Atlas of Procedures in Surgical Oncology

ATLAS OF PROCEDURES IN SURGICAL ONCOLOGY WITH CRITICAL, EVIDENCE-BASED COMMENTARY NOTES

N E W J E R S E Y • L O N D O N • S I N G A P O R E • B E I J I N G • S H A N G H A I • H O N G K O N G • TA I P E I • C H E N N A I

World Scientific

Whiston Hospital, University of Liverpool, UK

Riccardo A AudisioEditor

ATLAS OF PROCEDURES IN SURGICAL ONCOLOGY WITH CRITICAL, EVIDENCE-BASED COMMENTARY NOTES

Library of Congress Cataloging-in-Publication DataAtlas of procedures in surgical oncology with critical, evidence-based commentary notes

(with DVD-ROM) / editor, Riccardo A. Audisio.p. ; cm.

Includes bibliographical references and index.ISBN-13: 978-981-283-293-1 (hardcover : alk. paper)ISBN-10: 981-283-293-9 (hardcover : alk. paper)

1. Cancer--Surgery--Atlases. I. Audisio, Riccardo A.[DNLM: 1. Neoplasms--surgery--Atlases. QZ 17 A88046 2009]RD651.A765 2009616.99'4059--dc22

2009011129

British Library Cataloguing-in-Publication DataA catalogue record for this book is available from the British Library.

For photocopying of material in this volume, please pay a copying fee through the CopyrightClearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, USA. In this case permission tophotocopy is not required from the publisher.

Typeset by Stallion PressEmail: [email protected]

All rights reserved. This book, or parts thereof, may not be reproduced in any form or by any means,electronic or mechanical, including photocopying, recording or any information storage and retrievalsystem now known or to be invented, without written permission from the Publisher.

Copyright © 2010 by World Scientific Publishing Co. Pte. Ltd.

Published by

World Scientific Publishing Co. Pte. Ltd.

5 Toh Tuck Link, Singapore 596224

USA office: 27 Warren Street, Suite 401-402, Hackensack, NJ 07601

UK office: 57 Shelton Street, Covent Garden, London WC2H 9HE

Printed in Singapore.

SC - Atlas of procedures.pmd 10/21/2009, 6:27 PM1

June 27, 2009 12:6 B-601 fm FA

Foreword

THE IMPORTANCE OF SURGICAL TECHNIQUE INSURGICAL ONCOLOGY

Quality surgery is crucial for the management of all solid malig-nant tumours. A multidisciplinary approach is accepted and there-fore chemotherapy and radiotherapy will contribute enormously to asatisfactory outcome. However, very few studies have demonstratedthat these or other modalities will correct for inadequate excisionalsurgery. Surgeons must have a leadership role in multidisciplinarycare so that possibilities, but also limitations, of non surgical treat-ments will be evaluated before a major resection is undertaken.

Surgeons have four major responsibilities in dealing with cancers.The cancer should be removed with a clear margin of excision to avoidlocal recurrence, which can be devastating. The surgeon must excisedraining lymph nodes which will improve prognosis but also deter-mine whether adjuvant therapy is required. Thirdly, it is essentialto achieve these aims with a low morbidity and mortality. Accord-ingly, careful and fastidious technique in excision and reconstructionis paramount. Finally, the surgeon must be cognisant of the need forgood cosmetic results to improve the quality of life. These proceduresshould be well documented so that the surgeon can review the resultsof short- and long-term outcomes.

v

June 27, 2009 12:6 B-601 fm FA

vi Foreword

In this book, Professor Audisio and colleagues have provided sur-gical oncologists with a practical, clinical and technical reference fordealing with malignant disease. All the common, as well as not socommon, malignancies are included and in each case, the contribu-tors are recognised experts in their field. The book provides essentialbasic information, but in addition, is full of good sense and tips forachieving optimal surgical results.

It is highly unlikely that an individual surgeon will attempt allthe different procedures described in this book but rather will con-centrate on a single specialty field, e.g. a colorectal surgeon mightdelve into TME for rectal cancer, robotic assisted laparoscopic surgery,total proctocolectomy and ileoanal pouch, reconstruction of the per-ineum, how to make a good stoma, pelvic extenteration for rectalcancer, extended hepatectomy, and atypical liver resections for col-orectal liver metastases. For those wishing to hone their plastic andreconstructive skills as part of a surgical oncological practice, thereare important chapters on flap technology and reconstructive tech-niques, breast reconstructive techniques, skill/nipple sparing mastec-tomy and reconstruction of the perineum by a gluteal fold flap. Thereis also much to interest head and neck surgeons with total thyroidec-tomy, neck dissection for thyroid carcinoma, total laryngectomy, andtotal paroidectomy.

These are merely examples of a comprehensive collection ofimportant technical articles for both the surgeon-in-training and theexperienced consultant. The European Society of Surgical Oncologysupports training of its members through courses and lectures but alsothrough important initiatives such as this book in the anticipation thatoutcomes for our patients will be improved.

June 27, 2009 12:6 B-601 fm FA

Foreword vii

The authors are to be congratulated for providing this valuableaddition to the literature on crucially important technical aspects ofsurgical oncology.

Professor Irving TaylorProfessor of Surgery

Director of Medical Studies & Vice-DeanUniversity College London, UK

ESSO Past-President

Professor Cornelis J.H. van de VeldeProfessor of Surgery

Leiden University Medical CenterDepartment of Surgery, The Netherlands

ESSO President

June 27, 2009 12:6 B-601 fm FA

Preface

Young surgeons and applicants to the EUMC examination have oftenbeen asking for a textbook on surgical oncology; a text they couldconsider as a standard in their education in cancer surgery. Textbookson medical oncology were predominantly mentioned but a surgicalcounterpart could not be identified.

This collection of surgical techniques represents our first step inthis direction. Surgery, like sailing, is an art, and just as there is no“exact” way to set your sails, there is no exact way to tie your knots.However, in surgery, as in sailing, experience and evidence are pivotalin improving our skills.

I am extremely grateful to all of the contributors who took thetime to put a short text together, summarising their expert views onthe surgical procedures that they have mastered. Importantly, the textis thoroughly referenced and supported by data from the literature,where available.

I would like to congratulate the young colleagues who haveassisted their mentors in setting this up; this project was alwaysintended to be educational. The true target of a great surgeon is to setup a team around him. The privilege and pleasure of sharing knowl-edge is immense. In this way, key contributors have been workingalongside their supportive teams to make this project possible.

A wide range of oncological procedures are taken into account:from urology to breast, colorectal to hepato-biliary, gynaecology, tho-racic, and so on. This is the completion of a goal that the EuropeanSociety of Surgical Oncology (ESSO) had in mind. ESSO was founded

ix

June 27, 2009 12:6 B-601 fm FA

x Preface

in 1981 to advance the art, science and practice of surgery for the treat-ment of cancer. I firmly believe that organ-based societies will not beable to represent the opinion of a surgical oncologist who is constantlyengaged in a multidisciplinary approach to cancer patients.

Scientific knowledge has no boundaries; although there are nogeographical limitations to medical progress, this book attempts tocollect examples of master knowledge from all around Europe.

This knowledge was conceived within the Education & TrainingCommittee at the European Society of Surgical Oncology. It is to thisSociety to which I am indebted for supporting me and providing anetwork of information, which has definitively been useful in assem-bling this collection of surgical procedures.

The image on the book cover is an original illustration by MichaelHoward, a brilliant visual artist who also contributed to some figureswithin the book.

It is my sincere hope that through this book the readers will expandtheir knowledge and experience and that this will be reflected inimproved care and treatment of patients.

Prof. Riccardo A. AudisioConsultant Surgical Oncologist

University of LiverpoolSt Helens Hospital

Marshalls Cross RoadSt Helens WA9 3DA - UK

June 27, 2009 12:6 B-601 fm FA

Contents

Foreword v

Preface ix

List of Contributors xvii

Chapter 1. Axillary Lymph Node Dissection forBreast Cancer

1

Elisabeth A. te Velde and Emiel J. Th.Rutgers

Chapter 2. Breast Reconstructive Techniques 7Fabricio Brenelli, Umberto Napoli,Stefano Martella and Jean-Yves Petit

Chapter 3. Skin/Nipple-Sparing Mastectomy 19Leif Perbeck

Chapter 4. Radio-Guided Occult LesionLocalisation of Subclinical BreastLesions

25

Hodigere S. J. Ramesh, Matilde M.Audisio and Riccardo A. Audisio

xi

June 27, 2009 12:6 B-601 fm FA

xii Contents

Chapter 5. Technical Note on Total Parotidectomy 33Eberhard Stennert and Orlando Guntinas-Lichius

Chapter 6. Total Thyroidectomy 41Niall O’Higgins

Chapter 7. Neck Dissection for Thyroid Cancer 45Jan Betka, Petr Lukeš, Zdenek Cada andJaroslav Betka

Chapter 8. Total Laryngectomy 55Mohssen Ansarin, Augusto Cattaneo andFausto Chiesa

Chapter 9. Transcervical Extended MediastinalLymphadenectomy

63

Jarosław Kuzdzał, Marcin Zielinski andŁukasz Hauer

Chapter 10. Minimally Invasive Techniques for EarlyLung Cancer

71

Contardo Vergani, Luca Despini andGiancarlo Roviaro

Chapter 11. Resection of Superior Sulcus Cancers:Anterior Approach

79

Marco Alifano, Salvatore Strano andOlivier Schussler

Chapter 12. Surgical Staging for Lung and MediastinalCancers

87

Ramón Rami-Porta, Sergi Call-Caja,Roser Saumench-Perramon andMireia Serra-Mitjans

June 27, 2009 12:6 B-601 fm FA

Contents xiii

Chapter 13. Transthoracic Oesophagectomy andLymphadenectomy

95

Philippe Nafteux, Willy Coosemans,Herbert Decaluwé, Georges Decker, Paul De Leyn,Dirk Van Raemdonck and Toni Lerut

Chapter 14. Transhiatal Esophagectomy 103J. Jan. B. van Lanschot, Khe T. C. Tran,Bas P. L. Wijnhoven and Hugo W. Tilanus

Chapter 15. Gastrectomy for Adenocarcinoma 109Hartgrink H. Hartgrink andCornelis J. H. van de Velde

Chapter 16. Stenting Gastro-Oesophageal Tumours 117Els M. L. Verschuur, Frank P. Vleggaar andPeter D. Siersema

Chapter 17. Total Pancreatectomy 125Jens Werner and Markus W. Büchler

Chapter 18. Radiofrequency Ablation in the Treatment ofLiver Tumours

133

Joris Joosten and Theo Ruers

Chapter 19. Atypical Liver Resections of ColorectalMetastases

141

Bjarne Ardnor and Peter Naredi

Chapter 20. Extended Hepatectomy for Primary andMetastatic Liver Lesions

149

René Adam, Emir Hoti, Dennis A. Wicherts andRobert J. de Haas

June 27, 2009 12:6 B-601 fm FA

xiv Contents

Chapter 21. Isolated Hepatic Perfusion: How It ShouldBe Done

157

Alexander L. Vahrmeijer, Liselot B. J. van Iersel,Peter J. K. Kuppen and Cornelis J. H. van de Velde

Chapter 22. Robot-Assisted Laparoscopic ColorectalSurgery

165

Omer Aziz and Ara W. Darzi

Chapter 23. How to Make a Good Stoma 171Robin Phillips and Simon Phillips

Chapter 24. Palliative Stenting for Colorectal MalignantStrictures

179

Thomas M. Raymond, R. Bhardwaj andMike C. Parker

Chapter 25. Technical Notes on TME for Rectal Cancer 187Bill J. Heald

Chapter 26. Total Proctocolectomy with Ileoanal PouchAnastomosis

195

Thomas Lehnert, Silke Schüle and Frank Starp

Chapter 27. Pouches and Coloanal Anastomosis 203Sylvain Kirzin, Guillaume Portier andFranck Lazorthes

Chapter 28. Pelvic Exenteration for Rectal Cancer 209Klaas Havenga and Theo Wiggers

Chapter 29. Reconstruction of the Perineum by GlutealFold Flap

215

Niri S. Niranjan

June 27, 2009 12:6 B-601 fm FA

Contents xv

Chapter 30. Local Treatment for Primary Melanoma 219Omgo E. Nieweg

Chapter 31. Ilioinguinal Dissection for Melanoma 223Alessandro Testori and Mark Zonta

Chapter 32. Surgical Treatment of PeritonealCarcinomatosis

229

Marcello Deraco, Dario Baratti, Barbara Laterza,Domenico Sabia and Shigeki Kusamura

Chapter 33. Laparoscopic Management of AdnexalTumours

237

Liselotte Mettler, Ivo Meinhold-Heerlein andAndreas G. Schmutzler

Chapter 34. Excision of Intra-Abdominal Sarcomas:Technical Notes on Surgical Procedures

245

Beate Rau and Peter M. Schlag

Chapter 35. Laparoscopic Adrenalectomy for Tumoursin the Adrenal Glands

253

Bergþór Björnsson, Guðjón Birgisson andMargrét Oddsdóttir

Chapter 36. Isolated Limb Perfusion 259Harald J. Hoekstra

Chapter 37. Cone and Wedge Resection in Renal CellCarcinoma

267

Frederik C. Roos and Joachim W. Thüroff

Chapter 38. Transperitoneal Laparoscopic RadicalNephrectomy

275

Hugh F. O’Kane, Alex MacLeod,Christopher Hagan and Thiagarajan Nambirajan

June 27, 2009 12:6 B-601 fm FA

xvi Contents

Chapter 39. Radical Prostatectomy for Locally AdvancedProstate Cancer

281

Marc Claessens, Steven Joniau andHendrik Van Poppel

Chapter 40. Flap Technology and ReconstructiveTechniques in Urology

289

Milomir Ninkovic and Gustavo Sturtz

Index 301

June 27, 2009 12:6 B-601 fm FA

List of Contributors

René AdamAP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, 12 Avenue PaulVaillant Couturier, F-94804 Villejuif, FranceInserm, Unité 785, F-94804 Villejuif, FranceUniversité Paris-Sud, UMR-S 785, F-94804 Villejuif, France

Marco AlifanoChirurgien des Hôpitaux, Unité de Chirurgie Thoracique, Hôtel-DieuUniversity Hospital, 1, Place du Parvis Notre-Dame, 75004 Paris,France

Mohssen AnsarinHead and Neck Department, European Institute of Oncology, ViaRipamonti, 435 I-20141 Milan, Italy

Bjarne ArdnorDepartment of Surgery, Umea University Hospital, S-90185 Umea,Sweden

Matilde M. AudisioCarmel College, Prescot Road, St Helens, Merseyside WA10 3AG, UK

Riccardo A. AudisioDepartment of Surgery, Whiston Hospital, Warrington Road, PrescotL35 5DR, UK

xvii

June 27, 2009 12:6 B-601 fm FA

xviii List of Contributors

Omer AzizDepartment of Biosurgery and Surgical Technology, Imperial CollegeLondon, 10th Floor, QEQM Building, St Mary’s Hospital, London W21NY, UK

Dario BarattiDepartment of Surgery, National Cancer Institute of Milan, 1, 20133Milan, Italy

Jan BetkaDepartment of Otorhinolaryngology and Head and Neck Surgery,Faculty Hospital Motol, Charles University, 150 06 Prague 5, CzechRepublic.

Jaroslav BetkaDepartment of Otorhinolaryngology and Head and Neck Surgery,Faculty Hospital Motol, Charles University, 150 06 Prague 5, CzechRepublic.

Rakesh BhardwajDepartment of Surgery, Darent Valley Hospital, Dartford, Kent DA28DA, UK

Guðjón BirgissonDepartment of Medicine, University of Iceland Medical School andLandspitali-University Hospital, Reykjavik, Iceland

Bergþór BjörnssonDepartment of Medicine, University of Iceland Medical School andLandspitali-University Hospital, Reykjavik, Iceland

Fabricio BrenelliDivision of Plastic and Reconstructive Surgery, European Institute ofOncology, Via Ripamonti, 435 20141-Milan-Italy

June 27, 2009 12:6 B-601 fm FA

List of Contributors xix

Markus W. BüchlerDepartment of General, Visceral, and Transplant Surgery, Universityof Heidelberg, INF 110, 69120 Heidelberg, Germany

Zdenek CadaDepartment of Otorhinolaryngology and Head and Neck Surgery, 1stFaculty of Medicine, Faculty Hospital Motol, Postgraduate MedicalSchool, Charles University in Prague

Sergi Call-CajaThoracic Surgery Service, Hospital Mutua de Terrassa, PlazaDr. Robert, 5, 08221 Terrassa, Barcelona, Spain

Augusto CattaneoHead and Neck Department, European Institute of Oncology, 435,I-20141 Milan, Italy

Fausto ChiesaHead and Neck Department, European Institute of Oncology, 435,I-20141 Milan, Italy

Marc ClaessensDepartment of Urology, University Hospital Leuven, UZ 3000 Leuven,Belgium

Willy CoosemansDepartment of Thoracic Surgery, University Hospital Leuven,UZ 3000 Leuven, Belgium

Ara W. DarziDepartment of Biosurgery and Surgical Technology, Imperial CollegeLondon, 10th Floor, QEQM Building, St Mary’s Hospital, London W21NY, UK

Herbert DecaluwéDepartment of Thoracic Surgery, University Hospital Leuven,UZ 3000 Leuven, Belgium

June 27, 2009 12:6 B-601 fm FA

xx List of Contributors

Georges DeckerDepartment of Thoracic Surgery, University Hospital Leuven,UZ 3000 Leuven, Belgium

Robert J. de HaasDepartment of Surgery, University Medical Center Utrecht, Utrecht,The Netherlands

Marcello DeracoDepartment of Surgery, National Cancer Institute, Via Venezian 1,20133 Milano, Itally

Luca DespiniDepartment of Surgical Sciences, State University of Milan andDepartment of General Surgery, Ospedale Maggiore Policlinico,Mangiagalli e Regina Elena, IRCCS, Milan, Via Francesco Sforza 35,20122 Milano, Italy

Orlando Guntinas-LichiusDepartment of Otorhinolaryngology, Friedrich-Schiller-UniversityJena, Lessingstrasse 2, D-07740 Jena, Germany

Christopher HaganDepartment of Urology, Belfast City Hospital, Lisburn Road, BelfastBT9 7AB, Northern Ireland

Hartgrink H. HartgrinkDepartment of Surgery, Leiden University Medical Center,2300 RC, Leiden, The Netherlands

Łukasz HauerDepartment of Thoracic Surgery, Pulmonary Hospital Zakopane,34-500 Zakopane, Poland

Klaas HavengaDepartment of Surgery, University Medical Center Groningen, 9700RB Groningen, The Netherlands

June 27, 2009 12:6 B-601 fm FA

List of Contributors xxi

Bill J. HealdDepartment of Colorectal Surgery, Pelican Cancer Foundation, NorthHampshire Hospital, Basingstoke RG24 9NA, UK

Harald J. HoekstraDivision of Surgical Oncology, Department of Surgery, GroningenUniversity Hospital, University of Groningen, PO Box 30.001, 9700RB Groningen, The Netherlands

Emir HotiAP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, 12 Avenue PaulVaillant Couturier, F-94804 Villejuif, FranceLiver Transplant Unit, Saint Vincent’s University Hospital, Dublin 4,Ireland

Steven JoniauDepartment of Urology, University Hospital Leuven, UZ 3000 Leuven,Belgium

Joris JoostenDepartment of Surgery, CanisiusWilhelmina Hospital, 6500 HB,Nijmegen, The NetherlandsDepartment of Surgical Oncology, The Netherlands Cancer Institute,Amsterdam, The Netherlands

Sylvain KirzinService de chirurgie digestive CHU Purpan, Place du Dr Baylac, 31059Toulouse, France

Peter J. K. KuppenDepartment of Surgery, Leiden University Medical Center,2300 RC, Leiden, The Netherlands

Shigeki KusamuraDepartment of Surgery, National Cancer Institute of Milan, 1, 20133Milan, Italy

June 27, 2009 12:6 B-601 fm FA

xxii List of Contributors

Jarosław KuzdzałDepartment of Thoracic Surgery, Pulmonary Hospital Zakopane,34-500 Zakopane, Poland

Barbara LaterzaDepartment of Surgery, National Cancer Institute of Milan, 1, 20133Milan, Italy

Franck LazorthesService de chirurgie digestive CHU Purpan, Place du Dr Baylac, 31059Toulouse, France

Thomas LehnertDepartments of General, Visceral, Vascular and Oncology Surgery,Klinikum Bremen-Mitte, St Juergen Strasse, 1, DE 28205 Bremen,Germany

Toni LerutDepartment of Thoracic Surgery, University Hospital Leuven,UZ 3000 Leuven, Belgium

Paul De LeynDepartment of Thoracic Surgery, University Hospital Leuven,UZ 3000 Leuven, Belgium

Petr LukešDepartment of Otorhinolaryngology and Head and Neck Surgery, 1stFaculty of Medicine, Faculty Hospital Motol, Postgraduate MedicalSchool, Charles University, 150 06 Prague 5, Czech Republic

Alexander MacLeodDepartment of Urology, Belfast City Hospital, Lisburn Road, BelfastBT9 7AB, Northern Ireland

Stefano MartellaDivision of Plastic and Reconstructive Surgery, European Institute ofOncology, Via Ripamonti, 435 20141-Milan-Italy

June 27, 2009 12:6 B-601 fm FA

List of Contributors xxiii

Ivo Meinhold-HeerleinDepartment of Obstetrics and Gynecology, Christian-Albrechts-University of Kiel, KlinikumSchleswig-Holstein, Campus Kiel, Michaelisstr. 16, 24105 Kiel,Germany

Liselotte MettlerDepartment of Obstetrics and Gynecology, Christian-Albrechts-University of Kiel, KlinikumSchleswig-Holstein, Campus Kiel, Michaelisstr. 16, 24105 Kiel,Germany

Philippe NafteuxDepartment of Thoracic Surgery, University Hospital Leuven,UZ 3000 Leuven, Belgium

Thiagarajan NambirajanDepartment of Urology, Belfast City Hospital, Lisburn Road, BelfastBT9 7AB, Northern Ireland

Umberto NapoliDivision of Plastic and Reconstructive Surgery, European Institute ofOncology, Via Ripamonti, 435 20141-Milan-Italy

Peter NarediDepartment of Surgery, Umea University Hospital, S-90185 Umea,Sweden

Omgo E. NiewegDepartment of Surgery, The Netherlands Cancer Institute, Antoni vanLeeuwenhoek Hospital, Plesmanlaan 121, 1066 CX Amsterdam, TheNetherlands

June 27, 2009 12:6 B-601 fm FA

xxiv List of Contributors

Milomir NinkovicDepartment of Plastic, Reconstructive, Hand and Burns Surgery,Hospital Bogenhausen — Technical University Munich, Munich81925, Germany

Niri S. NiranjanDepartment of Plastic and Reconstructive Surgery, St. AndrewsCentre for Plastic Surgery, Broomsfield Hospital, Broomsfield,Chelmsford CM1 7ET, Essex, UK

Margrét OddsdóttirDepartment of Surgery, Landspitali-University Hospital, 101 Reyk-javik, Iceland

Niall O’HigginsDepartment of Surgery, RCSI Medical University of Bahrain,Busaiteen 436, Kingdom of Bahrain

Hugh F. O’KaneDepartment of Urology, Belfast City Hospital, Lisburn Road, Belfast,Northern Ireland

Mike C. ParkerDepartment of Surgery, Darent Valley Hospital, Dartford, Kent DA28DA, UK

Leif PerbeckDepartment of Surgery, Karolinska University Hospital, SE-171 76Stockholm, Sweden

Jean-Yves PetitDivision of Plastic and Reconstructive Surgery, European Institute ofOncology, Via Ripamonti, 435 20141-Milan-Italy

Robin PhillipsDepartment of Surgery, Imperial College London, South KensingtonCampus, London SW7 2AZ

June 27, 2009 12:6 B-601 fm FA

List of Contributors xxv

Simon PhillipsDepartment of Surgery, Imperial College London, South KensingtonCampus, London SW7 2AZ

Hendrik Van PoppelDepartment of Urology, University Hospital Leuven, UZ 3000 Leuven,Belgium

Guillaume PortierService de chirurgie digestive CHU Purpan, Place du Dr. Baylac, 31059Toulouse, France

Dirk Van RaemdonckDepartment of Thoracic Surgery, University Hospital Leuven,UZ 3000 Leuven, Belgium

Hodigere S. J. RameshDepartment of Surgery, Whiston Hospital, Warrington Road, PrescotL35 5DR, UK

Ramón Rami-PortaThoracic Surgery Service, Hospital Mutua de Terrassa, PlazaDr. Robert, 5, 08221 Terrassa, Barcelona, Spain

Beate RauDepartment of Surgery and Surgical Oncology, University of Berlin,Charité Campus Milte, Charite platz 1, 10 M7 Berlin, Germany

Thomas M. RaymondDepartment of Surgery, Darent Valley Hospital, Dartford, Kent DA28DA, UK

Frederik C. RoosDepartment of Urology, Johannes Gutenberg-University MainzMedical School, 55101 Mainz, Germany

June 27, 2009 12:6 B-601 fm FA

xxvi List of Contributors

Giancarlo RoviaroDepartment of Surgical Sciences, State University of Milan andDepartment of General Surgery, Ospedale Maggiore Policlinico,Mangiagalli e Regina Elena, IRCCS, Milan, Via Francesco Sforza 35,20122 Milano, Italy

Theo RuersDepartment of Surgical Oncology, The Netherlands Cancer Institute,1066 CX Amsterdam, The Netherlands

Emiel J. Th. RutgersDepartment of Surgical Oncology, Antoni van LeeuwenhoekHospital, PO Box 90203, 1006 BE Amsterdam, The Netherlands

Domenico SabiaDepartment of Surgery, National Cancer Institute of Milan, ViaVenezian 1, 20133 Milano, Italy

Roser Saumench-PerramonThoracic Surgery Service, Hospital Mutua de Terrassa, PlazaDr. Robert, 5, 08221 Terrassa, Barcelona, Spain

Peter M. SchlagDepartment of Surgery and Surgical Oncology, University of Berlin,Charité Campus Milte, Charite platz 1, 10 M7 Berlin, Germany

Andreas G. SchmutzlerDepartment of Obstetrics and Gynecology, Christian-Albrechts-University of Kiel, Klinikum Schleswig-Holstein, Campus Kiel,Michaelisstr. 16, 24105 Kiel, Germany

Silke SchüleDepartments of General, Visceral, Vascular and Oncology Surgery,Klinikum Bremen-Mitte, St. Juergen Strasse, 1, DE 28205 Bremen,Germany

June 27, 2009 12:6 B-601 fm FA

List of Contributors xxvii

Olivier SchusslerChirurgien des Hôpitaux, Unité de Chirurgie Thoracique, Hôtel-DieuUniversity Hospital, 1, Place du Parvis Notre-Dame, 75004 Paris,France

Mireia Serra-MitjansThoracic Surgery Service, Hospital Mutua de Terrassa, PlazaDr. Robert, 5, 08221 Terrassa, Barcelona, Spain

Peter D. SiersemaDepartment of Gastroenterology and Hepatology, University MedicalCentre Utrecht, The NetherlandsDepartment of Gastroenterology and Hepatology, University Utrecht,PO Box 85500, 3508 GA Utrecht, The Netherlands

Frank StarpDepartments of General, Visceral, Vascular and Oncology Surgery,Klinikum Bremen-Mitte, St. Juergen Strasse, 1, DE 28205 Bremen,Germany

Eberhard StennertDepartment of Otorhinolaryngology, Jean-Uhrmacher-Institute,University of Cologne, Geibelstrasse 29-31, Koeln, Germany

Salvatore StranoChirurgien des Hôpitaux, Unité de Chirurgie Thoracique, Hôtel-DieuUniversity Hospital, 1, Place du Parvis Notre-Dame, 75004 Paris,France

Gustavo SturtzDepartment of Plastic, Reconstructive, Hand and Burns Surgery,Hospital Bogenhausen – Technical University Munich, Munich,Germany

June 27, 2009 12:6 B-601 fm FA

xxviii List of Contributors

Alessandro TestoriDivision of Melanoma and Soft Tissue Sarcoma, European Instituteof Oncology, ItalyEuropean Institute of Oncology, via Ripamonti 435, 20141 Milano,Italy

Elisabeth A. te VeldeDepartment of Surgical Oncology, Antoni van LeeuwenhoekHospital, 1006 BE Amsterdam, The Netherlands

Joachim W. ThüroffDepartment of Urology, Johannes Gutenberg-University MainzMedical School, 55101 Mainz, Germany

Hugo W. TilanusDepartment of Surgery, Suite H-996, Erasmus Medical 2040, 3000 CARotterdam, the Netherlands

Khe T. C. TranDepartment of Surgery, Suite H-996, Erasmus Medical 2040, 3000 CARotterdam, the Netherlands

Alexander L. VahrmeijerDepartment of Surgery, Leiden University Medical Center,PO Box 9600, 2300 RC, Leiden, The Netherlands

Cornelis J. H. van de VeldeDepartment of Surgery, Leiden University Medical Center,PO Box 9600, 2300 RC, Leiden, The Netherlands

Liselot B. J. van IerselDepartment of Clinical Oncology, Leiden University Medical Center,Albinusdreef 2, 2333 ZA, Leiden, The Netherlands

J. Jan. B. van LanschotDepartment of Surgery, Suite H-996, Erasmus Medical 2040, 3000 CARotterdam, the Netherlands

June 27, 2009 12:6 B-601 fm FA

List of Contributors xxix

Contardo VerganiDepartment of Surgical Sciences, State University of Milan andDepartment of General Surgery, Ospedale Maggiore Policlinico,Mangiagalli e Regina Elena, IRCCS, Milan, Via Francesco Sforza 35,20122 Milano, Italy

Els M. L. VerschuurDepartment of Gastroenterology and Hepatology, University Utrecht,3508 GA Utrecht, The Netherlands

Frank P. VleggaarDepartment of Gastroenterology and Hepatology, University MedicalCentre Utrecht, Heidelberglann 100, 3584 cx Utrecht, The Netherlands

Jens WernerDepartment of General, Visceral, and Transplant Surgery, Universityof Heidelberg, INF 110, 69120 Heidelberg, Germany

Dennis A. WichertsAP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, 12 Avenue PaulVaillant Couturier, F-94804 Villejuif, FranceDepartment of Surgery, University Medical Center Utrecht, Utrecht,The Netherlands

Theo WiggersDepartment of Surgery, University Medical Center Groningen, 9700RB Groningen, The Netherlands

Bas P. L. WijnhovenDepartment of Surgery, Suite H-996, Erasmus Medical 2040, 3000 CARotterdam, The Netherlands

Marcin ZielinskiDepartment of Thoracic Surgery, Pulmonary Hospital Zakopane,34-500 Zakopane, Poland

June 27, 2009 12:6 B-601 fm FA

xxx List of Contributors

Mark ZontaDivision of Melanoma and Soft Tissue Sarcoma, European Instituteof Oncology, ItalyEuropean Institute of Oncology, via Ripamonti 435, 20141 Milano,Italy

June 9, 2009 14:6 B-601 ch01 FA

chap

ter1

Axillary Lymph Node Dissectionfor Breast Cancer

Elisabeth A. te Velde and Emiel J. Th. Rutgers∗,†

INDICATIONS

Nowadays, for diagnostic staging of the axilla, dissection of the sen-tinel lymph node is the advised procedure, preferably preceded byultrasound of the axilla with fine needle aspiration (FNA) if suspi-cious lymph nodes are seen. Consequently, axillary lymph node dis-section for breast cancer is indicated mainly for treatment of (early)lymph node metastases.

An axillary dissection is performed if:

• The sentinel node is considered positive, with a tumour load ofmore than 0.2 mm1;

• FNA cytology or core biopsy confirms lymph node metastases;• The sentinel node cannot be found or is not performed.

∗Corresponding author.†Department of Surgical Oncology, Antoni van Leeuwenhoek Hospital, PO Box90203, 1006 BE Amsterdam, The Netherlands. E-mail: [email protected]

1

June 9, 2009 14:6 B-601 ch01 FA

2 E. A. te Velde and E. J. Th. Rutgers

TECHNIQUE

We prefer the following technique for axillary lymph node dissectionfor breast cancer:

• The patient is in a supine position, tilted away from the surgeon.The lateral chest wall of the patient is placed close to the side of thetable. The ipsilateral arm is in maximal abduction on an arm boardand can be draped separately.

• Curvilinear incision is cranial along the lateral border of the pec-toralis major muscle and distal towards the posterior axillary line.

• Dissect the dorsal skin flap down to Scarpa’s fascia to reach the freeanterior border of the latissimus dorsi (LD) muscle.

• Free the LD muscle from the anterior by lifting the muscle upwardsby traction to the skin with the free hand. This is the lateral borderof the dissection.

• Free the thoracodorsal bundle (nerve and vessels) and secure cross-ing vessels until the axillary vein. Usually, by retracting the axillaryfat pad ventrally, the nerve is medial to the vessels at the cranialpart (Fig. 1).

FIGURE 1 � The thoracodorsal bundle (nerve and vessels) has been freed. The axillaryfat pad is retracted ventrally.

June 9, 2009 14:6 B-601 ch01 FA

Axillary Lymph Node Dissection for Breast Cancer 3

• Intercostobrachial nerves are sensory nerves for the medial aspectof the upper arm, and the posterior aspect of the axilla and can bepreserved.2,3 It is uncertain whether this will lead to less sensorydisturbances.

• From dorsolateral the fascia of the serratus anterior muscle can becleared.

• The long thoracic nerve can be identified at the level of the highestdescending branch of the intercostobrachial vessels towards thethoracic wall. It should not be dissected from the thoracic wall.

• The ventral skin flap is dissected to free the lateral border of thepectoralis major muscle and further dorsal to the pectoralis minormuscle. The crossing vessels can be spared, harvesting the interpec-toral nodes (Rotter’s nodes).

• Cranially, the axillary vein’s inferior margin is dissected and formsthe cranial border of the dissection. The small motor nerves to thelateral part of the pectoralis minor muscle should be spared. Thedescending ventral branch(es) of the vein usually needs to be dis-sected. Care should be taken not to clear completely the perivascularfascia and the fatty tissue surrounding the vein.

• The total content of the axilla dorsal from the pectoralis minor mus-cle is removed (level II).

• The caudal border of the dissection is the axillary tail of the breasttissue.

• Finally, the axillary specimen is cleared from the serratus anteriormuscle fascia, the proximal part of the thoracodorsal nerve and ofthe anterior plane of the subscapular muscle (Fig. 2).

• If level III needs to be dissected (in the case of palpable nodes),the complete proximal part of the minor pectoral muscle is liftedby a large Langenbeck’s retractor and the area boarded mediallyby the clavipectoral fascia, which can be palpated as a bridgingfascia, cranially by the subclavian vein, and the medial border ofthe pectoralis minor muscle cleared and the fat pad removed.

• Remove the specimen. It is advised to mark the medial apex (top)and the axillary tail of the breast specimen for orientation by thepathologist.

June 9, 2009 14:6 B-601 ch01 FA

4 E. A. te Velde and E. J. Th. Rutgers

FIGURE 2 � The axillary dissection is completed and the apex is marked.

• Closure of Scarpa’s fascia by absorbable sutures. Obliteration ofdead space of the axilla by tagging down the subcutis to the serratusanterior fascia is optional.4

• Skin closure by running subcuticular absorbable sutures (Fig. 3).• There is no need for external compression dressing.

FIGURE 3 � Skin is closed by running sutures without a dressing. The axilla is drainedfor 24 hours.

June 9, 2009 14:6 B-601 ch01 FA

Axillary Lymph Node Dissection for Breast Cancer 5

• Different drain policies are advocated:

— None5;— 24-hour suction drainage6;— 3–5 days.

An alternative — more traditional — method is described by Unget al.7 Our dorsal approach has the great advantage that the importantmotoric nerves are easily identified and spared, also in obese patients.

REFERENCES

1. Lyman GH, Giuliano AE, Somerfield MR, et al.; American Society of Clin-ical Oncology. (2005) American Society of Clinical Oncology guidelinerecommendations for sentinel lymph node biopsy in early-stage breastcancer. J Clin Oncol 23(30): 7703–7720.

2. Muscolino G, Leo E, Sacchini V, et al. (1988) Resectable breast cancer:axillary dissection sparing pectoralis muscles and nerves. Eur J Surg Oncol14(5): 429–433.

3. Salmon RJ, Ansquer Y, Asselain B. (1998) Preservation versus section ofintercostal-brachial nerve (IBN) in axillary dissection for breast cancer —a prospective randomized trial. Eur J Surg Oncol 24(3): 158–161.

4. Chilson TR, Chan FD, Lonser RR, et al. Seroma prevention after modifiedradical mastectomy. Am Surg 58(12): 750–754.

5. Garbay JR, Picone O, Baron-Merle G, et al. (2004) Axillary lymphadenec-tomy with muscular padding, without drainage. Gynecol Obstet Fertil32(12): 1039–1046.

6. Baas-Vrancken Peeters MJ, Kluit AB, Merkus JW, Breslau PJ. (2005) Shortversus long-term postoperative drainage of the axilla after axillary lymphnode dissection: a prospective randomized study. Breast Cancer Res Treat93(3): 271–275.

7. Ung O, Tan M, Chua B, Barraclough B. (2006) Complete axillary dissection:a technique that still has relevance in contemporary management of breastcancer. ANZ J Surg 76(6): 518–521.

June 9, 2009 14:6 B-601 ch02 FA

chap

ter2

Breast Reconstructive Techniques

Fabricio Brenelli†, Umberto Napoli†, Stefano Martella†

and Jean-Yves Petit∗,†

The reconstruction of the breast is a hallmark in the surgical manage-ment of breast cancer. It reduces the anxiety of the patient and therebyimproves the quality of life. It can be done at the time of mastectomy(immediate reconstruction) or any time after (delayed reconstruction).It can be performed either using prosthesis or an autogenous tissue.If the preference is for a prosthesis, either a temporary implant (tis-sue expander) or a definitive implant (silicone or saline prosthesisor a definitive expander) can be used. If reconstruction with autoge-nous tissue is preferred, a latissimus dorsi (LD) or a transverse rectusabdominal muscle (TRAM) flap can be used. Pedicle free flaps aregaining space, mainly the free TRAM flap and the deep inferior epi-gastric (DIEP) flap, both of them require a microsurgery-trained team,this will be not discussed in this chapter.

RECONSTRUCTION WITH PROSTHESIS

Breast Reconstruction with a Definitive Prosthesis

Technique: Drawing of both inframammary fold and sternal line mustbe done preoperatively as an anatomical reference. Measurement ofthe breast’s base helps to program the width of the prosthesis to beplaced (Fig. 1).

∗Corresponding author.†Division of Plastic and Reconstructive Surgery, European Institute of Oncology, ViaRipamonti, 435 20141-Milan-Italy. E-mail: [email protected]

7

June 9, 2009 14:6 B-601 ch02 FA

8 F. Brenelli et al.

FIGURE 1 � Pre-operative drawing of the inframammary fold and sternal line.

The technique consists of a complete or partial muscular pocket.After mastectomy, smooth dissection of the space between the pec-toralis major and minor muscle is performed. This is followed bya sharp dissection, undermining the subpectoral space, cutting themuscle’s insertion medially from the sternum up to 4–5 cm from themammary fold. Inferiorly, dissection is completed achieving the infra-mammary fold after complete severance of the pectoralis fibbers. Thelateral extent of the dissection continues beneath the serratus anteriormuscle, and stops at the predetermined lateral border of the breast(Figs. 2 and 3).

If the lateral skin of the mastectomy is thick and well irrigated, acomplete muscular pocket can be avoided, in order to give more lateralprojection to the breast. The implant is placed in the subpectoralis

June 9, 2009 14:6 B-601 ch02 FA

Breast Reconstructive Techniques 9

FIGURE 2 � Mastectomy defect and exposure of the pectoralis major muscle.

FIGURE 3 � Dissection of the sub-pectoralis space: Medially, severance of the pectoralismajor fibers from the sternum; inferiorly: Severance of the pectoralis fibers achievingthe inframmary fold; lateraly: Completion of the muscular pocket with dissection ofthe serratus anterior muscle.

June 9, 2009 14:6 B-601 ch02 FA


FIGURE 4 � Partial pocket; lateraly, the prosthesis is covered by the lateral skin flapof the mastectomy.

space as well, and just an inferior portion of the anterior serratus isdissected. Then the pocket is closed with the pectoralis major and thelateral part of the mastectomy (Fig. 4).

Indications: Cases of small and medium breasts, where mastectomydoes not require extent skin removal or partial removal of musculartissue.

Contraindications: When muscular invasion exists, or when a largeamount of skin must be excised, making it impossible to build amuscular pocket or having an adequate skin envelope. Adjuvantradiotherapy is a relative contraindication.

Breast Reconstruction with Tissue Expander

This technique consists of the placement of a temporary or definitiveimplant which is inflated with saline solution until the desired volumeis reached, and is exactly the same technique as described above.Afterthe expander is positioned inside the muscular pocket, the catheterand port are tunnelled and brought to a position under the skin in

June 9, 2009 14:6 B-601 ch02 FA


FIGURE 5 � Temporary tissue expander. Expantion is performed with saline solutionthrough the port.

the axilla. As an alternative, in some expanders the port is located onthe surface of the implant itself. In such cases a magnetic device canhelp to localize the port and thereby guide the inflation. The expanderis inflated by passing a needle through the port and injecting salinesolution through it (Fig. 5). After suitable expansion, the expander isreplaced by a permanent prosthesis.

RECONSTRUCTION WITH LATISSIMUS DORSI FLAP(L. D.)

Technique: The donor site skin must correspond to the quantity ofbreast skin that will be removed. The drawing should be elliptical toprovide adequate closure, minimising scar defect. It can be horizontal(better aesthetical result as the scar remains under the bra), or oblique(facilitates the closure) (Fig. 6). The patient’s position is very impor-tant. A lateral decubitus position provides the surgeon an easy accessto the L.D. muscle and surrounding tissues. Its position is securedwith a bean bag.

June 9, 2009 14:6 B-601 ch02 FA


FIGURE 6 � Different possibilities of skin pad donation in the L.D. flap. In the left,horizontal scar that can be hidden by the bra.

