia and peritoneum, and a small cutdown is made onto the tip of this clamp, approximately 3-4 cm lateral to the fascia and the peritoneal incision. The catheter is brought through this stab wound into the peritoneal cavity.

The Port-A-Cath catheter is arranged in a manner that will allow it to traverse the entire peritoneal cavity. The Port-A-Cath can be sutured to various points in the peritoneal cavity to allow maximum distribution of infused drug without creating the potential of a "clothesline" effect of the catheter whereby a knuckle of bowel can become involved in an internal hernia.

The incision in the peritoneum and rectus fascias are closed in layers with delayed absorbable sutures.

The Port-A-Cath is in its pocket under the skin. The catheter travels through the peritoneal cavity to deliver the drug to the pelvis and upper abdomen.

The surgeon can adjust the placement of the catheter to meet individual needs. It can be placed adjacent to the liver, diaphragm, or wherever the maximum tumor burden lies.

The Port-A-Cath is flushed at the end of the procedure with heparinized saline solution.

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