Claes Tropè MD
Recently updated 17.04.2012
Oslo University Hospital
- The patient lies in the supine position.
- For cancer of the adnexa, a mid-line incision is made.
- Make an incision from the top of the symphysis to the navel extending into the epigastrium as needed. Make the incision long enough allowing for sufficient space to prevent rupturing of the ovaries during mobilization.
- If present, aspirate ascites into a syringe with a catheter.
- If there are no ascites, rinse the abdomen with 50 ml NaCl 9 mg/ml and aspirate in the same syringe. Deliver the aspirate for a cytological examination.
- Arrange the Bookwalters retractor to obtain optimal working space and overview.
- Inspect and palpate the entire abdomen for possible metastasis. Inspect the adnexa and abdominal cavity. Check the liver, spleen, lymph nodes, diaphragm, stomach, intestines, and omentum.
- Pack away the intestines with compresses saturated with NaCl 9 mg/ml. Keep them in out of the operation field with disharp and the retractors.
- Check that the individual retractors are not pressing on the psoas muscles and femoral nerve to avoid compression injuries, neuropathy, and paralysis in the femoral area.
- Lower the cranial end of the opration table (Trendelenburg’s position).
- Clamp with Kochers forceps on each corner of the uterus. The assisting surgeon should hold the uterus.
- Clamp the round ligament on both sides.
- Split the peritoneum over the bladder.
- If the tumor is localized to the adnexa without adherences to the peritoneum, a simple removal of the adnexa is carried out. The specimen is sent for frozen sectioning. If there is infiltration of the peritoneum, the infiltrated part is removed along with the adnexa.
- Split the peritoneum along the pelvic wall.
- Open the extraperitoneal space along the pelvic wall.
- Identify the ureter and avoid it.
- Divide the suspensory ligament containing the blood supply to the adnex.
- Dissect the peritoneum off the ureter and its accompanying structures, and push the ureter down before the peritoneum is divided.
- Dissect along the peritoneal to the uterus.
- Separate the adnex from the uterus.
- Send the adnexes for examination by frozen microscopy.
- Push the bladder peritoneum down to below the cervix.
- Clamp the parametrium close to the uterus using Leibingers forceps.
- Place the Leibinger forceps closely and obliquely towards the vagina and cut with scissors.
- Place Kocher forceps on the vagina immediately under the cervix to lift the vagina.
- Use diathermy to remove the uterus and cervix immediately distal to the cervix.
- Close the top of the vagina with surures.
- Carry out lymph node staging.
- Perform an omentectomy.
- Close the abdominal wall.
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