The flap comprises skin paddle, underlying fat and L.D. muscle.After skin incision, flap is taken down to the muscle, and the area ofadjacent skin is undermined. The flap is mobilised by incising musclealong its anterior margin and continuing the dissection posteriorly,and the flap is thus liberated from the underlying rib cage. Periph-eral attachments are severed by sharp dissection, beginning inferiorlyand continuing superiorly.Along the superior aspect of the dissection,particular attention must be taken to identify and preserve the tho-racodorsal pedicle which provides the flap’s blood supply (Fig. 7).Finally, a tunnel is created with blunt dissection between the axilla,from the donor site to the mastectomy defect, allowing the rotation ofthe flap.

Suction drain is positioned and the back wound is closed in twolayers. The patient is rotated to a supine position. The final step isshaping of the flap, fixing it to the muscular chest wall, creating apocket. A prosthesis is placed in order to achieve a symmetric breastvolume (Fig. 8).

June 9, 2009 14:6 B-601 ch02 FA


FIGURE 7 � Irrigation of the L.D. muscle. The thoracodorsal pedicle and itsamplification.

FIGURE 8 � Placement of the L.D. muscle over the prosthesis, creating a new pocket.

A total breast reconstruction with L.D. flap is feasible in cases ofsmall or medium breast, with an extended latissimus dorsi flap (ELD).The technique involved is the same as the one described above, butthe undermining of the adjacent skin is performed on a subcutaneous

June 9, 2009 14:6 B-601 ch02 FA


plane, and the muscle is removed together with the superficial fatlying above it, resulting in a more voluminous flap.

Indications: Almost every case of mastectomy and breastreconstruction.

Contraindications: Cases where a great amount of skin must beremoved and the flap skin is not enough to cover it. Relative con-traindication is the presence of homolateral arm lymphedema due toprevious axillary dissection.

RECONSTRUCTION WITH TRAM FLAP

Technique: The patient must be marked preoperatively with anindelible ink. The donor site is outlined superiorly just above theumbilicus, laterally to the iliac crest, and inferiorly, the position beingdependent on the possibility of performing a good closure withoutmuch tension (Fig. 9).

FIGURE 9 � Pre-operative drawing of the TRAM flap donor site: Superiorly, just abovethe umbilicus; Lateraly at the Iliac crest; Inferiorly, above the pubis, always when itallows a good closure.

June 9, 2009 14:6 B-601 ch02 FA


After incision, sharp dissection is performed just above the rec-tus abdominal fascia, undermining the subcutaneous space, from thesuperior incision up to the xiphoid, creating a tunnel. The lateralanatomical reference is the rib cage. The random part of the flap thatwill not be attached to the muscle is undermined until the rectus isreached, preserving as much perforator vessel as possible.

At this point, the rectus fascia is opened on its longitudinal axisup to the xiphoid and the muscle is exposed. The rectus muscle isdissected free posteriorly and the lateral aspect of the rectus sheath isdivided with a scalpel up to the superior border of the flap. The medialborder of the rectus sheath is divided to the level of the umbilicus,which is then dissected free from the flap. The surgeon places twofinger underneath the rectus and lifts it anteriorly with gentle tension,permitting the palpation and vision of the inferior pedicle, which isligated while the muscle is being divided.

The rectus muscle is completely mobilised by sharp and bluntdissection and the superior pedicle is identified. A tunnel is cre-ated through the inframammary fold, communicating with themastectomy defect. The flap is then rotated into the wound (Fig. 10).

FIGURE 10 � Positioning the contra-lateral TRAM flap: Attention to avoid tension orstrugling of the pedicle. The lateral part of the flap (less irrigated) is placed in thelateral part of the defect, allowing an easier flap ressection in case of partial necrosis.

June 9, 2009 14:6 B-601 ch02 FA


FIGURE 11 � Positioning of the ipsi-lateral TRAM flap.Attention to avoid torsion of thepedicle, folding the rectus upon itself. The lateral part of the flap remains external tothe mastectomy defect.

The pedicle can be ipsi or contralateral to mastectomy (Figs. 10 and 11).Great attention must be paid to its positioning, in order not to causeits distension or strangulation. At the end, shapening of the flap isperformed by cutting off the excess tissue from zone 3 and 4 (thefarthest zone from the pedicle).

When the mastectomy defect is very large, and the flap must beused on its full dimension, it is necessary to perform a bipedicle TRAMflap, using both abdominal rectus (Fig. 12). The technique used is thesame as described above, but implicates the use of the two rectusmuscles.

Abdominal closure is a very important step. The suture of thefascia should be done with the patient in the lying position, whilethe closure of the cutaneous flaps will be done at the end in a sittingposition. The fascia can be closed directly with nonabsorbable stitchesunder moderate tension in cases of a mono pedicle. Otherwise, in casesof important tension and bipedicle TRAM, we recommend the use ofa nonabsorbable mesh.

June 9, 2009 14:6 B-601 ch02 FA


FIGURE 12 � Bipedicle TRAM flap. Both rectus are dissected, a small amount of midlineFascia being kept, preserving the umbilicus and its irrigation.

Close attention must be paid to the umbilicous repositioning,especially in cases of a mono pedicle TRAM. Centralisation can beobtained, thanks to a plicature of the fascia of the opposite muscle. Itis also possible to create the future hole of the umbilicus on the medianline and to use its length to centralizate.

Indications: Almost every case of breast reconstruction.

Contraindications: Relative, in cases of obesity, heavy smokers andprevious abdominal surgery.

June 9, 2009 14:6 B-601 ch03 FA

chap

ter3

Skin/Nipple-Sparing Mastectomy

Leif Perbeck∗

INTRODUCTION

Skin sparing mastectomy (SSM) and nipple-sparing mastectomy(NSM) followed by immediate breast reconstruction have gained pop-ularity, since they result in a shape of a natural breast with an intactsubmammary fold and require only one operation, except for the nip-ple reconstruction in SSM. SSM has been described as an operationincluding resection of the nipple–areola complex and any existingbiopsy scar, and removal of the entire breast parenchyma.1 SSM andNSM require technical expertise to avoid partial or full-thickness lossof skin flaps,2 which can lead to delay in starting chemotherapy orradiotherapy.3 There are concerns about the oncological safety. Bypreserving the skin there is a large area in which a local recurrencecan occur, such as the nipple–areola complex. A local recurrence is arisk factor for systemic relapse and the patients have a survival curvecorresponding to that in cases with one metastasis in the axilla atthe primary operation.4 The local recurrence can be treated with localexcision, followed by radiotherapy and further oncological treatment.However, it is a psychological burden for the patient. There is no

∗Department of Surgery, Karolinska University Hospital, SE-171 76 Stockholm,Sweden. E-mail: [email protected].

19

June 9, 2009 14:6 B-601 ch03 FA

20 L. Perbeck

consensus regarding the indications for SSM and NSM, but there arecontraindications, such as excessive skin involvement in both casesand additionally for NSM the existence of a retro-nipple area can-cer within 2.5 cm from the base of the nipple.5 There have been norandomised trials comparing SSM and NSM with mastectomy, butseveral articles have addressed the oncological safety.4 The introduc-tion of anatomically shaped cohesive silicon gel has improved thecosmetic outcome for the patient.

TECHNIQUE

The following description refers to NSM. There are roughly threetypes of breast shapes to consider, namely 0–2 cm ptosis, 2–4 cm pto-sis and over-4-cm ptosis, demanding different kinds of skin incisionsand different locations of the implant. In breasts with 0–2 or 2–4 cmptosis, either a lazy-S incision from the upper border of the areolaand laterally, or an incision 1.5 cm above and parallel to the submam-mary fold is used (see Table 1). The advantage of the lazy-S incision isthat it permits good exposure of the whole breast (Fig. 1). The dissec-tion is at the level of Scarpa’s fascia and the breast glandular tissue isfirst mobilised medially and laterally from the nipple–areola complexbefore a biopsy sample for frozen section is taken under the base ofthe nipple. If a frozen biopsy sample is negative for tumour cells, the

Table 1 Incision and Implant Location in Relation to the Ptosis of the Breast

Breast Shape 0–2 cm Ptosis 2–4 cm Ptosis >4 cm Ptosis

Incision Lazy-S submam-mary fold

Lazy-S submam-mary fold

Subcutaneousreductionmammaplasty

Cranial pedicle

Implant location Submuscular Craniallysubmuscular

Caudallysubcutaneous

Submuscular

June 9, 2009 14:6 B-601 ch03 FA

Skin/Nipple-Sparing Mastectomy 21

FIGURE 1 � The lazy-S incision.

nipple–areola complex is preserved. The thickness of the breast glan-dular tissue that is left beneath the nipple is 3 mm and its diameter is10 mm. After the breast glandular tissue has been mobilised from thesubcutaneous tissue, it is removed from the pectoralis major mus-

cle, leaving the fascia behind. Any tissue around the earlier resectioncavity area is properly removed to avoid future local recurrence. Theincision 1.5 cm above and parallel to the submammary fold has theadvantage that the scar is hidden behind the ptotic breast, but the dis-section of the breast glandular tissue is more difficult. With this inci-sion the breast glandular tissue is first mobilised from the pectoralismajor muscle, making the breast more mobile when the skin flapsare dissected in the subcutaneous layer. The dissection is performedunder direct vision. A pocket for the implant is dissected between thepectoralis major and minor muscles, and in cases where the implantis placed submuscularly the pocket is dissected 1.5 cm below the sub-mammary fold and laterally behind the serratus anterior muscle. Inpatients with ptosis of 2–4 cm the intention is to preserve the sub-mammary fold and try to create a natural ptosis. The pectoralis majormuscle is divided caudally as low as possible and the muscle is thensutured to the overlying subcutaneous tissue without skin tension.An anatomical cohesive gel implant is placed under the pectoralismajor muscle cranially and subcutaneously caudally, thereby creatinga natural ptosis. The use of a test implant, with the patient in a sittingposition, facilitates an optimal choice of size of the permanent implant.

June 9, 2009 14:6 B-601 ch03 FA

22 L. Perbeck

Inapatientwith>4 cmptosis a subcutaneous reductionmammaplasty(SRM) is needed. In SRM it is safer to use a cranial pedicle, becauseof its shorter distance to the nipple–areola complex, than a cau-dally located pedicle, in which the circulation has been shown tobe only 13% of the normal circulation (Figs. 2 and 3).6 The implant

FIGURE 2 � The construction of the vertical pedicle of the skin and fat.

FIGURE 3 � The final result of subcutaneous reduction of mammaplasty.

June 9, 2009 14:6 B-601 ch03 FA

Skin/Nipple-Sparing Mastectomy 23

is placed submuscularly in SRM and usually a cohesive gel is used,but an expander implant can be considered if a volume of >225 cc isdesired.

DISCUSSION

The advantage of NSM is that the whole breast reconstruction is per-formed in one operation and results in the appearance of a naturalbreast with the patient’s own nipple–areola complex. It is possibleto spare the submammary fold. Usually no contralateral operation isneeded except for SRM. Historically, submuscular placement of theimplant is preferred because of the high frequency of capsular con-tracture when a silicon implant is located subcutaneously. The use of asaline-filled implant located subcutaneously results in a capsular con-tracture frequency after 5 years of 14%, and if radiotherapy is given,of 41%, but after one re-operation with capsulotomy or capsulec-tomy of the ventral surface of the capsule, no further capsulectomy isrequired.7 With the introduction of an anatomically shaped cohesivegel breast implant and with the use of a test implant, an adequatepermanent implant can be chosen which does not lose volume withtime as do saline-filled implants. Future studies are needed to deter-mine whether there are any differences between different implants inrelation to their textured surfaces with different pore sizes.

REFERENCES

1. Carlson GW, Bostwick J III, Styblo TM, et al. (1997) Skin-sparing mas-tectomy: oncologic and reconstructive considerations. Ann Surg 223:570–575.

2. Meretoja TJ, Rasia S, Von Smitten KAJ, et al. (2007) Late results of skin-sparing mastectomy followed by immediate breast reconstruction. Br JSurg 94: 1220–1225.

3. Hultman CS, Daiza S. (2003) Skin-sparing mastectomy flap complicationsafter breast reconstruction: review of incidence, management, and out-come. Ann Plast Surg 50: 249–255.

June 9, 2009 14:6 B-601 ch03 FA

24 L. Perbeck

4. Benediktsson KP, Perbeck L. (2007) Survival in breast cancer afternipple-sparing subcutaneous mastectomy and immediate reconstructionwith implants: a prospective trial with 13 year median follow-up in 216patients. Eur J Surg Oncol 1–6. E-pub.

5. Cense HA, Rutgers Th EJ, Lopes Cardozo M, Van Lanschot JJB. (2001)Nipple-sparing mastectomy in breast cancer: a viable option? Reviewarticle. Eur J Surg Oncol 27: 521–526.

6. Perbeck L, Proano E, Westerberg L. (1992) Circulation in the nipple–areola complex following subcutaneous mastectomy in breast cancer.Scand J Plastic Reconstr Hand Surg 26: 217–221.

7. Benediktsson K, Perbeck L. (2006) Capsular contracture around saline-filled and textured subcutaneously-placed implants in irradiated andnon-irradiated breast cancer patients: five years of monitoring of aprospective trial. J Plast Reconst Aesthet Surg 59(1): 27–34.

June 9, 2009 14:6 B-601 ch04 FA

chap

ter4

Radio-Guided Occult Lesion Localisationof Subclinical Breast Lesions

Hodigere S. J. Ramesh†, Matilde M. Audisio‡

and Riccardo A. Audisio∗,†

INTRODUCTION

With the introduction of screening mammography, the incidenceof sub-clinical lesions has doubled in the past decade. One out ofthree breast cancer operations are aimed at removing non-palpablelesions. These lesions need to be removed with precision, satisfyingthe oncological criteria (safe margin) as well as patient expectations(cosmesis). Several localisation techniques have been described. Themost popular one is wire-guided lumpectomy (WGL), although thismay be associated with several drawbacks, such as difficult place-ment of the wire in a dense breast, displacement, traumatic injury topatient and surgeon, long needle tract, interference in the process-ing of the specimen, and inflexibility in the approach to the lesiondue to the entry point of the wire. New methods of localisationare now being developed; examples are ultrasound-guided skin

∗Corresponding author.†Whiston Hospital, Warrington Road, Prescot L35 5DR, UK. E-mail: [email protected]‡Carmel College, St Helens, UK.

25

June 9, 2009 14:6 B-601 ch04 FA

26 H. S. J. Ramesh et al.

marking, intra-operative ultrasound-guided excision, carbon tracer,haematoma-directed ultrasound-guided excision and radio-guidedoccult lesion localisation (ROLL).

EVOLUTION OF ROLL

The use of radio-pharmaceutical compounds to localise breast lesionswas pioneered in the 1990s at the European Institute of Oncology,Milan.1–3 It immediately gained popularity because of its precisionin localising non-palpable lesions while allowing the use of sentinelnode biopsy.

The technique described below is our modification of the originalone to reduce radioactive dosage and an extra day of hospital stay,6–8

as well as to eliminate pre-operative scintigraphy.

GENERAL PRINCIPLES99mTc-labelled (t/2 = 6 hours) is suspended in a macro-aggregate ofalbumin (LyoMAA). It contains approximately 90,000 particles andhas a particle size of 10–90 µm. The radioactivity administered is1 MBq, equal to 0.02 msv (i.e. the same dosage as for a chest X-ray).This radio-pharmaceutical is delivered in a pre-loaded, sterile-packedsyringe within a protective lead case. It is important to shake thesyringe gently to mix the macro-aggregates before injection. Withinthe core of the lesion, 0.2 ml of LyoMAA is injected under ultrasoundguidance 1–4 hours before surgery, as 75% of lesions are ultrasound-visible. Alternatively, stereotactic localisation can be employed.

ROLL localisation is used for diagnostic excision biopsy of sus-picious lesions and therapeutic excision of a proven cancer. The aimis to localise precisely the target and to excise it within the small-est amount of glandular tissue in order to achieve excellent cosmeticresults. The procedure is performed under general anaesthesia andas a day case. Initial diagnostic imaging (i.e. mammogram and/orUS) should be available at the time of localisation, in order to plan the

June 9, 2009 14:6 B-601 ch04 FA

Radio-Guided Occult Lesion Localisation of Subclinical Breast Lesions 27

surgical approach and to compare the specimen X-ray for the presenceof the lesion.

PRE-OPERATIVE CONSIDERATIONS

Indications

• Micro-calcifications• Parenchymal distortions, i.e. radial scars, atypical hyperplasia• Suspicious soft tissue masses• Impalpable cancers following neo-adjuvant chemotherapy• Foreign bodies within soft tissue

Contraindication

• Allergy to albumin

BEFORE ANAESTHESIA

It is important to check for radioactive signals with the patient in asitting and a supine position. This will not only ensure the functional-ity of equipment (gamma camera and radioisotope) but also providea final opportunity to plan, discuss and mark the most appropriateapproach to the lesion.

PATIENT POSITION

The patient should rest in a supine position, with the arm wellabducted to expose the outer quadrants and axilla. The extendedelbow should rest on a well-padded arm board.

INCISIONS

The skin incision should allow lesion removal in accordance with theoncological principles while giving the best cosmetic results. ROLL

June 9, 2009 14:6 B-601 ch04 FA


offers flexibility in the approach to the lesion, bearing in mind that theincision line should fall within the boundaries of the subsequent mas-tectomy or lumpectomy. When possible we make an infra-mammaryincision for lesions at the lower quadrants (Fig. 1), a peri-areolar inci-sion for lesions at the central quadrant (Fig. 2), or an axillary incisionfor lesions at the upper-outer quadrant (Fig. 3), which offer excellentcosmetic results. Skin incisions paralleling Langer’s lines which result

FIGURE 1 � Sub-mammary approach.

FIGURE 2 � Peri-areolar approach.

June 9, 2009 14:6 B-601 ch04 FA


FIGURE 3 � Preferred incisions: axillary approach, peri-areolar approach, sub-mammary approach.

in thin, cosmetically acceptable scars may also be considered for allperipheral lesions when a direct approach is preferred.

HANDLING OF THE GAMMA CAMERA

The gamma camera with a mounted collimator is wrapped in a sterilepolythene cover. After the skin is incised, checks for gamma signalsfacilitate choosing the most direct approach to the lesion. A radio-guided excision biopsy is carried out following audible signals andtissue palpation. We aim to achieve 1 cm of healthy margins encasingthe neoplasm surgery.

The complete excision of the target is confirmed by the presenceof signals in the specimen and the absence of residual signals in theexcision cavity. The specimen is marked with standard orientationstitches, as per agreed laboratory practice.

June 9, 2009 14:6 B-601 ch04 FA


SPECIMEN X-RAY

The specimen X-ray ensures the presence of the target within theexcised tissue, although it must be appreciated that this does not mea-sure the adequacy of the excision margin for neoplasm.

WOUND CLOSURE

The best cosmetic result is obtained by approximating the breast platesof the excision cavity with an absorbable running suture. The skinedge is approximated with a continuous sub-cuticle absorbable 000suture. The wound edges are reinforced with 1/4” steri-strips. The useof breathable dressing or pressure dressing is avoided and we do notroutinely drain the surgical cavity.

POST-OPERATIVE CARE

Resume normal activities on the evening of the surgery.

ADVANTAGES6–10

• Accurate localisation and surgical removal• Improved margin clearance• Reduced size of the excised specimen• Better cosmetic results• Reduced localisation time• Cost-effectiveness• Patient satisfaction (reduced pain)• Reduced local recurrence rate

Finally, the simultaneous use of two radioisotopes to localise bothprimary cancer and the sentinel lymph node known as SNOLL isfeasible.4,5,11

June 9, 2009 14:6 B-601 ch04 FA


RADIATION SAFETY

The radiation dose absorbed by hospital personnel is low and requiresneither radiation protection control nor separation of exposed work-ers into classAand class B. Special containers for radioactive waste arenecessary in the administration room but not in the operating room,where possible contamination is negligible.12 In the case of a sur-geon performing 100 procedures per annum, an FD dose of approxi-mately 1 mSv is received, well within the annual dose limit of 150 mSv.The annual WBD (whole body dosage) to assisting staff may reach0.04 mSv, compared to an annual limit of 6 mSv. These low doses andthe lack of contamination of radioactive waste indicate that no addi-tional radiation protection measures are required.11

REFERENCES

1. Luini A, Zurrida S, Galimberti V, Paganelli G. (1998) Radioguidedsurgery of occult breast lesions. Eur J Cancer 34(1): 204–205.

2. Gennari R, Galimberti V, De Cicco C, et al. (2000) Use of technetium-99m-labeled colloid albumin for preoperative and intraoperative localizationof nonpalpable breast lesions. J Am Coll Surg 190(6): 692–698.

3. De Cicco C, Pizzamiglio M, Trifiro G, et al. (2002) Radioguided occultlesion localisation (ROLL) and surgical biopsy in breast cancer: technicalaspects. Q J Nucl Med 46(2): 145–151.

4. Feggi L, Basaglia E, Corcione S, et al. (2001) An original approach in thediagnosis of early breast cancer: use of the same radiopharmaceuticalfor both non-palpable lesions and sentinel node localisation. Eur J NuclMed 28(11): 1589–1596.

5. Ronka R, Krogerus L, Leppanen E, et al. (2004) Radio-guided occult lesionlocalization in patients undergoing breast-conserving surgery and sen-tinel node biopsy. Am J Surg 187(4): 491–196.

6. Audisio RA, Nadeem R, Harris O, et al. (2005) Radioguided occult lesionlocalisation (ROLL) is available in the UK for impalpable breast lesions.Ann Roy Coll Surg 87(2): 92–95.

7. Nadeem R, Chagla LS, Harris O, et al. (2005) Occult breast lesions: acomparison between radioguided occult lesion localisation (ROLL) vs.wire-guided lumpectomy (WGL). The Breast 14(4):283–289.

June 9, 2009 14:6 B-601 ch04 FA


8. Thind CR, Desmond S, Harris O, et al. (2005) Radio-guided localizationof clinically occult breast lesions (ROLL): a DGH experience. Clin Radiol60(6): 681–686.

9. Ramesh HSJ,Anguille S, Chagla LS, et al. Recurrence after ROLLlumpec-tomy for invasive breast cancer. Submitted.

10. Rampaul RS, Dudley NJ, Thompson JZ, et al. (2003) Radioisotope foroccult lesion localisation (ROLL) of the breast does not require extraradiation protection procedures. The Breast 12(2): 150–182.

11. Ramesh H, Chagla LS, Ray A, et al. (2007) SNOLL is up and running inUK — an early experience. EJSO 33: 1121.

12. Ferrari M, Cremonesi M, Sacco E, et al. (1998) Radiation protection in theuse of tracers in radioguided breast surgery. Radiol Med (Torino) 96(6):607–611.

June 9, 2009 14:6 B-601 ch05 FA

chap

ter5

Technical Note on Total Parotidectomy

Eberhard Stennert∗,† and Orlando Guntinas-Lichius‡

DEFINITION OF AND INDICATIONS FOR TOTALPAROTIDECTOMY

In the literature, the definition of total parotidectomy is inconsis-tent. Often, total parotidectomy is declared although only subtotalparotidectomy has been performed. Therefore, it is important todifferentiate between the two techniques: subtotal parotidectomyincludes a lateral parotidectomy, i.e. the resection of all parotid tissuelateral to the facial plexus, and partially medial to the facial plexus, butnot necessarily including the deep portion, under preservation of thefacial nerve. To fulfil the criteria for total parotidectomy, an additionalcomplete resection of the deep portion is mandatory. Absolute indi-cations for total parotidectomy are malignant parotid tumours inde-pendent of the subtype, metastasis to the parotid gland and chronicparotitis.

∗Corresponding author.†Jean-Uhrmacher-Institute, University of Cologne, Geibelstrasse 29-31, D-50931Koeln, Germany. E-mail: eberhard.stennert@ uni-koeln.de‡Department of Otorhinolaryngology, Friedrich-Schiller-University Jena, Lessing-strasse 2, D-07740 Jena, Germany. E-mail: [email protected]

33

June 9, 2009 14:6 B-601 ch05 FA

34 E. Stennert and O. Guntinas-Lichius

STEP 1: BEDDING OF THE PATIENT

The patient is rested in a supine position in order to minimiseintraoperative bleeding, with his hyperextended head rotated to theopposite side. The bed is tilted head up–feet down as far as isdefensible.

STEP 2: FACIAL NERVE MONITORING

In addition to standard surgical coverage, the ipsilateral face is cov-ered with a transparent sheath to guarantee optical monitoring ofthe face by the assistant surgeon (Fig. 1). By this, even slight move-ments of the face become obvious when anaesthesia is performedwithout relaxation. In addition, electric monitoring can be performedoptionally.

FIGURE 1 � Tumour in the infra-auricular region of the left parotid gland. Ipsilateralface is covered with transparent sheath for optical facial nerve monitoring. Tumourlocalisation, incision line, angle of the mandibule and course of the zygomatic archare plotted on the face.

June 9, 2009 14:6 B-601 ch05 FA

Technical Note on Total Parotidectomy 35

STEP 3: SKIN INCISION AND SKINFLAP PREPARATION

A preauricular and submandibular lazy S incision (modified Blairsincision) is performed (Fig. 1). It is oriented along the preauricularcrease and inferior in the neck along natural skin lines. A distance ofat least 2 cm from the mandibule is important, to avoid damage to themarginal mandibular branch of the facial nerve. If a neck dissectionis planned, the submandibular incision can be modified easily. If thetumour is lying lateral to the main trunk of the facial nerve or if anexposure of its intramastoidal segment is necessary, the incision canalso be extended retroauricularily. By blunt dissection, the parotidgland is separated from the ear cartilage in the preauricular regionand from the sternocleidomastoid muscle until the exposure of thedigastric muscle. It is often necessary to ligate the greater auricularnerve. Ligation is mandatory in order to prevent neuroma formation.However, preservation of its posterior branch should be intended.The preparation of the buccal skin flap is most important. The flap islifted in the layer between the parotid pseudocapsule and the deepbuccal fascia, combined with a short platysmal dissection in the neck.The fascia has to be protected as a barrier in order to decrease Frey’ssyndrome.

STEP 4: ANATOMICAL LANDMARKS FORIDENTIFICATION OF THE FACIAL NERVE

The primary approach to identifying the facial nerve depends on thesite and extension of the lesion. The preparation of the entire plexus,i.e. the nerve trunk and all peripheral branches, is performed undermicroscopic control to minimise their trauma. There are three surgicalapproaches:

(1) Anterograde approach: identification of the facial nerve at its exitat the stylomastoid foramen. Then, the bifurcation and the dif-ferent branches are prepared in the proximal-to-distal direction.

June 9, 2009 14:6 B-601 ch05 FA


Three landmarks help to identify the main trunk: (a) Conley’spointer is a conchal cartilage extension of the ear canal at themedial end of its anterior–inferior edge; the nerve lies 5–6 mminferior to this pointer (see Video-clip); (b) the tympanomastoidfissure is better palpable than visible; the facial nerve lies 6–8 mmmedial to the anterior end of the fissure; (c) the lateral surface ofthe digastric muscle lies in the same plane as the facial nerve.

(2) Retrograde approach: the best landmark to start with this prepa-ration is the middle third of the zygomatic arch, where the frontalbranch crosses its periosteum. A zygomatic branch is found about1 cm inferior to the arch. Alternatively, identification of Stenson’sduct might be helpful, which is crossed by a buccal branch.

(3) In many cases, a combination of the anterograde and the retro-grade approach is necessary. Anyway, the parotid surgeon has tobe trained in all these techniques.

STEP 5: LATERAL PAROTIDECTOMY

The anterograde and the retrograde preparation, or a combinationof the two procedures, lead step by step to exposure of the wholeperipheral nerve plexus, including the trunk and bifurcation. Hereby,the parotid tissue lateral to these nerve structures is progressivelydissected free and finally delivered. Touching of the tumour has to beavoided. If the tumour is lying in the lateral lobe, the lateral parotidis removed with the associated tumour en bloc (Fig. 2).

STEP 6: COMPLETION OF TOTAL PAROTIDECTOMY

The main trunk and the facial nerve branches are dissected fromthe underlying tissue in an atraumatic fashion. Step by step, everybranch is gently lifted by using rubber slings to dissect the underly-ing parotid tissue. Stretch and compression trauma to the nerve hasto be avoided. Finally, the underlying masseter muscle is visible inthe whole area. To clear the retromandibular space, it is mandatory

June 9, 2009 14:6 B-601 ch05 FA


FIGURE 2 � Situs after lateral parotidectomy as the first step of total parotidectomy.The complete facial nerve fan is explored. Upper right inlay: Resected specimencorresponds to the lateral lobe of the parotid gland including the tumour.

to resect the retromandibular vein by ligation distally in the sub-mandibular fossa and proximally next to the zygomatic arch. Finally,the parotid tissue of the deep lobe has to be resected completely alongthe skull base up to the stylomastoid process (Fig. 3).

STEP 7: DEFECT FILLING

Its accomplishment depends on the underlying disease, the size of thedefect and the patient’s will. There are two options:

(1) Preparation of a muscle flap from the craniolateral aspect of thesternocleidomastoid muscle lateral to the spinal accessory nerve,which is rotated anteriorly into the defect. The mastoid attachmenthas to be preserved, to ensure occipital blood supply to the flap.

(2) For large defects, primarily abdominal fat is used. The fat is har-vested via a periumbilical incision. Meticulous bleeding control isnecessary, to avoid abdominal haematoma formation. Some over-correction is necessary because of postoperative shrinkage. Thefat is fixed with several sutures, avoiding any contact with nervebranches.

June 9, 2009 14:6 B-601 ch05 FA


FIGURE 3 � Final situs after total parotidectomy. For the resection of the medial “lobe”and the deep portion it is mandatory to mobilise the complete facial nerve plexus.

STEP 8: WOUND CLOSURE

A Redon drainage is placed without contact with nerve structures.The wound is closed in two layers by subcutaneous and cutaneoussutures.Acircular head–neck bandage is recommended. The drainageis removed within 24–72 h.

REFERENCES

1. Guntinas-Lichius O, Kick C, Klussmann JP, et al. (2004) Pleomorphic ade-noma of the parotid gland: a 13-year experience of consequent manage-ment by lateral or total parotidectomy. Eur Arch Otorhinolaryngol 261(3):143–146.

2. Guntinas-Lichius O, Klussmann JP, Wittekindt C, Stennert E. (2006)Parotidectomy for benign parotid disease at a university teaching hos-pital: outcome of 963 operations. Laryngoscope 116(4): 534–540.

3. O’Brien CJ. (2005) The parotid gland as a metastatic basin for cutaneouscancer. Arch Otolaryngol Head Neck Surg 131(7): 551–555.

4. Patel RS, Low TH, Gao K, O’Brien CJ. (2007) Clinical outcome after surgeryfor 75 patients with parotid sialadenitis. Laryngoscope 117(4): 644–647.

June 9, 2009 14:6 B-601 ch05 FA


5. Stennert E, Kisner D, Jungehuelsing M, et al. (2003) High incidence oflymph node metastasis in major salivary gland cancer. Arch OtolaryngolHead Neck Surg 129(7): 720–723.

6. Stennert E, Wittekindt C, Klussmann JP, et al. (2004) Recurrent pleomor-phic adenoma of the parotid gland: a prospective histopathological andimmunohistochemical study. Laryngoscope 114(1): 158–163.

7. Wittekindt C, Streubel K, Arnold G, et al. (2007) Recurrent pleomorphicadenoma of the parotid gland: analysis of 108 consecutive patients. HeadNeck 29(9): 822–828.

June 9, 2009 14:6 B-601 ch06 FA

chap

ter6

Total Thyroidectomy

Niall O’Higgins∗

(1) The operation is usually carried out under general anaesthesiawith the patient in the supine position with the neck slightlyextended and the table top tilted so that the head is raised.

(2) The incision is planned in a transverse skin crease approximatelyhalf way between the suprasternal notch and the thyroid carti-lage. The incision line is mainly horizontal, with a slight upwardconcavity depending on skin creases. It is rarely necessary toextend the incision further than the anterior borders of the stern-ocleidomastoid muscle. For large multinodular goitres extendingbehind the sternum, the incision is placed somewhat higher inthe neck to facilitate access to the upper pedicles of the thyroid,as these are likely to be situated higher in the neck than is thecase with a normal thyroid.

(3) The skin incision is deepened in the same line through theplatysma. The flap of skin and platysma is dissected upwardsas far as the thyroid cartilage and downwards to the supraster-nal notch. This dissection is facilitated by staying close to thedeep surface of the platysma rather than the superficial surfaceof the underlying deep fascia.

∗Department of Surgery, RCSI Medical University of Bahrain, Kingdom of Bahrain.E-mail: [email protected]

41

June 9, 2009 14:6 B-601 ch06 FA

42 N. O’Higgins

(4) Once the flaps have been developed and retracted, the deep fas-cia is divided in the midline between the strenohyoid musclesand incised upwards and downwards to the extent of the ele-vated skin/muscle flaps. The midline is easy to identify lowerin the neck where the space between the sternohyoid musclesis readily seen as they separate before insertion to the sternum.The underlying sternothyroid muscles are then identified andelevated with the sternohyoids on each side. If the thyroid is big,the sternothyroids may become attenuated and stretched andmay lie lateral to the midline. Elevation of the sternohyoid andsternothyroid (strap) muscles exposes the plane of the thyroid.Retraction of these muscles provides good access to the thyroidand it is rarely necessary to divide them. (Clip 1: Exposure andretraction of the strap muscles.)

(5) Retraction of the upper part of the strap muscles allows the supe-rior pole of the thyroid to be displayed. A useful instrument hereis the Dunhill double-angled retractor. The main lobe of the thy-roid is retracted downwards medially, a manoeuvre sometimesfacilitated by a transfixing suture into the belly of the lobe. Thesuperior thyroid vessels can thereby be exposed. (Clip 2: Displayof the superior thyroid vessels.)

(6) The external branch of the superior laryngeal nerve, runningdownwards and medially along the cricothyroid muscle, canoften be seen. (Clip 3: Demonstration of the external laryngeal nerve.)The superior thyroid are ligated or clipped and divided sepa-rately, care being taken to ensure that there is a substantial cuffof the artery and vein artery distal to the clip or ligature in orderto minimise the risk of slippage. In a small percentage of cases,the superior laryngeal nerve runs between the superior arteryand vein and could then be damaged if the vessels are not sepa-rately ligated.

(7) Once the superior pedicle has been divided, the lobe of the thy-roid is rolled medially and held in this position with the aid ofa dry swab. Lateral retraction of the strap and sternocleidomas-toid muscles together with the carotid sheath brings the middle

June 9, 2009 14:6 B-601 ch06 FA

Total Thyroidectomy 43

thyroid veins and the border of the gland into view. Once themiddle thyroid vein or veins have been divided, the inferior thy-roid artery, the parathyroids and the recurrent laryngeal nerveare sought. (Clip 4: Exposure of the superior and inferior parathyroidglands.) The nerve, usually behind but sometimes anterior to theartery, has a distinctive serpiginous blood vessel on its surfaceand should be traced throughout its cervical course to the pointwhere it dips into the larynx. The small branches of the artery arefollowed to the surface of the gland, where they are divided. Thiscapsular dissection technique has the advantages of (i) preserv-ing the blood supply to the parathyroid glands, which receive theblood supply from the inferior thyroid artery before its branchesenter the thyroid, and (ii) protecting the recurrent laryngeal nerveand the parathyroid glands from inadvertent damage.

(8) At this stage the full cervical extent of the recurrent laryngealnerve can be traced. (Clip 5: The recurrent laryngeal nerve exposedthroughout its cervical extent to its entry to the larynx.) The remain-ing attachment of the upper pole by the ligament of Berry can besafely divided with a pointed blade, the nerve being displacedlaterally.

(9) Attention is then turned to the inferior thyroid veins as they runvertically from the lower part of the gland. (Clip 6: Demonstrationof the inferior thyroid veins before they are divided). After these havebeen divided, the lobe is almost completely free.

(10) Steps 5–8 are repeated on the contralateral lobe. (Clip 7: Dis-section of the contralateral recurrent laryngeal nerve from metastaticlymph nodes.) The entire gland, which is now fully mobilised, isdissected off the trachea from inferior to superior by sharp dis-section. The gland is now attached only by the pyramidal lobe.(Clip 8: Display of the total thyroidectomy specimen attached only bythe pyramidal lobe.) Holding the thyroid away from the tracheaallows the pyramidal lobe to be traced upwards and removedcompletely and en bloc with the rest of the thyroid.

(11) Care is taken to ensure complete haemostasis. A small oozeof venous blood sometimes occurs near where the recurrent

June 9, 2009 14:6 B-601 ch06 FA

44 N. O’Higgins

laryngeal nerve enters the larynx. This can readily be stoppedwith a pledget of gauze. Use of diathermy near the nerve shouldbe avoided.

(12) Prospective studies have demonstrated that the use of vacuumdrains following thyroidectomy is of no particular benefit, yet thepractice remains common as a small amount of blood is almostalways collected in vacuum drains during the first few hoursafter the operation.

(13) The strap muscles are reunited with absorbable interruptedsutures, the platysma is similarly sutured and a subcuticular 4/0or 5/0 suture is inserted. A loose dressing is applied.

REFERENCES

1. Harness JK, Fung L, Thompson NW, et al. (1986) Total thyroidectomy:complications and technique. World J Surg 10(5): 781–786.

2. Delbridge L, Reeve TS, Khadra M, Poole AG. (1992) Total thyroidectomy:the technique of capsular dissection. Aust N Z J Surg 62(2): 96–99.

3. Reeve TS, Thompson NW. (2000) Complications of thyroid surgery: howto avoid them, how to manage them, and observations on their possibleeffect on the whole patient. World J Surg 24(8): 971–975.

4. Wheeler MH. (1998) The technique of thyroidectomy. JR Soc Med91(Suppl) 33: 12–16.

June 9, 2009 14:6 B-601 ch07 FA

chap

ter7

Neck Dissection for Thyroid Cancer

Jan Betka∗,†, Petr Lukeš†, Zdenek Cada† and Jaroslav Betka†

The importance of treating lymph node metastasis of thyroid papillaryand follicular carcinoma is still controversial. The extent of treatmentof lymph node metastasis of papillary and follicular carcinoma is stillbeing discussed and many different points of view on this subject stillexist.

The first problem to discuss is: Is it beneficial to treat lymph-node-metastatic involvement? There is not even a general consensus aboutthe importance of lymph-node-metastasic involvement in the cur-rently used classification and staging system for differentiated thyroidcarcinoma. Lymph-node-metastatic involvement is not even includedin some of the prognostic criteria. For example, the criteria being usedat the Mayo Clinic, called MACIS, include as prognostic criteria dis-tant metastasis, patient age, completion of resection, local invasionand tumour size. So lymph nodes are not included. Another prognos-tic schema, called GAMES, is used by the Memorial Sloan-KetteringCancer Center. In their GAMES scoring system, G is for Grade, A forAge of the patient when the tumour is discovered, M for Metastase ofthe tumour (other than neck LN), E for Extent of the primary tumour

∗Corresponding author.†Department of Otorhinolaryngology and Head and Neck Surgery, 1st Faculty ofMedicine, Faculty Hospital Motol, Postgraduate Medical School, Charles Universityin Prague. E-mail: [email protected].

45

June 9, 2009 14:6 B-601 ch07 FA

46 J. Betka et al.

and S for Size of the tumour. So, again, lymph node metastases aremissing. In the sixth edition of the American Joint Committee on Can-cer (AJCC), 2002, it is already seen that authors started to imagine theimportance of metastasic spread into the regional lymph nodes fortreatment of differentiated thyroid carcinoma. They divide the N sta-tus more accurately than for previous classifications:

N No: metastatic nodesN1: regional lymph node metastasisN1a: metastases in ipsilateral cervical lymph node(s)N1b: metastases in bilateral, midline or contralateral cervical or medi-astinal lymph node(s); unifocal T1 (≤ 1 cm) N0M0 and no extensionbeyond the thyroid capsule

In accordance with this system, the panel on European consensusfor the management of patients with differentiated thyroid carcinomaagreed to group patients into three risk categories at the time of initialtreatment. The lymph nodes play an important role in this division.These groups are:

Very low risk: unifocal T1 (−1 cm) N0M0 and no extension beyondthe thyroid capsule or T2N0M0 or multifocal T1N0M0

Low risk: T1 (> 1 cm) N0M0 or T2N0M0 or multifocal T1N0M0

High risk: any T3 and T4 or any T, N1 or any M1

Not all authors believe that lymph node involvement in differ-entiated thyroid carcinoma has little or no importance for the finalresult on treatment of thyroid carcinoma. Massaferi.1,2 states that rad-ical surgery can positively influence overall survival and that cur-rent tumour staging systems are too inaccurate to guide surgery. Hebelieves, on the basis of his long-time observations and similar stud-ies, that an aggressive approach to initial management and follow-upmay render nearly 90% of the patients permanently tumour-free. Lin3

analysed patients with lymph node involvement and postulated, thatit did not influence the survival rate, but that patients with poor prog-nostic factors needed more aggressive treatment to avoid progression

June 9, 2009 14:6 B-601 ch07 FA

Neck Dissection for Thyroid Cancer 47

of the cancer. Lymph node metastases can develop even in early stagesof thyroid carcinoma.4 Patients with positive lymph nodes have ahigher recurrence risk, but no significant increase in death. Surgi-cal radicalness and technique can positively influence the survivalof patients with papillary thyroid cancer.5 Even European consensusplaced all patients with positive lymph nodes in the high risk group.8

In conclusion, we currently feel that radical surgery can positivelyinfluence recurrence risk and maybe even survival of patients.

The next problem is: Who is indicated for lymph node surgery?Wada6 writes in his article that patients with differentiated carci-noma who had lymphonodopathy, which is palpable, should havetherapeutic node dissection. Palpable disease in the lateral neck iswidely accepted as an indication for neck treatment by many oth-ers. The problem starts when positive nodes are not palpable. Cur-rently, ultrasonography is the most accurate imaging technique forthe detection of suspicious cervical lymph nodes as small as a few mil-limetres in diameter. Ultrasonographic features suggestive of malig-nant lymph nodes depend on typical appearance, size, shape, hyper-vascularity and internal architecture. A rounded lymph node or onecausing a mass effect is also at elevated risk of being malignant. Lymphnodes with short axis measuring more than 7 mm should be consid-ered suspicious. Yasuhiro7 advocated that neck treatment is not indi-cated in a group of patients without lateral node metastasis detectedby ultrasonography preoperatively. Many other papers support thisexperience and neck dissection is not indicated as elective surgery.Prophylactic node dissection is not beneficial to those without palpa-ble or ultrasonographically suspicious neck lymphonodopathy. Ultra-sonography is ideally connected with fine needle aspiration biopsy.This technique in the experienced hands of a trained cytologist cangive an accuracy of about 95%. The next indication for neck inter-vention can be preoperatively proven and by frozen section verifiedpositive metastatic lymph node.

