Gynecologic Oncology

Gina Westhoff MD¹

Nelson N. Teng MD, PhD¹

Clifford A. Schmiesing MD²

¹SURGEONS

²ANESTHESIOLOGIST

STAGING LAPAROTOMY FOR OVARIAN, FALLOPIAN TUBE, AND PRIMARY PERITONEAL CANCER

SURGICAL CONSIDERATIONS

Description: Ovarian carcinoma has the highest mortality rate of all gynecologic malignancies because it is usually discovered in advanced stages with a pelvic mass, omental caking, and ascites. Surgery is used for staging as well as therapy. Studies have demonstrated an inverse relationship between postop residual tumor mass and survival; therefore, the goals of surgery are accurate staging and optimal tumor debulking (< 1 cm residual disease). The standard procedure consists of a meticulous exploration of the abdominopelvic cavity, abdominopelvic cytology, multiple random and targeted biopsies, total abdominal hysterectomy (TAH), bilateral salpingo-oophorectomy (BSO), pelvic and paraaortic lymph node dissection, infracolic omentectomy, appendectomy, and additional cytoreductive procedures. After access to the abdomen is obtained through a midline abdominal incision, cytologic washings of the pelvis, pericolic gutters, lesser sac, and hemidiaphragms are done. The peritoneal cavity is carefully explored. A TAH/BSO is performed by ligating and transecting the round, infundibulopelvic, broad, cardinal, and uterosacral ligaments on both sides. The specimen is cut away from the vagina and the cuff closed. Pelvic and paraaortic lymph node dissections are then performed. Pelvic lymphadenectomy is performed by opening the pelvic peritoneum, developing the paravesicle and pararectal space, identifying the ureter and removing the lymph node tissue
adjacent to the common and external iliac vessels and obturator vein and nerve. Paraaortic lymph node dissection is performed by opening the peritoneum over the great vessels followed by removal of the lymph node bundles from the preaortic, lateral aortic, and retroaortic spaces. All residual tumor is removed, using sharp dissection and/or Cavitron Ultrasonic Surgical Aspirator (CUSA) and/or argon beam coagulator (ABC), and then an appendectomy is usually performed. The omentum is clamped, transected, and ligated along its attachment to the transverse colon. A bowel resection with possible colostomy formation may be necessary to achieve optimal cytoreductive surgery (see Pelvic Exenteration, p. 781). Next, the peritoneal cavity is irrigated copiously. Targeted and random biopsies of bladder, cul-de-sac of Douglas, pericolic gutters, hemidiaphragms, small bowel, large bowel, and anterior abdominal wall are performed. A peritoneal port may be placed subcutaneously for use in future intraperitoneal chemotherapy. Approximately 25% of patients undergoing cytoreductive surgery for advanced stages of ovarian carcinoma require bowel resection with either primary reanastomosis or colostomy. A splenectomy is not routinely done unless the spleen is involved with tumor. Some patients with unresectable disease and bowel obstruction will require a gastrostomy tube placement at this time. A less extensive surgical procedure may be appropriate if a large volume of unresectable tumor is discovered. Surgery in these cases must be individualized. In addition, laparoscopic surgical staging has recently become more common for early stage lesions.

Figure 8.1-1. Aortic node dissection in staging laparotomy for ovarian cancer. In this case, both right and left node dissections have occurred, leaving the kidney, renal hilum, and psoas muscle exposed. Because the dissection is infrarenal and anterior to the lumbar vessels, there is residual fatty and nodal tissue at the posterior limit of the dissection.

In some Stage I lesions, a unilateral salpingo-oophorectomy (USO) is sufficient therapy. The decision to use this approach depends on cell type, age, reproductive status, and extent of disease. Limited USO staging is usually performed as a fertility sparing procedure for young women with early stage tumors. Generally, biopsies, a retroperitoneal lymph node dissection, omentectomy, and appendectomy also are performed.

