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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

Application of Uterine Afterloading
for Intracavitary
Radiation Therapy

Therapy for carcinoma of the cervix can be achieved with pelvic irradiation. It is difficult to deliver appropriate doses of ionizing irradiation to the cervix with external beam therapy alone. Therefore, the proper application of intracavitary radiation therapy to the cervix in a manner that produces an isodose curve that will deliver maximum irradiation to the cervix, lower uterine segment, parametrium, and upper vagina is vital.

It is not the purpose of intracavitary therapy to irradiate the pelvic wall. This must be done by external beam therapy. To date, a combination of properly applied paracervical and intrauterine irradiation along with external beam therapy has given the best results for cure of carcinoma of the cervix in advanced stages.

The purpose of this operation is to apply a uterine tandem with symmetrically placed paracervical ovoids in a manner that will deliver maximum irradiation to the cervix without excessive irradiation to the base of the bladder or rectum.

Physiologic Changes.  Physiologic changes in this operation are those of ionizing irradiation passing through malignant tissue.

Points of Caution. It is vital that the cervical os be identified and the endocervical canal and endometrial cavity be sounded prior to insertion of the intracavitary therapy applicators. This can be one of the most difficult parts of this procedure. The cervical os is generally more posterior than it would seem because the malignant tissue expands from the anterior lip and distorts the configuration of the cervix.

The uterine tandem should be inserted into the entire length of the endometrial canal.

The ovoids should be positioned so that they are in the vaginal fornices and there is approximately 3.0 cm between the surfaces of the two ovoids. The upper vagina should not be stretched.

Gauze packing should be applied in a manner that gives maximum distance between the sources and the base of the bladder and rectum.


A weighted posterior retractor is placed in the vagina. The anterior lip of the cervix is grasped with a wide-mouthed tenaculum, such as a Jacobs tenaculum. Single-toothed tenacula should be avoided to prevent tearing of tumor tissue. The cervical os is identified, and the uterus is sounded for depth and direction. A tapered cervical dilator, such as a K-Pratt dilator, is used to dilate the cervical canal to 6 mm.

The Fletcher tandem is inserted up to the uterine fundus, and the flange on the tandem is locked into position. If perforation occurs and the position of the tandem is in doubt, diagnostic laparoscopy may aid the surgeon in repositioning the tandem within the uterus.

The largest Fletcher ovoid is fitted for size. The largest ovoids that will symmetrically fit into the vaginal fornices are selected and placed. The upper vagina should not be stretched. The fulcrum of the ovoid applicator is locked.

The tandem and ovoid applicator are packed into the vagina, leaving the maximum distance between the bladder and radium sources.

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