In conclusion, compartment-oriented dissection of lymph nodesshould be performed in cases of preoperatively suspected and/or

June 9, 2009 14:6 B-601 ch07 FA

48 J. Betka et al.

intraoperatively proven lymph node metastases. The rationale for thissurgical approach is based on evidence that radical primary surgeryhas a favourable impact on survival in high-risk patients, and on therecurrence rate in low-risk patients.

On the other hand, there is little benefit from prophylactic (elec-tive) surgical nodal treatment in the absence of pre or intraoperativeevidence for nodal disease. There is no evidence that it improves recur-rence or mortality rates, but it may be better and an accurate stagingof the disease that may guide subsequent treatment and follow-up.

SURGICAL MANAGEMENT AND TECHNIQUE

The standard procedure for treatment of lymph node metastases isposterolateral and central compartment neck dissection.9 Posterolat-eral neck dissection refers to the removal of lymph nodes at levelsII–V — basically all nodal groups except levels IA and IB (Fig. 1).The standard procedure is selective modified posterolateral neckdissection with preservation of the non-lymphatic structures: thespinal accessory nerve, internal jugular vein and sternocleidomastoidmuscle.10

The procedure is carried out under general anaesthesia. The sur-gical field must not be sterilised with iodine solution, as this wouldcompromise radioiodine uptake. The skin incision is a combinationof classical horizontal (for thyroidectomy) continuing to mastoid onthe operated side. It is possible to also make a single horizontal longincision. This incision is cosmetically more favourable, but there isdifficulty in making it reach all parts of the surgical field. Next is ele-vation of the skin flaps together with platysma muscle, and the deepneck fascia is exposed. The fascia is separated from sternocleidomas-toid muscle and included in the dissection. The dissection usuallystarts cranially. The great auricular nerve is identified and the spinalaccessory nerve is separated, and both are saved. Compartments IIAand IIB are dissected, and the cervical/brachial plexus is exposed andthe lateral cervical triangle cleared. The transverse cervical artery and

June 9, 2009 14:6 B-601 ch07 FA


FIGURE 1 � Lateral view of neck compartments.

vein can usually be spared. The space above the clavicle is very impor-tant (compartment VB), as metastatic lymph nodes can be hidden infatty tissue here. The anterocranial border of the dissection is the sub-mandibular salivary gland and we identify the hypoglossal nerve andlymph nodes with fatty tissue from the carotid and jugular sheet. Thevagus nerve comes into view and all structures are isolated gently andfollowed caudally (Fig. 2). If the en-bloc dissection is connected withthyroidectomy, it is the time to identify the superior thyroid vascularpedicle and ligate it, preferably just above the lateral lobe of the thy-roid gland. This secures the superior laryngeal nerve. Dissecting theanterior border of compartments III and VI, we open up space aroundthe laryngeal recurrent nerve, which must be identified and spared.Also, both parathyroid glands are visible and must be separated fromthe thyroid gland and neck dissection tissue from the anterior aspect,as both have blood supply from the inferior thyroid artery, which

June 9, 2009 14:6 B-601 ch07 FA

50 J. Betka et al.

FIGURE 2 � Posterolateral neck dissection.

gives them a connection from the inferior aspect. In this area there isno strict anatomical borderline between compartment IV and com-partment VI. Sternocleidomastoid muscle is elevated and tissue fromthe lateral triangle is removed together with the specimen, taking thesubclavian vessels as the caudal border. If the surgery continues withthyroidectomy, the specimen can be left with a connection to the thy-roid gland (Fig. 3). It is recommended that there be negative suctionfor two days after surgery.

Central compartment neck dissection refers to the bilateralremoval of lymph nodes surrounding the midline visceral structuresof the anterior neck — level VI. The lymph nodes include the pre-and paratracheal, the precricoid (Delphian) and the perithyroidal. Thesuperior limit of the dissection is the hyoid bone, the inferior limit isthe suprasternal notch, and the lateral limits are the carotid arterysheets.

This surgery is preferably performed together with thyroidec-tomy. If the primary thyroid tumour is having a rupture through

June 9, 2009 14:6 B-601 ch07 FA


FIGURE 3 � Drain position.

the thyroid capsule, it is indicated to dissect prelaryngeal musclesas sternohyoid, sternothyroid and thyreoglossus. Dissection belowthe hyoid bone lateral borders are carotid arteries and compartmentIV. We have to the pay meticulous attention to the recurrent laryngealnerve and especially the inferior parathyroid gland, where blood sup-ply can be in danger. The next important structure is the thoracic duct,and it is usually ligated to prevent postoperative lymphorrhoea. Thedissection runs caudally, following as the lateral border both carotidarteries, and ends below the suprasternal notch following the tra-cheal rings (Fig. 4). In young patients we meet the apex of the thymus

June 9, 2009 14:6 B-601 ch07 FA

52 J. Betka et al.

FIGURE 4 � Frontal view of central neck dissection.

gland, and it can be dissected. After finishing dissection we shouldask the anaesthesiologist to perform positive thorax pressure to makesure that there is no bleeding from mediastinal vessels. Before suture,negative suction is inserted.

COMPLICATIONS

Permanent hypocalcaemia can be seen in 3–5% of operative cases. It ismore likely to develop after bilateral posterolateral and central neckdissection with total thyroidectomy. It can be due to revascularisationof parathyroid glands or their accidental removal. It is more likelyto remove or injure the inferior parathyroid glands. If a parathyroidgland is removed, it must be implanted back into the muscle. Beforeimplantation, the parathyroid gland is divided by a sharp instrumentinto small cubes not larger than 1 mm. The implanted parathyroid

June 9, 2009 14:6 B-601 ch07 FA


tissues are integrated and have blood supply from the surroundingmuscle bed.

The second-most-common complication is recurrent laryngealnerve injury. It is reported to be about 1–2% and is more likelywith more excessive surgery. To prevent nerve injury the recurrentnerves must be identified, and the vascular bed of the nerves must berespected. Routine use of a neurostimulator to identify the recurrentnerves is recommended. If bilateral vocal cord palsy occurs, it is anindication for immediate surgical revision under the guidance of athyroid surgical expert.

Future development will probably focus on minimising surgi-cal complications. It can be predicted that there will be routineuse of magnifying loops or microscopes for a better understand-ing of the operative field. The nerve neurostimulator will be a rou-tine tool in every operating theatre. Endoscopically assisted surgerycan avoid the necessity for large incisions, and a well-illuminatedand magnified surgical field can be beneficial in avoiding surgicalcomplications.

REFERENCES

1. Mazzaferri EL. (1999) An overview of the management of papillary andfollicular thyroid carcinoma. Thyroid 9(5): 421–427.

2. Mazzaferri EL. (2007) Management of low-risk differentiated thyroidcancer. Endocr. Pract. 13(5): 498–512.

3. Lin JD, Liou MJ, Chao TC, et al. (1999) Prognostic variables of papillaryand follicular thyroid carcinoma patients with lymph node metastasesand without distant metastases. Endocr Relat Cancer 6(1): 109–115.

4. Reddy RM, Grigsby PM, Moley JF, Hall BL. (2006) Lymph node metas-tases in differentiated thyroid cancer under 2 cm. Surgery 140(6): 1050–1054.

5. Roh J-L, Park J-Y, Park CI. (2007) Total thyroidectomy plus neck dis-section in differentiated papillary thyroid carcinoma patients. Ann Surg245(4): 604–610.

June 9, 2009 14:6 B-601 ch07 FA

54 J. Betka et al.

6. Wada N, Duh QY, Sugino K, et al. (2003) Lymph node metastasis from 259papillary thyroid microcarcinomas: frequency, pattern of occurrence andrecurrence, and optimal strategy for neck dissection. Ann Surg 237(3):399–407.

7. Yasuhiro I, Chisato T, Takashi U, et al. (2004) Preoperative ultra-sonographic examination for lymph node metastasis: usefulness whendesigning lymph node dissection for papillary microcarcinoma of thethyroid. World J Surg 28(5): 498–501.

8. Pacini F, et al. (2006) European consensus for the management of patientswith differentiated carcinoma of follicular epithelium. Eur J Endocrinol154: 787–803.

9. Astl J. (2007) Surgical Treatment of Thyroid Gland Diseases, Maxdorf, Ed.Jessenius, Prague, p. 208 (in Czech).

10. Betka J, Mrzena L, Astl J, et al. (1997) Surgical treatment strategy forthyroid gland carcinoma nodal metastases. Eur Arch Otorhinolaryngol254(Suppl 1): S169–S174.

June 9, 2009 14:6 B-601 ch08 FA

chap

ter8

Total Laryngectomy

Mohssen Ansarin†, Augusto Cattaneo† and Fausto Chiesa∗,†

INTRODUCTION

The first total laryngectomy (TL) was performed by Billroth, in 1873,1

while Bottini2,3 was the first surgeon to carry out a laryngectomy forcancer, in 1875. The separation of the trachea from the larynx to createan end stoma and the primary closure of the pharynx was performedby Gluck in the early 1900.4 Between 1920 and 1950, radiotherapy wasthe treatment of choice.5 From 1950, TL was the gold standard for thetreatment of advanced or recurrent laryngeal carcinomas.6 Betweenthe end of the last century and the beginning of the third millenniumTL played a restricted role in the management of untreated advancedlaryngeal cancer owing to the progressive increase of non-surgicaltherapies, the so-called organ preservation schedules: neoadjuvantchemotherapy followed by radiotherapy or concomitant chemoradi-ation treatment.7 Hoffman in 2006 reported a decreasing survival rateamong patients with laryngeal cancer during the last two decadesin the US.8 In his opinion these poor results could be explained bythe increasing use of conservative treatment modalities (i.e. selectiveneck dissection, conservative surgical techniques such as laser resec-tion and organ preservation schedules).

∗Corresponding author.†Head and Neck Department, European Institute of Oncology, Milan, Italy. E-mail:[email protected]

55

June 9, 2009 14:6 B-601 ch08 FA

56 M. Ansarin et al.

Today TL remains the gold standard therapy for laryngo-hypopharyngeal cancers in the following cases: (a) advancedsquamous cell carcinoma (SCC) or other non-epithelial tumoursof the larynx with massive invasion of the cartilage framework;(b) recurrences after chemo-radiotherapy; (c) recurrence after conser-vative laryngectomy; (d) as an emergency procedure in massive air-way obstructive tumours or in rare complications of previous treat-ments such as chondro-radionecrosis.

Before performing a TL, we must also consider the potentialmetastatic spread of laryngeal carcinoma to the cervical lymph nodes.The supraglottic area has a rich lymphatic network and about 50%of T1–T4 tumours of this area develop metastases into the cervicalnodes. However, glottic carcinoma has a low rate (<10%) of nodalmetastases in early stages (T1–T2), and about 30% in T3–T4 cancers.7

Primary subglottic carcinoma is unusual (<3% of laryngeal cancers)and tends to spread to the nodes of the central neck compartment (VIlevel). In laryngeal cancer, the cervical nodes at risk are levels II–III–IVand VI.

We therefore suggest performing a selective neck dissection (II–Vand VI) in cN0 T2–T4 laryngeal cancers, enlarged to hemi- or totalthyroidectomy if the tumour invades the cartilage framework or thesubglottic area.9

TECHNIQUE

We may summarize the operation in five steps, starting from the inci-sion in the neck and going through the mobilization of the larynx,resection of the trachea, removal of the larynx and, finally, closurewith repair of the neo-pharynx.

These surgical steps were carried out for a patient who hadundergone previous tracheotomy for a severe dyspnoea due to bulkytransglottic tumour of the left hemilarynx with fixation of the crico-arythenoid joint and significant submucosal extension to the left sub-glottic area. The surgical indication was TL with bilateral selective

June 9, 2009 14:6 B-601 ch08 FA

Total Laryngectomy 57

neck dissection (II–V levels) enlarged to hemi-thyroidectomy and leftparatracheal lymph nodes (central compartment) dissection.

The neck incision should provide a good exposure not only of thelarynx but also of the laterocervical compartment if a neck dissectionor an extended laryngectomy needs to be carried out. When plan-ning the incision, surgeons should also consider providing for thenecessity of enlarging the excision to other structures, such as baseof tongue, hypo-pharynx or tracheal rings and the possible recon-structive procedures (e.g. the creation of a permanent end stoma),without causing tension and subsequent necrosis of flaps, mainly inpatients previously treated with radiotherapy. The “apron flap” inci-sion guarantees both good access and good cover for the pharyngealsuture line (Fig. 1). All structures involved or at risk of being involvedby the tumour must be resected: laryngeal box, preepiglottic space,

FIGURE 1 � Apron flap incision of the neck: (a) previous tracheotomy; (b) subplatismalflap; (c) anterior jugular vein; (d) external jugular vein; (e) superficial cervical fascia.

June 9, 2009 14:6 B-601 ch08 FA


tracheostoma, strap muscles, and ipsilateral lobe of the thyroid glandand paratracheal lymph nodes.

The larynx is mobilized by resecting the pharyngeal and pre-laryngeal strap muscles, separating the thyroid gland and ligatingits vascular pedicules. The strap muscles are cut at their insertionon the sternum and on the superior edge of the hyoid bone; ipsi-lateral thyroid artery and veins are ligated, the recurrent laryngealnerve is cut in the tracheo-oesophageal groove and the pharyngealmuscles are excised along the posterior edge of the thyroid carti-lage. The larynx is now freed on the opposite side, and mobile upto the level of the hyoid bone in order to better control the tumor(Figs. 2 and 3).

FIGURE 2 � Mobilization of the larynx: (a) hyoid bone; (b) left submandibular gland;(c) internal jugular vein; (d) carotid artery; (e) strap muscles, sectioned.

June 9, 2009 14:6 B-601 ch08 FA


FIGURE 3 � Mobilization of the larynx: (a) constrictor muscle; (b) carotid artery;(c) sternocleidomastoid muscle; (d) thyroid cartilage; (e) thyroid gland.

The trachea is divided at the second ring or below according tothe extension of the tumour, the superior part of the remaining ringis sewn to the lower skin border and a cuffed tube is placed in thetrachea.

The entire larynx can now be removed from above downward pay-ing attention to cuts in healthy tissue. The base of the tongue is dividedand the pharynx opened. The tip of the epiglottis is grasped and pulledanteriorly and inferiorly and the pharyngeal mucosa together with thepharyngeal constrictor muscles is cut on each side of the epiglottis,and of the superior cornu of thyroid cartilage toward the posterior partof the arythenoid cartilage, below the crico-arytenoid joint (Fig. 4).

The final step is the repair of the pharynx and the closure of theentire neck. The pharynx should be closed, with a line of interruptedsutures, in three layers: mucosal, facial and muscular (constrictor

June 9, 2009 14:6 B-601 ch08 FA


FIGURE 4 � Opening of the larynx: (a) epiglottis; (b) pyriform sinus; (c) superior cornuof the thyroid cartilage; (d) sternocleidomastoid muscle; (e) trachea; (f) tumor.

muscles) (Fig. 5). The skin is closed in two layers, and two suctiondrains are placed close to the suture and one or two more are placedin the laterocervical space (in the case of monolateral or bilateral neckdissection). The lower part of the apron flap is sutured to the mem-branous part of the trachea.

DISCUSSION

Indications for the management of advanced laryngeal cancer canbe found in the National Comprehensive Cancer Network (NCCN)practice guidelines.10 When post-operative histology shows involvedmargins or extracapsular extension of nodal metastases, a combinedchemoradiation post-surgical approach is recommended.11 Clinicaltrials based on different treatment modalities in advanced laryngeal

June 9, 2009 14:6 B-601 ch08 FA


FIGURE 5 � Closure of the neopharynx: (a) mucosa; (b) extra-mucosal suture;(c) carotid artery; (d) sternocleidomastoid muscle.

cancers should be planned considering the severe physical and psy-chological outcomes which arise as a result of the mutilation followingTL, and the low cure rate of alternative treatment schedules.

REFERENCES

1. Billroth T, Gussenbauer C. (1874) Ulber die Erst durch T. Billroth am Men-schen ausgefuhrte kehlkopf-Extirpation. Und die Auswendung einesKunstichen Kehlkopfes. Arch Clin Chir 17: 343–356.

2. Alberti PW. (1975) Panel discussion: the historical development of laryn-gectomy. II. The evolution of laryngology and laryngectomy in the mid-19th century. Laryngoscope 85: 288–298.

3. Thomson StC. (1939) The history of cancer of the larynx. J Laryngol Otol54: 61–87.

June 9, 2009 14:6 B-601 ch08 FA


4. Gluck T. (1912) Die chirurgische Terapie des Kehlkopfkarzinomas.Jahreskurse Artzt Forbild 2: 20–41.

5. Lederman M. (1975) Panel discussion: the historical development oflaryngectomy. VI. History of radiotherapy in the treatment of cancerof the larynx, 1896–1939. Laryngoscope 85: 333–353.

6. Ogura JH, Bello JA. (1952) Laryngectomy and neck dissection for carci-noma of the larynx. Laryngoscope 62: 1–52.

7. Marioni G, Marchese-Ragona R, Cartei G, et al. (2006) Current opinionin diagnosis and treatment of laryngeal carcinoma. Cancer Treat Rev 32:504–515. Epub 2006 Aug 22. Review.

8. Hoffman HT, Porter K, Karnell LH, et al. (2006) Laryngeal cancer in theUnited States: changes in demographics, patterns of care, and survival.Laryngoscope 116 (Suppl 111): 1–13.

9. Chiesa F, Tradati N, Calabrese L, et al. (2001) Surgical treatment of laryn-geal carcinoma with subglottis involvement. Oncol Rep 8: 137–140.

10. National Comprehensive Cancer Network. (2007) Clinical practiceguidelines in head and neck cancers. www.nccn/org

11. Bernier J, Cooper JS, Pajak TF, et al. (2005) Defining risk levels in locallyadvanced head and neck cancer: a comparative analysis of concurrrentpost-operative radiation plus chemotherapy trials of EORTC (n. 22931)and RTOG (n. 9501). Head and Neck 27: 843–850.

June 9, 2009 14:6 B-601 ch09 FA

chap

ter9

Transcervical Extended MediastinalLymphadenectomy

Jarosław Kuzdzał∗,†, Marcin Zielinski† and Łukasz Hauer†

INTRODUCTION

Despite the recent developments in the imaging of metastatic medi-astinal lymph nodes, these techniques have not replaced the tissuediagnosis in the pre-treatment staging in non–small cell lung cancer(NSCLC) patients. The advances of the technique of endoscopic nee-dle aspiration biopsy have made it a promising alternative for aconsiderable percentage of these patients, but the surgical biopsyis still necessary in many of them. For this purpose, cervical medi-astinoscopy (CM) is regarded as the gold standard. Although thestandard CM is simple and safe, it only enables access to 5 out of12 mediastinal lymph node stations (2R, 2L, 4R, 4L and 7, accordingto the UICC classification1). Some other techniques have been devel-oped to overcome this weakness of CM, but none of them enablesremoval of the whole content of all the 12 mediastinal nodal compart-ments (see Table 1). The technique called transcervical extended medi-astinal lymphadenectomy (TEMLA), developed in 2004 by MarcinZielinski, makes it possible to remove the whole lymphatic content

∗Corresponding author.†Department of Thoracic Surgery, Pulmonary Hospital Zakopane, Poland. E-mail:[email protected]

63

June9,2009

14:6B

-601ch09

FA

64J.Kuzdzałetal.

Table 1 Comparison of Invasive Techniques for Mediastinal Staging of NSCLC

Technique Nodal StationsAccessible

Surgical Approach ChestTube

Advantages Disadvantages

CervicalMediastinoscopy

2R, 2L, 4R, 4L, 7 Cervical incision(about 3 cm)

No Simplicity, short operativetime, safety

Limited number ofaccessible lymph nodestations

CervicalMediastinoscopy PlusExtended CervicalMediastinoscopy

2R, 2L, 4R, 4L, 7,5, 6

Cervical incision(about 3 cm)

No Possibility of biopsy ofstation 5 and 6 nodes

Risk of seriouscomplications; limitednumber of accessiblelymph node stations

Anterior Mediastinotomy 5, 6 Parasternal incision No Possibility of biopsy ofstation 5 and 6 nodes

Additional skin incision;limited number ofaccessible lymph nodestations

VTS 2R, 4R, 7, 8, 9∗or 5, 6, 7, 8 9†

3 ports on each side Yes Possibility of biopsy ofsome stations inaccessibleduring mediastinoscopy

Considerable number ofunsuccessful procedures(adhesions); selectiveventilation necessary;post-operative chest tube

VAMLA 2R, 2L, 4R, 4L, 7 Cervical incision(about 3 cm)

No Lymphadenectomy (ratherthan a biopsy) in the rangeaccessible during thestandard mediastinoscopy

Limited number ofaccessible lymph nodestations

TEMLA 1, 2R, 2L, 3A, 4R,4L, 5, 6, 7, 8

Cervical incision(5–6 cm)

No Complete mediastinallymphadenectomy (withthe exception of station 9nodes); no need forre-staging

Long operative time,learning curve

∗For right-sided VTS.†For left-sided VTS.

June 9, 2009 14:6 B-601 ch09 FA

Transcervical Extended Mediastinal Lymphadenectomy 65

of the mediastinum, with the exception of the pulmonary ligamentnodes (station 9) and the most distant 4L nodes.

TECHNIQUE

The principle of the TEMLA technique is the use of the cervical inci-sion to gain wide access to the mediastinum, enabling open-fashiondissection of the lymph nodes. It is possible due to two manouevres:(1) elevation of the sternum using a retractor connected to the table-mounted frame, and (2) dissection free of the trachea and the greatvessels of the superior mediastinum and lower neck, enabling retrac-tion of these structures to the left or right. The two manouevres usedtogether create a fairly wide space for the dissection.

After making a 6 cm collar incision in the lower neck, the skin flapsare developed in the subplatysmal plane: the upper one to the level ofthe thyroid cartilage, and the lower one to the level of the sternal notch.The strap muscles are divided in the midline and retracted aside. Next,both of the common carotid arteries are dissected — the lower thyroid

FIGURE 1 � The right paratracheal space.

June 9, 2009 14:6 B-601 ch09 FA

66 J. Kuzdzał et al.

FIGURE 2 � The subcarinal region.

FIGURE 3 � The region of aorto-pulmonary window.

veins are clipped and divided. Having dissected the carotid arteriesfree, the recurrent nerves are identified using a method described indetail elsewhere.2 The station 1 nodes, lying above the left innominatevein, are removed en bloc, together with the fatty tissue surrounding

June 9, 2009 14:6 B-601 ch09 FA


the lower thyroid veins (the veins are clipped and divided close tothe innominate vein). Whilst dividing the tissue along the recurrentnerves, the cautery should not be used. Retracting the trachea andthe innominate artery to the left side, the right paratracheal space isopened and its contents (stations 2R and 4R) are dissected using apeanut sponge to the level below the azygos vein. The borders of thedissection are the superior vena cava anteriorly, the ascending aorta,the trachea and the oesophagus on the left side, the mediastinal pleuraon the right side and the spine posteriorly. The right main bronchus,the right pulmonary artery and its upper trunk are the lower marginof dissection. In some patients the retrotracheal nodes (station 3P) canbe found and removed. Next, the trachea is retracted to the right side,the left common carotid artery and aortic arch to the left and anteri-orly, and the left paratracheal nodes (stations 2L and 4L) are dissectedto the level of the bifurcation of the left main bronchus, carefully pre-serving the left laryngeal recurrent nerve, which should be visualisedin its whole course. In some patients the most distal station 4L nodesare dissected with the aid of a mediastinoscope after removal of thestation 7 and 8 nodes. For the dissection of the subcarinal and paraoe-sophageal nodes (stations 7 and 8), the Wolf mediastinoscope (RichardWolf GmbH, Knittlingen, Germany) is used. The right pulmonaryartery is retracted upwards with the spreadable, upper blade of themediastinoscope, and the subcarinal nodes are dissected. The lengthof the mediastinoscope (19 cm) enables dissection along the oesoph-agus to a level about 5 cm below the carina. The access to the regionof the aortopulmonary window is gained in the plane between theleft common carotid artery and the left innominate vein. The plane isdeveloped by blunt dissection along the course of the vagus nerve, theartery and the aortic arch are pushed downwards and the aortopul-monary window (station 5) nodes are removed. The Botallo ligamentis visualised, and the paraaortic (station 6) nodes located to the rightof the ligament and in front of the aortic arch are removed. It shouldbe noted that the left phrenic nerve courses close to the region of thestation 6 nodes, and care must be taken to avoid injury to the nerve

June 9, 2009 14:6 B-601 ch09 FA


during dissection of the nodes or when using cautery in this area. Asthe approach to the aortopulmonary window is relatively narrow, anadditional source of light is useful (we use the rigid thoracoscope forthis purpose). The last step is dissection of the anterior surface of theconfluence of innominate veins and the superior vena cava, whichare pushed downwards, and removal of the prevascular (station 3A)nodes. The whole dissection is performed in the open fashion, usingstandard instruments. The wound is closed by approximating thestrap muscles and then placing the subcutaneous sutures and the skinsutures. No drain is left in the mediastinum. The technique of TEMLAis presented in detail in the Multimedia Manual of CardiothoracicSurgery (http://mmcts.ctsnetjournals.org/cgi/content/full/2006/1009/mmcts.2005.001693). This manual also includes video presen-tations of the technique.

DISCUSSION

Regarding the completeness of the mediastinal lymphadenectomy,TEMLA compares favourably with all other techniques of surgicalstaging (see Table 1). It is more complete even than the dissection atthoracotomy, as the latter enables removal of 6 stations (right thora-cotomy) or 5 stations (left thoracotomy, unless the aortic arch is notmobilised to gain access to the left paratracheal nodes). In the recentlypublished analysis of 256 procedures, the mean number of lymphnodes removed is 38.9. TEMLA was proved to be highly sensitive andaccurate in detecting metastatic mediastinal lymph nodes, with thesensitivity 94.1%, accuracy 98% and NPV 97.2%. The mean operativetime was 161 min (range: 80–330 min).3 This seems to be quite long, buttaking into account the number of nodes removed, the time necessaryfor dissection of one node was only 4.1 min. Complications associatedwith the TEMLA procedure occurred in 11.3% of patients and mostof them were mild, not requiring any treatment. Temporary laryngealrecurrent nerve palsy occurred in 6 of 256 patients (2.3%) and perma-nent nerve palsy in 2 of 256 patients (0.8%).3 These figures are much

June 9, 2009 14:6 B-601 ch09 FA


smaller than those reported for thyroid surgery, where permanentlaryngeal recurrent nerve palsy occured in 1.7–3.8% of patients oper-ated on for benign conditions and in 8% for thyroid cancer.4 It shouldbe noted that during thyroid surgery the recurrent nerves are vulner-able only in a short part, whereas during TEMLA they are dissectedfree over almost all their length. The only other technique includinga similar extent of dissection in the vicinity of the recurrent nerves isoesophagectomy with three-field lymphadenectomy. For this proce-dure the rate of the laryngeal recurrent nerve palsy was reported tobe as high as 69% (42% temporary and 27% permanent).5

The TEMLA technique was compared with the standard cervicalmediastinoscopy in a prospective, randomised trial, which has shownthat TEMLA was significantly more effective in detecting mediastinalnode metastases in NSCLC patients than cervical mediastinoscopy,while there was no significant difference in invasiveness between thetwo procedures, except for the post-operative pain.6 Also, it is notassociated with a greater incidence of respiratory insufficiency anddoes not increase the number of patients unfit for subsequent pul-monary resection, compared to standard mediastinoscopy. Moreover,the TEMLA procedure does not produce greater alterations in lungventilation or gas diffusion across the alveolar capillary membrane,compared to standard mediastinoscopy.7

Further, there is potential for therapeutic impact of bilateral lym-phadenectomy in NSCLC patients. However, the follow-up is cur-rently too short for a final conclusion in this regard, the preliminaryresults may suggest some therapeutic impact for patients who under-went TEMLA and subsequent R0 resection.3

REFERENCES

1. Mountain CF, Dresler CM. (1997) Regional lymph node classification forlung cancer staging. Chest 111(6): 1718–1723.

2. Zielinski M, Kuzdzal J, Szlubowski J, Soja J. (2005) Safe and reliable tech-nique of visualization of the laryngeal recurrent nerves in the neck. Am JSurg 189: 200–202.

June 9, 2009 14:6 B-601 ch09 FA


3. Zielinski M. (2007) Transcervical extended mediastinal lymphadenec-tomy: results of staging in two hundred fifty-six patients with non–smallcell lung cancer. J Thorac Oncol 2(4): 370–372.

4. Wagner HE, Seiler C. (1994) Recurrent laryngeal nerve palsy after thyroidgland surgery. Br J Surg 81(2): 226–228.

5. Fujita H, Sueyoshi S, Tanaka T, et al. (2003) Optimal lymphadenectomyfor squamous cell carcinoma in the thoracic esophagus: comparing theshort- and long-term outcome among the four types of lymphadenectomy.World J Surg 27(5): 571–579.

6. Kuzdzal J, Zielinski M, Papla B, et al. (2007) The transcervical extendedmediastinal lymphadenectomy versus cervical mediastinoscopy in non–small cell lung cancer staging. Eur J Cardiothorac Surg 31: 88–94.

7. Kuzdzal J, Zielinski M, Papla Narski M, et al. (2007) Effects of bilateralmediastinal lymphadenectomy on short-term pulmonary function. Eur JCardiothorac Surg 31: 161–166.

June 9, 2009 14:6 B-601 ch10 FA

chap

ter10

Minimally Invasive Techniques for EarlyLung Cancer

Contardo Vergani∗,†, Luca Despini† and Giancarlo Roviaro†

BASIC CONSIDERATIONS

Although a number of authors1–5 advocate VATS for staging andtreating stage I lung cancer, this approach is still widely debated.More than 16 years since the first videothoracoscopic lobectomyin 1991,6 thoracoscopic major resections still have to achieve dif-fusion, mainly owing to persistent concerns about their oncologicvalidity.

Initial fear of intraoperative accidents has gradually faded and, atpresent, evidence shows that VATS lobectomies are safe, with mor-tality and morbidity comparable to conventional procedures. In ourseries of 230 VATS lobectomies for cancer, we recorded no intraoper-ative mortality, and a postoperative mortality rate of 0.87%.1 Similarresults have been observed in other series.5,7,9 Altough videothoraco-scopic dissection of the pulmonary vessels is a delicate procedure, therisk of intraoperative bleeding has proved small.1–5,7–9

∗Corresponding author.†Department of Surgical Sciences, State University of Milan and Department of Gen-eral Surgery, Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, IRCCS,Milan, Via Francesco Sforza 35, 20122 Milano, Italy. E-mail: [email protected]

71

June 9, 2009 14:6 B-601 ch10 FA

72 C. Vergani et al.

According to several randomised studies, postoperative pain isreduced in comparison with muscle-sparing thoracotomy,1,5,8–10 eventhough others could not find any difference.11

According to some non-randomised studies, pulmonary functionseems better after VATS than after conventional lobectomy.9

Technical differences regard the site and size of the utility thora-cotomy, the use of the rib spreader, and the site of insertion of the tro-cars. Most authors agree that thoracoscopic lobectomy should entailseparate dissection and securing of the hilar elements. Simultaneousstapling mass ligation of the hilum12 is considered an unorthodoxprocedure by most.

The oncologic validity of VATS lobectomies for cancer is stillunproven, but evidence is mounting that they offer results similarto those of open lobectomy.

Concern about increased recurrence rates or tumour seeding onthe port sites seems inconsistent, provided that careful manipulationduring dissection and wound protection during the extraction of thespecimen is adopted. We have not experienced any recurrence, andin the other clinical series the recurrence rate has been low or null.1,7,8

Regarding long term results, in our experience VATS lobectomyfor stage I lung cancer yelded a global survival rate of 77.7% at threeyears and 63.64% at five years. For patients younger than 70 yearsold the rate is significantly (p < 0.01) better (82.4% at three yearsand 72.3% at five years).7 Other large clinical series have confirmedresults similar to those of open resection or even better.2,7–9 Thesegood results have been attributed to a more favourable immunologicalresponse after VATS, better preservation of cell-mediated immunity,reduced release of stress hormones, and lower levels of C-reactiveprotein and IL-6.10,8

VATS resection should follow the same principles as oncologicsurgery, and the desire to offer the patient the advantages of VATSresection should not authorise one to perform lesser resection in caseof difficult lobectomy. Formal lobectomy is the standard; however,sublobar resections are acceptable in frail patients. Despite the initial

June 9, 2009 14:6 B-601 ch10 FA

Minimally Invasive Techniques for Early Lung Cancer 73

studies stressing the increased rate of local recurrences after segmen-tectomy or wedge resection, many authors now report very goodresults after sublobar resection. The problem is still open.

INDICATIONS

Indications are not unanimously defined. We limit VATS lobectomyto peripheral T1N0 and T2N0 lung cancer with no infiltration of thelobar bronchus, no atelectasis, or infiltration of the parietal pleura,even though VATS lobectomy for cancer is technically feasible in manyother conditions.

TECHNIQUE

The patient is intubated with a double lumen Carlens tube for selectiveventilation or collapse of the chosen lung, and in lateral decubitus asfor postero-lateral thoracotomy. A pillow is placed under the chest,and the table is flexed in order to avoid any limitation on movementsof the camera by the iliac crest.

The surgical team is positioned according to Fig. 1. Positions willchange depending on the different steps of the operation.

The optics are inserted in the seventh or eighth intercostal spaceon the mid-axillary line. A second port is inserted in the fourth or fifthspace posteriorly and a 3–4 cm incision is carried out along the infra-mammary sulcus in the third or fourth space, where the intercostalspaces are wider and no major muscles must be sectioned. This “util-ity thoracotomy” permits the introduction of non-endoscopic instru-ments, provides useful access in case of problems, and ensures theextraction of the specimen at the end of the resection. Rib spreadersare not used except for extracting the specimen, in order to preventnerve damage and reduce postoperative pain.

We always start the procedure with a thorough “surgical” explo-ration (which we have called videothoracoscopic operative staging,VOS) of the pleural cavity to rule out inoperability and to confirm the

June 9, 2009 14:6 B-601 ch10 FA


FIGURE 1 � Positioning of the patient, the team and the equipment. Two monitors areplaced at the head of the patient who is in lateral decubitus. The surgeons usuallystands in front of the patient. Positions of the team can change rapidly.

videothoracoscopic feasibility of the lobectomy. This exploration canentail lysis of the adhesions and section of the pulmonary ligament,but also complex manoeuvres such as dividing the azygos vein, oropening the pericardium.

Diffuse pleural adhesions can impair lung collapse, and can callfor conversion.

MEDIASTINAL PHASE (FIGS. 2 AND 3)

Isolation of mediastinal vessels can be achieved with sharp and bluntdissection, through gentle swabbing towards the lung (never in the

June 9, 2009 14:6 B-601 ch10 FA


FIGURE 2 � Right upper lobectomy: isolation of the right upper pulmonary vein.

FIGURE 3 � Right upper lobectomy: isolation of the anterior trunk.

opposite direction), and must be more extensive than in open surgery,to allow positioning of the endostapler. Once isolated the vessel isencircled with a thread to facilitate the positioning of the stapler.Finding the correct angle of insertion of the stapler can be diffi-cult and changing the site of insertion may be necessary. Any dan-gerous traction on the instruments must be avoided. As a rule the

June 9, 2009 14:6 B-601 ch10 FA


artery is divided before the vein and the bronchus is sectioned last,but sometimes it is more convenient to separate the vein before theartery.

FISSURAL PHASE (FIG. 4)

Isolating the artery within the fissure is a crucial step. The lobar hilumis complex and sometimes lymphnode reaction or partially developedfissure makes the approach more difficult. Once the artery and itsbranches have been isolated, they can be stapled or clipped accordingto their size. Smaller vessels, such as veins and arteries for the middlelobe, the lingula, the left upper lobe or the posterior ascending artery,can usually be sectioned between clips. An incomplete fissure can becompleted, but sometimes a thick parenchyma must be pressed witha clamp before stapling it. Sealed fissure or adherent lymphnodescan make the arterial isolation difficult or impossible and can requireconversion.

FIGURE 4 � Right lower lobectomy: intrafissural isolation and sectioning of the arteryto the lower lobe.

June 9, 2009 14:6 B-601 ch10 FA


BRONCHIAL PHASE

The bronchus is usually the last element to be divided. Isolation canbe accomplished with a mounted swab, endoscissors and judicioususe of electrocoagulation. It must be sufficient to pass the endostapler,but vascularisation of the stump must be preserved. Lobar bronchi areusually secured with 3.5 mm staples, whereas the main stem bronchusor thickened lobar bronchi require 4.8 mm staples.

LYMPHADENECTOMY

VATS lymphadenectomy is technically feasible to the same extent asopen surgery and follows the same steps.

All suspect lymphnodes are sent for frozen section examinationand, when the response is positive, we convert the intervention to anopen procedure, irrespective of whatever phase of the procedure hasbeen reached.

In skilled hands and with accurate selection of patients, VATSlobectomy for cancer is a safe and valid alternative to the conventionalopen procedure, with similar short- and long-term results. Notwith-standing, larger series are needed to confirm these attractive results.

REFERENCES

1. Roviaro GC, Varoli F, Vergani C, Maciocco M, Nucca O, Pagano C.(2004) Video-assisted thoracoscopic major pulmonary resections: tech-nical aspects, personal series of 259 patients, and review of the literature.Surg Endosc 18: 1551–1558.

2. Naruke T. (2000) Thoracoscopic lobectomy with mediastinal lymph nodedissection or sampling. In: Yim APC, Hazelrigg SR, Izzat MB et al., (eds.),Minimal Access Cardiothoracic Surgery. Philadelphia, PA, WB Saunders,pp. 116–126.

3. Kaseda S, Aoki T, Hangai N. (1998) Video-assisted thoracic surgery(VATS) lobectomy: the Japanese experience. Semin Thorac Cardiovasc Surg10: 300–304.

June 9, 2009 14:6 B-601 ch10 FA


4. Yim APC. (2002) VATS major pulmonary resection revisited — contro-versies, techniques, and results. Ann Thorac Surg 74: 615–623.

5. McKenna RJ Jr et al. (1998) VATS lobectomy: the Los Angeles experience.Semin Thorac Cardiovasc Surg 10: 321.

6. Roviaro GC, Rebuffat C, Varoli F, et al. (1992) Videoendoscopic pul-monary lobectomy for cancer. Surg Laparosc Endosc 2: 244–247.

7. Roviaro GC, Varoli F, Vergani C, Nucca O, Maciocco M, Grignani F. (2004)Long-term survival after videothoracoscopic lobectomy for stage I lungcancer. Chest 126: 725–732.

8. Walker SW, Codispoti M, Soon SY, et al. (2003) Long-term outcomes fol-lowing VATS lobectomy for non-small cell bronchogenic carcinoma. EurJ Cardiothorac Surg 23: 397–402.

9. Sugiura H, Morikawa T, Kaji M, et al. (1999) Long-term benefits for thequality of life after video-assisted thoracoscopic lobectomy in patientswith lung cancer. Surg Laparosc Endosc 9: 403–410.

10. Sugi K, Kaneda Y, Esato K. (2000) Video-assisted thoracoscopic lobec-tomy reduces cytokine production more than conventional open lobec-tomy. Jpn J Thorac Cardiovasc Surg 48: 161–165.

11. Kirby TJ, Mack MJ, Landreneau RJ, et al. (1993) Initial experience withvideo-assisted thoracoscopic lobectomy. Ann Thorac Surg 56: 1248–1253.

12. Lewis RJ, Caccavale RJ. (1998) VATS lobectomy. Semin Thorac CardiovascSurg 10: 332–339.

June 9, 2009 14:6 B-601 ch11 FA

chap

ter11

Resection of Superior Sulcus Cancers:Anterior Approach

Marco Alifano∗,†, Salvatore Strano† and Olivier Schussler†

Superior sulcus tumours are generally defined as primary lungcancers involving the apex of the chest wall and usually associ-ated with pain in the shoulder and/or arm. Invasion of one ormore of the following structures is frequent: lower roots of thebrachial plexus, stellate ganglion and sympathetic trunk, upperthoracic ribs or vertebrae, subclavian vessels.1,2 A multimodalityapproach (including pre- and/or post-operative radiotherapy andchemotherapy) has been used for some decades in the treatmentof this condition.1,3 Surgical access is classically achieved by thePaulson–Shaw posterior approach.1,4 This access is fully satisfactorywhen one is dealing with posteriorly located tumours, but may beinadequate in the presence of involvement of anterior structures.For this reason, several anterior approaches have been developed,including the cervicosternothoracotomy,5 the hemiclamshell,6 and thetranscervical-transthoracic approach with resection of the clavicle.7

∗Corresponding author.†Chirurgien des Hôpitaux, Unité de Chirurgie Thoracique, Hôtel-Dieu UniversityHospital, 1, Place du Parvis Notre-Dame, 75004 Paris, France. E-mail: [email protected]

79

June 9, 2009 14:6 B-601 ch11 FA

80 M. Alifano et al.

More recently, the transmanubrial approach, which will bedescribed in detail in this article, has been proposed and it representsour first-choice approach for anterior forms of the superior sulcustumours.8 In our practice, indications for this anterior approach areas follows: (1) presence of a palpable supraclavicular mass, (2) clini-cal involvement of the C7 and/or C8 root, (3) Horner syndrome, and(4) proven or suspected vascular infiltration.

The operation is carried out under general anaesthesia anddouble-lumen intubation to allow single-lung ventilation. The patientis positioned in the supine position, with the neck hyperextended andthe head turned towards the side controlateral to the involved one.A vertical roll is placed under the spine to allow the shoulder of theoperated side to gently fall. The operative field includes the wholehomolateral neck and thorax, and skin preparation and draping isextended some centimetres away from the midline.