Usual preop diagnosis: Ovarian cancer/pelvic mass

▪ SUMMARY OF PROCEDURE

Position	Supine, dorsal lithotomy (if anticipating lower bowel resection)
Incision	Midline or paramedian abdominal
Special instrumentation	CUSA, Vital View (suction-irrigation device combined with light source) helpful; laparoscopic biopsy forceps (laparoscope, laparoscopic instruments for evaluation of upper abdomen through lower vertical abdominal incision); Argon beam coagulator (ABC); TA, GIA, EEA stapling devices.
Unique considerations	Removal of large amounts of ascites may → fluid shifts and intravascular volume depletion intraop and postop. Consider preop prophylactic heparin. Most patients will have had bowel prep and will be hypovolemic at the start of surgery. Optimal debulking may require bowel resection, splenectomy, pancreatectomy, or other advanced procedure. During lymphadenectomy, there is a risk of vascular injury that may lead to significant blood loss and need for rapid volume replacement.
Antibiotics	Cefoxitin 2 g or Cefotetan 1-2 g iv; redose or as indicated by large EBL, duration of surgery.
Surgical time	1-5 h, including splenectomy and bowel surgery for more advanced stages
Closing considerations	Consider NG tube placement by anesthesiologist (in select cases with extensive bowel involvement or bowel procedures); peritoneal or central venous access for subsequent chemotherapy
EBL	500-1000 mL; 250-500 mL for Stage I lesions; > 1000 mL for more advanced stages
Postop care	Extensive peritoneal raw surfaces → intraperitoneal fluid 3rd-spacing. Patients require aggressive hydration to maintain intravascular volume. Central hemodynamic monitoring and ICU admission are useful in selected patients. Use SCDs and prophylactic heparin for VTE prophylaxis.
Mortality	1-2/1000
Morbidity	Grade 3-4 hemorrhage 7% Postop fever: 14-19% Wound infection: < 5% Wound dehiscence: 0.3-3% VTE: 1-2% Ureteral injury: < 1% Vaginal vault prolapse: Rare
Pain score	7-8

▪ PATIENT POPULATION CHARACTERISTICS

Age range	All age groups; most common, 60-69 yr, mean age 63
Incidence	9.4/100,000 (22,280 new cases/yr); 1.4% lifetime risk of ovarian cancer
Etiology	Unknown
Risk factors	Family Hx of ovarian carcinoma; personal or family Hx of breast cancer (BRCA gene mutations); ↑ age at first pregnancy; nulliparity; advancing age; late menopause; obesity; gonadal dysgenesis; exposure to radiation; environmental factors
Associated conditions	Familial cancer syndromes (e.g., Lynch, BRCA); Peutz-Jeghers syndrome—5% of cases develop gonadal stromal tumor; XY gonadal dysgenesis—gonadoblastomas; multiple nevoid basal cell carcinoma (Gorlin’s syndrome); ataxia telangiectasia (hereditary, progressive cerebellar lack of muscular coordination associated with recurrent pulmonary infections and ocular and cutaneous telangiectasias)

ANESTHETIC CONSIDERATIONS

PREOPERATIVE

Ovarian carcinoma is usually diagnosed at a late stage, and therefore, the patient may have malignant ascites and pleural effusion, large tumor mass, and omental spread. Surgery is indicated for resection of localized tumor and for staging of distant and local metastases. Additional procedures, including bowel resection or lymph node dissection, may be performed at the same time.

Respiratory	Significant ascites and pleural fluid may produce respiratory compromise. The presence of dyspnea, orthopnea, tachypnea, or other chest findings need to be investigated. Underlying lung diseases, such as asthma, also may be exacerbated by the abdominal distension/ascites. Tests: Consider CXR; ± ABG; others as indicated from H&P. Consider pleural effusion drainage preop if severe respiratory compromise.
Cardiovascular	An ECHO or other studies may be requested to evaluate cardiac function. Exercise tolerance should be evaluated in every patient and any pre-existing cardiac disease explored in the preop visit. Irreversible, dose-dependent cardiotoxicity may result from doxorubicin chemotherapy. Tests: Consider ECG, others as indicated from H&P.
Gastrointestinal	Patient should have adequate preop iv hydration if given a bowel prep overnight. Opiate use may cause ↓ GI motility. May be malnourished.
Neurological	Not usually significant. Taxol and cisplatin may → peripheral neuropathy.
Hematologic	Bone marrow suppression common following chemotherapy. Carboplatin, commonly used for ovarian cancer, often induces thrombocytopenia. Tests: CBC
Laboratory	CBC, hepatic function, PT/PTT, T & S or T & cross, Assess renal function if large pelvic mass at risk of causing postrenal impairment.
Premedication	Consider midazolam 1-2 mg iv

INTRAOPERATIVE

Anesthetic technique: GETA ± epidural analgesia. Typically, a balanced anesthetic with inhalational agents and/or propofol infusion (25-150 mcg/kg/min) and narcotics. An epidural catheter may be placed for postop pain management and also may be used intraop to ↓ anesthetic requirements.

