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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

Pelvic High-Dose Afterloader

If, at the time of total pelvic exenteration, tumor margins are close to the pelvic wall or if microscopic tumor remains on the pelvic wall in the area of radical excision of the pelvic wall, it is recommended that the tumor bed be irradiated even if the patient has already received total pelvic irradiation and intracavitary radiation therapy.

Physiologic Changes. After total pelvic irradiation at 5000 cGy plus intracavitary radiation sources, either intracavitary radiation therapy with tandem and ovoid or high-dose afterloader techniques, the tumor on the pelvic wall frequently has not received enough irradiation to destroy it. In fact, the pelvic wall frequently receives no more than 5600 cGy in most techniques. Thus after total pelvic exenteration, there may be additional microscopic tumor present. It would be extremely difficult and dangerous to give more external beam therapy to the pelvic wall, and because of the inverse square law, there would be no method of giving standard tandem and ovoid therapy in the vagina that would significantly reach the pelvic wall.

Therefore, if, following total pelvic exenteration, microscopic tumor remained on the pelvic wall, the high-dose afterloader technique could be used through a standard support frame device to give an additional cytoreductive dose of radiation to the tumor.

Points of Caution. The destructive effect of radiation on the external iliac artery and vein and the possibility of radiation osteomyelitis to the ischial bones of the pelvis must be considered. In addition, the radiation should be covered by omental flaps or a rectus abdominal flap to give greater distance from the high-dose afterloader tubes in order not to damage adjacent intestine and allow neoangiogenesis to revascularize the pelvic wall.


A total pelvic exenteration has been performed. Microscopic tumor remains on the pelvic side wall. One notes the stump of the rectum, the vagina, and the urethral meatus. The ureters have been cut at the pelvic brim.

The high-dose afterloader tubes for delivery of the radioactive material are seen placed into the slots of the frames that have been designed to deliver an even isodose curve of irradiation to the tumor. The high-dose afterloader frames manufactured out of a modified polygalactide L-lactide material that will undergo hydrolysis when left in the pelvis do not require removal.

The omental flap plus a rectus abdominis muscle flap ("VARM" flap) is moved over the frames and the radiation tubes to protect the adjacent intestine by at least 4 cm and allow neoangiogenesis to revascularize the pelvic wall.

The radiation tubes are exteriorized through the right flank or right lower quadrant and attached to the high-dose afterloader device. At the completion of the radiation treatment, the tubes can be surgically removed. The frames, made of polygalactide L-lactide, will dissolve.

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