The skin incision includes a vertical presternocleidomastoid inci-sion which is prolonged over the upper sternal manubrium andthen horizontally two transverse fingers below the clavicle up tothe deltopectoral groove. The lower portion of the internal jugu-lar vein is dissected, and the manubrium and upper portion of thesecond rib are exposed. The first intercostal space is opened, thusallowing finger exploration of the pleural cavity and anticipationof further technical aspects of the operation. Internal thoracic ves-sels are subsequently dissected and transected at the first intercostalspace level. This allow exposition of the lateral aspect of the sternalmanubrium, which can be now transected by an oscillating saw inan L-shaped fashion: midline vertical, and horizontal from the mid-line to the lateral aspect. This allows preservation of the sternoclav-icular joint (Fig. 1). The sternoclavicular flap may be opened onlyafter scissors section of the first rib cartilage at its sternal insertionand provided that no tumour invasion is present at this level. Inparallel with flap elevation, section of the costoclavicular ligamentis carried out, thus providing increasing amplitude to the operativefield.

June 9, 2009 14:6 B-601 ch11 FA

Resection of Superior Sulcus Cancers 81

FIGURE 1 � The manubrial sternum has been transacted and the first intercostal spaceopened. * = sternocleidomastoid muscle; ** = jugular vein; ↑ = cut sternal manubrium.

Exposure of the whole cervicothoracic junction is now achieved.Further dissection depends on the extent of tumours and infiltrationof different structures (upper ribs, especially in their anterior por-tion, subclavian vessels, apical pleura, sympathetic chain and brachialplexus). Section of the internal jugular vein may seldom be necessaryin order to allow better access to posterior plans. The subclavian veinis dissected and spared if free, or easily resected without subsequentrevascularisation if invaded. Thus the main venous axis, the phrenicnerve and the anterior scalene muscle are exposed. Section of this mus-cle in a tumour free margin, after mobilisation of the phrenic nerve(if not infiltrated by the tumour), allows exposition of the subclavianartery. Sacrifice of its branches may be required; care should be takento spare, if possible, the vertebral artery. If the tumour is adherent tothe subclavian artery, dissection in the subadventitial plane is oftensufficient to dissect the tumour with free margins (Fig. 2); if this kindof dissection seems not adequate, resection of the artery is necessary.End-to-end anastomosis may be sufficient to re-establish arterial flow

June 9, 2009 14:6 B-601 ch11 FA


FIGURE 2 � Subclavian vessels are retracted laterally and upward (the artery has beendissected in the subadventitial plane and encircled), allowing exposition of the apicaltumour.

if the extent of resection is limited, otherwise polytetrafluoroethylenegraft interposition is necessary.

Chest wall resection represents another fundamental step of theoperation. In our opinion it should be carried out en bloc with thelobectomy. Anterior section of the first rib is carried out as a step ofthe anterior access, as previously described, and its posterior sectionmay also be easily performed using the anterior approach. The num-ber of ribs to be resected is variable. If the transmanubrial approachhas been chosen, anterior rib involvement should be limited to thefirst (maximum the first two) ones; otherwise, alternative anteriorapproaches (such as the hemiclamshell incision) should have beenadopted. On the other hand, if involvement concerns the ribs posteri-orly, below the second or the third one, the transmanubrial approachis carried out as described, and posterior rib resection is performed

June 9, 2009 14:6 B-601 ch11 FA


FIGURE 3 � Closure of the approach: the metallic wires have been passed.

through an associated posterior approach which is also used to carryout lobectomy and nodal dissection.

After dissection and/or resection of the chest wall and remainingstructures of the cervicothoracic junction (apical pleura, sympatheticchain, brachial plexus), the osteomuscular flap is returned to its posi-tion, sternal manubrium is sutured with two metallic stitches andsoft tissues are closed in the usual way. Motility of the shoulder isthus completely preserved (Fig. 3). The patient is then turned in thefull lateral position for posterolateral thoracotomy to perform lobec-tomy and possibly complete chest wall resection. In a few cases (thinpatients with limited tumours not involving hilar structures or theposterior chest wall), lobectomy may be carried out through the ante-rior approach. In our opinion, lobectomy should constitute the stan-dard pulmonary resection and we perform sublobar resections onlyin the presence of severe respiratory impairment. Nodal dissection isroutinely carried out.

June 9, 2009 14:6 B-601 ch11 FA


We have recently reviewed retrospectively the results of surgicaltreatment of superior sulcus tumours by our team.2 An isolated poste-rior approach was used in 49% of the cases, whereas all the remainingpatients but one (who had an isolated anterior approach) had com-bined anterior and posterior approaches. In this study operative mor-tality was 8.9%, a percentage which is relatively high but is explainedby the extent of resection in patients presenting frequently importantcomorbidities. Long-term results were relatively satisfactory, with fig-ures of overall survival (including non-cancer-related deaths) of 54%and 36.2% at 2 and 5 years, respectively. Multivariate analysis showedthat the completeness of resection (82% of the cases in our series),T status and the presence of associated comorbidities were inde-pendent prognostic factors. It is noteworthy that patients with T3N0tumours experienced a 5-year survival of 47.7%.2

Our results are similar to those published in other, often smaller,retrospective series and compare very favourably with series of non-surgical treatment. Thus, it is generally accepted that surgical treat-ment should be proposed in operable patients, although the level ofevidence is relatively low.1−3,9 On the other hand, the kind and timingof association of neo-adjuvant or adjuvant treatments remains con-troversial. A phase II study including patients with disease initiallyconsidered resectable showed that induction chemo-radiotherapy haslimited morbidity and mortality but results in post-induction surgeryin only 80% of cases.10 This strategy is associated with a satisfac-tory percentage of complete resection (76%), and provides satisfac-tory results with regard to long-term outcome (5-year survival ratesof 44%). It now warrants confirmation by further study, to increasethe level of evidence.

REFERENCES

1. Wright CD, Moncure AC, Shepard JA, et al. (1987) Superior sulcus lungtumors: results of combined treatment (irradiation and radical resection).J Thorac Cardiovasc Surg 94: 69–74.

June 9, 2009 14:6 B-601 ch11 FA


2. Alifano M, D’Aiuto M, Magdeleinat P, et al. (2003) Surgical treatmentof superior sulcus tumors: results and prognostic factors. Chest 124:996–1003.

3. Martinod E, D’Audiffret A, Thomas P, et al. (2002) Management of supe-rior sulcus tumors: experience with 139 cases treated by surgical resec-tion. Ann Thorac Surg 73: 1534–1539.

4. Shaw RR, Paulson DL, Lee JL. (1961) Treatment of superior sulcus tumorby irradiation followed by resection. Ann Surg 54: 29–40.

5. Masoaka A, Ito Y, Yasumitsu T. (1979) Anterior approach for tumors ofthe superior sulcus. J Thorac Cardiovasc Surg 78: 413–415.

6. Bains MS, Ginsberg RJ, Jones WG, et al. (1994) The clamshell incision:an improved approach to bilateral pulmonary and mediastinal tumors.Ann Thorac Surg 105: 1025–1034.

7. Dartevelle PG, Chapelier AR, MacChiarini P, et al. (1993) Anteriortranscervical-thoracic approach for radical resection of lung tumorsinvading the thoracic inlet. J Thorac Cardiovasc Surg 105: 1025–1034.

8. Grunenwald D, Spaggiari L. (1997) Transmanubrial osteomuscular spar-ing approach for apical chest tumor. Ann Thorac Surg 63: 563–566.

9. Rusch VW, Parekh KR, Leon L, et al. (2000) Factors determining outcomeafter surgical resection of T3 and T4 lung cancer of the superior sulcus.J Thorac Cardiovasc Surg 119: 1147–1153.

10. Rusch VW, Giroux DJ, Kraut MJ, et al. (2007) Induction chemoradia-tion and surgical resection for superior sulcus non-small-cell lung car-cinomas: long-term results of Southwest Oncology Group Trial 9416(Intergroup Trial 0160). J Clin Oncol 25: 313–318.

June 9, 2009 14:6 B-601 ch12 FA

chap

ter12

Surgical Staging for Lung and MediastinalCancers

Ramón Rami-Porta∗,†, Sergi Call-Caja†,Roser Saumench-Perramon† and Mireia Serra-Mitjans†

INTRODUCTION

Surgical staging for lung and mediastinal cancers, as well as for thosetumours that may extend into the mediastinum from neighbouringareas, such as pleural mesothelioma, is crucial for planning treat-ment and assessing prognosis. Staging evidence derived from surgicalexplorations has the highest certainty, compared with clinical evalu-ation, radiological explorations and endoscopies with or without fineneedle aspiration or biopsy.1

MEDIASTINOSCOPY

Mediastinoscopy is the gold standard for staging lymphatic spreadand direct invasion of lung cancer into the mediastinum. Cur-rent European guidelines recommend mediastinoscopy if there are

∗Corresponding author.†Thoracic Surgery Service, Hospital Mutua de Terrassa, Plaza Dr. Robert, 5, 08221Terrassa, Barcelona, Spain. E-mail: rramip@ terra.es

87

June 9, 2009 14:6 B-601 ch12 FA

88 R. Rami-Porta et al.

enlarged nodes on computed tomography (CT) or abnormal uptakeon positron emission tomography (PET). If CT is normal, medi-astinoscopy still is recommended except in cT1N0 squamous cellcarcinomas. If PET does not show abnormal uptake in the medi-astinum, surgical exploration is recommnended in central tumours,tumours with low uptake, nodes larger than 1.6 cm, and when there isevidence of N1 disease.2 Other indications include diagnosis and stag-ing of mediastinal lymphoma, mesothelioma, mediastinal tumours,and diagnosis of granulomatosis and infections. A 3–5-cm-long col-lar incision above the upper limit of the manubrium, followed bydeeper dissection and opening of the pretracheal fascia, allows thesurgeon to insert the index finger and create a pretracheal space intowhich the mediastinoscope will be inserted. The range of explorationof mediastinoscopy includes all lymph nodes around the trachea andthe main bronchi, and those in the subcarinal space. Mediastinoscopyallows the surgeon (i) to inspect — usually, normal mediastinal nodesare black and those involved with tumour, greyish; (ii) to palpate andfeel the intimate relation of nodes or tumours with the trachea andto differentiate mere contact from tumour invasion; (iii) to puncturewith the double purpose to determine if the structure that will bebiopsied is a vessel or not, and to aspirate material for cytologicalexamination from nodes and tumours adhered to vessels; and (iv) tobiopsy lymph nodes, mediastinal fat and tumours. These manoeu-vres are best performed if the surgeon sits at the head of the patient.3

Remediastinoscopy to stage recurrent or new primary tumours and toassess tumour response after induction therapy is technically feasibleand useful for identifying patients who will benefit most from lungresection.4

PARASTERNAL MEDIASTINOTOMY

For tumours or nodal stations beyond the range of mediastinoscopy,other procedures are required. Parasternal mediastinotomy allowsone to explore and biopsy subaortic and anterior mediastinal nodeson the left side, and prevascular nodes on the right side, as well as

June 9, 2009 14:6 B-601 ch12 FA

Surgical Staging for Lung and Mediastinal Cancers 89

FIGURE 1 � Bimanual palpation from the cervical incision of mediastinoscopy andfrom the incision of left parasternal mediastinotomy.

any anterior mediastinal tumour. Parasternal mediastinotomy is arequired complement to mediastinoscopy for staging lung cancers ofthe left upper lobe and hilum, because these can spread to subaorticand anterior mediastinal nodes.5 Bimanual palpation of the aortic archis indicated in tumours of the aortopulmonary window, which maybe invading vascular structures and be deemed unresectable (Fig. 1).A 5–7 cm incision is performed on the second or third costal cartilageon the required side. The cartilage can be removed or not, depend-ing on the operative field needed. The internal mammary vessels areidentified, and individually ligated if needed. If direct inspection ofthe mediastinum is not adequate, the mediastinoscope can also beinserted through this incision. This versatile approach gives access tothe pleural space and the lung, and the pericardial space by openingthe mediastinal pleura and the pericardium, respectively.

EXTENDED CERVICAL MEDIASTINOSCOPY

Extended cervical mediastinoscopy is an alternative to left paraster-nal mediastinotomy for staging cancers of the left lung.6 From thecollar incision of mediastinoscopy, a passage is created by finger

June 9, 2009 14:6 B-601 ch12 FA


dissection over the aortic arch between the innominate artery andthe left carotid artery. The mediastinoscope is then inserted intothe incision and obliquely advanced over the aortic arch along thedissected passage, leaving the left innominate vein either in frontof or behind the mediastinoscope. Once the pulsating aortic arch is

FIGURE 2 � Extended cervical mediastinoscopy: the mediastinoscope is advancedobliquely from the cervical incision over the aortic arch.

FIGURE 3 � Extended cervical mediastinoscopy: the mediastinoscope is positionedbetween the innominate artery and the left carotid artery.

June 9, 2009 14:6 B-601 ch12 FA


seen, the mediastinoscope is advanced further into the subaortic spaceand the anterior mediastinum (Figs. 2 and 3). Lymph nodes are thendissected from the fatty tissue that usually occupies this area andremoved or biopsied (video-clip on CD). Published data are scarcebut homogeneous, and sensitivity values ranging from 0.60 to 0.81,diagnostic accuracy of 0.91–0.95, and negative predictive values of0.89–0.91 have been reported.6,7 Specificity and positive predictivevalues are 1.

THORACOSCOPY AND VIDEO-ASSISTEDTHORACOSCOPIC SURGERY

Posterior mediastinal tumours, tumours at the cardiophrenic angles,and the inferior mediastinal nodes cannot be reached with theprocedures described above. In these situations thoracoscopy withor without video assistance is most useful.8 Lung cancers with pleu-ral effusion or additional ipsilateral or contralateral nodules, andmesothelioma also benefit from thoracoscopic staging. Video-assistedthoracoscopic surgery allows removal of peripheral pulmonary nod-ules, creation of pericardial windows, and biopsy or removal of medi-astinal nodes and tumours.

TRANSCERVICAL MEDIASTINALLYMPHADENECTOMY

The most recent and relevant advance in surgical staging for lungcancer derives from two procedures with the objective of removingall upper mediastinal lymph nodes: video-assisted mediastinoscopiclymphadenectomy (VAMLA)9 and transcervical extended medi-astinal lymphadenectomy (TEMLA).10 VAMLA is a completelyendoscopic procedure performed with the two-valved Wolf video-mediastinoscope. It consists of en bloc removal of the fatty tissue andnodes of the subcarinal space, the right paratracheal and pretracheal

June 9, 2009 14:6 B-601 ch12 FA


areas, and the left paratracheal space. TEMLA is a combined openand endoscopic procedure facilitated by an enlarged cervical incisionresulting from the pulling of the sternum with a hook. The removalof the upper mediastinal nodes is performed with standard instru-ments. Then a videothoracoscope is used as an aid to dissect andremove the subaortic and anterior mediastinal nodes, and a video-mediastinoscope is used to complete dissection and removal of thesubcarinal and paraoesophageal nodes. In both series, sensitivity,diagnostic accuracy and negative predictive value were close to 1. Thepractical advantage of VAMLA and TEMLA over other staging pro-cedures is that, in patients with lung cancer who eventually undergolung resection, mediastinal lymphadenectomy of the explored sta-tions is unnecessary because remnant lymphatic tissue is negligible.

REFERENCES

1. Sobin LH, Wittekind Ch (eds.). (2002) International Union Against Cancer:TNM Classification of Malignant Tumours, 6th edn. (NewYork: Wiley-Liss),p. 15.

2. De Leyn P, Lardinois D, Van Schil PE, et al. (2007) ESTS guidelines forpreoperative lymph node staging for non-small cell lung cancer. Eur JCardiothorac Surg 32: 1–8.

3. Rami-Porta R, Mateu-Navarro M. (2002) Videomediastinoscopy.J Bronchol 9: 139–144.

4. Van Schil P, De Waele M, Hendriks J, Lauwers P. (2007) Remedi-astinoscopy. J Thorac Oncol 2: 365–366.

5. Jiao X, Magistrelli P, Goldstraw P. (1997) The value of cervical medi-astinoscopy combined with anterior mediastinotomy in the periopera-tive evaluation of bronchogenic carcinoma of the left upper lobe. Eur JCardiothorac Surg 11: 450–454.

6. Ginsberg RJ, Rice TW, Goldberg P. (1987) Extended cervical medi-astinoscopy: a single staging procedure for bronchogenic carcinoma ofthe left upper lobe. J Thorac Cardiovasc Surg 94: 673–678.

7. Lopez L, Varela A, Freixinet J, et al. (1994) Extended cervical medi-astinoscopy: prospective study of fifty cases. Ann Thorac Surg 57:555–557.

June 9, 2009 14:6 B-601 ch12 FA


8. Rendina EA, Venuta F, De Giacomo T, et al. (1994) Comparative meritsof thoracoscopy, mediastinoscopy, and mediastinotomy for mediastinalbiopsy. Ann Thorac Surg 57: 992–995.

9. Witte B, Hürtgen M. (2007) Video-assisted mediastinoscopic lym-phadenectomy (VAMLA). J Thorac Oncol 2: 367–369.

10. Zielinski M. (2007) Transcervical extended mediastinal lymphadenec-tomy: results of staging in two hundred fifty-six patients with non-smallcell lung cancer. J Thorac Oncol 2: 370–372.

June 17, 2009 14:52 B-601 ch13 FA

chap

ter13

Transthoracic Oesophagectomyand Lymphadenectomy

Philippe Nafteux∗,†, Willy Coosemans†, Herbert Decaluwé†,Georges Decker†, Paul De Leyn†, Dirk Van Raemdonck†

and Toni Lerut†

INTRODUCTION

In oesophageal cancer, several controversies have arisen over the sur-gical approach, as well as the need for and the extent of lymph nodedissection.

Hulscher et al. published in 2002 a randomised study showing aclear, beneficial trend in survival favouring the more radical transtho-racic approach which comprises two-field lymphadenectomy overthe transhiatal approach to resectable adenocarcinoma of the distaloesophagus and the gastro-oesophageal junction. In particular, inthe subset of patients presenting with adenocarcinoma of the dis-tal oesophagus, the same group reported a 17% survival benefit infavour of the transthoracic approach. For this reason, the transthoracicapproach with radical lymph node dissection is now considered atmost centres as the gold standard procedure for resecting oesophagealcancer in the majority of patients.

∗Corresponding author.†Department of Thoracic Surgery, UZ Gasthuisberg, Herestraat 49, 3000 Leuven,Belgium. E-mail: [email protected]

95

June 17, 2009 14:52 B-601 ch13 FA

96 P. Nafteux et al.

TECHNIQUES

The transthoracic approach can be carried out either through a right ora left thoracotomy, depending on the location of the tumour within theoesophagus and the preference of the surgeon. Our centre advocatesright-sided approach for tumours above the carina level and a left-sided approach for tumours below.

Right-sided Approach

Classically, a three-hole approach (McKeown) is advocated, with thepatient installed in a left lateral position for the thoracic part of theoperation and in a supine position for the laparotomy and cervico-tomy. Some centres prefer a two-hole approach (Ivor-Lewis) and makethe anastomosis at the apex of the chest, thus omitting the cervicotomy.

The thoracotomy is performed by entering the fifth intercostalspace. The azygos vein is divided and ligated. The oesophagus ismobilised with all its surrounding soft tissue. This is performed asa so-called en bloc resection, taking together with the oesophagus allperioesophageal tissues, the azygos vein, the thoracic duct, and sub-carinal and paraoesophageal lymph nodes as a single entity (Fig. 1a).All branches of the azygos vein and arterial branches for the oesoph-agus coming off the aorta have to be divided and ligated or clipped.Great care is taken not to damage the membranous part of the air-ways. The dissection of the oesophagus is performed down into thehiatus oesophagei and cranially up into the neck.After the completionof those manoeuvres, the paratracheal nodes are removed separately,starting by dissecting the right paratracheal region, and removing allfatty and lymphatic tissues. The dissection is continued alongside theright recurrent nerve up to the neck, where the lymph nodes at thelevel of the brachiocephalic trunk extending into the basis of the neckare removed (Fig. 1b). If these nodes prove to be malignant on frozensection, a three-field lymphadenectomy (i.e. adding the cervical field)will be performed. Equally, the lymph nodes in the aortopulmonary

June17,2009

14:52B

-601ch13

FA

TransthoracicO

esophagectomy

andLym

phadenectomy

97

(a) (b) (c)

FIGURE 1 � Right-sided oesophagectomy. (a) View of the posterior mediastinum after mobilisation of the oesophagus through aright-sided thoracotomy. The azygos vein and thoracic duct are removed en bloc with the oesophagus. (b) Visualisation of bothrecurrent nerves after oesophageal mobilisation and lymph node dissection. The right vagus nerve and the origin of the rightrecurrent nerve as well as the left recurrent nerve are clearly seen. Great care has to be taken not to damage these structures duringlymph node dissection. (c) The trachea and the left main stem bronchus are retracted ventrally. Note the left pulmonary arteryand the aortic arch after oesophageal mobilisation and lymph node clearance of the aortopulmonary window.

June 17, 2009 14:52 B-601 ch13 FA


window and alongside the left recurrent nerve are dissected awayfrom these structures, taking care not to damage them (Fig. 1c). Afterclosure of the chest and turning the patient to a supine position, alaparotomy is performed, using a midline or a bisubcostal incision,according to the surgeon’s preference. Mobilising the left hepatic lobefacilitates access to the hiatus in order to finalise the dissection of theoesophagus. As in general a gastric tube is used to restore continuity,it will be prepared accordingly. The greater curve is mobilised, pre-serving the right gastroepiploic vessels by dividing its branches for thegreater omentum, as well as the short gastric vessels. The lesser omen-tum is opened and after dividing the hepatic branches of the vagalnerves the dissection is continued towards the hiatus oesophagei. Thephreno-oesophageal ligament is incised, exposing the abdominal anddistal oesophagus. If required for oncologic reasons a muscular rimof the hiatus oesophagei is resected as well. The right gastric arteryis divided at a level close to the pylorus. The left gastric artery andvein are dissected and ligated with resection of all lymphatic and fattytissues surrounding them. The gastric tube is fashioned using linearstaplers (Fig. 2a). The lymph node dissection is continued by remov-ing all nodes starting from the celiac axis, and extending further alongthe splenic artery into the splenic hilum. To the right all the lymphnodes and soft tissue along the common hepatic artery are cleared,the limit being the inferior vena cava and portal vein. This equals aDII lymphadenectomy.

The gastric tube is then fixed to the partitioned lesser curvaturewith two stay sutures. A left cervical incision is performed, along theanterior border of the sternocleidomastoid muscle. The neurovascu-lar structures are retracted laterally, and after dividing the inferiorthyroid artery the prevertebral fascia is easily identified. Usually thecervical oesophagus and the attached gastric tube can be pulled intothe operating field straightaway, since the mobilisation of the cervicaloesophagus has already been carried out from the chest. An end-to-side anastomosis is then performed, manually or using staplers(Fig. 2b).

June 17, 2009 14:52 B-601 ch13 FA

Transthoracic Oesophagectomy and Lymphadenectomy 99

(a) (b)

FIGURE 2 � (a) Gastric tube. Note the length that can be achieved. (b) Semi-mechanicalanastomosis in the neck. The posterior aspect of the end-to-side oesophagogastros-tomy has been performed using a stapler. Note the broad V-shaped widening that isachieved. This diminishes the incidence of anastomotic strictures requiring dilation.

Left-sided approach

A thoracoabdominal approach (thoracophrenotomy) provides excel-lent exposure to both the upper abdomen and the mediastinum. It isused for tumours of the distal oesophagus and the gastro-oesophagealjunction.

The operation is performed with the patient placed in a right lat-eral position with the left hip rolled slightly towards the back to facil-itate abdominal exposure. A posterolateral thoracotomy through thesixth intercostal space is extended across the costal margin slightlyinto the abdomen and is combined with a peripheral phrenotomy(leaving a diaphragmatic rim of 2 cm on the chest wall, which willpermit closure of the diaphragm), thus preserving the phrenic inner-vation and related diaphragmatic function (Fig. 3a).

The oesophagus is mobilised from its bed, taking it widely with allits surrounding soft tissues and paraoesophageal lymph nodes fromthe aortic arch flush along the descending aorta down to the hiatus.The pericardium can be resected en bloc if need be. The peritoneal foldbehind the spleen is incised and the spleen together with the pan-creas tail is mobilised. This exposes widely the left upper quadrant,facilitating not only lymphadenectomy but also the clearing-out of allsurrounding fatty tissues and peritoneum, as well as creating better

June17,2009

14:52B

-601ch13

FA

100P.N

afteuxetal.

(a) (b) (c)

FIGURE 3 � Left-sided oesophagectomy. (a) Left-sided approach through a sixth interspace thoracophrenotomy. The costal arch istransected, followed by a limited extension of the incision into the abdominal wall. An incision of the diaphragm at its peripheryconserving the phrenic nerve is then performed to complete the incision. (b) Upper abdominal compartment after lymph nodedissection with visualisation of the arterial branches, portal vein and inferior vena cava (DII dissection). IVC — inferior venacava; LGAS — left gastric artery stump; SA — splenic artery; CHA — common hepatic artery; PV — portal vein. (c) View of theposterior mediastinum after mobilisation of the oesophagus through the left-sided approach. Note the retracted oesophagus andaorta. Visualisation of both main bronchi and subcarinal region after lymph node dissection.

June 17, 2009 14:52 B-601 ch13 FA

Transthoracic Oesophagectomy and Lymphadenectomy 101

exposure to safely and completely resect bulky tumours. The greatercurvature is mobilised fully, till the level of the pylorus is reached. Thegastrohepatic ligament is divided, as well as the right gastric vessels.The left gastric vessels are divided as described above, and the gastrictube is fashioned.

In the abdomen the lymph node dissection starts at the splenichilum, going downwards alongside the splenic artery till the leftgastric artery stump. To the right of the celiac trunk, the nodes andsoft tissue surrounding the common hepatic artery are removed, thelimit of the lymphadenectomy being the inferior vena cava and portalvein. Finally, the celiac axis nodes are removed, completing the DIIlymphadenectomy (Fig. 3b).

The thoracic oesophagus is freed behind the aortic arch using bluntdissection (décroisement aortique). The pleura is incised above the aorticarch and the blunt dissection of the oesophagus is continued upwardsinto the neck. Great care is taken not to damage the recurrent nerveor the membranous part of the trachea in this blunt dissection.

Thoracic lymph node dissection is continued at the level of thesubcarinal region and also includes the pulmonary hilar nodes andparatheaortic and aortopulmonary window nodes (Fig. 3c). Left para-tracheal nodes are normally removed from behind and above the aor-tic arch. Enlarged brachiocephalic nodes can be palpated from theleft and when judged appropriate can be removed by performing athree-field lymphadenectomy.

The oesophagus is transected at the top of the chest and the gastrictube is placed in the bed of the oesophagus, brought up behind theaortic arch and fixed to the oesophageal stump using two stay sutures.

Using the cervical procedure described above, the oesophagusand gastric tube can be pulled into the operating field and an anasto-mosis is performed.

June 17, 2009 14:52 B-601 ch13 FA


REFERENCES

1. Hulscher JB, van Sandick JW, de Boer AG, et al. (2002) Extended transtho-racic resection compared with limited transhiatal resection for adenocar-cinoma of the esophagus. N Engl J Med 347(21): 1662–1669.

2. Hulscher JB, van Lanschot JJ. (2005) Individualised surgical treatmentof patients with an adenocarcinoma of the distal oesophagus or gastro-oesophageal junction. Dig Surg 22(3): 130–134.

3. Ferguson MK. (2007) Ivor-Lewis esophagectomy. In: Ferguson MK (ed.),Thoracic Surgery Atlas. Philadelphia, Saunders, pp. 192–1195.

4. Launois B, Maddern G. (2006) Abdominal and right thoracic subtotalesophagectomy. In: Kaiser L, Jamieson G (eds.), Operative Thoracic Surgery,5th ed. London, Hodder Arnold, pp. 367–377.

5. Ferguson MK. (2007) Esophagectomy via left thoracotomy. In: Fer-guson MK (ed.), Thoracic Surgery Atlas. Philadelphia, Saunders,pp. 192–1195.

6. Liu JF. (2006) Left thoracic subtotal esophagectomy. In: Kaiser L, JamiesonG (eds.), Operative Thoracic Surgery, 5th ed. London, Hodder Arnold,pp. 379–395.

7. Hagen JA, DeMeester SR, Peters JH, et al. (2001) Curative resection foresophageal adenocarcinoma: analysis of 100 en bloc esophagectomies. AnnSurg 234(4): 520–530.

8. Lerut T, Coosemans W, Decker G, et al. (2005) Surgical techniques. J SurgOncol 92: 218–229.

9. Lerut T, Nafteux P, Moons J, et al. (2004) Three-field lymphadenectomyfor carcinoma of the esophagus and gastroesophageal junction in 174 R0resections: impact on staging, disease-free survival, and outcome: a pleafor adaptation of TNM classification in upper-half esophageal carcinoma.Ann Surg 240: 962–972.

June 9, 2009 14:6 B-601 ch14 FA

chap

ter14

Transhiatal Esophagectomy

J. Jan. B. van Lanschot∗,†, Khe T. C. Tran†, Bas P. L. Wijnhoven†

and Hugo W. Tilanus†

INTRODUCTION

The best potentially curative treatment option for (advanced)esophageal carcinoma is surgical resection with or without neoadju-vant chemoradiation. For years the procedure of choice for esophagealresection has been the Ivor Lewis operation, in which the primarytumor and periesophageal tissue with adjacent lymph nodes areresected through a right-sided thoracotomy in combination with alaparotomy.1 In the last decades, two major surgical strategies toimprove survival rates have emerged.

To improve the cure rate, one strategy is to perform a more radical,en-bloc transthoracic resection with extended lymph node dissection.Alternatively, one could aim at a decrease in early postoperativemorbidity and mortality by limiting the extent of operation. Thismight be achieved by a transhiatal resection, in which the esopha-gus is resected through a cervico-abdominal approach, thus avoid-ing a formal thoracotomy. Moreover, various minimally invasive

∗Corresponding author.†Department of Surgery, Suite H-996, Erasmus Medical Center, P.O. Box 2040, 3000CA Rotterdam, the Netherlands. E-mail: [email protected]

103

June 9, 2009 14:6 B-601 ch14 FA

104 J. J. B. van Lanschot et al.

(thoracoscopically and/or laparoscopically assisted) techniques haverecently been developed, but it remains to be determined whetherthese technically challenging approaches will lower morbidity or mor-tality and ultimately improve survival rates.2

TRANSHIATAL ESOPHAGECTOMY: TECHNICALASPECTS3

The transhiatal esophagectomy without thoracotomy has a number ofpractical advantages, such as short duration of operation, probably alower incidence of pulmonary complications, and avoidance of post-thoracotomy pain. This surgical approach is particularly appropriatefor tumors originating from the cardia and gastroesophageal junc-tion; via a surgically widened hiatus, the lower mediastinum can beapproached. The organ for reconstruction is preferably the stomach,which is anastomosed to the remaining cervical esophagus. This canbe achieved via the esophageal bed (the prevertebral route) or via theretrosternal route. The last option is preferable if a macroscopic locore-gional residual tumor is left behind in the posterior mediastinum.

Operative Technique

The operation is started with a median laparotomy; the incisionextends from the xiphoid process to just below the umbilicus. Theabdominal contents are inspected and palpated for metastases; ifdistant metastases are found, proceeding with a resection is con-traindicated. After mobilizing the left lobe of the liver, the esophagealhiatus is visualized and inspected for tumor invasion. Subsequently,the stomach is mobilized. The esophagus is dissected in the hiatus,and, if necessary, a surrounding cuff of diaphram can be resecteden-bloc with the specimen. Next, the central tendon of the right hemi-diaphragm is incised, thus opening the lower mediastinum. Theperiesophageal fatty tissues of the left and right parietal pleura andpericardium are included in the surgical specimen (dotted line in

June 9, 2009 14:6 B-601 ch14 FA

Transhiatal Esophagectomy 105

FIGURE 1 � Transhiatal esophagectomy: an early stage of the operation. After splittingthe diaphragm, mobilisation of the distal esophagus, including periesophageal tissue(dotted line) is performed under direct vision. After fashioning of a gastric tube andtranssecting of the esophagus in the neck, stripping of the esophagus is performedblindly using a “vein stripper”. The esophagus invaginates while the stripper ispulled distally. A string has been attached to the stripper.

Fig. 1). This procedure can be extended as far as the inferior pul-monary veins. The more proximal and, so far, unmobilized, part ofthe (normal) esophagus is bluntly mobilized or stripped, using avein-stripper from the neck (Fig. 1). After completion of the intra-abdominal dissection, a neoesophagus is created, preferably fashion-ing a 3 cm-wide tube from the stomach (Fig. 2). During this procedure,lymph nodes along the right and left gastric artery are removed. Thegastric tube is pulled/pushed, via the prevertebral route, to the neckwhere an esophago-gastrostomy is created. When the retrosternalroute is chosen, a tunnel is created by blunt retrosternal dissection

June 9, 2009 14:6 B-601 ch14 FA


FIGURE 2 � After resecting of the lesser curvature, a gastric tube is fashioned. Thistube receives its vascularization from the right gastro-epiploic artery and vein. Thestring, which has been pulled through the posterior mediastinum, is fixed to the topof the tube, after which the gastric tube is pulled up into the neck.

from the xiphoid process to the jugular notch. This retrosternal tun-nel must be sufficiently spacious to avoid compromising the perfu-sion of the interposed conduit because of undue compression. Thisrequirement sometimes necessitates resection of the sternoclavicularjoint.

EVIDENCE IN FAVOR OF TRANSHIATALOR TRANSTHORACIC APPROACH

In 2001, a systematic review was published on the differences betweentranshiatal and transthoracic resections with respect to perioperativemorbidity, early mortality and long-term survival.4 For this purpose,

June 9, 2009 14:6 B-601 ch14 FA

Transhiatal Esophagectomy 107

50 studies which were published in the English literature between1990 and 1999 and which met the predefined quality criteria wereanalyzed. It was concluded that a transthoracic resection seemed tohave a higher incidence of early postoperative complications and ahigher hospital mortality, while there was no clear survival benefitof one approach over the other. However, this systematic review hasseveral important limitations. First, many of the analyzed studies didnot supply sufficient technical operative details. For that reason, thisreview compared surgical approaches rather than the extent of resec-tion. Second, only three of the analyzed publications had a random-ized study design and had included in total only 138 patients.

Therefore, a large randomized trial was undertaken compar-ing a limited transhiatal resection and extended transthoracic resec-tion with a two-field lymph node dissection. The limited transhiatalresection showed a lower morbidity than the extended transthoracicresected.5 After medium term follow-up, survival was not signifi-cantly different between the two groups, although there was a trendtowards an improved survival in favor of the extended approach. Inthe final analysis of this trial after a minimum potential follow-upof five years, this trend persisted.6 In a subgroup analysis, patientswith a true esophageal cancer (Siewert type-1) had an absolute 14%overall five-year survival benefit if operated via the chest. For patientswith a gastroesophageal junction tumor (Siewert type-2), no survivalbenefit was seen for either approach. In a second subgroup analy-sis, especially patients with a limited number (1–8) of positive nodesin the resection specimen took advantage of an extended resection,while in patients without positive nodes and in patients with morethan eight positive nodes, there was no survival difference.

Based on this best available evidence, we now favor an extendedtransthoracic resection in patients with a type-1 tumor, unless thepatient is unfit to undergo a thoracotomy. This is especially so, if thereis a limited number of suspicious nodes at the preoperative stagingprocedures. On the other hand, we advocate a transhiatal approach inpatients with a type-2 tumor at the gastroesophageal junction, unless

June 9, 2009 14:6 B-601 ch14 FA


there are suspicious nodes at the (supra-) carinal level, which canobviously not be removed without a thoracotomy.

REFERENCES

1. Lewis I. (1946) The surgical treatment of carcinoma of the oesophaguswith special reference to a new operation for growths of the middle third.Br J Surg 34: 18–31.

2. Smithers BM, Gotley DC, Martin I, Thomas JM. (2007) Comparison of theoutcomes between open and minimally invasive esophagectomy. AnnSurg 245: 232–240.

3. Lerut T, Van Lanschot JJB. (2004) Cancer of the esophagus and gastroe-sophageal junction; surgical aspects. In: Van Lanschot JJB et al. (eds),Integrated Medical and Surgical Gastroenterology, pp. 54–63. Thieme Verlag,Stutgartt.

4. Hulscher JBF, Tijssen JGP, Obertop H, Van Lanschot JJB. (2001) Transtho-racic versus transhiatal resection for carcinoma of the esophagus: a meta-analysis. Ann Thorac Surg 72: 306–313.

5. Hulscher JBF, Van Sandick JW, De Boer AG et al. (2002) Extendedtransthoracic resection compared with limited transhiatal resection foradenocarcinoma of the esophagus. N Engl J Med 347: 1662–1669.

6. Omloo JMT, Lagarde SM, Hulscher JBF, et al. (2007) Extended transtho-racic resection compared with limited transhiatal resection for adenocarci-noma of the middle/distal esophagus: five year survival of a randomizedclinical trial. Ann Surg: 246: 992–1001.

June 9, 2009 14:6 B-601 ch15 FA

chap

ter15

Gastrectomy for Adenocarcinoma

Hartgrink H. Hartgrink∗ and Cornelis J. H. van de Velde†

The only curative treatment for gastric adenocarcinoma is a radi-cal resection. However, more extended treatment may lead to anincreased operative morbidity and mortality. This chapter attempts togive evidence-based guidelines for the technique and extent of gastricresections.

Lymph node dissections are defined according to the guidelines ofthe Japanese Research Society for the Study of Gastric Cancer. Theseguidelines are also recommended by the American Joint Committeeon Cancer, and by the International Union Against Cancer. In theseguidelines, 16 different lymph node compartments (stations) are iden-tified as surrounding the stomach (Fig. 1). In general, the perigastriclymph node stations along the lesser (stations 1, 3, and 5) and greater(stations 2, 4, and 6) curvature are grouped as N1, while the nodesalong the left gastric (station 7), common hepatic (station 8), celiac(station 9), and splenic (stations 10 and 11) arteries are grouped as N2.D1 dissection entails removal of the involved part of the stomach (dis-tal or total), and the N1 lymph nodes including the greater and lesseromentum. For D2 dissection the N2 lymph nodes are also removed.

∗Corresponding author.†Department of Surgery, Leiden University Medical Center, PO Box 9600, 2300 RC,Leiden, The Netherlands. E-mail: [email protected]

109

June 9, 2009 14:6 B-601 ch15 FA

110 H. H. Hartgrink and C. J. H. van de Velde

FIGURE 1 � Lymph node stations surrounding the stomach. 1 = right cardial nodes;2 = left cardial nodes; 3 = nodes along the lesser curvature; 4 = nodes along thegreater curvature; 5 = suprapyloric nodes; 6 = infrapyloric nodes; 7 = nodes alongthe left gastric artery; 8 = nodes along the common hepatic artery; 9 = nodes aroundthe celiac axis; 10 = nodes at the splenic hilus; 11 = nodes along the splenic artery;12 = nodes in the hepatoduodenal ligament; 13 = nodes at the posterior aspect ofthe pancreas head; 14 = nodes at the root of the mesenterium; 15 = nodes in themesocolon of the transverse colon; 16 = para-aortic nodes.

In order to perform adequate surgery for gastric cancer, a wideoperative field should be achieved. Although several abdominal inci-sion lines can be used, we prefer the vertical incision. With strongretractors the costal arches are pulled upwards. First, the greater

June 9, 2009 14:6 B-601 ch15 FA

Gastrectomy for Adenocarcinoma 111

FIGURE 2 � When the left gastric artery is divided at its origin, nodes at the celiac andsplenic artery can be dissected (stations 9 and 10).

omentum is divided from the transverse colon. It will be removeden bloc with the stomach. The right gastroepiploic artery is dividedat its origin. The lesser omentum is divided as close to the liveras possible and the right gastric artery ligated. The duodenum ismobilised from the gastroduodenal artery and divided with a sta-pling device distally to the pylorus. Now the lymph nodes along thehepatic artery can be dissected (stations 8 and 12). Following the hep-atic artery will lead one to the left gastric artery, which is divided at itsorigin. Now lymph nodes along the celiac axis and the splenic arterycan now be removed (stations 9 and 11) (Fig. 2). In a partial gastrec-tomy, all branches of the left gastric artery towards the stomach fromthe peritoneal plica over the oesophagus until as far as the resectionline are ligated and divided (Fig. 3).

June 9, 2009 14:6 B-601 ch15 FA


FIGURE 3 � Branches of the left gastric artery are ligated and divided.

Total gastrectomy has a higher morbidity and hospital mortalityrate than partial gastrectomy. A randomised trial in Italy showed thatthere is no survival benefit from total gastrectomy if resection marginsare free of tumour.1 Total gastrectomy should be performed only if thesite of the cancer does not allow a partial gastrectomy to be performed.Frozen sections of the resection margins are recommended.2

For many years it has been debated whether an extended lymphnode dissection (D2) for gastric cancer is beneficial. Theoretically,removal of a wider range of lymph nodes by extended lymph nodedissection increases the chance of a cure. Such resection, however,may be irrelevant if there are no lymph nodes affected or if the cancerhas developed into a systemic disease, or if it increases morbidity andmortality substantially. Of five randomised studies,3–7 only the mostrecent one shows a significant overall survival benefit for extendedlymphadenectomy.7 In the Dutch D1–D2 trial it has been shownthat for patients with N2 disease, there is a significant benefit froma D2 dissection.6 The main problem, however is to identify these

June 9, 2009 14:6 B-601 ch15 FA


patients preoperatively. Furthermore, the cancer-related death ratein the Dutch study is higher in the D1 dissection group than in the D2dissection group. The removal of too little lymph nodes may, however,an insufficient, diminish survival.8 It is recommended that at least 15lymph nodes should be removed, preferably more.

Splenectomy and pancreatectomy are important risk factors formorbidity and hospital mortality after D2 dissection. Randomisedtrials in Chili, Korea, found no survival benefit from a splenectomyin patients with total gastrectomy whereas morbidity was signifi-cantly increased.9,10 One Japanese trial is ongoing,11 two previousJapanese studies showed no beneficial effect on survival if pancre-atosplenectomy was combined with total gastrectomy, whereas mor-bidity was increased in these patients.12,13 In the Dutch study, patientswho did not require additional pancreatectomy and/or splenectomystill had increased morbidity and hospital mortality after D2 dis-section, but there also was a significant survival advantage for theD2 dissection group. There seems to be a survival benefit froman extended lymph node dissection if morbidity- and mortality-increasing procedures like pancreatectomy and splenectomy can beavoided.