Induction	Standard induction (see p. B-2), though consider full stomach precautions if ascites present.
Maintenance	Standard maintenance (p. B-3). Continue muscle relaxation based on nerve stimulator response. Epidural bupivacaine/narcotic combination if catheter is placed preop. Consider NG/OG tube. Patients with combined regional/GA may require increased fluids due to vasodilation and ↓ BP.
Emergence	The patient may be extubated at the conclusion of surgery, unless hemodynamically unstable and/or requiring continued vigorous fluid resuscitation. Reverse muscle relaxant with neostigmine 0.07 mg/kg and glycopyrrolate 0.01 mg/kg, and give supplemental O2 after extubation. Consider postop ICU bed for unstable patients or those requiring invasive monitoring for fluid management.
Blood and fluid requirements	Significant blood loss possible IV: 16-18 ga × 2 NS/LR at 4-6 mL/kg/h 5% albumin 6% hetastarch	Blood loss may be > 1 L. Order T & S or T & cross preop. 5% albumin or 6% hetastarch are useful for rapid volume replacement if Hct is acceptable. If large volumes of ascites are removed, significant ↓ BP may develop. Third-space losses may be significant (≥ 10-15 mL/kg/h). Consider alternating NS and LR to avoid development of a nonanion gap hyperchloremic acidosis 2° NS. Warm fluids. Strive to maintain euvolemia based on clinical data: BP, HR, ABG, UO, EBL, and fluid shift estimates, ± CVP, etc.
Monitoring	Standard monitors (p. B-1) ± Arterial catheter ± CVP catheter Foley catheter	Arterial and CVP catheters indicated for extensive surgery and/or patients with significant comorbidities (CHF, CAD, COPD, CKD, etc.).
Positioning	[check mark] and pad pressure points, especially important for longer surgeries [check mark] eyes Antiembolism stockings and SCDs
Complications	Hypothermia Coagulopathy	Hypothermia likely to develop. Warm all iv fluids. Heating blanket on bed and forced-air warming blanket should be used. Preop malnutrition and/or significant blood loss may → coagulopathy

POSTOPERATIVE

Complications

Hemorrhage

VTE

Ascites/pleural effusion

Respiratory insufficiency

PONV

See p. B-8

See p. B-6

Pain management

PCA

Epidural

Adjuncts

See PCA and epidural narcotic recommendations on pages C-2 and C-3. Epidural may ↓ pain, PONV, and risk of VTE.

Consider PO/IV tylenol, gabapentin, celebrex

Suggested Readings

1. Berek JS, Longacre TA, Friedlander M: Ovarian, fallopian tube, and peritoneal cancer. In: Berek JS, ed. Berek & Novak’s Gynecology, 15th edition. Lippincott Williams, & Wilkins, Philadelphia: 2011, 1350-1427.

2. Cohn DE, Alvarez RD: High-grade serous carcinomas of the ovary, fallopian tube, and peritoneum. In: Karlan BY, Bristow RE, Li AJ, eds. Gynecologic Oncology Clinical Practice and Surgical Atlas. McGraw-Hill Professional, New York: 2012, 237-256.

3. Copeland LJ: Epithelial ovarian cancer. In: DiSaia PJ, Creasman WT, eds. Clinical Gynecologic Oncology. CV Mosby, St Louis: 2007, 289-350.

4. Fleming GF, Ronnett BM, Seidman J, Zaino RJ, Rubin SC: Epithelial ovarian cancer. In: Barakat RR, Perelman RO, Markman M, Randal M, eds. Principles and Practice of Gynecologic Oncology, 5th edition. Lippincott Williams, & Wilkins, Philadelphia: 2009, 763-831.

INTERVAL, SECONDARY CYTOREDUCTIVE, AND SECOND LOOK ASSESSMENT LAPAROTOMY

SURGICAL CONSIDERATIONS

In patients where neoadjuvant chemotherapy was utilized or when optimal debulking could not be performed at initial surgery, an interval (after 3-6 cycles of chemotherapy) or secondary debulking laparotomy is done to achieve optimal cytoreduction. Similar to primary cytoreduction, the surgery involves methodical and meticulous exploration of all of the abdomen and pelvis, multiple cytologies and biopsies, lysis of adhesions, and resection of the residual tumor, as well as the pelvic and periaortic lymph nodes (if not done at time of first surgery). Patients may also be candidates for secondary or tertiary cytoreductive surgical procedures, particularly if isolated recurrences are found in the setting of longer disease-free intervals.

