- A midline incision in made. It may be necessary to extend this into the epigastrium.
- If ascites is present, a sample is taken and sent for a cytological examination.
Survey the extent of the tumor tissue
- Inspect the pelvic organs and peritoneal surfaces in the entire abdominal cavity including the diaphragm.
- Inspect the intestines and the entire length from the ligament of Treitz to the rectum.
- Palpate organs for tumors.
- Palpate lymph node stations along the pelvic wall and paraaortally.
- If there is no macroscopic tumor in the abdominal cavity, biopsies should be taken from the peritoneum, and an omentectomy should be performed to diagnose possible metastasis.
- Describe the size, localization, and number of remaining tumor changes after the operation.
Prepare a plan for the operation
- Try to remove all tumor tissue.
- If this is not possible, try to reduce the amount of tumor tissue so the size of remaining elements is as small as possible, or under 1 cm regardless.
- If it is not possible to adequately remove the tumor tissue, there will be no benefit of removing organs. The operative procedure then cannot be expected to improve the patient's prognosis.
- If there is spreading of tumor tissue to the peritoneum, this is removed along with the tumor. An extraperitoneal technique is then recommended.
- If the recto-sigmoideum is infiltrated, it may be necessary to perform a recto-sigmoid resection (low anterior resection).
- The urinary tracts are usually spared since the bladder is rarely infiltrated.
- The greatest limitation for removal of all tumor tissue is the presence of extensive carcinomatosis on the small intestine, as well as tumor in the hepatic port, or metastasis to the liver.
- Omentum infiltrated with tumor is often removed without damaging the colon.
- If necessary, the colon can be resected to remove tumor tissue.
- If tumor infiltrates the peritoneum, the area can be removed.
- If the spleen in infiltrated, it can be removed.
- A partial or total diaphragmatic resection is performed if the diaphragm is infiltrated.
- Enlarged lymph nodes are removed, if possible, and of benefit to the patient's prognosis.
- If all visible tumor is removed, thoroughly check the lymph nodes stations in the pelvis and paraaortally, and take representative biopsies.
Removal of extensive tumor in the pelvis
- The bladder is dissected off the anterior of the uterus.
- The peritoneum is divided on the pelvic walls.
- Cut down to the retroperitoneal space of the pelvic walls.
- Identify the ureters and dissect them down to the inlet of the bladder.
For a simultaneous en bloc low anterior resection of the recto-sigmoideum (to remove all tumor tissue in the pelvis where tumor is infiltrating the colon/sigmoideum/rectum):
- Divide the sigmoid colon with GIA® proximal to the tumor tissue.
- Divide and ligate the ovarian arteries.
- Divide the peritoneum across to the pelvic inlet.
- Divide and ligate the arteries to the intestines.
- Then, divide extraperitoneally and free the ureter from the peritoneum. The autonomous nerves following the ureter should be preserved. The dissection should be carried on down behind the sigmoideum and rectum.
- Divide and ligate the uterine arteries. This must be done at the level of the ureter or on the pelvic wall.
- Divide and suture ligate the parametria.
- Open the anterior vagina and divide it.
- Dissect retrograde up between the rectum and uterus until reaching tumor tissue.
- Divide and suture ligate the sacrouterine ligaments.
- Isolate the rectum at the level of division.
- Clamp the rectum with TA® and divide it.
- Remove the specimen consisting of the uterus, adnexa, and part of the recto-sigmoideum and tumor tissue.
- Anastomosize the remaining sigmoid colon/descending colon with rectal stump with CEEA®. To accomplish this, the left colon flexure and the descending colon is mobilized. This part of the operation is usually left until the end.
- See procedure for omentectomy.
- In some cases, the transverse colon must be resected to remove tumor.
- It may be necessary to resect parts of the small intestine if there is tumor infiltration. In the case of tumor on the ileocoecal transition, it may be necessary to perform an ileocoecal resection.
- Divide the mesenterium.
- Cut and ligate/suture the arteries.
- Divide the intestine with GIA®.
- Anastomosize the ends with GIA®.
- Suture the openings with GIA® in the intestine in two layers.
- Suture the opening in the intestinal mesenterium.
To finish, place a vacuum drain to the Douglasi pouch and then close the abdominal wall.