The main reason for performing a pancreatectomy and splenec-tomy with a D2 dissection is to allow an adequate dissection of stations10 and 11. However, metastasis in these lymph nodes, means a poorprognosis. In the Dutch study, patients with metastasis at stations 10and 11 had a survival rate at 11 years of 8% and 11% respectively,whereas patients without metastass had a survival rate of 27% and35% respectively.6 So the relevance of the dissection of these nodeshas to be questioned as the survival benefit is small and morbidityand hospital mortality are significantly increased.

Adjuvant chemotherapy for gastric cancer was analysed in meta-analysis showing a significant but very small advantage. However,perioperative chemotherapy as tested in the MAGIC study has showna significant advantage in overall survival of 13%.14 At this momentthe ECX and EOX seem to be the most effective treatment regimens.15

June 9, 2009 14:6 B-601 ch15 FA


The use of adjuvant radiochemotherapy was shown to be beneficial inthe study16 and is now the standard treatment in the US. This studywas criticised for the poor surgery performed (54% D0 resections).In the Netherlands, the CRITICS randomised trial is now underwayto evaluate the use of adjuvant radiochemotherapy after adequatesurgery and neoadjuvant chemotherapy. Sweden is also participatingin this study, and probably other countries will join in soon.

In conclusion, partial gastrectomy is sufficient treatment if theresection margins are free of tumour. At least 15 lymph nodes shouldbe removed. Extended lymph node dissection is probably bene-ficial if morbidity- and mortality-increasing procedures like pan-createctomy and splenectomy can be avoided. The pancreas andspleen should be removed only if they are invaded by tumour. Peri-operative chemotherapy is recommended. The benefit of adjuvantradiochemotherpy is under further investigation.

REFERENCES

1. Bozzetti F, Marubini E, Bonfanti G, et al. (1999) Subtotal versus totalgastrectomy for gastric cancer: five-year survival rates in a multicenterrandomised Italian trial. Ann Surg 230: 170–178.

2. Songun I, Bonenkamp JJ, Hermans J, van Krieken JHJM, van de VeldeCJH, and the Cooperative Investigators of the Dutch Gastric CancerTrial. (1996) Prognostic value of resection-line involvement in patientsundergoing curative resections for gastric cancer. Eur J Cancer 32A:433–437.

3. Dent DM, Madden MV, Price SK. (1988) Randomized comparison of R1and R2 gastrectomy for gastric carcinoma. Br J Surg 75: 110–112.

4. Robertson CS, Chung SCS, Woods SDS, et al. (1994) A prospective ran-domized trial comparing R1 subtotal gastrectomy with R3 total gastrec-tomy for antral cancer. Ann Surg 220: 176–182.

5. Cuschieri A, Weeden S, Fielding J, et al. (1999) Patient survival afterD1 and D2 resections for gastric cancer: long-term results of the MRCrandomized surgical trial. Br J Cancer 79: 1522–1530.

June 9, 2009 14:6 B-601 ch15 FA


6. Hartgrink HH, van de Velde CJH, Putter H, et al. (2004) Extended lymphnode dissection for gastric cancer: who may benefit? Final results of therandomised Dutch Gastric Cancer Group trial. J Clin Oncol 22: 2069–2077.

7. Wu CW, Hsiung CA, Lo SS, et al. (2006) Nodal dissection for patients withgastric cancer: a randomized controlled trial. Lancet Oncol 7: 309–315.

8. Huhndahl SA, Peeters KC, Kranenbarg EK, et al. (2007) Improvedregional control and survival with “low Maruyama Index” surgery ingastric cancer: autopsy findings from the Dutch D1–D2 trial. GastricCancer 10: 84–86.

9. Csendes A, Burdiles P, Rojas J, et al. (2002) A prospective randomizedstudy comparing D2 total gastrectomy versus D2 total gastrectomy plussplenectomy in 187 patients with gastric carcinoma. Surgery 131: 401–407.

10. Yu W, Choi GS, Chung HY. (2006) Randomized clinical trial of splenec-tomy versus splenic preservation in patients with proximal gastriccancer. Br J Surg 93: 559–563.

11. Sano T, Yamamoto S, Sasako M, for the Japan clinical oncology group.(2002) Randomised controlled trial to evaluate splenectomy in total gas-trectomy for proximal gastric carcinoma. Jpn J Clin Oncol 32: 363–364.

12. Kodera Y, Yamamura Y, Shimizu Y, et al. (1997) Lack of benefit of com-bined pancreaticosplenectomy in D2 resection for proximal-third gastriccarcinoma. World J Surg 21: 622–628.

13. Kitamura K, Nishida S, Ichikawa D, et al. (1999) No survival benefit fromcombined pancreaticosplenectomy and total gastrectomy for gastric can-cer. Br J Surg 86: 119–122.

14. Cunningham D, Allum WH, Stenning SP, et al. (2006) Perioperativechemotherapy versus surgery alone for resectable gastroesophagealcancer. N Engl J Med 6: 11–20.

15. Cunningham D, Starling N, Rao S, et al. (2008) Capecetabine and oxali-platin for advanced esophagogastric cancer. N Engl J Med 358: 36–46.

16. Macdonald JS, Smalley SR, Benedetti J, et al. (2001) Chemoradiotherapyafter surgery compared with surgery alone for adenocarcinoma of thestomach or gastroesophageal junction. N Engl J Med 345: 725–730.

June 9, 2009 14:6 B-601 ch16 FA

chap

ter16

Stenting Gastro-Oesophageal Tumours

Els M. L. Verschuur†, Frank P. Vleggaar ∗ andPeter D. Siersema∗,†

INTRODUCTION

Despite recent advances in the curative treatment of oesophageal andgastric cardia cancer,1 more than 50% of patients have inoperable dis-ease at presentation. For these patients, palliative treatment to relieveprogressive dysphagia is usually the only treatment option. Self-expanding stents are commonly used for the palliation of dysphagiadue to irresectable primary carcinoma of the mid and distal oesoph-agus and gastric cardia.2 Stents are also effective in patients withcomplicated (oesophagorespiratory fistulas, or malignant tumoursnear the upper oesophageal sphincter) and recurrent oesophagogas-tric cancer after surgery.3,4 The aim of stent placement is to improvefood intake, which, as a consequence, is associated with a positiveeffect on the experienced quality of life of patients.5

It has been demonstrated that stent placement should primarilybe reserved for patients with dysphagia and a short life expectancy

∗Corresponding author.Department of Gastroenterology and Hepatology, University Medical Centre Utrecht,The Netherlands.†Department of Gastroenterology and Hepatology, University Medical CentreUtrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands. E-mail: [email protected]

117

June 9, 2009 14:6 B-601 ch16 FA

118 Els M. L. Verschuur et al.

(≤3 months), needing rapid relief, but also for patients with persis-tent or recurrent tumour after a single dose intraluminal radiotherapy(brachytherapy).6,7

TECHNIQUE

Stents

Covered stents are now the most frequently used in patients withoesophageal and gastric cardia cancer. The ideal stent would have thefollowing characteristics:

• It would have a large internal diameter to ensure the passage of anormal diet;

• It would be flexible and non-traumatic while still achieving fullexpansion;

• It would not migrate, yet could be repositioned or removed ifnecessary.

Although this ideal stent does not exist, all available covered stentsdo meet some of these criteria (Table 1).

Stent placement procedure (video)

Stent placement is usually done with the patient under conscioussedation with midazolam.

The first step is to identify the upper and lower ends of the tumour(Fig. 1). If tumour obstruction does not allow passage of a standarddiameter (8–10 mm) endoscope, either the tumour should be dilatedto a maximum of 10–12 mm or, preferably, the standard endoscopeshould be changed for a small diameter (4.9–5.9 mm) endoscope tomeasure stricture length and to place a guidewire for stent placement.Dilation may increase the risk of perforation; however, there is noconsensus on whether stepwise dilation in more than one session willlower the perforation risk.

June9,2009

14:6B

-601ch16

FA

StentingG

astro-OesophagealTum

ours119

Table 1 Characteristics of Currently Used Covered Self-expanding Stents

Stent Type Cover Length(cm)

Diameter (mm) RadialForce

Degree ofShortening

Flexibility Material Stent andCover

Company

Ultraflex Partial 10, 12, 15 prox.: 28/mid:23prox.: 23/mid:18

Medium 30–40% High Nitinol withpolyurethanecover

Boston Scientific,Natick, USA

Wallstent II Partial 10, 15 prox.: 28/mid:20 High 20–30% Medium Stainless steel withsilicone cover

Boston Scientific,Natick, USA

FlamingoWallstent

Partial 12 14 prox.: 23/dist.:16prox.: 30/dist.:20

High 20–30% Medium Elgiloy withpolyethylenecover

Bosten Scientific,Natick, USA

Z stent Complete 6, 8, 10,12, 14

prox.: 25/mid:18prox.: 25/mid:23

Medium No Low Stainless steel withpolyethylenecover

Wilson Cook,Winston-Salem,USA

Choo stent Complete 8, 11, 14 prox.: 22/mid: 18 Medium No Low Stainless steel withpolyurethanecover

M.I. Tech, Seoul,South Korea

Polyflex Complete 9, 12, 15 prox.: 20/mid: 16prox.: 23/mid: 18prox.: 25/mid: 21

High 20–30% Low Polyester + silicone Boston Scientific,Natick, USA

Alimaxx-E Complete 7, 10, 12 prox.: 24/mid: 22prox. 20/mid: 18

Medium 10–20% High Nitinol withpolyurethanecover

Alveolus,Charlotte, USA

SX-Ella Complete 8.5, 11,13.5

prox.: 25/mid: 20 High 5–10% Medium Nitinol withpolyethylenecover

Ella-CS, HradecKralove, CzechRepublic

Niti-S Complete 9, 12, 15 prox.: 26/mid: 18 High 10–20% Medium Nitinol withpolyurethanecover

TaewongMedical, Seoul,South Korea

June 9, 2009 14:6 B-601 ch16 FA


FIGURE 1 � The first step of oesophageal stent placement is to identify the upper andlower ends of the tumour. In this figure, a patient with a gastric cardia tumour isshown in retroversion.

When fluoroscopy is used, the proximal and distal margins of thestricture are demarcated by placing skin markers or intraoesophagealclips, or by the intramucosal injection of a radiopaque contrast agent.Injection of the lipid-soluble contrast agent lipiodol results in a per-sistent mark (Fig. 2).

The next step is to place a stiff guidewire, such as a 0.038-inchSavary guidewire or 0.035-inch Amplatz guidewire, across the stric-ture into the stomach or, preferably, the duodenum and withdraw theendoscope.

The stent is then carefully advanced over the guidewire. Moststents shorten during expansion (Table 1), which must be taken intoconsideration when positioning the introduction system. In order toprevent stent migration upon release from the introduction system,the system should not be advanced too distally. Astent no longer than2–4 cm of the stricture length should be used, to allow for a 1–2 cmextension above and below the proximal and distal tumour margins.For stents placed across the gastro-oesophageal (GE) junction, stentlength is guided by the rule that the proximal part of the stent should

June 9, 2009 14:6 B-601 ch16 FA

Stenting Gastro-Oesophageal Tumours 121

FIGURE 2 � The proximal and/or distal margins of the tumour can be demarcatedby the intramucosal injection of the lipid-soluble contrast agent lipiodol. In thisfigure, the upper end of a gastric cardia tumour (at the gastro-oesophageal junction)is demarcated.

lie at least 2–3 cm above the tumour margin, whereas the distal partshould not overlap the tumour margin by more than 1 cm, to preventulceration of the posterior wall of the stomach by the distal end of thestent and avoid kinking of the stent, which could hinder food passage.

Stents can be placed under fluoroscopic control and/or endo-scopic control, or using the markers on the stent introduction system,as is the case with Ultraflex stents (Boston Scientific, Natick, USA)and SX Ella stents (Ella-CS, Hradec Kralove, Czech Republic). Thereis no objection to confirming endoscopically that the upper stent endis placed proximal enough and distal enough from the upper tumourmargin; however, one should avoid passing the endoscope throughthe stent, as stent dislodgement caused by friction between the insuf-ficiently deployed stent and the endoscope can be a consequence.Stent expansion can be confirmed endoscopically under direct vision(Fig. 3), by fluoroscopy, or, afterwards, with a barium swallow.

Stent placement is an outpatient procedure which takes about15–20 minutes. We prefer to prescribe high-dose proton pomp

June 9, 2009 14:6 B-601 ch16 FA


FIGURE 3 � Stent expansion can be confirmed endoscopically under direct vision.

inhibitors to patients for whom the distal end of the stent is positionedacross the GE junction to prevent GE reflux after the procedure. Alter-natively, a stent with an anti-reflux mechanism, such as a Z stent witha Dua valve (Wilson Cook, Winston-Salem, USA) or a Do stent (M.I.Tech, Pyongtack, Korea), can be used. In addition, all patients shouldbe provided with eating instructions, such as thorough chewing offood and taking effervescent drinks between bites and after meals, toflush the stent.

There is not a single stent that fits all patients with malignantdysphagia. The choice of stent type depends on the location (prox-imal vs. more distal), length and characteristics (extrinsic vs. exo-phytic; benign vs. malignant) of the tumour. In the case where astent has migrated into the stomach, the first step is to re-positionthe stent, but if this is not successful, another stent design shouldbe inserted or an alternative treatment should be used to adequatelytreat the symptoms. Additional stent placement is also the treatmentof choice in patients with tumoural or nontumoural in- or overgrowth,whereas endoscopic cleansing of the stent is preferred if food obstruc-tion occurs.2−4,8,9

June 9, 2009 14:6 B-601 ch16 FA

Stenting Gastro-Oesophageal Tumours 123

DISCUSSION

Stent placement is a relatively easy procedure in patients withobstructing oesophageal or gastric cardia cancer. The technical suc-cess rate for metal stent placement is, in general, close to 100%. Causesof technical failure include severe pain during placement, extensivetumour growth in the stomach, failure of the stent to release from theintroduction system and immediate stent migration due to tumourcharacteristics or resulting from placement of the stent too distally.Almost all patients experience improvement of dysphagia and thiswill remain stable until a specific complication (such as perforation,haemorrhage and fistula formation) or recurrent dysphagia (such asstent migration, tumoural or nontumoural in- or overgrowth, andfood obstruction) occurs. The dysphagia score usually improves froma median of 3 (liquids only) to 1 (some difficulties with solids). Overthe last few years, no differences have been reported in complicationrates regardless the stent type, whereas some stent types effectivelyreduce recurrent dysphagia.4,8−10

In conclusion, stent placement is a safe and effective procedurein patients with dysphagia from inoperable oesophageal or gastriccardia cancer.

REFERENCES

1. Stein HJ, Siewert JR. (2004) Improved prognosis of resected esophagealcancer. World J Surg 28: 520–525.

2. Siersema PD, Marcon N, Vakil N. (2003) Metal stents for tumors of thedistal esophagus and gastric cardia. Endoscopy 35: 79–85.

3. Siersema PD, Schrauwen SL, van Blankenstein M, et al. (2001) Self-expanding metal stents for complicated and recurrent esophagogastriccancer. Gastrointest Endosc 54: 579–586.

4. Verschuur EML, Kuipers EJ, Siersema PD. (2007) Esophageal stents formalignant strictures close to the upper esophageal sphincter. GastoinstestEndosc 66: 1082–1090.

5. Homs MY, Essink-Bot ML, Borsboom GJJM, et al. (2004) Quality oflife after palliative treatment for esophageal carcinoma: a prospective

June 9, 2009 14:6 B-601 ch16 FA


comparison between stent placement and single dose brachytherapy.Eur J Cancer 40: 1862–1871.

6. Homs MY, Steyerberg EW, Eijkenboom WM, et al. (2004) Single-dosebrachytherapy versus metal stent placement for the palliation of dys-phagia from oesophageal cancer: multicentre randomised trial. Lancet364: 1497–1504.

7. Steyerberg EW, Homs MY, Stokvis A, et al. (2005) Stent placement orbrachytherapy for palliation of dysphagia from esophageal cancer: aprognostic model to guide treatment selection. Gastrointest Endosc 62:333–340.

8. Verschuur EML, Repici A, Kuipers EJ. (2008) New esophageal stents forthe palliation of dysphagia from esophageal or gastric cardia cancer: arandomized trial. Am J Gastroenterol 103: 304–312.

9. Verschuur EML, Steyerberg EW, Kuipers EJ, Siersema PD. (2007) Effectof stent size on complications and recurrent dysphagia in patients withesophageal or gastric cardia cancer. Gastoinstest Endosc 65: 592–601.

10. Verschuur EM, Homs MY, Steyerberg EW, et al. (2006) A new esophagealstent design (Niti-S stent) for the prevention of migration: a prospectivestudy in 42 patients. Gastrointest Endosc 63: 134–140.

June 9, 2009 14:6 B-601 ch17 FA

chap

ter17

Total Pancreatectomy

Jens Werner∗,† and Markus W. Büchler†

INTRODUCTION

In the 1960s and 1970s, dissatisfaction with the early results ofpancreatoduodenectomy for cancer of the head of the pancreas ledsurgeons to look for an alternative operation. Total pancreatectomy(TP) was proposed by some as a rational choice for some reasons. Itcan eliminate multifocal disease and achieve wider resection margins.It can also achieve a more extensive lymphadenectomy. And, finally,it allows one to avoid complications from the pancreatic remnant.However, in practice, the use of TP to reduce hospital mortality andimprove prognosis proved disappointing.1 Therefore, TP was aban-doned by many surgeons as a standard operation for pancreatic dis-ease. The fear of performing TP was especially increased by reportsof patients with brittle diabetes mellitus, and severe malabsorptionsecondary to the loss of exocrine pancreatic tissue.

However, advances in peri- and postoperative management aswell as surgical techniques in recent years have allowed one to

∗Correspondind author.†Department of General, Visceral, and Transplant Surgery, University of Heidelberg,INF 110, 69120 Heidelberg, Germany. E-mail: [email protected].

125

June 9, 2009 14:6 B-601 ch17 FA

126 J. Werner and M. W. Büchler

perform TP with a morbidity and mortality comparable to that ofother pancreatic resection procedures.2,3 The limitations caused bythe ensuing insulin-dependent diabetes mellitus do not justify avoid-ing TP in selected patients. The indications for TP today include:

• Oncological. To achieve an R0 resection in extended or multifocaladenocarcinoma of the pancreas.4 Similarly, longitudinal involve-ment of the pancreatic duct in some cases of intraductal papillarymucinous neoplasia (IPMN).3,4

• Chronic pancreatitis. In some patients with chronic pancreatitis, TPwithout or after previous partial pancreatic resection is indicatedfor recurrent complications of the disease.3,6,7

• Technical. TP might be indicated in the presence of an atrophic,soft and friable pancreatic remnant which does not hold sutures.8

Similarly, completion pancreatectomy might be necessary in casesof postoperative anastomotic complications.3

• Prophylactical. Patients with hereditary pancreatic cancer, hered-itary chromic pancreatitis, or other known premalignant lesionsin the pancreas and a considerable risk of developing pancreaticcancer.3,9

TECHNIQUE

Initially, a wide Kocher manoeuvre is performed to assess theretroperitoneum, as well as to appraise the tumour and its relations tothe SMA. We proceed with the resection only if we find no evidencethat will preclude an R0 resection.

The first steps are identical to the technique used for a pancreatichead resection. Access into the lesser sac is achieved by division of thegastrocolic ligament. On the left side, we divide the gastrocolic liga-ment only as far as the most medial branch of the short gastric vessels.This is to ensure an alternative venous drainage for the splenic bloodflow in the event of any venous resection of the SMV-PV trunk. Thegastrocolic venous trunk of Henle will be encountered here and, by

June 9, 2009 14:6 B-601 ch17 FA

Total Pancreatectomy 127

tracing it down, it will lead to the SMV. The gastroepiploic vein isthen divided where it empties into the gastrocolic trunk. The SMVis then traced to the inferior margin of the pancreas. Cholecystectomyis performed, and the common bile duct transected just cephalic to thecystic duct. The proper hepatic artery is then identified and looped.The gastroduodenal artery can be isolated and dissected. Nodal tis-sues surrounding the proper hepatic artery and the common hepaticartery are excised. If preservation of the pylorus is planned, the rightgastric and right gastroepiploic arteries are divided, and the duode-num is skeletonised beyond the pylorus and divided using a linearstapler. A tunnel is cautiously created between the SMV-PV trunkposteriorly and the pancreatic neck anteriorly. A silicon drain is theninsinuated into this tunnel to loop up the neck.

TP is performed en bloc in those cases where the tumour involvesthe whole pancreas (e.g. some cases of IPMN; Fig. 1) or in the casesdescribed above. In patients with adenocarcinoma of the head of thepancreas, the pancreas is normally divided on the left margin of theportal vein for a Whipple procedure, and pancreatectomy completedin those cases with a positive resection margin. If venous resection isrequired, it is reserved as the last step in the extirpative phase andthe resection is performed en bloc. To gain the best vascular control,

FIGURE 1 � Pancreatectomy specimen: IPMN which involves the whole pancreas.

June 9, 2009 14:6 B-601 ch17 FA


mobilisation of the left pancreas is performed in those cases to controlthe superior mesenteric, portal, and splenic vein before resection.

If a TP is necessary because of cancer involvement of the distalstump, we resect the pancreas together with the spleen in order toensure radicality. The short gastric vessels are divided. The splenicartery is divided at its origin, while the splenic vein is divided at itsconfluence with the SMV-PV trunk using a vascular stapler or justwith suture closure. The distal pancreatic stump, together with theunderlying splenic vein, is then retracted to the left, and the speci-men dissected off the retroperitoneum towards the spleen. The IMVis ligated and divided. The last step is the division of the lienorenalligament.

We preserve the spleen in all cases where there is no oncologicalneed for splenectomy, because of the potential deterioration of theimmunological and haematological functions as well as the risk ofportal thrombosis. In our series this has been the case in 33%. All theshort gastric vessels are preserved, in case the splenic vessels needto be divided. This is followed by the tedious process of ligating orclipping, and cutting the multiple branches that connect the splenicvein and the splenic artery to the pancreas in the attempt to preserveboth the splenic artery and the splenic vein.

The pylorus is preserved in the same manner as we would inpylorus-preserving pancreatoduodenectomy. A distal gastrectomy isperformed only if necessary secondary to oncological reasons or if theperfusion is compromised.

Portal vein or superior mesenteric vein resection should be per-formed whenever necessary to achieve an R0 resection in pancreaticcancer. Vein resections can be performed with low morbidity and thereconstruction is performed either by direct end-to-end anstomosis orby vascular reconstruction with a Gore-tex graft. Secondary to the riskof graft thrombosis, grafts should only be used in cases where directanstomosis is technically not possible. Since TP for adenocarcinomais mainly indicated in more advanced cancers, venous resection hasbeen performed in 26% of our patients.

June 9, 2009 14:6 B-601 ch17 FA


FIGURE 2 � Reconstruction after total pancreatectomy: biliodigestive (hepaticojejunal)anastomosis with a retrocolic jejunal limb. An antecolic end-to-side duodeno-jejunostomy is performed about 50–60 cm downstream from the bilioentericanastomosis.

Reconstruction after TP consists of an interrupted end-to-sidesingle-layer hepaticojejunal anastomosis with a retrocolic jejunallimb. An antecolic end-to-side duodenojejunostomy is then con-structed about 50 cm downstream from the bilioenteric anastomosis(Fig. 2).

DISCUSSION

Safety

As there is no survival advantage for TP, most surgeons practise partialpancreatic resection for right-sided lesions, reserving TP for lesionsextensively involving the gland or the rare situation in which thepancreas remnant is too inflamed, friable or soft for one to safely per-form a pancreaticojejunostomy. However, today, an elective TP can be

June 9, 2009 14:6 B-601 ch17 FA


performed with a perioperative morbidity and mortality comparableto that of other pancreatic resections.3

Oncological Advantage

Acurative resection (R0) is the single most important factor determin-ing the outcome in patients with pancreatic adenocarcinoma.4 Hence,positive resection margins on frozen-section surgical margin analy-sis remains one of the few indications for us to proceed with a TP.Similarly, longitudinal involvement of the pancreatic duct in cases ofIPMN is another reason for us to cut back until lesion-free margins areobtained, and on some occasions TP becomes necessary. Nevertheless,recent evidence has shown that the presence of atypia or carcinoma-in-situ at the ductal resection margin was not associated with a pooroutcome,5 suggesting the abandonment of this practice with clearmargins in cases of IPMN. However, most centres, including ours,believe that surgical resection should be tailored to the longitudinalspreading into the pancreatic duct, as established by routine frozen-section of the surgical margins.

Functional Consequences

Avoidance of TP prevents the inevitable total loss of exocrine andendocrine function and allows preservation of the spleen. Besidesrendering a patient diabetic, TP takes a nutritional toll as a conse-quence of the loss of exocrine function, leading to persistent diarrhoeaand steatorrhoea. If TP is accompanied by gastric resection vis-à-visa standard Whipple, there will be further nutritional compromise dueto decreased dietary intake as a result of the loss of gastric reservoirfunction. However, recent series have demonstrated that despite lim-itations caused by the ensuing insulin-dependent diabetes mellitus,the overall quality of life is acceptable.3,6 In fact, some centres advo-cate the combination of TP with islet autotransplantation for chronicpancreatitis.7

June 9, 2009 14:6 B-601 ch17 FA


CONCLUSION

In conclusion, the limitations do not justify avoiding total pancreate-ctomy in patients in whom the complete removal of the pancreas isrequired for oncological, technical, prophylactical or complications-related reasons. Total pancreatectomy is a viable option in selectedpatients.

REFERENCES

1. Grace PA, Pitt HA, Tompkins RK, et al. (1986) Decreased morbidity andmortality after pancreatoduodenectomy. Am J Surg 151: 141–149.

2. Billings BJ, Christein JD, Harmsen WS, et al. (2005) Quality of life after totalpancreatectomy: is it really that bad on long-term follow-up? J GastrointestSurg 9: 1059–1066.

3. Müller MW, Friess H, Kleeff J, et al. (2007) Is there still a role for totalpancreatectomy? Ann Surg 246: 966–975.

4. Wagner M, Redaelli C, Lietz M, et al. (2004) Curative resection is the singlemost important factor determining outcome in patients with pancreaticadenocarcinoma. Br J Surg 91: 586–594.

5. D’Angelica M, Brennan, MF, SuriawinataAA, et al. (2004) Intraductal pap-illary mucinous neoplasms of the pancreas: an analysis of clinicopatho-logic features and outcome. Ann Surg 239: 400–408.

6. Behrmann SW, Mulloy M. (2006) Total pancreatectomy for the treatmentof chronic pancreatitis: indications, outcomes, and recommendations.Am Surg 72: 297–302.

7. Blondet JJ, Carlson AM, Kobayashi T, et al. (2007) The role of total pan-createctomy and islet autotransplantation for chronic pancreatitis. SurgClinics North Am 87: 1477–1502.

8. Büchler MW, Wagner M, Schmied BM, et al. (2003) Changes in morbidityafter pancreatic resection: toward the end of completion pancreatectomy.Arch Surg 138: 1310–1314.

9. Brentnall TA. (2005) Management strategies for patients with hereditarypancreatic cancer. Curr Treat Options Oncol 6: 437–445.

June 9, 2009 14:6 B-601 ch18 FA

chap

ter18

Radiofrequency Ablation in the Treatmentof Liver Tumours

Joris Joosten∗,† and Theo Ruers†

INTRODUCTION

Surgical resection is still considered the gold standard for the treat-ment of malignant liver tumours. However, only a selected groupof patients is amenable to resection. Several local tumour ablativetechniques may offer an alternative therapeutic option in the caseof non-resectable liver tumour. These techniques can be used eitheralone or in combination with resection. Among all local ablative tech-niques, radiofrequency ablation (RFA) is the most widely used. Thistechnique is easy to perform and morbidity is low.

Less commonly used techniques, with variable results indifferent series, are percutaneous ethanol injection (PEI), transarte-rial chemoembolisation (TACE), cryosurgery and laser-induced ther-motherapy (LITT).

Liver tumours of all origins can be treated by RFA. Where thetechnique has shown to be effective in hepatocellular carcinoma and

∗Corresponding author.Department of Surgery, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands.E-mail: [email protected]†Department of Surgical Oncology, The Netherlands Cancer Institute, Amsterdam,The Netherlands. E-mail: [email protected]

133

June 9, 2009 14:6 B-601 ch18 FA

134 J. Joosten and T. Ruers

neuroendocrine tumours, its efficacy in patients with colorectal livermetastases is still debatable.

TECHNIQUE AND RESULTS

Radiofrequency current in tumour treatment was first describedaround 1910, when Beer and Clark treated bladder, breast and skincancers. The basic idea behind local tumour ablation in liver tumoursis to selectively destroy tumour tissue (including a rim of normal tis-sue around the tumour) without significant damage to vascular struc-tures in the remaining liver and hence consequent loss of large areasof normal liver tissue.

During RFA a small electrode is placed within the tumour,enabling the delivery of radiofrequency energy directly to the tissue.Radiofrequency current generates ionic agitation, which is convertedinto frictional heat. Tissue damage already occurs at temperaturesabove 42◦C. Above 60◦C denaturation of cellular proteins starts andcell damage is irreversible.

At the moment there is a great variety in RFA electrodes and elec-trode systems. In general plain, cooled, expandable, wet and bipolarelectrodes can be recognised. Also, there are electrode designs usingdouble combinations like cooled–wet or expandable–wet electrodes.Even triple combination electrodes are on the market. Electrode sys-tems can be used with one or multiple electrodes, and also the electricmode in which they are used is variable. In the monopolar modeall electrodes have the same polarity and current flows in the samedirection to the grounding pad. Using bipolar electrode systems, thecurrent flows between two or more parallel-inserted electrodes.

A major problem when one is comparing different reports onRFA is the lack of uniformity and incomplicity in which the usedRFA techniques are described. Evidently there was a strong needfor standardisation of terminology and reporting criteria, as wererecently provided by the International Working Party on Image-guided Tumour Ablation.1

June 9, 2009 14:6 B-601 ch18 FA

Radiofrequency Ablation in the Treatment of Liver Tumours 135

It has to be stated that with the (ongoing) developments inradiofrequency equipment, data from the early days of RFA are lessconvincing then recent results, which show much better total tumourablation, less local recurrence and greater ablation zones even at dif-ficult anatomic sites.

RFA can be performed in several ways: percutaneously, laparo-scopically and by laparotomy.2–4 The open and laparoscopic approachmay have several advantages. First, during the open approach, RFAofnon-resectable lesions can be performed in combination with resec-tion of lesions that cannot be treated effectively by RFA because oftheir large size. Second, laparotomy or laparoscopy allows thoroughevaluation of the extent of liver involvement by inspection and intra-operative ultrasound. Third, during open and laparoscopic RFA adja-cent organs can easily be protected from burn injuries. The advan-tages of percutaneous techniques are obvious: less surgical trauma,shorter hospital stay and lower costs. It is also easier to repeat percu-taneous treatment in the case of residual tumour or recurrence. Themain disadvantage of such treatment seems to be that it is less reliable,especially for larger lesions and superficial lesions.

For all approaches, correct positioning of the RFA probe is cru-cial, which requires honed skills. Poon et al. have described a clearlearning curve for RFA percutaneously as well as surgically.5 In theirfirst 50 patients complete tumour ablation was achieved in 85% (mostincomplete ablations in percutaneously treated patients), while in thenext 50 patients 100% tumour ablation was accomplished.

Postoperative Follow-up Imaging

After local ablative treatment, a contrast-enhanced CT scan is gener-ally used for follow-up. More recently, the FDG-PET scan has beenused to follow up local ablative treatment. After successful treat-ment metastatic lesions become photopenic. Persistent activity afterlocal tumour treatment is highly suspicious, suggesting inadequatetreatment. Moreover, the reappearance of activity in photopenic areasis strongly indicative of tumour recurrence.6

June 9, 2009 14:6 B-601 ch18 FA


Complications

Mulier et al. have reported in an extensive review on the complica-tion rates in 3670 patients, treated for a variety of liver tumours byRFA either percutaneously, laparoscopically or during laparotomy.7

The complication rates were 7.2%, 9.5% and 9.9% respectively. Themortality rate during percutaneous RFA was 0.5% and zero for bothof the other approaches.

The most-encountered complications were intra-abdominalbleeding (1.6%), abdominal infection (1.1%) and biliary tract dam-age (1.0%). Other complications, which occurred less frequently, werepulmonary-related complications, dispersive pad skin burns, liverfailure, visceral damage and hepatic vascular damage. When RFAwas combined with resection, mortality and morbidity rates werecomparable to those for patients treated by resection alone — 4.5%and 31.8%, respectively. The authors conclude that although the com-plication rate after RFA is low, it is higher than assumed and manycomplications can be prevented.

Local Recurrence

A meta-analysis of the local recurrence rate after hepatic RFA wasrecently published by Mulier et al.8 Amongst others, this series com-prised hepatocellular carcinoma (2369 lesions), unspecified lesions(1046) and colon cancer metastases (763 lesions). In a multivariateanalysis, significantly less local recurrences were observed for smallsize lesions (P < 0.001) and for lesions treated using a surgical (versuspercutaneous) approach (P < 0.001). Moreover, lesions close to vascu-lar structures or located subcapsularly showed a higher tendency forrecurrence. Except for neuroendocrine tumours that showed a morefavourable local recurrence rate, histology of the lesions was of lessimportance.

In an earlier analysis the same authors described 806 patients withcolorectal liver metastases treated by RFA.9 For tumours <3 cm, the

June 9, 2009 14:6 B-601 ch18 FA


FIGURE 1 � Introduction of radiofrequency probe into metastases.

local recurrence rate after the open or laparoscopic approach was zeroversus 19% for the percutaneous approach. For lesions > 3 cm, thelocal recurrence rate after the open or laparoscopic approach was 20%versus 51% for the percutaneous approach. However, most percuta-neous RFA procedures were performed under ultrasound guidance;series that report MRI-guided or CT-guided RFAprocedures generallyreport better local control rates.

Overall Survival

A five-year survival of 18.4% is described in the largest and longestfollow-up study of RFA in colorectal metastases.10 Strong predictorsof survival are the number and dominant size of the metastases andthe preoperative CEAlevel. In general, one-year overall survival afterradiofrequency of non-resectable colorectal liver metastases variesbetween 80% and 93%, two-year overall survival is reported asbetween 50% and 75%, and three-year overall survival varies between21% and 53%.11,12

June 9, 2009 14:6 B-601 ch18 FA


FIGURE 2 � Ultrasound monitoring of treatment effect. Note air bubbles in treatmentzone.

FIGURE 3 � FDG-PET scan after RFAtreatment. Note dark photopenic areas, indicatingsuccessful treatment.

Survival rates for hepatocellular carcinoma are even more encour-aging. A five-year overall survival of 55% is described by Raut et al.13

These figures strongly point to a difference in treatment successbetween different tumour origins.

June 9, 2009 14:6 B-601 ch18 FA


CONCLUSION

Recent literature shows that RFAfor liver tumours is feasible and safe.Although RFA has proved to be effective for local tumour control, atpresent there is no direct evidence that RFAis equal to resection. Untilsuch a proof is obtained, resection of liver tumours should still beconsidered the gold standard.

REFERENCES

1. Goldberg SN, Grassi CJ, Cardella JF, et al. (Society of Interventional Radi-ology Technology Assessment Committee). (2005) Image-guided tumorablation: standardization of terminology and reporting criteria. J VascInterv Radiol 16(6): 765–778.

2. Tateishi R, Shiina S, Teratani T, et al. (2005) Percutaneous radiofrequencyablation for hepatocellular carcinoma: an analysis of 1000 cases. Cancer103(6): 1201–1209.

3. Berber E, Siperstein AE. (2007) Perioperative outcome after laparoscopicradiofrequency ablation of liver tumors: an analysis of 521 cases. SurgEndosc 21(4): 613–618.

4. Amersi FF, McElrath-Garza A, Ahmad A, et al. (2006) Long-term survivalafter radiofrequency ablation of complex unresectable liver tumors. ArchSurg 141(6): 581–587.

5. Poon RT, Ng KK, Lam CM, et al. (2004) Learning curve for radiofrequencyablation of liver tumors: prospective analysis of initial 100 patients in atertiary institution. Ann Surg 239(4): 441–449.

6. Langenhoff BS, Oyen WJ, Jager GJ, et al. (2002) Efficacy of fluorine-18-deoxyglucose positron emission tomography in detecting tumor recur-rence after local ablative therapy for liver metastases: a prospectivestudy. J Clin Oncol 20(22): 4453–4458.

7. Mulier S, Mulier P, Ni Y, et al. (2002) Complications of radiofrequencycoagulation of liver tumours. Br J Surg 89(10): 1206–1222.

8. Mulier S, Ni Y, Jamart J, et al. (2005) Local recurrence after hepaticradiofrequency coagulation: multivariate meta-analysis and review ofcontributing factors. Ann Surg 242(2): 158–171.

9. Mulier S, Jamart J, Michel L. (2004) Hepatic radiofrequency coagula-tion: less local recurrences after surgical approach. Eur J Surg Oncol 30:193–194.

June 9, 2009 14:6 B-601 ch18 FA


10. Siperstein AE, Berber E, Ballem N, Parikh RT. (2007) Survival afterradiofrequency ablation of colorectal liver metastases: 10-year experi-ence. Ann Surg 246(4): 559–567.

11. Joosten J, Ruers T. (2007) Local radiofrequency ablation techniques forliver metastases of colorectal cancer. Crit Rev Oncol Hematol 62(2): 153–163.

12. Ruers TJ, Joosten JJ, Wiering B, et al. (2007) Comparison between localablative therapy and chemotherapy for non-resectable colorectal livermetastases: a prospective study. Ann Surg Oncol 14(3): 1161–1169.

13. Raut CP, Izzo F, Marra P, et al. (2005) Significant long-term survivalafter radiofrequency ablation of unresectable hepatocellular carcinomain patients with cirrhosis. Ann Surg Oncol 12(8): 616–628.

June 9, 2009 14:6 B-601 ch19 FA

chap

ter19

Atypical Liver Resections of ColorectalMetastases

Bjarne Ardnor† and Peter Naredi∗,†

INTRODUCTION

Indications

Radical resection of colorectal metastases to the liver is associatedwith a 30%–60% five-year survival rate, while the natural course ornon-radical treatment options rarely give a survival rate past threeyears. The survival outcome is acceptable also after resection of bilobarlesions and when more than four metastases are present. Re-resectionsresult in a survival rate similar to that after a primary liver resec-tion. As a consequence, more patients undergo liver resections andinstead of lobe resections multiple small resections are often preferredto preserve liver parenchyma.

Resection Margin

A resection margin of at least 1 cm has been considered importantto avoid recurrence in the resection area and it also correlates withbetter survival.1 Most cancer cells in the parenchyma can be found

∗Corresponding author.†Department of Surgery, Umea University Hospital, S-90185 Umea, Sweden. E-mail:[email protected]

141

June 9, 2009 14:6 B-601 ch19 FA

142 B. Ardnor and P. Naredi

within 2 mm from the colorectal liver metastases.Anarrower resectionmargin is therefore considered adequate if necessary. A surgical mar-gin of 2 mm is an acceptable minimum requirement, with a 6% riskof margin-related recurrence. A margin of less than 2 mm increasesthe risk of relapse but is still better than refraining from resection.2 Infact, the size of the surgical margin did not influence the recurrencerate after curative liver resection.3

From a surgical oncology perspective there is another reasonto avoid a narrow margin: when the resection is to close to thetumour, there is an increased risk of rupture of the surroundingsoft liver parenchyma during resection of firm colorectal liver metas-tases. A rupture increases the risk of cancer cell seeding and tumourrecurrence.

Surgical Techniques

The parenchyma can be transected by several methods, and the choiceof technique can be decided by the surgeon as no method has provedto be superior or inferior. The clamp crushing technique (Kelly clamp)with Pringle’s manoeuvre was found in a randomised trial to be fasterand less costly than ultrasonic surgical aspiration, hydrojet or dis-secting sealer.4 A drawback in that study was that Pringle’s manoeu-vre was performed only with the clamp crushing technique. Othertechniques are the finger fracture technique, diathermy, ultrasoniccoagulating shears and staples. We prefer to use ultrasonic surgicalaspiration with a nose cone for electrocoagulation.

TECHNIQUE

An atypical liver resection is not primarily performed with anatom-ical borders, but with the location of the tumour being decisive asto how the resection should be performed. While segmental or loberesections are mostly performed by central ligature of the vesselsbefore parenchymal transection, the atypical resection is done with

June 9, 2009 14:6 B-601 ch19 FA

Atypical Liver Resections of Colorectal Metastases 143

a different technique. The vessels are occluded during the parenchy-mal transection.

The tumour location determines whether the atypical resection isa wedge resection or has the form of a crater. Tumours close to the leftor caudal border of segments I–VI are suitable for wedge resections(Fig. 1). Tumours more centrally located or at the dome of segment V,VII or VIII are resected leaving a crater (Fig. 2).

The liver is exposed through a right subcostal incision which issometimes extended to the left side. Ligamentum teres and the fal-ciform ligament are always divided and we prefer to mobilise theleft or right triangular ligament, depending on the tumour location.Except for tumours deeply central in the right lobe, any tumour canbe taken out with an atypical resection. After mobilisation we per-form an ultrasound to visualise blood vessels and bile ducts aroundthe tumour. The liver capsule is marked 2 mm deep, with diathermy

FIGURE 1 � Surgical anatomy with vessels and bile ducts to each liver segment.

June 9, 2009 14:6 B-601 ch19 FA


FIGURE 2 � Atypical liver resections in segments VI and VII (wedge resection) andsegment V (crater-formed resection).

at the site of transection. If possible, this is at least 1 cm outside theouter border of the tumour. The intended line of transection is con-firmed by ultrasound as the capsule mark is seen as a shadow andthe margin between the tumour and the shadow can be estimated.Next, we adapt a cotton ribbon around the hepatoduodenal ligamentand are prepared to strangle the inflow (Pringle’s manoeuvre) if nec-essary. The parenchymal transection is then performed by ultrasonicdissection (Integra CUSAEXcel™ Ultrasonic 36 kHz handpiece with aCEM™ nose cone, providing simultaneous or independent activationof ultrasonic and electrosurgical functions) and electrocoagulation ofvessels with a diameter of less than 3 mm. Argon beam coagulationis effective if vessels are still bleeding. Vessels and bile ducts largerthan 3 mm are ligated with 3-0 or 4-0 nonabsorbable coated braidedpolyester sutures or sutured with 3-0 or 4-0 nonabsorbable monofilpolypropylene sutures (Fig. 3). We prefer to use half-circle-shaped

June 9, 2009 14:6 B-601 ch19 FA


FIGURE 3 � The liver parenchyma is dissected with ultrasonic apiration, leaving ves-sels and bile ducts as bridges. These are ligated and divided.

needles with a length of 26 or 36 mm, in order to avoid unneseccarytraction in the parenchyma.