Description: Historically, surgery in the form of “second-look” laparotomy was undertaken to determine whether a patient was surgically and pathologically free of disease, after an appropriate number of treatment cycles with platinum-based (CDDP or carboplatin) chemotherapy. However, 50% of patients with negative second-look surgeries ultimately recur, and the number of second-look surgeries has decreased significantly in favor of noninvasive evaluation including the use of tumor markers (CA-125) and imaging techniques (CT, MRI, PET). Select patients will benefit from second-look surgery to guide further therapy. Intraabdominal assessment may be performed in conjunction with placement of an intraperitoneal port.

Usual preop diagnosis: Ovarian carcinoma

▪ SUMMARY OF PROCEDURE

Position	Supine or dorsal lithotomy
Incision	Midline or paramedian vertical abdominal
Antibiotics	Cefoxitin 2 g or cefotetan 1-2 g iv, further doses as indicated by large EBL, duration of surgery
Surgical time	2-3 h
Additional considerations	Placement of permanent central venous or intraperitoneal access; Preoperatively consider prophylactic heparin
EBL	350-700 mL
Postop care	PACU → ward
Mortality	1-2/1000
Morbidity	Postop fever: 14-19% Wound infection: < 5% Wound dehiscence: 0.3-3% PE: 1-2% Incisional hernia: 0.5-1% Ureteral injury: 0.5-1%
Pain score	7-8

ANESTHETIC CONSIDERATIONS

PREOPERATIVE

Patients undergoing interval cytoreductive laparotomy have generally been treated with 3-6 cycles of chemotherapy. Depending on the type of adjunctive treatment given, the patient may come to surgery in poor physical condition from malnutrition or toxicity from chemotherapy (see Table 8.1-1). Vascular access may be difficult to obtain due to sclerosis or thrombosis of peripheral veins.

Respiratory

Pulmonary function may be impaired by several chemotherapeutic drugs, most commonly bleomycin. Patients often have a Hickman catheter or other central line already in place, which can be used for induction of anesthesia. Consider preop CXR to assess the presence of lung injury if prior chemo given. Patients with dyspnea at rest or with mild exertion, or who have known pulmonary fibrosis, should be evaluated by PFTs, including FVC, FEV1, MMEF_25-75, and ABGs. Patients who received bleomycin should not receive O₂ > 39% intraop, but arterial O2 saturation ideally should be kept ≥ 93%. The pulmonary toxicity of bleomycin is dose-related with a much higher incidence occurring if > 200 mg/m2 received. Combination chemotherapy with vincristine or cisplatin also increases pulmonary toxicity.

Tests: Consider CXR; others as indicated from H&P.

Cardiovascular

Cardiotoxicity is seen with several antineoplastic agents, especially daunorubicin and doxorubicin. The cardiomyopathy produced by these drugs occurs in two forms: (1) acute— ST-T wave changes and dysrhythmias, which are transient and usually not a serious problem; and (2) chronic—a dose-related toxicity manifested by CHF. Total doses of doxorubicin as low as 250 U can cause myocardial damage, but is more common at doses > 400 U. Cardiac irradiation, or combination chemotherapy with cyclophosphamide, increases the risk of cardiac toxicity. Patients who have received cardiotoxic drugs are usually followed by serial ECHOs, and the results should be reviewed preop. Patients with CHF or ECG changes should have a cardiology consultation preop to optimize their medical condition.

Tests: ECG; others as indicated from H&P

Table 8.1-1. Toxicities of Selected Antineoplastic Chemotherapeutic Agents

Agent	Toxic Effects
Vincristine, vinblastine	Neuropathies, SIADH, myelosuppression
Cyclophosphamide	Prolonged neuromuscular block
Mechlorethamine	Prolonged neuromuscular block
Bleomycin	Pulmonary fibrosis
Doxorubicin, daunorubicin	Cardiotoxicity, GI upset, myelosuppression
Methotrexate	Myelosuppression, GI upset, stomatitis, pulmonary infiltrates
Fluorouracil	Myelosuppression, hepatic and GI alterations, nervous system dysfunction
Mercaptopurine	Myelosuppression
Thioguanine	Myelosuppression
Actinomycin D	Myelosuppression, GI upset, stomatitis
Mitomycin	Myelosuppression, GI upset
Cisplatin	Myelosupression, GI upset, electrolyte disturbances, nephrotoxicity, peripheral neuropathy
Carboplatin	Myelosuppression, peripheral neuropathy, GI upset, electrolyte disturbances
Paclitaxel	Myelosuppression, peripheral neuropathy, GI upset, arthralgia/myalgias, mucositis, interstitial pneumonitis
Docetaxel	Myelosuppression, peripheral neuropathy, malaise, maculopapular rash, GI upset

Neurological	Peripheral neuropathies are produced by vincristine, cyclophosphamide, Taxol (paclitaxel), 5-fluorouracil and several other drugs. Vincristine can also → SIADH. Other CNS effects include N/V, seizure, and cerebellar dysfunction. A preop neurologic exam is useful for patients with evidence of neurotoxicity. Document presence of neurologic deficits preop for subsequent comparisons.
Endocrine	Corticosteroids (e.g., prednisone) are commonly used with chemotherapeutic agents, as treatment for pulmonary fibrosis and other complications of chemotherapy. The use of > 10 mg prednisone (or equivalent) per day for > 2 wk suppresses the endogenous secretion of the adrenal cortex, which may take up to 6 mo to recover fully. Hydrocortisone 100 mg iv, preop with an additional 2-3 subsequent doses q 8 h will provide adequate “stress dose” coverage perioperatively. The dose is tapered rapidly over 2 or 3 d postop. Tests: As indicated by the H&P
Renal	Many chemotherapeutic drugs have renal toxicity; therefore, renal function testing indicated. Patients with impaired renal function should be given appropriate dosages of medications (e.g., antibiotics), which depend on renal excretion. Tests: Renal function tests
Musculoskeletal	Vincristine produces a neurotoxicity manifested by numbness and tingling in the extremities, weakness, foot drop, loss of reflexes, ataxia, and muscle pains. Muscle weakness in the arms and legs indicates that the drug should be stopped. Muscle weakness may also involve the larynx and extraocular eye muscles. Reduced amounts of NMBs should be used intraop and a nerve stimulator used to follow twitches.
Gastrointestinal	Consider hydration overnight if given a bowel prep or if there is significant N/V. Look for ascites and malnutrition. Tests: Consider electrolytes, LFTs.
Hematologic	Bone marrow suppression is a common side effect of antineoplastic drugs. The toxicity usually produces a reversible drop in leukocytes, erythrocytes, and platelets, with a nadir 10-14 d posttreatment. Patients with a total neutrophil count of < 1000 should be kept in isolation until counts improve. A low Plt count (<50,000) is an indication for Plt transfusion preop. Regional anesthesia in patients with thrombocytopenia needs to be considered carefully due to ↑ risk of bleeding complications.
Laboratory	Consider CBC, Cr, albumin, lytes, PT/PTT.
Premedication	Consider midazolam 1-2 mg iv. Stress-dose hydrocortisone (100 mg iv) if indicated.

INTRAOPERATIVE

Anesthetic technique: GETA or combined GETA/epidural. Consider CSE ± sedation if severe bleomycin pulmonary toxicity present.

General anesthesia:

Induction

Standard induction (see p. B-2). Consider renal function and surgery duration when deciding on agents.

Maintenance

Standard maintenance: see Anesthetic Considerations for Staging Laparotomy, p. 641.

An epidural may be used to reduce GA requirements (p. B-2).

Emergence

Extubate when patient is responsive and neuromuscular block is fully reversed. In patients with borderline pulmonary function, extubation may be delayed until patient is in the PACU or ICU, and after ABG is checked while the patient breathes spontaneously. Consider PONV prophylaxis (see p. B-6).

Regional anesthesia:

Epidural	2% lidocaine ± epinephrine 1:200,000 (10-20 mL) or 0.25% bupivacaine (10-20 mL) initially; then at ˜3-5 mL/h. Narcotics, such as morphine (2-4 mg) or hydromorphone (0.3-0.6 mg) may be given in the epidural for postop pain control.
Blood and fluid requirements	IV: 16-18 ga × 1-2 NS/LR at 7-10 mL/kg/h Keep UO > 0.5 mL/kg/h Consider PRBC for Hct < 25% 5% albumin 6% hetastarch FFP/Plt	Excessive use of NS can lead to hyperchloremic metabolic acidosis; therefore, alternating NS and LR solutions makes sense when giving large volumes of iv fluids. 5% albumin or 6% hetastarch may be used as volume replacement, although no proven advantages over crystalloid solutions. Consider FFP and Plt if evidence of significant coagulopathy (↑ PT, ↑ PTT, ↓ Plt).
Monitoring	Standard monitors (see p. B-1). ± Arterial line ± CVP catheter Foley catheter	Consider arterial and CVP catheters for patients with compromised cardiac or pulmonary function or patients having extensive surgical procedures.
Positioning	[check mark] and pad pressure points [check mark] eyes Anti-embolism stockings and SCD	It is useful to maintain access to at least one arm for blood drawing and additional iv access.
Complications	Hypothermia Bleeding	Warm fluids; keep heating pad on bed; use forced-air warmer [check mark] PT; PTT, Plts periodically if large blood loss