Awedge resection is straightforward, paying attention to the 1 cmtransection margin without the need to occlude any main branches toa liver segment. In a crater-formed resection the cylindric transectionis continued past the depth of the tumour before the line of transectionis directed 1 cm underneath the tumour. Centrally located tumours areoften close to vital structures. We dissect the tumour free from the leftand the right portal branch, the left or the right hepatic bile duct andthe left or the right hepatic artery. At least one of the liver veins issaved.

It is rare that resections of tumours with a diameter of 1 cm orless and located close to the surface have to involve large vessels.When the tumour is deep in the parenchyma or larger (> 2 cm), thetransection will be at least 3 cm deep. As a consequence, segmentalvessels or larger liver veins are often part of the margin.

June 9, 2009 14:6 B-601 ch19 FA


Avoidance of bleeding is pivotal. This is simplified by decreasingthe venous backflow and by inflow control. The venous backflowfrom hepatic veins is controlled by low central venous pressure (0–5 cm H2O).5 and by hand pressure on the parenchyma by the assis-tant. Inflow control by Pringle’s manoeuvre makes the resection easyand with minimal bleeding. The duration of the inflow control cansafely be 60 minutes, and in most cases up to 90 minutes if the patienthas normal liver function. There was less hepatic ischaemia with pre-conditioning and reperfusion in younger patients or patients withsteatosis.6 Most patients with liver metastases have normal liver func-tion, while liver cirrhosis and liver insufficiency are more common inpatients with hepatocellular carcinomas. Inflow control rarely needsto be maintained for more than 20 minutes during an atypical resec-tion and therefore Pringle’s manoeuvre can be used for 3–5 atypicalresections during the same operation.

DISCUSSION

Several factors influence whether an atypical or a segmental resec-tion should be made. The size and location of the tumour and thenumber of metastases are most important. The residual volume andquality of the liver parenchyma are considered. Lobe or segment resec-tions are often technically easier, but not necessary to perform or theywould leave insufficient functional liver volume. An atypical resec-tion should not be mistaken as a tumour excision or biopsy. Up to25% of wedge resections were reported to be non-radical and there-fore segment resections have been recommended as the preferredmethod.7 In our opinion the 1 cm margin can normally be achieved inwell-planned atypical resections. Our position of favouring atypicalresections is also based on our and others’3 experience that marginrecurrences are rare and that atypical resections have not been asso-ciated with a worse survival outcome.8

June 9, 2009 14:6 B-601 ch19 FA


REFERENCES

1. Elias D, Cavalcanti A, Sabourin JC, et al. (1998) Results of 136 curativehepatectomies with a safety margin of less than 10 mm for colorectalmetastases. J Surg Oncol 69(2): 88–93.

2. Kokudo N, Miki Y, Sugai S, et al. (2002) Genetic and histological assess-ment of surgical margins in resected liver metastases from colorectalcarcinoma: minimum surgical margins for successful resection. Arch Surg137(7): 833–840.

3. Bodingbauer M, Tamandl D, Schmid K, et al. (2007) Size of surgical margindoes not influence recurrence rates after curative liver resection for col-orectal cancer liver metastases. Br J Surg 94(9): 1133–1138.

4. Lesurtel M, Selzner M, Petrowsky H, et al. (2005) How should transectionof the liver be performed? Aprospective randomized study in 100 consec-utive patients: comparing four different transection strategies. Ann Surg242(6): 814–822, discussion 822–823.

5. Jones RM, Moulton CE, Hardy KJ. (1998) Central venous pressure and itseffect on blood loss during liver resection. Br J Surg 85(8): 1058–1060.

6. Clavien PA, Selzner M, Rudiger HA, et al. (2003) A prospective random-ized study in 100 consecutive patients undergoing major liver resectionwith versus without ischemic preconditioning. Ann Surg 238(6): 843–850,discussion 851–852.

7. DeMatteo RP, Palese C, Jarnagin WR, et al. (2000) Anatomic segmentalhepatic resection is superior to wedge resection as an oncologic operationfor colorectal liver metastases. J Gastrointest Surg 4(2): 178–184.

8. Zorzi D, Mullen JT, Abdalla EK, et al. (2006) Comparison between hepaticwedge resection and anatomic resection for colorectal liver metastases.J Gastrointest Surg 10(1): 86–94.

June 9, 2009 14:6 B-601 ch20 FA

chap

ter20

Extended Hepatectomy for Primaryand Metastatic Liver Lesions

René Adam∗,†,§,‖, Emir Hoti†,¶, Dennis A. Wicherts†,‡ andRobert J. de Haas†,‡

INTRODUCTION

Surgical resection is the only potentially curative treatment for themajority of primary and metastatic liver lesions. For example, curativeresection of colorectal liver metastases may achieve five-year survivalrates of >50% in selected patients.1 Due to significant improvementsin liver surgery techniques, the possibility of curative hepatectomy isdetermined only by the extent of the resection in relation to the rem-nant liver volume. Resection of up to 75% of normal parenchymacan be performed without the risk of postoperative liver failure.2

Clearly, the most important indication for extended hepatectomy isthe presence of extensive intrahepatic tumour, caused by either multi-nodular bilobar disease or large tumour size. Additionally, lesions

∗Corresponding author.†AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, 12 Avenue Paul VaillantCouturier, F-94804 Villejuif, France. E-mail: [email protected]‡Department of Surgery, University Medical Center Utrecht, Utrecht, TheNetherlands.§Inserm, Unité 785, F-94804 Villejuif, France.‖Université Paris-Sud, UMR-S 785, F-94804 Villejuif, France.¶Liver Transplant Unit, Saint Vincent’s University Hospital, Dublin 4, Ireland.

149

June 9, 2009 14:6 B-601 ch20 FA

150 R. Adam et al.

closely related to vascular or biliary structures may require largerresections. Extended hepatectomies can currently be performed withlow mortality and acceptable morbidity, not so different from thosereported overall for liver resections.3

The classification of extended hepatectomies is based on the seg-mental liver anatomy described by Couinaud.4 Extended hepaticresections are defined as resections exceeding the boundaries of anormal right (segments V–VIII) or left (segments II–IV) hepatectomyand are divided into six different types. Right hepatectomies canbe extended to segment IV, segment I, or both [Figs. 1A–1C]. Simi-larly, extended left hepatectomies may include segment I, segments Vand VIII, or segments I,V and VIII [Figs. 2A–2C].

FIGURE 1(A)–1(C) � Right hepatectomy extended to segment IV (A), segment I (B), andsegments I and IV (C).

FIGURE 2(A)–2(C) � Left hepatectomy extended to segment I (A), segments V and VIII(B), and segments I, V and VIII (C).

June 9, 2009 14:6 B-601 ch20 FA

Extended Hepatectomy 151

TECHNIQUE

Preoperative Evaluation and Patient Selection

Computed tomography and magnetic resonance imaging of the liverare the preferred investigative modalities. Determining the intra-hepatic extent of the disease and its relation to important vascularand biliary structures is essential for planning the extensiveness ofthe resection.

The functional capacity of the liver is measured by the indo-cyanine green (ICG) test, to determine the necessary volume of theremaining liver after hepatectomy. Portal vein embolisation (PVE)may be considered when the remnant liver is too small in relation tothe planned resection and the functional capacity. By compensatoryhypertrophy of the nonembolised lobe, the future liver remnant mayincrease to a sufficient volume enabling resection.5 In general, to per-form a safe resection, the remnant liver should have >30% of func-tional parenchyma in the absence of prolonged chemotherapy andnormal ICG clearance. On the other hand, for patients who have hadprolonged chemotherapy or abnormal ICG clearance, the functionalparenchyma volume should be >40%.

Surgical Procedure

A bilateral subcostal incision with a vertical extension is widelyemployed for extended liver resections. Once the abdomen is entered,thorough exploration is performed to identify all hepatic and extra-hepatic disease, and if there are no contraindications to resection, livermobilisation should start. At this point, it is important to use intra-operative ultrasound to define the resection plane correctly, which isa crucial step of the procedure.

Extended Right Hepatectomy

The initial steps of this procedure are identical to those of a righthepatectomy. In addition, supplying vessels to segment IV should be

June 9, 2009 14:6 B-601 ch20 FA

152 R. Adam et al.

divided. This is done by transecting the parenchymal bridge betweensegments III and IV, followed by dissection on the right side of the lig-amentum teres, identifying and suture-ligating all the portal brancheswith the accompanying arteries and ducts. In resections where seg-ment I has to be included, its mobilisation is achieved by rotatingthe right lobe medially. The exposed hepatic veins can be dividedand ligated from below upwards. The dissection is then continued onthe lateral side of the inferior vena cava (IVC) dividing the drainingveins of segment I under direct vision. This manoeuvre leaves theliver attached only on the main hepatic veins. The operation contin-ues with the hilar dissection in order to divide the feeding vessels tosegment I which arise from the left hepatic artery and vein.6 Anotherdescribed approach involves anterolateral dissection; however, this istechnically more difficult and surgeons often adopt a combination ofapproaches.7

The parenchyma is divided progressing posteriorly towards thejunction of the right hepatic vein with the IVC. Transection is usuallydone by using an ultrasonic dissector. Hemostasis of the cut liversurface is secured by suture-ligation combined with a bipolar or argonbeam. During this stage, using a tape along the retrohepatic surfacecan be useful in controlling the direction of the transection.

Extended Left Hepatectomy

The initial steps are the same as for a left hepatectomy. Before definingthe plane of parenchymal transection, it is important to complete twomanoeuvres involving the portal triad and the common trunk of themiddle and left hepatic vein. The structures of the portal triad are dis-sected above the origin of the feeding vessels to segment I, to secureand preserve them intact. However, if segment I has to be included inthe resection, both bile duct and portal vein are ligated and dividedclose to the hilum. Further dissection continues to control the rightanterior and posterior sectorial pedicle. Once this step is completed,the hepatic veins are dealt with. Their control, which is usually done

June 9, 2009 14:6 B-601 ch20 FA


in their extrahepatic portion, is very important as it facilitates thelater parenchymal transection and reduces blood loss. After a com-plete left lobe mobilisation and medial retraction, further dissectionbetween the left hepatic vein (top of the caudate lobe) and the IVCopens a window which allows complete control of the middle and lefthepatic vein.

The parenchymal resection is done in an upward direction. Defin-ing the resection plane is important, as it allows the preservation ofthe posterior sectorial pedicle which supplies segments VI and VII.Usually, this plane runs anterior to the right hepatic vein extendinghorizontally to the right of the gallbladder fossa. Early clamping ofthe anterior sectorial pedicle can be useful, as it better defines the lineof resection by producing a clear parenchyma demarcation.

Haemorrhage Control

Despite technical refinements, operative bleeding still remains a con-cern, clearly being an independent risk factor in the postoperativeoutcome.8 Inflow clamping is the most used technique to reduce bloodloss. Vascular pedicles can be divided either during the preliminaryportal dissection or during the division of the parenchyma.

For complex hepatic resections where bleeding is anticipated, totalvascular exclusion with or without IVC clamping and venovenousbypass can be useful.9,10 This approach has the advantage of elim-inating bleeding as well as enabling vascular reconstruction. Obvi-ously, vascular exclusion without clamping the IVC is the preferredapproach as it avoids the negative consequences of IVC clamping[Fig. 3A]. When such a step is not feasible, for example in case ofproximity of the tumour to the hepatic vein confluence, a true lobeischaemia with IVC clamping should be performed [Fig. 3B]. A testclamp lasting 5 minutes should be done to see if the haemodynamicchanges are tolerated by the patient. If IVC clamping is not tolerated,venovenous bypass remains the only available option through whichresection can be done [Fig. 3C].

June 9, 2009 14:6 B-601 ch20 FA

154 R. Adam et al.

FIGURE 3(A)–3(C) � Selective total vascular exclusion of the liver (A). Total vascularexclusion with clamping of interior vene cava (B). Total vascular exclusion combinedwith venous bypass (C).

DISCUSSION

Resection of primary and metastatic liver lesions depends solely onthe technical ability to resect the total number of lesions, while leav-ing a sufficient volume of remnant parenchyma. Accordingly, preop-erative PVE can be used to facilitate such resections. For extendedright and left hepatectomies, the control of supplying vessels to seg-ments I and/or IV, and segments I and/or V and VIII, respectively, isa very important step to consider. Measures aimed at reducing bloodloss, such as intermittent selective portal clamping and total vascularexclusion with or without bypass, should always be considered whenperforming extended hepatectomies.

REFERENCES

1. Simmonds PC, Primrose JN, Colquitt JL, et al. (2006) Surgical resectionof hepatic metastases from colorectal cancer: a systematic review of pub-lished studies. Br J Cancer 94: 982–999.

June 9, 2009 14:6 B-601 ch20 FA


2. Vauthey JN, ChaouiA, Do KA, et al. (2000) Standardized measurement ofthe future liver remnant prior to extended liver resection: methodologyand clinical associations. Surgery 127: 512–519.

3. Vauthey JN, Pawlik TM, Abdalla EK, et al. (2004) Is extended hepatec-tomy for hepatobiliary malignancy justified? Ann Surg 239: 722–732.

4. Couinaud C. (1957) Le foie: études anatomiques et chirurgicales. Masson etCie, Paris.

5. Azoulay D, Castaing D, Smail A, et al. (2000) Resection of nonresectableliver metastases from colorectal cancer after percutaneous portal veinembolization. Ann Surg 231: 480–486.

6. Yamamoto J, Takayama T, Kosuge T, et al. (1992) An isolated caudatelobectomy by the transhepatic approach for hepatocellular carcinoma incirrhotic liver. Surgery 111: 699–702.

7. Elias D, Lasser PH, Desruennes E, et al. (1992) Surgical approach to seg-ment I for malignant tumors of the liver. Surg Gynecol Obstet 175: 17–24.

8. Jarnagin WR, Gonen M, Fong Y, et al. (2002) Improvement in periopera-tive outcome after hepatic resection: analysis of 1803 consecutive casesover the past decade. Ann Surg 236: 397–407.

9. Cherqui D, Malassagne B, Colau PI, et al. (1999) Hepatic vascular exclu-sion with preservation of the caval flow for liver resections. Ann Surg230: 24–30.

10. Shaw Jr BW, Martin DJ, Marquez JM, et al. (1984) Venous bypass in clinicalliver transplantation. Ann Surg 200: 524–534.

June 9, 2009 14:6 B-601 ch21 FA

chap

ter21

Isolated Hepatic Perfusion: How ItShould Be Done

Alexander L. Vahrmeijer†, Liselot B. J. van Iersel‡,Peter J. K. Kuppen† and Cornelis J. H. van de Velde∗,†

INTRODUCTION

Isolated hepatic perfusion (IHP) is based on the expectation thattumour cells confined to the liver can be killed by drug doses thatwould kill a patient if delivered systemically but will not cause fatalhepatotoxicity. Based on pre-operative CT scans, and when neces-sary MRI or PET scans in difficult cases, patients with irresectablemetastases confined to the liver are considered for IHP treatment.Most experience is obtained in patients with irresectable colorectalcancer hepatic metastases.1–5 An obvious limitation of IHP is that itseffect totally depends on a high peak concentration during a relativelyshort exposure time: the duration of IHP is usually limited to one hour.Alkylating compounds like the most frequently used drug, Melphalan

∗Corresponding author.†Department of Surgery, Leiden University Medical Center, PO Box 9600, 2300 RC,Leiden, The Netherlands. E-mail: [email protected]‡Medical Oncology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA,Leiden, The Netherlands.

157

June 9, 2009 14:6 B-601 ch21 FA

158 A. L. Vahrmeijer et al.

(L-PAM), are effective after a relatively short exposure time and showa steep dose–response relationship, and are therefore a logical choicefor testing in an IHP setting. Throughout the perfusion period, sys-temic leakage should be avoided and an accurate leakage detectionsystem is absolutely necessary.

TECHNIQUE OF IHP

The liver is mobilised from the diaphragm through a hockey-stick-shaped abdominal incision. Ultrasonography should be performedin order to prove irresectable disease and to exclude extrahepaticpathology. Moreover, one should estimate the amount of normalliver tissue, which should be at least 40% to prevent post-operativeliver failure. Adequate mobilisation of the liver is mandatory. Theround ligament is divided and the falciform ligament is dissectedover its full length, just anterior to the inferior vena cava (IVC). Thesuperior ligamentous attachments and the triangular ligaments aredivided. The right adrenal gland should be separated from the liverand the adrenal veins are ligated. Mobilisation of the liver contin-ues until the IVC is fully exposed (Fig. 1). Lumbar veins are ligated

FIGURE 1 � Dissected inferior vena cava prior to cannulation.

June 9, 2009 14:6 B-601 ch21 FA

Isolated Hepatic Perfusion: How It Should Be Done 159

FIGURE 2 � Dissected hepatoduodenal ligament prior to cannulation.

to prevent systemic leakage of perfusate. The gastrohepatic ligamentshould be dissected and inspected for a replaced left hepatic artery.The latter is extremely important, because in eight patients treatedvia the portal vein only at our institution, no tumour response wasobserved. Therefore, infusion of chemotherapy via the hepatic arteryis absolutely necessary. At present, aberrant arterial anatomy is a con-traindication for IHP. The common bile duct, the portal vein andthe common hepatic artery are dissected over an adequate length inthe hepatoduodenal ligament (Fig. 2). After heparinisation, the com-mon hepatic artery is cannulated via the gastroduodenal artery (8-Fr77008 one-piece pediatric arterial cannula; Medtronic, Minneapolis,Minnesota, USA). Subsequently, the portal vein is cannulated (12-Fr perfex perfusion catheter). Both inflow limbs are connected to aheart–lung machine which consists of two independent roller pumps(model 10-30-00; Cobe/Stöckert, Munich, Germany). The inflow in thehepatic artery and portal vein is usually about 360 and 330 ml/minrespectively.1 The IVC is cross-clamped above the hepatic veins, just

June 9, 2009 14:6 B-601 ch21 FA


below the diaphragm, and cannulated proximal of the renal veins(Polystan 36-Fr, straight, A/S; Värlöse, Denmark) to allow undis-turbed blood flow from the hepatic veins through the IVC towardsthe heart–lung machine. The perfusion medium consists of intra-hepatically trapped blood and 1250 mL Gelofusine� (Vifor Medical,Sempach, Switzerland) plus 2500 units heparin (Leo Pharma, Breda,The Netherlands) to yield a final volume of approximately 2 litres.Throughout the 1 h perfusion period, the perfusate is kept at a tem-perature of 39.5◦C by a heat exchanger and oxygenated using anoxygenator (Cobe VPCML; Cobe Cardiovascular, Arvada, Colorado,USA, or Dideco D901; SORIN group Italia, Mirandola, Italy). To iso-late the hepatic circuit, tourniquets are secured around the hepaticartery, portal vein and IVC above the right renal vein. Blood fromthe IVC below the tourniquet and from the mesentery is shunted byapplying a venovenous bypass. For the extracorporeal venovenousbypass, the right femoral vein (22-Fr cannula DIITF022L; EdwardsLifesciences, Irvine, California, USA) and the portal vein (17-Fr per-fex perfusion catheter CH17; B. Braun) (proximal to the tourniquet)are cannulated and connected to the right axillary vein (18-Fr 7326perfusion cannula; Lifestream International, The Woodlands, Texas,USA). The venovenous bypass is supported by a centrifugal pump(Medtronic BIO-Medicus, Eden Prairie, Minnesota, USA) and primedwith 700 mL 0.9% saline.

SAFETY

Leakage of perfusate into the systemic circulation is monitored usinga 99mTechnetium-pertechnetate (99mTc)-based method that is adaptedfrom a method described by Runia et al.6 Before isolation of the liver,tin pyrophosphate (1 mg in 2 ml of PBS) (Technescan Pyp, Mallinck-rodt Medical) is intravenously injected. This will bind 99mTc to redblood cells: detection of leakage is based on measurement of leakage

June 9, 2009 14:6 B-601 ch21 FA


FIGURE 3 � Isolated hepatic perfusion circuit with extracorporeal veno-venousbypass.

of erythrocytes from the isolated circuit to the systemic circulation.After 15–30 min, the liver is isolated from the systemic circulation asdescribed above. Next, 10 MBq 99mTc is added to the isolated circuit.The level of radioactivity is measured continuously by two detectors(NaI scintillation counters, model 51S51, efficiency 15.5%; Canberra,Cedex, France) — one placed above the tube of the venovenous bypassand the other above the tubing that directs blood flow from the liver(vena cava) to the heart–lung machine (Fig. 3). The detectors areshielded from the background using a cover of lead 1 cm thick. Tub-ing under the detector is winded to increase the detection volume inorder to increase sensitivity. The volume under the systemic detec-tor is 10.4 ml and under the isolated circuit detector 5.5 ml. Special

June 9, 2009 14:6 B-601 ch21 FA


software, based on the algorithms described by Runia et al.6 has beendeveloped (Canberra Eurisys Benelux, Zellik, Belgium) for real timemonitoring of leakage with a sensitivity of <1%. In case of leakage,the surgeons try to detect and solve the problem. Usually, clampingof the caval vein is not complete or lumbal veins at the back of theliver are not sufficiently ligated. Melphalan (200 mg total dose in ourseries) is administered if no leakage is detected and re-circulated dur-ing 1 h. During perfusion with melphalan, leakage is continuouslymonitored and in case of any leakage that cannot be stopped by thesurgeons, the procedure is aborted and the liver flushed before a levelof 10% leakage is reached. After perfusion, the liver is flushed forapproximately 10 min with 3 litres Gelofusine�. Next, all cannulasand clamps are removed, and the normal circulation is restored. Toprevent possible post-operative chemotherapy-induced cholecystitis,a cholecystectomy is performed.

DISCUSSION

Recently, phase II studies involving IHP in colorectal cancer patientshave shown hepatic response rates of up to 76%, with a median timeto hepatic progression of up to 14.5 months, a median overall survivalof 27 months and 5-year survival of 9%, establishing its value in thetreatment of colorectal liver metastases.1–5 Hepatic metastases derivemost of their blood supply from the hepatic artery and, therefore, inan attempt to increase local drug concentrations, L-PAM was continu-ously infused at reduced flow (±100 ml/min) into the hepatic artery ina subset of patients.5 However, slow (20 min) infusion of L-PAM selec-tively in the hepatic artery did indeed increase the L-PAM concentra-tion in the inflow catheter, but the tumour response rate was reduced.5

Most likely the decreased arterial flow resulted in a decreased arterialpressure, which probably caused insufficient tumour perfusion anddecreased drug uptake. Therefore, it is recommended to perform an

June 9, 2009 14:6 B-601 ch21 FA


IHP procedure at high arterial flow. At present, percutaneously per-formed IHP procedures suffer from high levels of systemic leakage ofperfusate7 and can therefore not replace the open technique, whereleakage seldom occurs. In order to increase the tumour response rate,we recently started a study combining L-PAM and Oxaliplatin deliv-ered via IHP at high arterial flow. At present, results from systemicchemotherapy trials are improving and therefore the timing of IHPbefore or after systemic chemotherapy is unclear. Further studies areneeded to solve this problem and to determine whether IHP deservesa place in the treatment of patients with colorectal cancer hepaticmetastases.

REFERENCES

1. Rothbarth J, Pijl ME, Vahrmeijer AL, et al. (2003) Isolated hepatic perfu-sion with high-dose melphalan for the treatment of colorectal metastasisconfined to the liver. Br J Surg 90(11): 1391–1397.

2. Alexander HR, Jr., Bartlett DL, Libutti SK, et al. (1998) Isolated hepatic per-fusion with tumor necrosis factor and melphalan for unresectable cancersconfined to the liver. J Clin Oncol 16(4): 1479–1489.

3. Bartlett DL, Libutti SK, Figg WD, et al. (2001) Isolated hepatic perfusionfor unresectable hepatic metastases from colorectal cancer. Surgery 129(2):176–187.

4. VahrmeijerAL, van Dierendonck JH, Keizer HJ, et al. (2000) Increased localcytostatic drug exposure by isolated hepatic perfusion: a Phase I clinicaland pharmacological evaluation of treatment with high dose melphalanin patients with colorectal cancer confined to the liver. Br J Cancer 82:1539–1546.

5. van Iersel LB, Verlaan MR, Vahrmeijer AL, et al. (2007) Hepatic arteryinfusion of high-dose melphalan at reduced flow during isolated hepaticperfusion for the treatment of colorectal metastases confined to the liver:a clinical and pharmacologic evaluation. Eur J Surg Oncol 33(7): 874–881.

6. Runia RD, de Brauw LM, Kothuis BJL, et al. (1987) Continuous measure-ment of leakage during isolated liver perfusion with a radiotracer. NuclMed Biol 14: 113–118.

June 9, 2009 14:6 B-601 ch21 FA


7. van Etten B, Brunstein F, van Ijken MG, et al. (2004) Isolated hypoxic hep-atic perfusion with orthograde or retrograde flow in patients with irre-sectable liver metastases using percutaneous balloon catheter techniques:a phase I and II study. Ann Surg Oncol 11(6): 598–605.

June 9, 2009 14:6 B-601 ch22 FA

chap

ter22

Robot-Assisted Laparoscopic ColorectalSurgery

Omer Aziz∗,† and Ara W. Darzi ‡

INTRODUCTION

The advantages of laparoscopic colorectal surgery are well describedin the literature and include reduced postoperative morbidity, smallwound size, reduced postoperative pain, improved cosmesis, andreduced length of hospital stay.1 There are, however, important lim-itations on laparoscopic equipment that include loss of visual depthperception (through monoscopic vision), loss of the eye–hand–targetaxis, unnatural hand–eye co-ordination, and inability by the surgeonto control the view himself.2 The long instruments used in laparo-scopic resections have limited degrees of freedom of movement, fixedentry points with a fulcrum effect, and a static position with non-idealergonomic characteristics.

∗Corresponding author.†Department of Biosurgery and Surgical Technology, Imperial College London,10th Floor, QEQM Building, St Mary’s Hospital, London W2 1NY, UK. E-mail:[email protected]‡Department of Biosurgery and Surgical Technology, Imperial College London,10th Floor, QEQM Building, St Mary’s Hospital, London W2 1NY, UK. E-mail:[email protected]

165

June 9, 2009 14:6 B-601 ch22 FA

166 O. Aziz and A. W. Darzi

The da Vinci surgical system (Intuitive Surgical, Sunnyvale,California), is a four-armed robot that tries to address these limita-tions in the following ways:Astereoscopic 3D vision system improvesthe surgeon’s view of the operative field as well as his depth per-ception, whilst a navigator system allows him to control the cam-era himself. The instruments all have a “wrist”, giving the operatorseven degrees of freedom of movement. The eye–hand–target axis isrestored, making movement intuitive and improving the ergonomics.Finally, tremor is removed, as is trocar resistance, and movementscaled.3 Other robotic systems include the single-armed robot AESOPand the three-armed robotic system Zeus.4,5

Despite this the da Vinci system, like laparoscopy, does notaccount for a loss of tactile feedback, which is something that canbe addressed in the future by incorporation of emerging haptic tech-nologies. Other limitations include a long set-up time, the large size ofthe robot, a limited variety of instruments compared to laparoscopy,and the need for a tableside surgeon and nurse to set up the system,place the trocars, and introduce the robotic instruments. Finally, thecosts of both the robot and consumables are still significant, and alarge number of procedures are required to make it cost-effective.

ROBOT-ASSISTED LAPAROSCOPIC SURGERY

The procedures described in this article include anterior resection,abdominoperineal resection, and sutured rectopexy.

(1) Preoperative preparation. It is important to note that patients shouldhave full bowel preparation prior to the procedure, and be ondeep venous thrombosis prophylaxis through the administrationof pneumatic compression stocking and prophylactic dose lowmolecular weight heparin after the procedure.

(2) Set-up. A nasogastric tube and a urinary catheter should beinserted and the patient placed in the modified Lloyd–Davisposition. Pneumoperitoneum is established and a 12 mm port is

June 9, 2009 14:6 B-601 ch22 FA

Robot-Assisted Laparoscopic Colorectal Surgery 167

FIGURE 1 � Port placement (left) and system layout (right).

placed at the umbilicus. The patient is positioned with a steephead-down tilt, and the da Vinci surgical cart is then positioned.The robotic arms are then placed over the patient and the 8 mmrobotic ports are placed. The system layout and port placement areshown in Fig. 1. A camera port is inserted through the umbilicalport and attached to the robotic camera arm. The primary sur-geon is placed at the console, where he is remote from the patientand has a magnified 3D view of the operating site and control ofboth the camera and two wristed robotic instruments with sevendegrees of freedom.

(3) Mobilisation of the rectum. Anatomical landmarks that need to beidentified are the sacral promontory, the right ureter, and theiliac artery. The peritoneum over the sacral promontory is placedunder tension and incised using diathermy, allowing the entryof carbon dioxide into the mesorectal plane. Most of the poste-rior dissection is undertaken from the right side, taking care toidentify the left ureter and pelvic nerves. The dissection is con-tinued posteriorly and laterally down to the level of the pelvicfloor and is assisted by retraction of the sigmoid colon by the useof an atraumatic grasper placed through the assistant port. Theanterior dissection is completed and the rectum fully mobilised.These steps are shown in Fig. 2.

June 9, 2009 14:6 B-601 ch22 FA


FIGURE 2 � Steps taken during mobilization of the rectum. The sacral promontory,iliac artery, and right ureter landmarks can be seen (far left). The peritoneum abovethe sacral promontary is shown being raised (middle), as is the completed mesorectalmobilization (far right).

(4) Anterior resection. The left ureter is identified, and the inferiormesenteric vessels are isolated and divided using a vascularlaparoscopic stapler. The proximal resection site is identified anddivided at this level using a laparoscopic gastrointestinal stapler,and the mesorectum is excised and divided 5 cm below the levelof the tumour. The distal bowel is then stapled and divided, andthe specimen removed through a small incision in the left iliacfossa. The anastomosis is performed intercorporeally, using a cir-cular stapler device, and the integrity of the anastomosis is testedusing air insufflation underwater. The key steps of the procedureare shown in Fig. 3.

(5) Abdominoperineal resection. Following full rectal mobilisation (asabove) and division on both the inferior mesenteric vesselsand stapled resection of the proximal bowel resection site, the

FIGURE 3 � Key steps taken during anterior resection of the rectum. The left ureter isidentified (far left), and the inferior mesenteric vessels dissected and ligated (middle).Following proximal, and distal resection, the intracorporeal anastomosis is performedusing a circular stapled anastomosis (far right).

June 9, 2009 14:6 B-601 ch22 FA

Robot-Assisted Laparoscopic Colorectal Surgery 169

FIGURE 4 � Key steps taken during a sutured rectopexy.

perineum is incised and perineal dissection performed. The spec-imen is removed through the perineal wound and a left iliac fossacolostomy performed.

(6) Sutured rectopexy. Once fully mobilised, the mesorectum is suturedto the presacral fascia in order to perform a rectopexy, as shownin Fig. 4.

CONCLUSION

Robot-assisted laparoscopic colorectal procedures are feasible andsafe. The advantages of the da Vinci robotic system are clear andinclude superior visualisation and enhanced dexterity when com-pared to conventional laparoscopy. This may be particularly impor-tant in total mesorectal excision (TME) for rectal cancer, where carefuldissection of an avascular plane between the presacral fascia and thefascia propria of the rectum is required, without injuring the properfascia of the rectum.6 Training on the da Vinci surgical robot is animportant consideration and has led to the development of a totalmesorectal excision simulator.7 Finally, cost and set-up time remainchallenges that need to be met if robotic colorectal surgery is to becomemainstream.

REFERENCES

1. Aziz O, Constantinides V, Tekkis PP, et al. (2006) Laparoscopic versus opensurgery for rectal cancer: a meta-analysis. Ann Surg Oncol 13(3): 413–424.

June 9, 2009 14:6 B-601 ch22 FA


2. Marecik SJ, Chaudhry V, Jan A, et al. (2007) A comparison of robotic,laparoscopic, and hand-sewn intestinal sutured anastomoses performedby residents. Am J Surg 193(3): 349–355; discussion 355.

3. Baik SH, Lee WJ, Rha KH, et al. (2008) Robotic total mesorectal excisionfor rectal cancer using four robotic arms. Surg Endosc 22(3): 792–797.

4. Satava RM. (2006) Robotics in colorectal surgery: telemonitoring and teler-obotics. Surg Clin North Am 86(4): 927–936.

5. Anvari M, Birch DW, Bamehriz F, et al. (2004) Robot-assisted laparoscopiccolorectal surgery. Surg Laparosc Endosc Percutan Tech 14(6): 311–315.

6. Enker WE, Thaler HT, Cranor ML, Polyak T. (1995) Total mesorectal exci-sion in the operative treatment of carcinoma of the rectum. J Am Coll Surg181(4): 335–346.

7. Marecik SJ, Prasad LM, Park JJ, et al. (2007) A lifelike patient simulator forteaching robotic colorectal surgery: how to acquire skills for robotic rectaldissection. Surg Endosc.

June 9, 2009 14:6 B-601 ch23 FA

chap

ter23

How to Make a Good Stoma

Robin Phillips∗ and Simon Phillips

INTRODUCTION

Few other surgical procedures adversely affect a patient’s quality oflife as much as a poorly functioning stoma.1,2 An ideal stoma meetstwo criteria:

(1) The site is optimally matched to a patient’s variability in bodyform, physical ability and activities.

(2) The construction minimises complications that relate to the use ofstomal appliances and minimises technical failings such as para-stomal hernia or prolapse.

This chapter will address technical aspects of construction for (loopand end) ileostomies and colostomies.

TECHNIQUE

A step-by-step description for each stage of stoma formation is given,then specific tips and adaptations for stomal types.

∗Corresponding author.†Department of Surgery, Imperial College London, South Kensington Campus,London SW7 2AZ. E-mail: [email protected]

171

June 9, 2009 14:6 B-601 ch23 FA

172 R. Phillips and S. Phillips

The Skin and Subcutaneous Incision

A circular stomal opening is generally preferred, though for tempo-rary stomata a linear incision minimises skin loss and may improvecosmesis after closure. We favour making a cruciate incision with cut-ting electrocautery, each quadrant being excised in a curved fashionwith electrocautery or curved (Mayo) scissors to prevent charring. Fortrephine stomata without laparotomy, both limbs of the cruciate inci-sion should equal the intended final diameter of the stoma. Duringlaparoscopically assisted stomal formation, distension occurs due tothe pneumo-peritoneum and the skin incision should take account ofthe retraction after release of the intra-abdominal pressure. Similarly,following laparotomy, the lateral diameter of the incision lengthenson closure of the abdominal wall and should be made shorter thanthe vertical incision so that a more geometric circle results.

Muscle Fascia

A cruciate incision of the muscle fascia is generally used, mirroringthat for the skin incision but without excision. It is common practiceduring laparotomy to align the muscle fasciotomy and skin incisionby medial retraction of the rectus sheath using tissue-grasping for-ceps (e.g. Lanes’). This may reduce angulation of the bowel throughthe abdominal wall, though is unlikely to affect the duration of para-lytic ileus in the post-operative phase and has little effect on eventualfunction.

Other adaptations have minimal effect. Suturing of the anteriormuscle fascia to Scarpa’s fascia does not alter peri-stomal bulging, noris there any evidence to support suture of the anterior and posteriormuscle fascia, though some believe that it reduces para-stomal her-nia formation. Similarly, fixation of the mesentery does not affect thepara-stomal hernia rate; nor does closure of the lateral space affectthe incidence of intestinal obstruction.3,4 Recently, prosthetic meshhas been advocated for reducing the incidence of para-stomal herniaformation,5 though it is unnecessary with temporary stoma formation

June 9, 2009 14:6 B-601 ch23 FA

How to Make a Good Stoma 173

and ill-advised in the emergency situation where bowel perforationhas occurred.

Muscle

A muscle-splitting incision through rectus abdominis is advocated,though this may simply be a necessary anatomical consequencereflecting the preference for an anterior stoma distant from theumbilicus, iliac crest and midline wounds. Stomal formation lat-eral to rectus abdominis does not actually seem to increase the riskof para-stomal hernia formation.3 This is unsurprising, since muscledivision and correct closure at apppendicectomy rarely leads to herniaformation.

The diameter chosen for the muscle and fascial aperture remainsa matter of intra-operative judgment with adjustment to account forbowel diameter, abdominal wall tissues and pathology. Narrow inci-sions may be widened more easily than those that are oversized,and para-stomal hernia is seen more commonly than stenosis at theabdominal fascia, suggesting that laxity, not tightness, is a greaterproblem.

Choice of Bowel for the Construction of a Stoma

The principles of good anastamotic healing apply equally to stomalconstruction. Attention to tissue handling, vascularity and lack oftension encourage primary healing at the muco-cutaneous junction.Poor technique risks separation of the muco-cutaneous junction andprolonged healing by granulation, leading to stenosis. Tension mayworsen stomal or spout retraction and can lead to difficulties in attach-ing stomal appliances to a concave stoma, particularly if a tight limb ofthe stoma gives a skin fold crease. Similarly, impaired vascularity canturn stomata a worrying colour, particularly if inotropes are requiredfor a critically ill patient, and although frank necrosis is rare, stenosismay result in the longer term.

June 9, 2009 14:6 B-601 ch23 FA


End Ileostomy (See Slide Sequence)

This is easiest to achieve with the terminal ileum due to the longterminal vascular arcade. For a more proximal end stoma, assessmentof the vascular pedicle is important in order to maximise length. If itproves difficult to isolate enough length for spout eversion (e.g. due toCrohn’s disease, in obese patients, or in emergencies with peritonitis),an “end-loop” ileostomy may be constructed with the over-sewn endleft in the abdominal subcutaneous tissue and the small bowel openedas for a loop ileostomy. The looser effluent and potential metabolicconsequences of a proximal stoma should be borne in mind.6

For formation of an everted (“Brooke”) ileostomy, the mesenteryshould emerge cranially such that mucosal eversion naturally pushesthe spout caudally. We recommend a “554 technique” (Fig. 1)7 with

FIGURE 1 � Head end to right of picture. At 2 and 10 o’clock on either side of themesentery, there is a 5 cm length from the sutured spout to a serosal stitch, but at6 o’clock, this is 4 cm: 554 ileostomy — on tying the sutures, there is a 2.5 cm superiorspout but only a 2 cm inferior spout.

June 9, 2009 14:6 B-601 ch23 FA


interrupted sero-muscular to full thickness dermal everting sutures andprefer a dissolvable, un-dyed, non-braided suture. Great care must betaken to judge the sero-muscular bite, particularly in Crohn’s diseaseor debilitated patients. An inadvertent full thickness bite or entero-tomy at this site may lead to a peri-stomal fistula with resulting leak-age and appliance slippage, irritation and pain, and often requiresstomal revision.

Loop Ileostomy

It is of primary importance that the ileal loop should reach theabdominal wall comfortably, without tension. If constructed withthe intention of subsequent closure, the commonest error is selec-tion of an ileal loop too close to the caecum, since ileostomy clo-sure may be considerably more difficult, particularly if the patienthas gained weight after an illness which required formation of thestoma. After restorative ileoanal pouch procedures, we routinelyuse a stomal bridge because of the inevitable tension caused by re-orientation of the superior mesenteric artery (SMA) arcade and ilealvessels. We rarely use a bridge for any loop stomata in other circum-stances unless there is excessive tension, since this increases stomalcomplications.8

For formation, operative aspects mirror those of end-ileostomyformation. We site the efferent limb superiorly (after ileoanal pouchformation this is inevitable), though some argue that an appliance canbe applied more closely to an inferior spout, particularly in patientswith impaired manual dexterity. A generous transverse enterotomyshould be made to facilitate spout eversion.

End Colostomy

A correctly sited end colostomy presents the fewest difficulties forpatients. Attention should be paid to tissue vascularity and ten-sion, as for all stomata. Some surgeons create a small (3–4 mm)spout to match the flange thickness of the stomal appliance,9 which

June 9, 2009 14:6 B-601 ch23 FA


can best be achieved by the sutures being placed leaving the knotsburied.

Loop Colostomy

There are several indications for loop colostomy formation. Whenconstructed electively before (radiotherapy) treatment for rectal oranal cancer, or for diversion for intractable incontinence, few spe-cific problems arise. Technical formation is similar to that of loopileostomy (though no spout is formed). For patients who have hadprevious abdominal surgery or colonic resection, laparoscopic assis-tance can greatly ease formation and is a technique we recommendsince a trephine colostomy may present a considerable technical chal-lenge, even in thin patients. Correct orientation is essential, partic-ularly if colon division is intended (with or without mucous fistulaformation). Several techniques are described to aid orientation butbeing mistaken about the correct end is an error surprisingly easy tomake. Care must be taken not to damage the (marginal) blood vesselarcade, since distal colonic ischaemia may result, particularly aftercolonic resection with distal anastomosis. This is a particular limi-tation on the use of a de-functioning loop colostomy after anteriorresection of the rectum, and ischaemia may result from traction of thebowel through the abdominal wall even if the vessel is not otherwisecompromised.

DISCUSSION

Stomal construction is a technique that is often delegated to junior staffat the end of procedures that may have been long and/or physicallytiring. Despite this, it has an enormous impact not just on patients’quality of life but also on health care resources. Complications arecommon in all types of stomata, and are more frequent when formedduring emergency surgery. Any technical modification or improve-ment in training to reduce this can be expected to have a large impact.

June 9, 2009 14:6 B-601 ch23 FA


Patients often judge a surgeon’s technical ability by the externalappearance of scars, and may also judge a surgeon’s care and precisionby the appearance and function of an abdominal stoma.

REFERENCES

1. Shellito PC. (1998) Complications of abdominal stoma surgery. Dis ColonRectum 41: 1562–1572.

2. Gooszen AW, Geelkerken RH, Hermans J, et al. (2000) Quality of life witha temporary stoma: ileostomy vs colostomy. Dis Colon Rectum 43: 650–655.

3. Leong AP, Londono-Schimmer EE, Phillips RK. (1994) Life-table analysisof stomal complications following ileostomy. Br J Surg 81: 727–729.

4. Londono-Schimmer EE, Leong AP, Phillips RK. (1994) Life table analy-sis of stomal complications following colostomy. Dis Colon Rectum 37:916–920.