POSTOPERATIVE

Complications

Bleeding

Infection

PONV (see p. B-6)

Respiratory insufficiency

VTE (see p. B-8)

Pain management

PCA (see p. C-3).

Epidural/spinal narcotics (see p. C-2).

Surgeons may infiltrate wound edges with 0.25% bupivacaine in those patients without epidurals. Consider iv ketorolac (30 mg)

Tests

CXR

ABG

As indicated by postop clinical findings.

Suggested Readings

1. Berek JS, Longacre TA, Friedlander M: Ovarian, fallopian tube, and peritoneal cancer. In: Berek JS, ed. Berek & Novak’s Gynecology, 15th edition. Lippincott, Williams, & Wilkins, Philadelphia: 2011, 1350-1427.

2. Chabner BA, Bertino J, Cleary J, et al: Cytotoxic agents. In: Hardman JG, Limbird LE, Gilman AG, eds. Goodman and Gilman’s: The Pharmacologic Basis of Therapeutics, 12th edition. McGraw Hill, New York: 2011, 1677-730.

3. DiSaia PJ, Creasman WT: Epithelial ovarian cancer. In: DiSaia PJ, Creasman WT, eds. Clinical Gynecologic Oncology. CV Mosby, St. Louis: 2002, 289-350.

4. Fleming GF, Ronnett BM, Seidman J, et al: Epithelial ovarian cancer. In: Barakat RR, Perelman RO, Markman M, Randal M, eds. Principles and Practice of Gynecologic Oncology, 5th edition. Lippincott Williams, & Wilkins, Philadelphia: 2009, 763-831.

RADICAL VULVECTOMY

SURGICAL CONSIDERATIONS

Description: Historically, invasive vulvar carcinoma has been treated with en bloc dissection of the inguinal-femoral region and the vulva. The surgery involves bilateral excision of lymphatic and areolar tissue in the inguinal and femoral regions, combined with removal of the entire vulva between the labia-crural folds, from the perineal body to the upper margin of mons pubis (Fig. 8.1-2). A large surgical wound is created and, if 1° closure without tension is not possible, a skin or myocutaneous graft may be necessary. Deep pelvic nodes are almost never involved with metastases when the superficial and deep groin nodes are free of disease; therefore, a pelvic lymphadenectomy is no longer routinely performed. If presence of tumor is documented in the groin nodes, particularly in Cloquet’s sentinel nodes (the most cephalad, deep inguinal nodes), a deep pelvic lymphadenectomy may be performed. Postop radiation therapy, however, is widely used instead of a pelvic lymph node dissection to minimize operative morbidity and confer a survival advantage.

A skin incision in the shape of a bull’s head (Fig. 8.1-2) allows access to the inguinal-femoral region. (The incision ideally should extend 2+ cm beyond the tumor margin.) The inguinal ligament and rectus fascia should be cleared bilaterally of all nodal tissues and the fossae ovalis on both sides identified. The lateral aspect of the femoral sheath is incised along the sartorius muscle, with care being taken not to injure the femoral nerve or vessels, and the cribriform fascia is cleaned off the femoral artery. The external pudendal artery, which marks the entrance of the saphenous vein into the fossa ovalis, should be identified and ligated. The proximal and distal segments of the saphenous vein should be ligated and excised as the fibrofatty, lymph-bearing tissue of the femoral sheath is resected. Cloquet’s nodes at the femoral ring beneath the inguinal ligaments on both sides should be resected and submitted for frozen-section pathology evaluation. The deep inguinal lymphatic chain is removed on both sides by opening the inguinal canal from the external inguinal ring. The vulvar incision is carried down through the labia-crural folds. The internal pudendal vessels at the posterior lateral margin of the vulvar incision are identified as they emerge from Alcock’s canal, and then they are ligated and incised.

Use of electrocautery in this portion of the procedure usually tends to decrease operative blood loss. The dissection is continued along the periosteum of the symphysis at the level of the fascia of the deep muscles of the urogenital diaphragm. The bulbocavernosus, ischiocavernosus, and superficial transverse perinei muscles are removed. A circumferential vaginal incision, excluding the urethral meatus, is then performed and the vulva is removed. The incisions overlying the groin node dissections should be closed with minimal tension after placement of closed-suction Jackson-Pratt drains. The vulvar surgical wound is closed by slightly undermining the skin of the edges of the incision
and suturing them to the vaginal mucosa. A vulvar reconstruction, using myocutaneous flaps, also can be performed at this time (see Pelvic Exenteration, p. 781).

Figure 8.1-2. En bloc radical vulvectomy incisions shown; bilateral inguinal lymphadenectomy is complete. (Reproduced with permission from Rock JA, Thompson JD: TeLinde’s Operative Gynecology, 8th edition. Lippincott Williams & Wilkins: 1997.)

Figure 8.1-3. 3-incision radical vulvectomy and bilateral inguinofemeral lymphadenectomy. (Produced with permission from Rock JA, Thompson JD: TeLinde’s Operative Gynecology, 8th edition. Lippincott Williams & Wilkins: 1997.)

Variant procedure or approaches: In 1962, Byran and associates popularized a 3-incision technique first described by Kehrer in 1918. This 3-incision technique, with separate vulva and groin incisions, is the most common approach (Fig. 8.1-3). This operative approach has led to a significant decrease in wound infection and breakdown, apparently without increasing tumor recurrence in the inguinal dermal bridge above the symphysis pubis. Another variant is the hemivulvectomy (Fig. 8.1-4), in which unilateral radical hemivulvectomy and groin node dissection are performed in selected stage I, nonmidline, unifocal vulvar cancer patients. This procedure will minimize morbidity, disfigurement, and sexual dysfunction. The observation that almost no contralateral groin metastases occur in the
absence of positive ipsilateral groin nodes allows the surgeon to perform only a unilateral groin node dissection. Recent trials have shown sentinel lymph node mapping may be an alternative to groin lymphadenectomy in select patients with early stage disease. For this approach, a radioactive tracer is injected intradermally 20-30 min before groin incision. Blue dye is also injected to improve visualization, but this is done after the patient is prepped due to the rapid movement of the dye to lymphoid tissue. Using both radioactivity and direct visualization allows identification of the sentinel lymph node. If a sentinel lymph node(s) is not found, full lymphadenectomy is performed. Benefits of this approach include less dissection of tissue and lower rates of postoperative complications.

Figure 8.1-4. Unilateral lymphadenectomy for a well-lateralized lesion. (Produced with permission from Rock JA, Thompson JD: TeLinde’s Operative Gynecology, 8th edition, Lippincott Williams & Wilkins: 1997.)

Usual preop diagnosis: Invasive vulvar cancer

▪ SUMMARY OF PROCEDURES

	En Bloc Dissection	3-Incision	Hemivulvectomy
Position	Modified dorsolithotomy in Allen universal stirrups	⇚	⇚
Incision	Bull’s head, from iliac crest to iliac crest and along labia-crural folds (Fig. 8.1-2)	2 separate groin incisions from iliac crest to pubic tubercle; 1 vulvar incision (Fig. 8.1-3)	1 or 2 separate groin incisions from iliac crest to pubic tubercle; vulvar incision (Fig. 8.1-4)
Special instrumentation	Argon Beam Coagulato	⇚	⇚
Unique considerations	Two-team approach to minimize surgical time. Preop bowel prep and constipating medications (e.g., Lomotil) to ↓ postop bowel movements. Consider preoperative prophylactic heparin	⇚	⇚
Antibiotics	Cefoxitin 2 g or cefotetan 1-2 g	⇚	⇚
Surgical time	3-4 h	⇚	2-3 h
Closing considerations	Possible skin graft; vulvar and groin suction drains	⇚	⇚
EBL	500-1000 mL	⇚	250-500 mL
Postop care	PACU or ICU, if necessary; aggressive local wound care. VTE prophylaxis (see Appendix B). NB: trauma to femoral vessels at time of groin lymph node dissection increases risk of thrombophlebitis and PE.	⇚	⇚
Mortality	1-2%	⇚	⇚
Morbidity	Wound infection and breakdown: 40-80% Introital stenosis and dyspareunia: 50% Lymphedema of lower extremities: 25-30% Lymphocysts: 10% Genital prolapse: 7% Stress incontinence: 5% Thrombophlebitis: 3-5% Hernia: 1-2% PE: 1-2%	15% ⇚ ⇚ ⇚ ⇚ ⇚ ⇚ ⇚ ⇚	< 15% ⇚ < 25% (if deep groin nodes not dissected) ⇚ 1-2% 1-2% 1-2% ⇚ ⇚
Pain score	8	8	7