5. Janes A, Cengiz Y, Israelsson LA. (2004) Randomized clinical trial of theuse of a prosthetic mesh to prevent parastomal hernia. Br J Surg 91:280–282.

6. Kaidar-Person O, Person B, Wexner SD. (2005) Complications of construc-tion and closure of temporary loop ileostomy. J Am Coll Surg 201: 759–773.

7. Hall C, Myers C, Phillips RK. (1995) The 554 ileostomy. Br J Surg 82: 1385.8. Speirs M, Leung E, Hughes D, et al. (2006) Ileostomy rod — is it a bridge

too far? Colorectal Dis 8: 484–487.9. Stephenson BM, Myers C, Phillips RK. (1995) Minimally raised end

colostomy. Int J Colorectal Dis 10: 232–233.

June 9, 2009 14:6 B-601 ch24 FA

chap

ter24

Palliative Stenting for ColorectalMalignant Strictures

Thomas M. Raymond∗,†, R. Bhardwaj† and Mike C. Parker†

INTRODUCTION

Self-expanding metal stents (SEMSs) are used to treat malignant lumi-nal obstruction of the gastrointestinal tract. Initially they were usedto relieve obstruction of biliary, hepatic and upper gastrointestinallesions, but with advancing technology and the introduction of flexi-ble stents with a larger lumen they are now used in the treatment ofcolonic obstruction, as first described by Dohmoto in 1991.1

Between 10 and 30% of patients with primary colonic cancerpresent with obstruction2 for which they are treated conventionallyby surgical intervention. Obstructing cancers (either primary col-orectal or extrinsic compression due to pelvic malignancy) are oftenadvanced at the time of presentation and therefore any treatmentis palliative. Furthermore emergency surgery is associated with ahigh morbidity and mortality and in the palliative setting the cre-ation of a stoma is almost inevitable. Stoma formation has seriousimplications for quality of life and may also be a burden to care-givers during the final months of life. Various non-surgical treatmentshave been tried, including balloon dilatation, laser photo-ablation

∗Corresponding author.†Darent Valley Hospital, Dartford, Kent DA2 8DA, UK. E-mail: [email protected]

179

June 9, 2009 14:6 B-601 ch24 FA

180 T. M. Raymond et al.

and electro-coagulation, but their effectiveness is limited by compli-cations, the need for repeated treatments and cost.3

Colorectal stents are an addition to the armamentarium in thepalliative treatment of colorectal obstruction. They allow rapidand effective decompression, thus avoiding surgery and the cre-ation of a stoma.4–6 They may be used as palliation alone or as abridge to surgery. They are contraindicated in very low rectal stric-tures, ischaemia, perforation or when there are multiple levels ofobstruction.

FIGURE 1 � Intra-luminal view of in situ stent.

SEMSS — TYPES

SEMSs are expandable metal tubes, usually of mesh design madefrom steel or nitinol (a nickel-and-titanium alloy with shape mem-ory). They are advanced to the site of obstruction in the collapsedstate, where following deployment they expand radially to their max-imum diameter under their own force, thereby achieving patency.They differ in luminal diameter, length and radial expansile force,

June 9, 2009 14:6 B-601 ch24 FA

Palliative Stenting for Colorectal Malignant Strictures 181

which allows selection of the most suitable stent for the procedure.The stent becomes incorporated into the tumour and surroundingtissue, which provides anchorage for the stent, preventing migration.

PLACEMENT

A retrograde radiographic contrast study or contrast CT should beobtained before stent placement to assess the anatomy, length of stric-ture and degree of obstruction and to exclude other levels of obstruc-tion that would negate the effect of stenting a single site.

Preparation with one to two cleansing enemas prior to the pro-cedure should be considered so as to ensure that the distal colon isclear. The patient is placed initially in the lateral decubitus position,and standard intravenous conscious sedation is usually administeredbut is not absolutely necessary.

FIGURE 2 � Radiographic view of stent following deployment.

June 9, 2009 14:6 B-601 ch24 FA


The stent is either placed under fluoroscopic guidance (shorterdelivery system but large diameter stent) or passed through an endo-scope (longer delivery system and smaller diameter stent).

Radiological Placement

The lesion is located fluoroscopically, using a water-soluble contrastmedium. The stricture is passed using a guide wire over which thestent is inserted into the obstructing lesion prior to release. Rarely, thismay require balloon dilatation to aid expansion.

Endoscopic/Fluoroscopic Placement

The distal end of the obstructing lesion is visualised endoscopically,at which point a biopsy may be taken. The length and configurationof the stenosis is demonstrated fluoroscopically, by injection of water-soluble contrast media. The guide wire is then passed through thestenosis and the stent delivery system inserted through the scope.The stent is positioned at the level of the stenosis and released underboth endoscopic and radiological vision.

EFFICACY

Stenting is technically and clinically successful in over 90% of cases(46–100%), with little difference between palliative and potentiallycurative patients.7,8 Failure is usually due to inability to pass the guidewire, particularly when negotiating a tortuous colon.

For palliative patients the median duration of patency is over 100days (68–288 days). For studies reporting patency rates the medianat the end of follow-up (or time of death) is 100% (53–100%).7 Re-intervention is required following 20% of palliative stent placements(0–100%) and includes unplanned surgery, placement of second or

June 9, 2009 14:6 B-601 ch24 FA


subsequent stents or interventions to maintain patency (laser ablation,colonic irrigation).

Patients undergoing palliative stenting have fewer admissions tothe intensive care unit, fewer stomas and a reduction in the medianhospital stay when compared with patients undergoing palliativesurgery.7,9 When comparing the median survival there is no signif-icant difference.1,8

SAFETY

For all colorectal stents the median rate of migration is 11% (0–50%),with similar rates when used for palliation.7 If migration occurs nointervention is required in over 50% of patients. The remainder mayrequire stent removal with no further intervention, stent re-insertionor surgery.

Perforation caused by either the guide wire or the stent occursin 4.5% (0–83%) of cases irrespective of the indication and may beincreased by balloon dilatation of the stricture prior to stent insertion.8

Re-obstruction occurs in 12% (1–92%) of patients due to tumourovergrowth or ingrowth, migration and faecal impaction, and occursfrom 48 hours to 480 days post-procedure. Modes of treatment includelaser photo-ablation, re-stenting or colonic irrigation.

Other reported complications include stent fracture, rectal bleed-ing, anal/abdominal pain, incontinence and tenesmus, particularly inpatients with distally placed stents. These are relatively rare and areusually well tolerated by patients.

COVERED VS UNCOVERED STENTS

Covered stents appear to resist tumour ingrowth, as reflected inlower re-obstruction rates, although they may be more prone tomigration.

June 9, 2009 14:6 B-601 ch24 FA


COST CONSIDERATIONS

The cost of palliative stenting may be half that of a surgically decom-pressed patient.10 This saving is due mainly to a shorter hospital stay,but also to fewer surgical procedures, less operating room time andreduced time in intensive care.

DISCUSSION

SEMSs provide a quick and effective tool in the palliative treatment ofobstructing colorectal lesions. They compare favourably with surgicalintervention and help to avoid formation of stomas in selected cases.

REFERENCES

1. Dohmoto M. (1991) New method — endoscopic implantation of rectalstent in palliative treatment of malignant stenosis. Endoscopia Digestiva3: 1507–1512.

2. Deans GT, Krukowski ZH, Irwin ST. (1994) Malignant obstruction of theleft colon. Br J Surg 81(9): 1270–1276.

3. Zollikofer CL, Jost R, Schoch E, Decurtins M. (2000) Gastrointestinalstenting. Eur Radiol 10(2): 329–341.

4. Law WL, Chu KW, Ho JW, et al. (2000) Self-expanding metallic stent inthe treatment of colonic obstruction caused by advanced malignancies.Dis Colon Rectum 43(11): 1522–1527.

5. Liberman H, Adams DR, Blatchford GJ, et al. (2000) Clinical use of theself-expanding metallic stent in the management of colorectal cancer. AmJ Surg 180(6): 407–411.

6. Turegano-Fuentes F, Echenagusia-Belda A, Simo-Muerza G, et al. (1998)Transanal self-expanding metal stents as an alternative to palliativecolostomy in selected patients with malignant obstruction of the leftcolon. Br J Surg 85(2): 232–235.

7. Watt AM, Faragher IG, Griffin TT, et al. (2007) Self-expanding metallicstents for relieving malignant colorectal obstruction: a systematic review.Ann Surg 246(1): 24–30.

8. Khot UP, Lang AW, Murali K, Parker MC. (2002) Systematic review ofthe efficacy and safety of colorectal stents. Br J Surg 89: 1096–1102.

June 9, 2009 14:6 B-601 ch24 FA


9. Law WL, Choi HK, Chu KW. (2003) Comparison of stenting with emer-gency surgery as palliative treatment for obstructing primary left-sidedcolorectal cancer. Br J Surg 90: 1429–1433.

10. Osman HS, Rashid HI, Sathananthan N, Parker MC. (2000) The cost-effectiveness of self-expanding metal stents in the management of malig-nant left-sided large bowel obstruction. Colorectal Dis 2: 233–237.

June 9, 2009 14:6 B-601 ch25 FA

chap

ter25

Technical Notes on TME for Rectal Cancer

Bill J. Heald∗

All good rectal cancer surgery involves “TME principles”. For all can-cers, either there must be 5 cm of mesorectum distal to the cancer orthe whole mesorectum must be excised intact. The muscle tube maybe divided 1–2 cm beyond a cancer but mesorectal clearance must begenerous.

PRE-OPERATIVE STAGING

Decisions regarding radiotherapy and chemotherapy now need to bemade before surgery.

• Clinical — especially digital rectal examination, and never omit thevaginal exam

• Colonoscopy• CT chest, Abdo and Pelvis for metastatic spread• Specialised, fine slice pelvic MRI — this delineates the mesorectal

fascial “holy plane”; cancer within 1 mm is the principal indicationfor pre-op CRT

∗Pelican Cancer Foundation, North Hampshire Hospital, Basingstoke RG24 9NA,UK. E-mail: [email protected]

187

June 9, 2009 14:6 B-601 ch25 FA

188 B. J. Heald

SURGERY

The rectum and the mesorectum constitute the embryological midlinehindgut, surrounded by:

• The autonomic nerves and hypogastric plexuses• The nonvisceral presacral fat pad (when present)• The parietal sidewall septum separating it from the internal iliac

vessels• The seminal vesicles• The prostate in the male• The vagina in the female

All of these should be painstakingly preserved, to avoid autonomicdysfunction or bleeding. The TME dissection plus pouch to anusreconstruction takes 3–5 hours; a conventional APE was often com-pleted in an hour.

OPERATIVE TECHNIQUE

Four great principles apply throughout:

• Precise dissection under direct vision — never “blind”• Three-directional traction and countertraction to open up the “holy

plane”• Sharp scissors or monopolar diathermy dissection of areolar tissue

“on stretch”• Circumferential dissection — first here, then there, and never for

too long on one area• Gentle surface protection with gauze swabs to avoid tearing

Throughout the operation the ultimate quality of the TME spec-imen — intact and untorn — should be paramount: “specimen-oriented surgery”.

June 9, 2009 14:6 B-601 ch25 FA

Technical Notes on TME for Rectal Cancer 189

THE INCISION — OPEN OR LAPAROSCOPIC?

A long midline incision is made from the symphysis pubis almostto the xiphisternum. Young women may prefer a suprapubic inci-sion with a vertical midline between the rectus muscles. Laparoscopicsurgery is now a real alternative — especially for abdominoperinealexcision (APE), avoiding an abdominal incision. The elevation ofan intact mesorectal package, safely encompassing a large cancer,needs substantial upward traction, which is not easy laparoscopicallywithout the risk of tearing. Great caution is advised with sphincter-preserving laparoscopy for tumours greater than 7 cm in size, whichare probably best dealt with open. In open surgery, for careful pack-ing and retraction clear access to the pelvis and long-lipped St. Marksretractors are essential.

STARTING RIGHT: THE “PEDICLE PACKAGE” —THE CLUE TO THE TOP OF THE “HOLY PLANE”

Starting correctly involves identification of the plane between the backof the “pedicle package” and the gonadal vessels, ureter, and preaor-tic sympathetic nerves. Key is the shiny fascial covering of the taper-ing embryological midline “sausage” with inferior mesenteric ves-sels within. This is gently lifted forward to open the plane. Start oneither the left or the right of the sigmoid mesocolon, and the superiorhypogastric plexus is carefully preserved.

HIGH LIGATION OF THE INFERIORMESENTERIC VESSELS

With the pedicle package lifted gently forward, the dissection behindit can be extended up to its origin. Separate high ligations of theinferior mesenteric artery and vein can be performed with the artery

June 9, 2009 14:6 B-601 ch25 FA

190 B. J. Heald

controlled by the left index finger and thumb between it and the vein.The artery is divided 1–2 cm anterior to the aorta, so as to spare thesympathetic nerve plexuses; the vein several cm to the left of the arteryabove its last tributary and close to the pancreas. Otherwise avascularplanes around this hindgut are developed for full mobilisation of thesplenic flexure. Occasionally a long and healthy sigmoid may be usedas an alternative. Pulsatile blood supply is essential.

“DIVISION OF CONVENIENCE”OF THE SIGMOID COLON

The sigmoid mesentery and the sigmoid colon are divided well abovethe cancer. This facilitates gentle opening of perimesorectal planes bycircumferential traction and countertraction.

PELVIC DISSECTION

Start posteriorly lifting the rectosigmoid forward and follow the “holyplane” at various points on the mesorectal circumference in a stepwisemanner. If bleeding in one area is troublesome tackle the oppositecircumference to apply pressure while progress continues.

HIGH POSTERIOR DISSECTION

The posterior embryological plane, i.e. the shiny posterior surfaceof the mesorectum within the bifurcation of the superior hypogastricplexus, is extended downward to beyond the tip of the coccyx, step bystep as other sectors of the circumference are developed. The fascialcondensation “rectosacral ligament” may require positive divisionwith scissors or diathermy. Blunt manual extraction, haste or rough-ness may tear into the mesorectum or presacral veins. A presacral fatpad should be left alone.

June 9, 2009 14:6 B-601 ch25 FA


PELVIC SIDEWALL DISSECTION

The plane is extended around the sides, gently liberating the adher-ent hypogastric nerves laterally off the mesorectal surface underdirect vision. The tangentially running hypogastric nerves are oftenfirst identified, the superior hypogastric plexus only later becomingapparent.

“LATERAL LIGAMENT” AREA

As the “holy plane” is followed downward toward the vesicles, theexpanding plexiform band of the inferior hypogastric plexus becomesincreasingly adherent. There is no actual ligament — only adherencebetween mesorectum and plexus: small branches of nerves and ves-sels penetrate through and usually no major “middle rectals” pedi-cle. Sympathetic hypogastric nerves curve distally from the superiorplexuses and “erigent pillars” (parasympathetic nerves) come for-ward from the roots of the sacral plexus. These erigent pillars piercethe sidewall septum to join the plexus and contribute nerve branchesto the mesorectum and rectum. These “neural T junctions” are thenearest to “lateral ligaments” that careful surgeons will find if they

FIGURE 1 � The autonomic nerves on the right pelvic sidewall.

June 9, 2009 14:6 B-601 ch25 FA

192 B. J. Heald

FIGURE 2 � Denonvillier’s septum: the anterior surface of a good TME.

dissect perfectly between the mesorectum and the inferior hypogas-tric plexus.

ANTERIOR DISSECTION — DENONVILLIERS SEPTUM

Following the correct plane forward will encompass the peritonealreflection which remains on the specimen, allowing positive iden-tification of seminal vesicles. Forceful forward retraction with a St.Mark’s retractor facilitates development of the areolar space betweenthem and the smooth Denonvilliers rectogenital septum. This isdivided transversely distally to the cancer as it becomes adherentto the posterior capsule of the prostate — carefully avoiding damageto the converging neurovascular bundles which form the neurovas-cular bundles of Walsh. These taper toward the urethra at the apexof the prostate, where they become the erectile nerves of the corporacavernosa.

MANAGEMENT OF THE ANORECTUM DISTALTO THE CANCER — STAPLING TECHNIQUES

In more than 90% of rectal cancers it is technically feasible, thoughnot necessarily optimal in terms of future function, to extend the

June 9, 2009 14:6 B-601 ch25 FA


FIGURE 3 � The inferior hypogastric plexus and right “erigent pillar.”

dissection down to a clean muscle tube where a cross clamp may beapplied with “finger and thumb” clearance below the cancer. This isa challenging moment requiring skill and experience. We use a linearstapler as a right-angled clamp (the Moran triple stapling technique).The first TA-45 or TA-30 (Covidien Healthcare) staple line seals themuscle tube so that the anorectal lumen beyond can be washed outwith water or a tumoricidal solution. A check with a proctoscope atthis point may be desirable. Incorporation of exfoliated intraluminalcells in the second staple line is thus eliminated. A second TA-45 orTA-30 is fired through the washed bowel with powerful upward trac-tion on the first (specimen-sealing) stapler. Only the washed stapleline remains within the patient. The first is clear of the palpable distaledge of the cancer, which is almost always the microscopic limit sincespread along the muscle tube is rarely important.

THE COLON POUCH, COLOPLASTY ORSIDE-TO-END?

Several variations of reconstruction are available — typically a GIA-60 is inserted 5 cm from the end of the fully mobilised colon to

June 9, 2009 14:6 B-601 ch25 FA

194 B. J. Heald

create a J pouch. The circular stapler, usually CEEA-31, is insertedtransanally. It is essential with ultra-low anastomoses that only theinternal sphincter is incorporated, i.e. only one thickness of musclearound the periphery of the cartridge.An adequate length of the colonis essential for the pouch to lie without tension in the sacral hollow,and demonstrably pulsatile blood supply is crucial. Two low-suctionAbdovac drains are used for 48 hours.

Suggested Reading

1. MERCURY Study Group. (2006) Diagnostic accuracy of preoperativemagnetic resonance imaging in predicting curative resection of rec-tal cancer: prospective observational study. Br Med J 333: 779; doi:10.1136/bmj.38937.646400.55.

2. Holm T, Ljung A, Häggmark T, et al. (2007) Extended abdominoperinealresection with gluteus maximus flap reconstruction of the pelvic floor forrectal cancer. Br J Surg 94(2): 232–238.

3. Quirke P. (2003) Training and quality assurance for rectal cancer: 20 yearsof data is enough. The Lancet Oncology 4(11): 695–702.

June 9, 2009 14:6 B-601 ch26 FA

chap

ter26

Total Proctocolectomy with IleoanalPouch Anastomosis

Thomas Lehnert∗,†, Silke Schüle† and Frank Starp†

Total proctocolectomy with ileoanal pouch anastomosis is used totreat familial adenomatous polyposis and a few rare hereditarycolorectal cancer syndromes, as well as ulcerative colitis.

BOWEL PREPARATION

We do not use any form of bowel preparation preoperatively apartfrom a microenema on the morning of the operation. Prophylac-tic antibiotics (second generation cephalosporine plus metronida-zole) are given with induction of anaesthesia, repeated once after sixhours and then discontinued. Before transanal transection of the rectalmucosa, a clamp is placed on the mobilised rectum in the abdomen,and the rectum is washed out with povidone and then stuffed withtwo or three swabs to avoid soiling with rectal contents.

∗Corresponding author.†Departments of General, Visceral, Vascular and Oncology Surgery, KlinikumBremen-Mitte, St Juergen Strasse, 1, DE 28205 Bremen, Germany. E-mail: [email protected]

195

June 9, 2009 14:6 B-601 ch26 FA

196 T. Lehnert et al.

If a hand-sutured ileoanal anastomosis is performed, there isalways some soiling from the pouch. Even if soiling was severe, localrinsing with copious saline and intraoperative rinsing of the pelvisthrough drains placed behind the pouch has in our experience reli-ably prevented septic complications in the pelvis.

ACCESS

Proctocolectomy can be accomplished by minimal access techniques,and this route may be preferred for cosmetic reasons by young patientsin which a prophylactic operation is planned.1 There are, however,drawbacks to this approach. The operation is much more time-consuming, lymphadenectomy may be compromised (see below) andlengthening of the mesentery is limited.

LYMPHADENECTOMY

In both conditions a decision has to be made regarding the extentof lymphadenectomy, depending on whether or not malignancy hasbeen demonstrated preoperatively. In patients with classical (100–1000 polyps) or severe (more than 1000 polyps) familial polyposis,we prefer a radical lymphadenectomy including total mesorectal exci-sion even if malignancy has not been proven preoperatively. There areseveral reasons for this approach: if an extensive number of polypsare present there is a risk of malignancy going undetected preopera-tively; there is no point in retaining the draining lymph nodes if thecorresponding large bowel is removed; and, most importantly, theoperation is much cleaner if blood vessels are divided at their originand dissection observes avascular tissue planes throughout.

In ulcerative colitis the same applies: the preoperative detectionof malignancy in a severely inflamed large bowel can be challen-ging, because carcinoma in ulcerative colitis tends to grow prima-rily infiltrating the bowel wall and only rarely appears to develop

June 9, 2009 14:6 B-601 ch26 FA

Total Proctocolectomy with Ileoanal Pouch Anastomosis 197

via polyps protruding into the bowel lumen. We, therefore, performa radical lymphadenectomy in almost all patients undergoing totalproctocolectomy for ulcerative colitis and particularly if some degreeof dysplasia has been detected preoperatively.

In patients in whom we plan radical lymphadenectomy, westrongly prefer open access over laparoscopically assisted procto-colectomy, because we believe that lymphadenectomy will be morecomplete. A meta-analysis of 14 randomised trials confirms thatsignificantly more lymph nodes were examined in colorectal cancerpatients undergoing the open procedure as compared to the minimalaccess technique (p < 0.004).2

In patients in whom large bowel cancer is diagnosed preopera-tively, lymphadenectomy follows the principles of oncologic surgery,even if this will mean that a pouch cannot be constructed, because theileocolic vessels have to be resected. On the other hand, even if theileocolic vessels have to be sacrificed, pouch formation is still possiblein many patients. If this is not possible, then ileorectal anastomosismay be an option for some patients with familial polyposis. We wouldrecommend this only in patients with limited polyposis of the rectum,as in attenuated forms of familial polyposis.

LENGTHENING OF THE MESENTERY

Tension-free anastomosis is crucial to the success of this operation. Inmany instances no particular measures are necessary and the pouchcan be advanced to the dentate line without tension. If this is not pos-sible, then intermediate blood vessels are divided under diaphany tolengthen the mesentery. We prefer to use vascular clamps for prelimi-nary interruption of perfusion before we actually ligate and dividevessels. Mistakes at this point inevitably result in the loss of smallbowel and jeopardise preservation of continence. It is noted thatdiaphany and selection of proper vessels for division is more diffi-cult if the abdomen is accessed via a transverse incision in the lowerabdomen (Caesarean).

June 9, 2009 14:6 B-601 ch26 FA


To achieve optimum length it is important to rotate the pouch sothat the mesentery runs anteriorly, because the distance between themesenteric root and the anterior circumference of the anal sphincteris the shortest. The antimesenteric bowel then nicely aligns with thehollow of the sacrum. If this does not result in sufficient length, thenthe next step is to incise the visceral peritoneum. Incisions are made at1–2 cm intervals at a 90◦ angle to the mesenteric vessels starting proxi-mal to the most peripheral arcades and progressing centrally towardsthe mesenteric root. They are made on both sides of the mesenteryand care is taken not to injure any blood vessels, especially veins.This usually affords at least another centimetre of mesenteric length.

If there is still too much distance for a tension-free anastomosis,then the mesenteric root is dissected free up to the pancreas, wherecare is taken to avoid injury to the uncinate process. This may addanother centimetre of length to the mesentery, but obviously this isnot easily achieved, if the dissection of the mesenteric root is to beaccomplished through a transverse incision in the lower abdomen asin laparoscopically assisted proctocolectomy.

Especially in tall patients it has been difficult to achieve sufficientlengthening of the mesentery to allow tension-free ileoanal anastomo-sis even after all three measures have been applied. In such cases wehave resorted to supporting the patient’s legs for a few days in orderto elevate the pelvis and thus reduce the distance between dentateline and mesenteric root. With these measures we have been lucky toavoid anastomotic complications in the past 50 patients.

RECTAL MUCOSECTOMY AND ILEOANALANASTOMOSIS

Any retained rectal mucosa is likely to increase the risk of an anasto-motic leak or formation of a pelvic fistula. In the long term there is alsothe risk of malignancy in both ulcerative colitis and familial polyposis.We, therefore, take great care to excise the mucosa completely, prefer-ably together with 1 or 2 mm of anal epithelium. To accomplish this

June 9, 2009 14:6 B-601 ch26 FA


we choose a transanal route. Injection of the mucosa with adrenaline-containing saline results in elevation of the mucosa from the analsphincter. With the patient in the Lloyd-Davies position, the mucosaldissection is always started posteriorly and advanced on both sides tothe anterior rectal circumference. As there is inevitable bleeding fromthe dissected mucosa, this approach allows better exposure. If themucosal dissection is started anteriorly, then blood collection at theposterior aspect of the rectum will make identification of the optimalline of incision more difficult. The mucosa is gradually dissected offthe muscular layer in a proximal direction, and the muscular cuff ofthe rectum is then transected approximately 2–3 cm above the dentateline to preserve as much of the anal sphincter as possible (Fig. 1). Tran-section of the anterior aspect of the rectal wall is usually performedfrom the abdomen.

We never use double stapling for this procedure, because this tech-nique results in unnecessary loss of sphincter muscle if the line oftransection is low enough to include all rectal mucosa (Fig. 2). Alter-natively, if the rectum is transected more proximally, then some rectal

FIGURE 1 � Staged transsection preserving the sphincter and completely removingthe rectal mucosa.

June 9, 2009 14:6 B-601 ch26 FA


FIGURE 2 � Low transsection including portions of the anal sphincter.

FIGURE 3 � High transsection retaining the rectal mucosa.

June 9, 2009 14:6 B-601 ch26 FA


mucosa is retained, which is not desirable, as explained above (Fig. 3).Also, in our experience, we have related double stapling of coloanalpouches to severe scarring resulting in anastomotic stenosis requiringprolonged dilatation and severely compromised anorectal function.

POUCH FORMATION

While we aim for a large pouch with a length of more than 15 cm, forpractical reasons the pouch length is determined to a great extent bythe mesenteric vasculature and optimal lengthening of the mesenteryto achieve a tension-free anastomosis. The latter is the superior goaland we would rather allow for a smaller pouch than take any riskof anastomotic dehiscence and pelvic sepsis. Alternatively, an exces-sively long pouch may result. This is easily reduced by resection of afew centimetres of the distal ileum.

For pouch formation we use linear staplers. Before they areinserted both limbs of the terminal ileum are aligned strictly antime-senterically with three to four 4–0 sutures to ensure that the transec-tion does not compromise blood supply. Linear staplers need to beinserted at least twice to achieve sufficient pouch length. For inser-tion we always open the pouch at its apex, which is to become thesite of the pouchanal anastomosis, and introduce the staplers alwaysthrough this opening. In the past we have introduced the second sta-pler through the ileal end and a proximal incision of the afferent limb.This has sometimes resulted in incomplete transection of the bowelwall and retention of a tissue bridge in the middle of the pouch, com-promising its volume.

Careful selection of the type of linear cutters appears warranted,as some do not ideally control bleeding from the suture line. Obvi-ously, arterial bleeding into the lumen of the just-created pouch is veryundesirable.

While we do use linear staplers to create the ileal pouch, wenever use staplers to create the pouchanal anstomoses, for fear of

June 9, 2009 14:6 B-601 ch26 FA


postoperative scarring, or insufficient mucosal or excessive muscularresection (Figs. 2 and 3). All ileoanal pouch anastomoses are hand-sutured transanally, using absorbable 3–0 braided sutures. Twelve orfourteen (never thirteen) interrupted sutures usually suffice. Severaltechniques have been proposed for exposure. We prefer to use a specu-lum, which is removed and re-inserted after each step to minimiseinjury to the anal sphincter.

PROTECTIVE ILEOSTOMY

We believe in the benefit of ileostomy. A randomised study and asubsequent meta-analysis3,4 have shown that a diverting ileostomyreduces the frequency of clinical leaks in low anterior anastomosis,and the same benefit is assumed for ileoanal pouch anastomosis. Aseptic pelvis jeopardises the pouch, and even if the pouch can besaved, pouch function may be seriously compromised after an episodeof severe pelvic sepsis.

REFERENCES

1. Polle SW, Dunker MS, Slors JF, et al. (2007). Body image, cosmesis, qualityof life, and functional outcome of hand-assisted laparoscopic versus openrestorative proctocolectomy: long-term results of a randomized trial.Surg Endosc 21(8): 1301–1307.

2. Lehnert T, Starp F, Hauschildt J, Schüle S. Personal Communication.3. Matthiessen P, Hallböök O, Rutegård J, et al. (2007). Defunctioning stoma

reduces symptomatic anastomotic leakage after low anterior resectionof the rectum for cancer: a randomized multicenter trial. Ann Surg 246:207–214.

4. Hüser N, Michalski CW, Erkan M, et al. (2008). Systematic review andmeta-analysis of the role of defunctioning stoma in low rectal cancersurgery. Ann Surg 248: 52–60.

June 9, 2009 14:6 B-601 ch27 FA

chap

ter27

Pouches and Coloanal Anastomosis

Sylvain Kirzin†, Guillaume Portier† and Franck Lazorthes∗,†

INTRODUCTION

Total mesorectal resection has led to reduced local recurrence andimproved survival in patients with rectal cancer. Straight coloanalanastomosis after total protectomy can lead to functional disor-ders, including increased bowel movements, clusterings and fecalincontinence. This evacuation dysfunction has been described as the“anterior resection syndrome”. Therefore, alternative strategies forrestoration, such as the colonic J pouch, side-to-end anastomosis andtransverse coloplasty, have been developed in order to improve bowelfunction.

Is a Pouch Necessary?

The first alternative process to be described was the colonic J pouch.1,2

Therefore, most of the studies compared this reconstruction to straightcoloanal anastomosis. Many randomised, controlled trials have beenperformed, providing a high level of evidence to answer the question

∗Corresponding author.†Service de chirurgie digestive CHU Purpan, Place du Dr Baylac, 31059 Toulouse,France. E-mail: [email protected]

203

June 9, 2009 14:6 B-601 ch27 FA

204 S. Kirzin, G. Portier and F. Lazorthes

whether a pouch is necessary. In particular, Heriot et al.3 conducted ameta-analysis of all published randomised, controlled trials in 2006.They identified 35 studies, which included 2240 patients. They con-cluded that there was significant reduction in the frequency of defe-cation per day and that the faecal urgency was less prevalent inpatients with a J pouch than in those with straight coloanal anas-tomosis, stressing the functional benefits of the colonic J pouch.

In 2007 Koh et al.4 compiled 10 randomised, controlled trialsconducted with high quality methodology. They concluded that thecolonic J pouch appeared more favourable in terms of stool frequencyand continence, with a slighty lower risk of anastomotic dehiscencecompared to straight coloanal anastomosis.

In 2008, the Cochrane Library published a meta-analysis.5 Six-teen randomised, controlled trials were selected from 2609 publishedstudies. Brown et al. stated that up to 18 months postoperativelythe colonic J pouch was superior to straight anastomosis in bowelfrequency, urgency, faecal incontinence and use of antidiarrhoealmedication.

Thus, the multiplicity of studies and their systematic conclusion infavour of the colonic J pouch, as well as the results of the meta-analysis,leave no doubt about its superiority. Nevertheless, there remain con-cerns regarding long-term maintenance of the functionnal benefits ofthe colonic J pouch. Indeed, the systematic review by the CochraneLibrary and the meta-analysis by Heriot et al. stated that there werefunctional benefits from the colonic J pouch for 18 and 24 postoper-ative months, respectively. Over that time period, the superiority ofthe colonic J pouch remains to be established. The work of the J pouchremains unclear: increased capacity or presence of a bowel segmentwith no functional peristalsis.

What Kind of Pouch?

Colonic J pouches have been used for more than 20 years. The colo-plasty pouch has been advocated more recently as an alternative to the

June 9, 2009 14:6 B-601 ch27 FA

Pouches and Coloanal Anastomosis 205

J pouch, particularly when the mesocolon is fat and bulky or in the caseof insufficient colonic length.6 In 2006, Heriot et al.3 concluded thatthe J pouch was functionally superior to straight anastomosis, but alsothat more trials were needed to make a conclusive statement aboutthe coloplasty. More recently, a randomised controlled trial has beenpublished by Fazio et al.7 including 354 patients, of which 96 couldnot have a colonic J pouch for different reasons — narrow pelvis,bulky mesentery, insufficient colonic length — and were excludedfrom the analysis. A total of 268 patients were randomised: 137 in theJ pouch (JP) group and 131 in the coloplasty (CP) group. The JP grouphad a smaller total number of daily bowel movements than the CPgroup at 4, 12 and 24 postoperative months. There were also differ-ences in favour of the J pouch concerning night bowel movements.The faecal incontinence score (FISI) was significantly lower in theJP group, indicating higher continence, than in the CP group. Otherrandomised, controlled studies have been performed with smallerconsequent numbers, showing more-confusing results.

Therefore the colonic J pouch remains obviously the gold stan-dard. Until further evidence is available, other procedures such ascoloplasty and side-to-end anastomosis should remain alternativetechnical solutions in case of difficulties in making a J pouch. More-over, in the study conducted by Fazio et al.,7 the 96 patients excludedfrom the trial for technical reasons were further randomised to receivea straight coloanal anastomosis (n = 49) or a coloplasty (n = 47). Theresults of the analysis showed no benefits from the coloplasty com-pared to straight anastomosis, suggesting that the best solution couldbe side-to-end anastomosis, a simple and fast solution, in case of tech-nical difficulties in making a J pouch.

TECHNIQUE

Historically, the J pouch was shown to have evacuatory problemsrelated to the loss of rectal sensibility, requiring enema or laxatives.These problems were resolved with a smaller pouch. A 5-cm-long

June 9, 2009 14:6 B-601 ch27 FA


pouch is enough, while 8–10 cm might be too long.8 There are few, ifany, evacuatory problems with a 5-cm-long J pouch. As for any lowanastomosis, the vascularisation of the colon has to be good, partic-ularly at the distal extremity. The anastomosis should be performedtension-free. The pouch has to fill the pelvic cavity. Contrary to thecustom, it seems to us that the colon should be folded to the left sideof the patient. Indeed, the medial side of the colon (the right side ofthe patient) is more richly vascular than the lateral side.

The GIA stapler can be introduced at the apex or the base of thepouch. Introduction at the apex was the originally described tech-nique (Fig. 1). It suits mechanical coloanal anastomosis. A short, lon-gitudinal colotomy is performed on the site of the future anastomosis.It should be slightly smaller than the diameter of the stapler and stand

FIGURE 1 � Colon folded on the left side of the patient, introduction of the stapler atthe apex of the pouch for mechanical anastomosis.

June 9, 2009 14:6 B-601 ch27 FA

Pouches and Coloanal Anastomosis 207

FIGURE 2 � Indroduction of the stapler at the base of the pouch for manual coloanalanastomosis; colon folded to the right side of the patients (usual fashion).

at an equal distance from the meso and the antimesenteric border ofthe colon. The colotomy is sewn around the head of the stapler. Thistechnique avoids septic handling.

In the second style (Fig. 2), the colon is incised on the base ofthe J pouch, opposite to the site of the future coloanal anastomosison both descenders of the J. This procedure is similar to the J pouchused during restorative coloproctectomy. After application of the GIAstapler there remains a link between the two descenders. Its sectionwill expose to the risk of stains. This technique is suitable for man-ual endoanal anastomosis, particularly after intersphincteric resec-tion when the pouch has to be pulled through the sphincter. Even ifcarefully sewn, an incision at the apex of the pouch would expose toleaks and stains during handling.

June 9, 2009 14:6 B-601 ch27 FA


In both styles, the distal extremity of the colon should be carefullychecked and readily cut again with a TA or TX stapler. As a conclu-sion, few subjects have previously been studied, and particularly withsuch a high quality of methodology in the field of surgery, to provideanswers with a high level of evidence.

REFERENCES

1. Lazorthes F, Fages P, Chiotasso P, et al. (1986) Resection of the rectumwith construction of a colonic reservoir and colo-anal anastomosis forcarcinoma of the rectum. Br J Surg 73 (2): 136–138.

2. Parc R, Tiret E, Frileux P, et al. (1986) Resection and colo-anal anastomosiswith colonic reservoir for rectal carcinoma. Br J Surg 73(2): 139–141.

3. Heriot AG, Tekkis PP, Constantinides V, et al. (2006) Meta-analysis ofcolonic reservoirs versus straight coloanal anastomosis after anteriorresection. Br J Surg 93(1): 19–32.

4. Koh PK, Tang CL, Eu KW, et al. (2007) A systematic review of the functionand complications of colonic pouches. Int J Colorectal Dis 22(5): 543–548.

5. Brown CJ, Fenech DS, McLeod RS. (2008) Reconstructive techniques afterrectal resection for rectal cancer. Cochrane Database Syst Rev 2: CD006040.

6. Z’Graggen K, Maurer CA, Buchler MW. (1999) Transverse coloplastypouch: a novel neorectal reservoir. Dig Surg 16(5): 363–366.

7. Fazio VW, Zutshi M, Remzi FH, et al. (2007) A randomized multicentertrial to compare long-term functional outcome, quality of life, and com-plications of surgical procedures for low rectal cancers. Ann Surg 246(3):481–488; discussion 488–490.

8. Lazorthes F, Gamagami R, Chiotasso P, et al. (1997) Prospective,randomized study comparing clinical results between small andlarge colonic J-pouch following coloanal anastomosis. Dis ColonRectum 40(12): 1409–1413.

June 9, 2009 14:7 B-601 ch28 FA

chap

ter28

Pelvic Exenteration for Rectal Cancer

Klaas Havenga∗,† and Theo Wiggers†

INTRODUCTION

The basis for successful treatment of rectal cancer is a radical resectionof the tumour. In the majority of cases, rectal cancer is confined to themesorectal package. Total mesorectal excision with long course orshort course preoperative (chemo-)radiotherapy, depending on themargin to the circumferential margin based on staging, is effective inthese cases.

In some cases rectal cancer extends to the anterior compartmentof the pelvis. In male patients the tumour may grow into the prostate,seminal vesicles or the bladder. In female patients the tumour maygrow into the posterior vaginal wall, the uterus or the bladder. Radicalresection of these tumors requires resection of the affected organs.This may result in partial bladder resection, resection of the seminalvesicles, or resection of the uterus or posterior vaginal wall en blocwith total mesorectal excision. If radical resection makes it necessaryto resect the prostate or the bladder, total pelvic exenteration — theresection of all pelvic viscera — is indicated.

In this technical note we will discuss the relevant surgical anatomyand surgical technique for total pelvic exenteration.

∗Corresponding author.†University Medical Center Groningen, Department of Surgery, PO Box 30.001,9700 RB Groningen, The Netherlands. †E-mail: [email protected]; [email protected]

209

June 9, 2009 14:7 B-601 ch28 FA

210 K. Havenga and T. Wiggers

SURGICAL ANATOMY

The pelvis consists of two compartments: a parietal outer compart-ment and a visceral inner compartment. The parietal compartment isbuilt around the skeletal part of the pelvis (sacrum, pubic, iliac andischiac bone). Muscles on the inside of the pelvis are the piriformismuscle, coccygeal muscle, levator ani muscle and obturator muscle.The common, internal and external iliac arteries and veins belong tothe parietal compartment as well as the lumbosacral nerve plexus.

Organs of the internal compartment are the rectum and bladderand the genitourinary organs: in females the uterus, the round liga-ment of the uterus, tubae and ovaries, and the vagina, in males theseminal vesicles, ductus deferens and prostate.

The visceral compartment is loosely connected to the parietal com-partment except for a zone on the lateral side and on the inferior side,where the anus and vagina or urethra come through the pelvic floor.On the anterior side of the visceral compartment, the bladder is con-nected to the pubic bone by a layer of loose areolar tissue. Dividingthis layer opens up the space of Retzius.

On the posterior side of the visceral compartment, the mesorectumis connected to the sacrum by another layer of loose areolar tissue(although not as loose as in Retzius’ space). Dividing this posteriorlayer open up the presacral space (Fig. 1). If both the presacral spaceand Retzius’ space are opened up, the visceral compartment is fixedto the pelvic side walls on the lateral side, in a line parallel to theinternal iliac artery. The ureter enters the visceral compartment closeto the bifurcation of the internal and external iliac arteries (Fig. 2).

SURGICAL TECHNIQUE FOR TOTAL PELVICEXENTERATION

Pelvic exenteration is in many ways similar to standard low ante-rior resection or abdominoperineal resection. The patient’s positionin stirrups, the midline incision from the pubic bone to just above

June 9, 2009 14:7 B-601 ch28 FA

Pelvic Exenteration for Rectal Cancer 211

FIGURE 1 � MRI reconstruction of the pelvic visceral compartment, showing a com-bined frontal/transversal reconstruction in 3 angles between the green lines, accord-ing to the pink line at the saggital reconstruction.

the umbilicus, the careful inspection of the abdomen and liver formetastatic disease and the exposition of the pelvis by installing a self-retaining retractor to keep the small bowel and omentum away areall the same. After mobilising and dividing the sigmoid, the superiorrectal artery is divided close to the inferior mesenteric artery.

June 9, 2009 14:7 B-601 ch28 FA


FIGURE 2 � Pelvic view, showing the location of the ureter and gonadal vessels.2

The presacral plane is developed. It is helpful to identify thehypogastric nerves at this stage and find the plane posterior to thesenerves, contrary to regular rectal resection. This outward plane fol-lows the outer layer of the visceral pelvic compartment. It is filledwith loose areolar tissue; some small vessels cross the layer. Often,this plane is oedematous by the neoadjuvant radiation therapy.

The ureter is encountered at its crossing of the iliac artery. Wedivide the ureter at this point, putting a temporarily small (char. 8)silicone catheter in it to allow observation of diuresis. Dividing theureter at this point allows an anastomosis to the Bricker loop at thepromontory.Alonger ureter could allow a Bricker anastomosis deeper

June 9, 2009 14:7 B-601 ch28 FA

Pelvic Exenteration for Rectal Cancer 213

FIGURE 3 � Puboprostatic ligament and dorsal venous complex.2

in the pelvis, at risk for leakage in the pelvis as it is not covered withtissue and for obstruction in the case of recurrent disease.