▪ PATIENT POPULATION CHARACTERISTICS

Age range	Median = 70 yr
Incidence	2.2/100,000; 4% of female genital malignancies
Etiology	Two pathways of vulvar cancer are thought to exist, one related to HPV infection and the second related to chronic inflammation or an autoimmune process.
Risk factors	HPV infection, vulvar dystrophies, tobacco use, immunosuppression, HIV
Associated conditions	Bowen’s disease, condyloma acuminata, diabetes, obesity, HTN, arteriosclerosis, cervical malignancy

ANESTHETIC CONSIDERATIONS

PREOPERATIVE

Patients with vulvar carcinoma are usually elderly. Consider and evaluate coexisting medical conditions, including HTN, CAD, and diabetes. Radical vulvectomy is performed for invasive tumor that has not metastasized to distant sites.

Respiratory	The presence of lung disease and smoking Hx should be discussed with the patient preop. Consider CXR and PFTs for patients with significant respiratory disease. Tests: Others as indicated from H&P.
Cardiovascular	There is an increased incidence of HTN and atherosclerosis in these patients. A cardiology consultation is indicated for angina, recent MI, CHF, or heart murmurs. Review ECG (<1 yr) for patients > 60. Tests: ECG; others as indicated from H&P.
Renal	With age, creatinine clearance decreases 2° ↓ renal mass, but serum creatinine remains unchanged because of decreased muscle mass. Tests: Serum creatine; others as indicated from H&P.
Gastrointestinal	Patients should have iv hydration preop if given bowel prep overnight.
Neurological	Document a neurological exam if Hx of stroke, Sz, or other neurologic disease. Hx of peripheral neuropathy or autonomic dysfunction should be assessed in diabetic patients. Tests: As indicated from H&P.
Endocrine	Diabetes, obesity, and hypothyroidism are common in this patient population. Tests: Fasting blood sugar; thyroid function; others as indicated from H&P.
Hematologic	Chronic anemia may be present. Tests: Hb/Hct; Plt count
Laboratory	Cr, if age > 65 (cr = creatinine)
Premedication	Consider midazolam iv 1-2 mg.

INTRAOPERATIVE

Anesthetic technique: GETA or regional anesthesia, alone or in combination.

General anesthesia:

Induction	Standard induction (see p. B-2).
Maintenance	Standard maintenance (see p. B-3).
Emergence	No special considerations

Regional anesthesia:

Epidural	2% lidocaine ± epinephrine 1:200,000 (10-20 mL) or 0.25% bupivacaine (10-20 mL) are used; then at ˜3-5 mL/h. Narcotics such as morphine (2-4 mg) in the epidural for postop pain control.
CSE	Hyperbaric bupivacaine (10-12 mg), ± preservative-free morphine (0.1-0.2 mg) → T10 sensory level.
Blood and fluid requirements	IV: 16-18 ga × 2 NS/LR at 6-8 mL/kg/h Warm iv fluids UO > 0.5 mL/kg/h	Occasionally, femoral vessels may be injured, requiring rapid blood replacement. Consider PRBCs for Hct < 21% in healthy patients and < 25% in patients with cardiac or pulmonary disease.
Monitoring	Standard monitors (p. B-1) ± Arterial line ± CVP line Foley catheter	Invasive monitors indicated for patients in poor condition or with cardiovascular or respiratory disease. An arterial catheter is useful for drawing labs in surgery to check Hct, coags, glucose, or ABGs.
Positioning	[check mark] and pad pressure points [check mark] eyes Antiembolism stockings and SCD

POSTOPERATIVE

Complications

Hypothermia

Bleeding

PONV

VTE

See p. B-6.

See p. B-8.

Pain management

PCA (p. C-3)

Epidural or spinal narcotics (p. C-2)

Incisions may be left open to granulate in or be covered with skin grafts. Epidural analgesia allows earlier ambulation with less sedation in elderly patients.

Tests

Tests as indicated from postop clinical findings