On the ventral side, the loose areolar tissue of Retzius’ space isdivided. The remaining bridge to the pelvic side wall is now divided.This dissection is carried out close to the internal iliac artery and veinand their subsequent branches, and just outside the pelvic autonomicnerve plexus we try to preserve in regular rectal resections. We use abipolar vessel-sealing device in this part of the operation.

June 9, 2009 14:7 B-601 ch28 FA


At the caudal edge of the pubic bone, firm attachments of theprostate to the bone are found: the puboprostatic ligament (Fig. 3).Under this ligament and lateral to this, an extensive venous plexusmay cause extensive bleeding if the dissection is carried forwardinto this plexus. It is better to identify and tie branches of thevesicoprostatic plexus cranially and/or to extent the dissection withinthe prostatic capsula towards the pelvic floor. The urethra is thenencountered and divided. The final part of the resection has twooptions. In the case of a distal tumour, a perineal resection is manda-tory. We advocate resecting the levator ani muscles en bloc with thespecimen to increase the resection margin in distal tumours.1 Inthe case of a more proximal tumour, sphincter preservation or leavingthe pelvic floor intact, preventing herniation, may be considered.

CONCLUSION

Total pelvic exenteration is very similar to total mesorectal excision.The difference lies in the extension of the resection line to includethe complete pelvic visceral envelope. Technically it is important todivide the ureter at the spot where it enters the visceral fascia (i.e.just medial to the iliac vessels). Secondly, it is important to incise theendopelvic fascia over the prostate anteriorly and to carefully ligatethe dorsal venous complex.

REFERENCES

1. Havenga K, Grossmann I, DeRuiter M, Wiggers T. (2007) Definition oftotal mesorectal excision, including the perineal phase: technical consid-erations. Dig Dis 25(1): 44–50.

2. Waldeyer W. (1899) Das Becken. Bonn, Cohen.

June 9, 2009 14:7 B-601 ch29 FA

chap

ter29

Reconstruction of the Perineumby Gluteal Fold Flap

Niri S. Niranjan∗

INTRODUCTION

The perineal region has two components: excretory and sexual. Hence,the aim of reconstruction should be to restore the function and theappearance. Here the video presentation is mainly reconstruction bygluteal fold flap of the vulval area. The perineum has a rich bloodsupply, provided by the femoral and iliac arteries. The branches ofthese arteries are medial-circumferential, superficial and deep exter-nal pudendal vessels, and the obturator artery and internal pudendalartery. From branches of these vessels arcades form around the uro-genital and anal orifices, and there are numerous perforators fromthese vessels. The skin of the gluteal fold area is supplied by the lat-eral branch of the internal pudendal artery. This is located just medialto the ischial tuberosity, and the lateral branch runs away laterally inthe gluteal fold area.

∗St. Andrews Centre for Plastic Surgery, Broomsfield Hospital, Broomsfield,Chelmsford, Essex.

215

June 9, 2009 14:7 B-601 ch29 FA

216 N.S. Niranjan

GLUTEAL FOLD FLAP

A large ellipse of skin within the gluteal fold can be harvested, mea-suring 15 cm by 8 cm. This island of skin can be transposed for vulvaldefects and also perianal defects. The gluteal fold flap is ideal forperineal reconstruction, even for cancer patients as the donor sitescar is well concealed and the lymphatic drainage is away from thedonor area. It also gives a large amount of skin for larger defectsup to 10 cm by 18 cm. Being local, it is very reliable and gives excel-lent cosmetic results. The disadvantage of the flap is loss of hair andsensation.

OPERATIVE TECHNIQUE

Prior to the surgery a gluteal fold is marked when the patient is in astanding position so that the resulting scar will be well hidden in thefold. The patient should be informed about the nature of the surgery,possible complications and the post-operative regime. The surgery isperformed under either general or regional anaesthesia. The patientis placed in the Lloyd–Davies position and can be manoeuvred fur-ther to suit while the resection and reconstructions are performed. Anindwelling catheter is inserted. The defect is created following exci-sion of a tumour or infected tissue. Once the dimension of the defectis mapped out, the required flap is planned over the donor area in areverse manner, by using a sterile swab or a sterile tape measure. Theflap harvesting should be carried out by using Loupe magnification.Initially an exploring incision is made at one edge of the flap downto the muscle. The flap is elevated, including the deep fascia. Usu-ally there are three perforating vessels noted from the gluteus muscleand they can be ligated once the medial-most perforator is identi-fied and also the lateral branch can be visualised just medial to theischial tuberosity. The dissection of this area should be performed byusing a pair of scissors, gently separating the tissue. Once the mainperforating branch to the flap is identified, the flap can be islanded

June 9, 2009 14:7 B-601 ch29 FA

Reconstruction of the Perineum by Gluteal Fold Flap 217

completely on the medial-most perforator if not the lateral branch ofthe internal pudendal vessel. Some amount of subcutaneous tissue isleft around this pedicle and this means less of a problem of venousdrainage. The flap is now ready to be rotated or transposed towardsthe defect. The suturing of the flap is by absorbable sutures and thedonor site can always be closed directly. A suction drain is insertedto prevent any haematoma. I usually use bulky dressings to keep theflap warm, and the patient is kept in a slightly abducted position and apillow is placed under the knees so that they are slightly flexed. Post-operatively the flap monitor should be functioning almost every hourfor the first 24 hours and infrequently for the next 24 hours. Patientswho have had gluteal fold flaps usually feel uncomfortable sittingfor a few weeks and they should be advised to use soft cushions.The indwelling catheter is removed after about three to five days andthe patient is usually discharged after a week to ten days, dependingon the extent of the reconstruction. Post-operative complications like

Michael Salmon (1936)Arteres de la peau

FIGURE 1 � X-ray plate reproduced from Salmon’s book on arteries of the skin, show-ing the fine anastomotic network that links the arteries of the skin of the pubic, vulvaland posterior perineal region in a woman aged 22 years. (Reproduced with permis-sion from Elsevier Ltd., Oxford, UK)

June 9, 2009 14:7 B-601 ch29 FA

218 N.S. Niranjan

venous congestion can be corrected by using leeches or removing thestitches at the pedicle area, and one should anticipate some of thesecomplications in patients who are obese or are smokers or diabetics.If there is only a small loss of flap, then this is generally allowed toheal be secondary intention following debridement.

REFERENCES

1. Cormack CG, Lambarty BG (1994). The Arterial Anatomy of Skin Flaps,2nd ed. Edinburgh, Churchill Livingstone.

2. Blondell PN, Morris SF, Hallock GG, Neligan PC (eds.) (2006). Perfora-tor Flaps: Anatomy, Technique and Clinical Applications. St Louis, Missouri,Quality Medical Publishing.

June 9, 2009 14:7 B-601 ch30 FA

chap

ter30

Local Treatment for Primary Melanoma

Omgo E. Nieweg ∗

A thorough physical examination must be performed when a patientpresents with a lesion suspicious for melanoma. The skin and sub-cutaneous tissue around the primary lesion and between it and theregional nodal basin should be examined for satellite and intransitmetastases. The regional nodal basin must be evaluated. The skin ofthe entire body must be examined for concurrent primary melanomas,as these occur in 1% of cases. Radiographic or laboratory studiesare not needed. Initial wide excision for simultaneous diagnosis anddefinitive treatment is discouraged for two reasons. Clinical assess-ment carries a false positive rate of 30%. Furthermore, the marginof therapeutic excision is determined by the Breslow thickness of thelesion. Measurement of the Breslow thickness is unreliable with frozensection microscopy.

A diagnostic excision with regional anaesthesia (field block) isadvised as a separate procedure prior to treatment. The orientation ofthe biopsy wound is planned with the definitive excision in mind. Thedirection of the scar is usually longitudinal on an extremity and trans-verse on the trunk. The excisional biopsy is carried out with a small

∗Corresponding author.Department of Surgery, The Netherlands Cancer Institute, Antoni van Leeuwen-hoek Hospital, Plesmanlaan 121, 1066 CX Amsterdam, the Netherlands. E-mail:[email protected].

219

June 9, 2009 14:7 B-601 ch30 FA

220 O. E. Nieweg

margin of surrounding skin (2 mm), and into the subcutaneous tissue.The diagnostic procedure should not be mutilating in a functional orcosmetic sense. A length three times as long as the width allows thewound to be closed easily with a nice cosmetic result. Punch biopsy,incisional or shave biopsy and excochleation, whether or not followedby electrocoagulation or cryotherapy, are discouraged. An incisionalbiopsy is acceptable when the primary lesion is large or situated in adelicate location, such as the face or the acra.An incisional biopsy doesnot increase the risk of recurrent disease or tumour-related demise.1

Fine needle aspiration for a cytological diagnosis is unreliable.Definitive treatment is exclusively surgical as a rule and entails

wide local re-excision of the biopsy wound with surrounding skin.The recommended margin of normal-appearing skin that needs tobe taken is a 1 cm margin for melanomas up to and including2 mm, according to Breslow. The optimal excision margin for thickermelanomas has been assessed in a British randomised study.2 It wasfound that survival after a 1 cm excision and after a 3 cm excisionwere similar, but local-regional recurrences were more often seen inthe narrow excision group. Retrospective studies suggest that a 2 cmmargin is adequate for such lesions.3,4 A Scandinavian study is cur-rently addressing this same subject.A2 cm margin appears acceptablefor these thick melanomas because the risk of (fatal) systemic metas-tases exceeds the risk of local recurrence by far.

These recommended margins are smaller than former directivesadvocate. Five randomised, prospective studies and two meta-analyses indicate that such a reduction is safe.5–7 Even narrower mar-gins are justified when the melanoma is situated on the face or acra;the perhaps somewhat improved cure rate after wide excision doesnot always outweigh the drawback of the additional mutilation. Thedefinitive excision can often be done with regional anaesthesia too.An easy way to do the procedure is to carry the incision into thesuperficial subcutaneous tissue around the entire area of skin that isto be removed. Then, carry the incision down to the underlying fas-cia at one end of the wound. Blood will not hamper the field of view

June 9, 2009 14:7 B-601 ch30 FA

Local Treatment for Primary Melanoma 221

if one starts at the end of the wound that is furthest from the table.Work steadily towards the opposite end. The fascia is usually leftintact but can be excised when it has been exposed during the initialdiagnostic procedure or in the case of a thin layer of subcutaneoustissue. Pulling firmly on the tissue that is being excised convenientlydemonstrates the plane that is to be followed. The wound is usuallyclosed primarily to provide the best possible long-term cosmetic andfunctional result. Undermining the skin edges can facilitate primaryclosure. The stitches are removed after three weeks. Earlier removalmay cause dehiscence, because the wound is closed with considerabletension. Asplit-thickness skin graft is applied if primary closure is notpossible. The donor site is chosen outside the tumour region.

Radiotherapy is virtually never used to treat localised lesions, withthe exception of lentigo maligna melanoma. The radiosensitivity ofthis particular melanoma type seems better than that of other typesof melanoma, and radiotherapy may occasionally be used as an alter-native to limit disfigurement.8

REFERENCES

1. Bong JL, Herd RM, Hunter JA. (2002) Incisional biopsy and melanomaprognosis. J Am Acad Dermatol 46: 690–694.

2. Thomas JM, Newton-Bishop JA, A’Hern RP, et al. (2004) Excision marginsin high-risk malignant melanoma. N Engl J Med 350: 757–766.

3. Heaton KM, Sussman JJ, Gershenwald JE, et al. (1998) Surgical marginsand prognostic factors in patients with thick (>4 mm) primary melanoma.Ann Surg Oncol 5: 322–328.

4. Ng AKT, Jones WO, Shaw JHF. (2001) Analysis of local recurrence andoptimizing excision margins for cutaneous melanoma. Br J Surg 88:137–142.

5. Lens MB, Dawes M, Goodacre T, et al. (2002) Excision margins in thetreatment of primary cutaneous melanoma: a systematic review of ran-domized controlled trials comparing narrow vs wide excision. Arch Surg137: 1101–1105.

6. Haigh PI, DiFronzo LA, McCready DR. (2003) Optimal excision marginsfor primary cutaneous melanoma: a systematic review and meta-analysis.Can J Surg 46: 419–426.

June 9, 2009 14:7 B-601 ch30 FA

222 O. E. Nieweg

7. Tsao H,Atkins MB, SoberAJ. (2004) Management of cutaneous melanoma.N Engl J Med 351: 998–1012.

8. Farshad A, Burg G, Panizzon R, et al. (2002) A retrospective study of150 patients with lentigo maligna and lentigo maligna melanoma andthe efficacy of radiotherapy using Grenz or soft X-rays. Br J Dermatol 146:1042–1046.

June 9, 2009 14:7 B-601 ch31 FA

chap

ter31

Ilioinguinal Dissection for Melanoma

Alessandro Testori∗,† and Mark Zonta†

INTRODUCTION

Ilioinguinal dissection for melanoma is indicated for positive sen-tinel nodes following selective lymphadenectomy or for palpable,histologically positive groin nodes. The procedure provides impor-tant staging information, helps with decision-making regarding adju-vant treatment, affords regional disease control and may be curativein patients without distant metastases. Several retrospective stud-ies have demonstrated the importance of deep inguinal and pelviclymphadenectomy in patients with superficial nodal involvementonly.1–5

TECHNIQUE

Under general anaesthesia and antibiotic prophylaxis, a urinarycatheter is inserted and the patient is positioned supine, with the ipsi-lateral lower limb slightly abducted to flex the knee.

∗Corresponding author.†Division of Melanoma and Soft Tissue Sarcoma, European Institute of Oncology,Italy.†European Institute of Oncology, via Ripamonti 435, 20141 Milano, Italy. E-mail:[email protected]

223

June 9, 2009 14:7 B-601 ch31 FA

224 A. Testori and M. Zonta

The operative field is prepared with a small drape to exclude thegenitals from the sterile field and to shift the genitals (male) contralat-erally. The remaining drapes are positioned to expose an area fromjust superior of the iliac crest to just inferior of the apex of the femoraltriangle.

Various skin incisions have been described. We employ either acurvilinear elliptical incision from just medial of the iliac crest to theapex of the femoral triangle, or separate incisions including a curvilin-ear elliptical infrainguinal incision and an oblique iliac fossa incision(Fig. 1). The incisions incorporate the previous biopsy site and skinoverlying palpable nodes.

A lateral subcutaneous flap is mobilised until the medial borderof the sartorius is exposed after incising the overlying fascia and spar-ing the lateral femoral cutaneous nerve. This flap is at least 0.5–1 cmthick, to avoid rendering it ischaemic. The superficial epigastric andsuperficial circumflex iliac vessels, the anterior saphenous vein and

FIGURE 1 � Preoperative photo showing an iliac fossa incision to approach the deeppelvic nodes and an elliptical infrainguinal incision incorporating the previous sen-tinel node biopsy site.

June 9, 2009 14:7 B-601 ch31 FA

Ilioinguinal Dissection for Melanoma 225

the intermediate femoral cutaneous nerve are encountered as this flapis mobilised along its full length.

Amedial flap of similar thickness is mobilised to the medial borderof the adductor longus. In males it is necessary to identify and retractthe spermatic cord medial to the dissection. Below the pubic tubercle,the fascia over the medial border of the adductor longus is incisedand dissected off this muscle and the pectineus after securing theexternal pudendal vessels, the accessory saphenous vein and the longsaphenous vein.

The suprainguinal lymph nodes are then dissected from theunderlying external oblique to the level of the inguinal ligament. Thefemoral sheath is incised below the ligament and the femoral vein isidentified just deep to the lateral border of the adductor longus. Thevein is skeletonised of its adventitia and nodal tissue and the saphe-nofemoral junction is suture-ligated and divided. Unless there is grossdisease involving the long saphenous vein, some surgeons preserveit to facilitate subsequent drainage of the limb. The femoral arteryis identified immediately lateral to the femoral vein and is similarlyskeletonised. The leash of motor branches of the femoral nerve are ina deeper plane and not usually exposed.

The specimen is divided at the femoral canal, as there is noproven benefit in maintaining its continuity with the deep pelvicnodes. Various approaches to these nodes have been proposed.We employ a pararectus approach without dividing the inguinalligament.

The inguinal ligament is retracted to allow dissection between itand the femoral vessels, and to secure the inferior epigastric vessels.This will facilitate blunt separation of the peritoneum from the abdom-inal wall and external iliac nodes once the ligament is suspendedand the abdominal wall divided along the lateral border of the rectusabdominis muscle. The retroperitoneal iliac fossa is exposed until thebifurcation of the common iliac artery and the ureter are identified.Retractors are positioned into the pelvic wound to maintain adequateexposure.

June 9, 2009 14:7 B-601 ch31 FA


The nodal dissection then continues from the common femoralvessels to the bifurcation of the common iliac artery. This involvesincising the adventitia of the anterior surface of the external iliac arteryand vein, and dissecting the nodal tissue from them and towardsthe obturator fossa until both vessels have been circumferentiallyskeletonised.

Proceeding cephalad, the vessels encountered during this phaseof the dissection include the deep circumflex iliac vessels coursing lat-erally, the inferior epigastric vessels medially, and a variable commu-nicating vein between the external iliac and obturator veins. Only thedeep circumflex vessels can be preserved, as they do not impede thedissection. Care is needed in identifying and dividing the communi-cating vein, because its inadvertent laceration can cause troublesomebleeding.

Once the common iliac bifurcation has been reached, an orienta-tion suture is secured to the most proximal lymph nodes. The cephaladretroperitoneal lymphatics are ligated to reduce postoperative lymph-orrhoea.

Dissection of the obturator nodes is then initially performed tosafely identify and preserve the obturator nerve posteriorly, and todissect the lymphatic structures immediately cephalad to the pelvicwall. The bladder is dissected off the medial aspect of the obturatornodes and sponge-holding forceps are used to remove the remainingnodal tissue from deep within the pelvis whilst always visualising thenerve (Fig. 2). The obturator dissection is considered adequate whenthe branches of the internal iliac artery have been exposed.

Following haemostasis a retroperitoneal pelvic drain is positionedvia the groin. The peritoneal sac is re-positioned and the abdominalwall is closed in two layers including the transversalis fascia and exter-nal oblique aponeurosis. To prevent a femoral hernia, non-absorbablemonofilament interrupted sutures are placed between Cooper’s liga-ment and the inguinal ligament. Some surgeons, including ourselves,recommend dividing the sartorius at its origin and rotating the muscleto cover the femoral vessels (Fig. 3), as this wound may be complicated

June 9, 2009 14:7 B-601 ch31 FA

Ilioinguinal Dissection for Melanoma 227

FIGURE 2 � Operative photo after deep pelvic lymphadenectomy with the externaliliac artery (broad arrow) and vein (narrow white arrow) and obturator nerve (blackarrow) exposed.

FIGURE 3 � The sartorius is mobilised on its preserved blood supply to be rotatedover the femoral vessels.

June 9, 2009 14:7 B-601 ch31 FA


by flap necrosis. The viability of each flap is assessed before closingthe subcutaneous tissue with a continuous absorbable suture and theskin with interrupted sutures.

DISCUSSION

The difference in morbidity by the addition of a pelvic dissection to aninguinal dissection is slight.6 In patients with microscopically positivesuperficial sentinel nodes, the incidence of deep nodal involvementmay be substantial,7 and the incidence is even higher in the presenceof palpable inguinal nodal metastases.8 Therefore, ilioinguinal dis-section is justified for these patients and is vitally important for thosewith positive deep nodes and no distant metastases.

REFERENCES

1. Mack LA, McKinnon JG. (2004) Controversies in the management ofmetastatic melanoma to regional lymphatic basins. J Surg Oncol 86:189–199.

2. Tonouchi H, Ohmori Y, Kobayashi M, et al. (2004) Operative morbidityassociated with groin dissections. Surg Today 34: 413–418.

3. Mann GB, Coit DG. (1999) Does the extent of operation influence theprognosis in patients with melanoma metastatic to inguinal nodes? AnnSurg Oncol 6: 263–271.

4. Hughes TM, Thomas JM. (1999) Combined inguinal and pelvic lymphnode dissection for stage III melanoma. Br J Surg 86: 1493–1498.

5. Strobbe LJ, Jonk A, Hart AA, et al. (2001) The value of Cloquet’s node inpredicting melanoma nodal metastases in the pelvic lymph node basin.Ann Surg Oncol 8: 209–214.

6. Karakousis CP, Thompson JF. (2004) Groin and pelvic dissection formelanoma. In: JF Thompson, DL Morton and BB Kroon (eds.), Textbookof Melanoma, pp. 285–295. London, Martin Dunitz.

7. Karakousis CP, Emrich LJ, Driscoll DL, et al. (1991) Survival after groindissection for malignant melanoma. Surgery 109: 119–126.

8. Karakousis CP, Emrich LJ, Rao U. (1986) Groin dissection in malignantmelanoma. Am J Surg 152: 491–495.

June 9, 2009 14:7 B-601 ch32 FA

chap

ter32

Surgical Treatment of PeritonealCarcinomatosis

Marcello Deraco∗,†, Dario Baratti‡, Barbara Laterza,‡

Domenico Sabia‡ and Shigeki Kusamura‡

INTRODUCTION

About three decades have passed since hyperthermic intraperitonealchemotherapy (HIPEC) was first conducted by Dr. Spratt.1 In thisperiod the treatment of peritoneal surface malignancy (PSM) withcytoreductive surgery (CRS) and HIPEC has gained enormous popu-larity, changing positively the expectations for a clinical condition thatin former times was considered incurable. Results of phase II studiestesting the efficacy of the combination in the treatment of pseudomyx-oma peritonei, peritoneal mesothelioma and ovarian cancer have beensomewhat encouraging.2−4 Results of a phase III trial have confirmedthe superiority of CRS + HIPEC in the treatment of patients with car-cinomatosis from colon cancer over other standard surgical and/orsystemic chemotherapy modalities.5 The purpose of this article is toprovide a short technical description of the local regional therapyof PSM.

∗Corresponding author.†Istituto Nazionale Tumori Milano, Via Venezian 1, 20133 Milano, Itally. E-mail: [email protected]‡Department of Surgery, National Cancer Institute of Milan, Italy.

229

June 9, 2009 14:7 B-601 ch32 FA

230 M. Deraco et al.

TECHNIQUE

The eligibility requirements for treatment are as follows: histologicallyconfirmed diagnosis of peritoneal carcinomatosis or sarcomatosis; age< 75 years; no distant metastasis; adequate renal, haematopoietic andliver functions; and performance status (ECOG) 0, 1 or 2.

The CRS is performed according to the Sugarbaker technique.6

Patients are put in the supine position with gluteal folds advancedto the break in the operating table. The surgical procedure startswith a xyphopubic, midline incision, and the successive layers of theabdominal wall are dissected until the parietal peritoneum is visu-alised. The dissection of the parietal peritoneum from the abdominalwall is begun without opening the peritoneal cavity and is continu-ous until the identification of the vena cava, aorta, iliac vessels andureters. Then, the parietal peritoneum is incised and full access to theabdominal cavity is achieved. Peritoneal carcinomatosis is quantifiedaccording to the Peritoneal Cancer Index.7

The surgical procedure is carried out with one or more of the fol-lowing steps, depending on disease extension, in order to achieve aresidual disease of less than 2.5 mm: (1) greater omentectomy, rightparietal peritonectomy ± right colon resection; (2) pelvic peritonec-tomy ± sigmoid colon resection ± hysteroadnexectomy; (3) lesseromentectomy and dissection of the duodenal–hepatic ligament ±antrectomy ± cholecystectomy; (4) right upper quadrant peritonec-tomy ± Glisson’s capsule; (5) left upper quadrant peritonectomy ±splenectomy; (6) other intestinal resection and/or abdominal massresection.

The stripping of the right upper quadrant continues until the barearea of the liver. At this point, tumour on the superior surface of theliver is electroevaporated until the liver surface is cleared.

In the case of massive tumour implantation on the liver (Fig. 1), theGlisson capsule from the superior surface of the liver can be removed.Dissection continues down to the right subhepatic space. The right

June 9, 2009 14:7 B-601 ch32 FA

Surgical Treatment of Peritoneal Carcinomatosis 231

FIGURE 1 � Intraoperative view of extensive peritoneal neoplastic dissemination inthe upper abdomen of a pseudomyxoma peritonei patient.

diaphragmatic peritoneum is resected together with the peritoneumlayering Morrison’s pouch.

The gall bladder is removed from its fundus toward the cysticartery and cystic duct. The triangular ligament of the left lobe of theliver is resected in performing the left subphrenic peritonectomy. Thiscompleted, the left lateral segment of the liver is retracted left to rightto expose the hepatogastric ligament. A circumferential release of thisligament from the fissure between liver segments 2, 3 and 1, and fromthe arcade of the right gastric artery to the left gastric artery along thelesser curvature of the stomach, is required.

To resect the peritoneum from the anterior aspect of the hepato-duodenal ligament, its reflection to the liver surface is released andthe peritoneum peeled away from the common bile duct and hepaticartery. Resection of the lesser omentum is always indicated, even inthe absence of metastatic disease in this structure.

June 9, 2009 14:7 B-601 ch32 FA


After stripping the left upper quadrant peritoneum from thediaphragmatic muscle, we begin the greater omentectomy ± splenec-tomy. The greater omentum is elevated, and separated from the trans-verse colon. This dissection continues beneath the peritoneum thatcovers the transverse mesocolon, so as to expose the pancreas. Thegastroepiploic and the short gastric vessels on the greater curvatureof the stomach are clamped, ligated and divided. The peritoneumanterior to the pancreas is stripped. The splenic vessels at the tail ofthe pancreas are ligated in continuity and proximally suture-ligated.

When the upper quadrant peritonectomy is completed, the stom-ach is reflected medially. Branches of the gastroepiploic arteries areligated. The left adrenal gland, the pancreas, the left perirenal fatty tis-sue and the anterior peritoneal surface of the transverse mesocolon aretotally exposed. A distal pancreatectomy is performed when requiredand the transection done using a GIA stapler with reinforcing hand-sewn separate Vycril 2-0 stitches.

Whether a partial or total gastrectomy is performed, a Roux-en-Yreconstruction is indicated. Small bowel and colic anastomoses arehand-sewn in an end-to-end fashion using single-layer extramucosalcontinuous Maxon 4-0 or 3-0 stitches (Fig. 2).

Most of the time the cul-de-sac area is filled with coalescingtumour implants that also include much of the sigmoid colon. A com-plete pelvic peritonectomy with a low anterior resection is frequentlyneeded to completely remove these tumour implants. The low col-orectal anastomosis is performed with an intraluminal stapler of29–33 mm diameter.

HIPEC

Generally speaking, there are two types of HIPEC modalities: theclosed and open abdomen techniques. At the National CancerInstitute of Milan the closed technique is used. After cytoreduction,four silicone catheters are placed in the abdominal cavity: one inthe right subphrenic cavity: one in the deep pelvis, one in the left

June 9, 2009 14:7 B-601 ch32 FA


FIGURE 2 � Aspect of the upper abdomen after a radical cytoreduction with partialgastrectomy.

subphrenic cavity and one in the superficial pelvic site cavity. Twothermocouples are placed in the abdominal cavity. Using the closedabdomen technique, the skin is closed with a running suture. Thecatheters are then connected to the extracorporeal circuit PerformerLRT®, RAND, Medolla (MO), Italy. The intraperitoneal chemother-apy regimens used are as follows: Cisplatin (CDDP-25 mg/m2/L)and Mitomycin C (MMC-3.3 mg/m2/L), or cisplatin (CDDP-43 mg/Lof perfusate) and doxorubicin (Dx-15.25 mg/L of perfusate). A heatexchanger keeps the intracavitary perfusate temperature at 42◦C to43◦C. The HIPEC lasts 60 to 90 minutes, depending on the drugschedule (Fig. 3).

DISCUSSION

The local–regional therapy (CRS + HIPEC) has already been stan-dardised and described in detail by its introducer.6 However, theincreasing number of surgeons and centres interested in setting upa local–regional therapy unit in the world renders the procedure sub-ject to several modifications.

June 9, 2009 14:7 B-601 ch32 FA


FIGURE 3 � Extracorporeal circuit in hyperthermic intraperitoneal chemotherapy. Thisschema represents the extracorporeal circuit in the closed abdomen technique.Theperfusate containing the drugs is mobilised by the pump and prepared by the heaterup to the temperature of 42.5◦C. Then, it is infused in the abdominal cavity throughtwo inflow catheters of Tenkhoff (5 and 6). After the circulation inside the abdominalcavity, the perfusate is recovered by the outflow catheters (7 and 8), to be instilledagain in the abdomen. The thermostat controls the temperature through four probeslocated respectively in the upper abdomen (1), lower abdomen (2), outflow (3) andinflow (4) of the circuit.

In December 2006 the National Cancer Institute of Milan organ-ised a consensus statement on the management of PSM. This confer-ence brought together experts in the field of local–regional therapyto discuss current approaches to PSM. The consensus was achievedwith several conflicting points regarding the technical variations ofCRS.8 The main conflicting points discussed were the radicalness ofthe peritonectomy procedure, the cytoreduction of neoplastic nodules< 2.5 mm, and indications of protective ostomies.

June 9, 2009 14:7 B-601 ch32 FA


A partial parietal peritonectomy restricted to the macroscopicallyinvolved regions could be indicated in all listed clinical conditionswith the exception of peritoneal mesothelioma. According to theexperts, a radical parietal peritonectomy is not advisable irrespectiveof the disease being treated.

The electrovaporisation of small non-infiltrating metastatic nod-ules (< 2.5 mm) in the mesentery, after the completion of CRS, wouldbe indicated, even if theoretically HIPEC could exert a microscopiccytoreductive effect. Regarding the policy for protective stomas, itcould be flexible and the procedure could be done at the surgeon’sdiscretion.

As to the modalities of HIPEC (open vs closed), it was concludedthat the evidence in the literature is not sufficient to confirm the supe-riority of one modality over the others in terms of outcome, morbid-ity, and safety of the personnel in the operating theatre. Each optionhas its own experimental evidence and operational advantages anddisadvantages.9

The continuous application of the local–regional treatment indifferent diseases and new clinical circumstances will require theadaptation of the original technique with further modifications. Thevalidation of the current and future variations of the techniquerequires prospective randomised studies to be conducted.

REFERENCES

1. Spratt JS, Adcock RA, Muskovin M, et al. (1980) Clinical delivery systemfor intraperitoneal hyperthermic chemotherapy. Cancer Res 40(2): 256–260.

2. Baratti D, Kusamura S, Nonaka D, et al. (2008) Pseudomyxoma peritonei:clinical pathological and biological prognostic factors in patients treatedwith cytoreductive surgery and hyperthermic intraperitoneal chemother-apy (HIPEC). Ann Surg Oncol 15(2): 526–534. Epub 2007 Nov 28.

3. Deraco M, Nonaka D, Baratti D, et al. (2006) Prognostic analysis of clin-icopathologic factors in 49 patients with diffuse malignant peritonealmesothelioma treated with cytoreductive surgery and intraperitonealhyperthermic perfusion. Ann Surg Oncol 13(2): 229–237. Epub 2006 Jan 18.

June 9, 2009 14:7 B-601 ch32 FA


4. Ryu KS, Kim JH, Ko HS, et al. (2004) Effects of intraperitoneal hyperther-mic chemotherapy in ovarian cancer. Gynecol Oncol 94: 325–332.

5. Verwaal VJ, van Ruth S, de Bree E, et al. (2003) Randomized trial of cytore-duction and hyperthermic intraperitoneal chemotherapy versus systemicchemotherapy and palliative surgery in patients with peritoneal carcino-matosis of colorectal cancer. J Clin Oncol 21: 3737–3743.

6. Sugarbaker PH. (1995) Peritonectomy procedures. Ann Surg 221: 29–42.7. Jacquet P, Sugarbaker PH. (1996) Current methodologies for clinical

assessment of patients with peritoneal carcinomatosis. J Exp Clin CancerRes 15: 49–58.

8. Kusamura S, O’Dwyer S, Baratti D, et al. (2008) Technical aspects of thecytoreductive surgery: results of consensus statement. J Surg Oncol, specialissue, in press.

9. Kusamura S, Dominique E, Baratti D, et al. (2008) Drugs, carrier solutionsand temperature in hyperthermic intraperitoneal chemotherapy. J SurgOncol, special issue, in press.

June 9, 2009 14:7 B-601 ch33 FA

chap

ter33

Laparoscopic Management of AdnexalTumours

Liselotte Mettler∗,†, Ivo Meinhold-Heerlein† andAndreas G. Schmutzler†

The adnexa provide a direct connection from the intraabdominalcavity to the outside through the Fallopian tubes across the uterus,cervix and vagina (Fig. 1). Bacteria can migrate to the genital tract andkidney region ascending across the cervix, the uterus and the tubes.On the other hand, a descending infection from the kidney region andthe tubes can reach the ureters and the bladder or the uterus and thecervix. In the lower pelvis of a female the bladder is connected to theoutside through the urethra and the uterus through the cervix so thatthe tubes have a natural predilection for infections and consecutivetubal occlusions. Till now no ovarian or tubal transplants have beenavailable, so the organs should be carefully diagnosed and treated. Aresection seems generally only indicated in the case of a malignantdisease or in old age. In addition, removal of a damaged Fallopiantube may increase the success rate of in vitro fertilisation and embryotransfer.

Even ovaries beyond the reproductive age carry a certain functionand should only be removed if indicated. Nearly all adnexal tumours

∗Corresponding author.†Department of Obstetrics and Gynecology, Christian-Albrechts-University of Kiel,Klinikum Schleswig-Holstein, Campus Kiel, Michaelisstr. 16, 24105 Kiel, Germany.E-mail: [email protected]

237

June 9, 2009 14:7 B-601 ch33 FA

238 L. Mettler et al.

FIGURE 1 � Anatomy of the right half of the uterus and the right adnexa.

can be managed laparoscopically. Procedures include excision ofovarian or paraovarian cysts, partial oophorectomy, total (salpingo-)oophorectomy, enucleation of ovarian cysts with borderlinemalignancy and the treatment of tubal pregnancy. Tubectomy, fim-broplasty, salpingostomy, end-to-end anastomosis and adnexectomyare possible.

In the case of ovarian cancer with an indication for radical surgery,the resection of the uterus, tubes and ovaries, as well as an extensivepelvic and parotic lymphadenectomy together with omentum resec-tion, is generally possible. However, the surgical treatment of ovariancancer by laparoscopy is still not widely accepted and the key generalsurgical options remain to be performed via laparotomy.6

The most common surgical procedures in the management ofbenign adnexal tumours are still the enucleation of ovarian cysts andadnexectomies. These two surgical procedures are performed asfollows:

(1) Ovarian cyst enucleationAn endoscopic ovarian cyst enucleation must be carried out in totoin the correct anatomical plane. Any remnant, as sometimes in

June 9, 2009 14:7 B-601 ch33 FA

Laparoscopic Management of Adnexal Tumours 239

cases of endometriosis, is destroyed by electrocoagulation or otherenergy sources. As an example, six steps of enucleation of a 5-cm-in-diameter ovarian cyst in a 23-year-old with a hyperechoiczone in ultrasonography with suspicion of borderline lesion aredemonstrated in Fig. 2. Step 5 is controversial, as most surgeonsprefer not to suture.

(2) AdnexectomyOvarectomy, tubectomy or adnexectomy is an easy laparoscopicprocedure if the adnexa are not pathologically attached to thepelvic sidewall. Figure 3 details schematically a right adnexec-tomy using a stapler in six individual steps. Under traction theadnexa are pulled away from the ovarian and infundibulopelvicligament, and separated from the uterus and infundibulopelvicligament using a stapling gun.

Other energy sources to be used are ultrasound, bipolar coagula-tion and thermofusion. Adnexa can only be reached intraperitoneally.Alternatively, sutures and the two- or three-loop ligation techniquecan be applied.6

Laparoscopic adnexal surgery has widely replaced laparotomyEvery ovarian cyst without any suspicion of malignancy in the

reproductive age range should be enucleated laparoscopically con-serving the organ. Any functional cyst in this age range, however,should first be treated by estrogen suppressants and excised onlyif it persists. Each adnexal tumour with an ovarian cyst should becarefully evaluated preoperatively, by imaging techniques, tumourmarker measurement and palpation. During endoscopic surgerythe most modern oncological criteria must be observed. At mostgynaecological–oncological surgical centres, in suspected ovariancancer a primary laparotomy with the aim of an RO resection withhysterectomy, adnexectomy, lymph node resection and omentectomyis carried out.

Only a few laparoscopic oncological centres have the know-howand the infrastructure to laparoscopically treat ovarian cancer. If

June 9, 2009 14:7 B-601 ch33 FA


FIGURE 2 � Ovarian cyst enucleation (with suspicion of borderline lesion) (A) Ultra-sound of the hyperechoic zone in a double-chambered ovarian cyst, tumour markernegative; (B) ovarian cyst, double the size of the normal ovary, between the ovary andthe uterus, near the normal-looking ovary; (C) dissection of a cyst capsule; (D) coag-ulation of the cyst pedicle; the cyst is enucleated out of its bed; (E) putting the ovariancyst in an endobag; (F) extraction of the cyst, tapping and adaption of wound edgeswith endosuture, and extracorporeal knotting.

malignancy is diagnosed during laparoscopy, the patient must beeither treated adequately laparoscopically or subjected to laparo-tomy in the same session or within the next 5–8 days.3,8 In thecase of borderline ovarian tumours, laparoscopic restaging shouldbe regularly performed.1 After incomplete initial ovarian cancer

June 9, 2009 14:7 B-601 ch33 FA


FIGURE 3 � Right adnexectomy using a stapling device and abdominal extraction inan endobag (A) Resection of the stretched adnexa from the uterus; (B) resection ofadnexa from the pelvic sidewall above the infundibulopelvic ligament; (C) puttingthe adnexa in an endobag; (D) closing the endobag; (E) pulling the endobag in a 10to 15 mm trocar; (F) widening the abdomen with two retractors and extraction of theendobag out of the abdomen.

surgery, laparoscopic restaging with pelvic and parotic lymphadenec-tomy, LAVH and/or salpingo-oophorectomy was found to essentiallyimprove the prognosis of such patients.4

Every effort is made to avoid intraoperative capsule rupture dur-ing primary surgery. If this does happen, irrigation is carried out

June 9, 2009 14:7 B-601 ch33 FA


carefully with copious normal saline even though it has not beenproved that rupture worsens the prognosis of ovarian carcinoma. Infive-year survival studies of stage I (FIGO) ovarian carcinoma, cap-sule rupture and “spilling” has appeared to play no role. The grade ofhistological differentiation and ascitis seem to play a greater role in thecase of stage I cancers.2,7 Vergote et al.9 proved in a multi-variate anal-ysis of surgery on 1545 patients with ovarian cancer that the degree ofdifferentiation is the most powerful prognostic indicator of disease-free survival — followed, however, by rupture before surgery, rup-ture during surgery, and age. The specimen obtained by laparoscopyshould be removed from the abdominal cavity in an endobag, so asto avoid port site metastases.

An aggressive operative regimen in the field of endoscopic surgeryfor genital carcinomas can be discussed on a broad basis only ifrandomised double blind studies show better success with endo-scopic surgery as compared to conventional surgery. In advanced ovar-ian carcinoma, we employ endoscopic methods merely for obtainingspecimens, to avoid exploratory laparotomy. In benign ovarian andadnexal tumours, endoscopic surgery has already replaced conven-tional laparotomy.

REFERENCES

1. Darai E, Tulpin L, Prugnolle H, et al. (2007) Laparoscopic restaging ofborderline ovarian tumors. Surg Endoscopy 21(11): 2039–2043.

2. Dembo AJ, Davy M, Stenwick, AE. (1990) Prognostic factors in patientswith stage I epithelial ovarian cancer. Obstet Gynecol 74: 263–273.

3. Kindermann G, Jung EM, Maassen V, Bise K. (1996) Incidence of primarymalignant lesions in clinically benign teratoma: on the problem of ade-quate surgical procedure. Geburtshilfe und Frauenheilkunde 56: 438–440.

4. Leblanc E, Querleu D, Narducci F, et al. (2005) Laparoscopic restaging ofearly-stage adnexal tumors: a 10-year experience. Obstet Gynecol Survey60(1): 31–32.

5. Medeiros LR, Stein AT, Fachel J, et al. (2007) Laparoscopy ver-sus laparotomy for benign ovarian tumor: a systematic review and

June 9, 2009 14:7 B-601 ch33 FA


meta-analysis. Int J Gynecol Cancer, Online-Article, publ. 10 Aug. 2007(http://www.blackwell-synergy.com).

6. Mettler L, Semm K, Gebhardt JH, et al. (2006) Manual for Laparoscopic andHysteroscopic Gynecological Surgery. Jaypee Brothers, New Delhi.

7. Sevelda P, Varra N, Schemper M, Salzer H. (1990) Prognostic factors forsurvival in stage I epithelial ovarian cancer. Cancer 65: 10.

8. Salfelder A, Nugent A, Lueken RP, et al. (2002) Laparoscopic treatment ofmalignant ovarian tumors — late results. Geburtshilfe und Frauenheilkunde62: 452–457.

9. Vergote I, de Brabanter J, Fyles A, et al. (2001) Prognostic importance ofdegree of differentiation and cyst rupture in stage I invasive epithelialovarian carcinoma. Lancet 357(9251): 176–182.

June 9, 2009 14:7 B-601 ch34 FA

chap

ter34

Excision of Intra-Abdominal Sarcomas:Technical Notes on Surgical Procedures

Beate Rau∗ and Peter M. Schlag

INTRODUCTION

Nonepithelial cancers derive from the various connective tissues and avariety of mesenchymal cell types (fibroblasts, adipocytes, osteoblastsand myocytes) throughout the body. These tumours, the sarcomas,constitute nearly 1% of the malignancies.

Soft tissue sarcomas are slightly increased in patients with a vari-ety of genetically transmitted diseases, and patients with soft tissuesarcoma very often have a recent history of a trauma or previousexposure to radiation.

Approximately 60% of sarcomas occur in the extremities, 9% inthe head and neck regions and 31% in the intra-abdominal cavity.Intra-abdominal soft tissue sarcomas (IASTS) are usually located inthe retroperitoneal space in 40%. The remaining tumours are locatedin the abdominal or chest wall, the mediastinum and the breast. Mostretroperitoneal soft tissue sarcomas are liposarcomas, leiomyosarco-mas or malignant fibrous histiocytomas.1

∗Corresponding author.Department of Surgery and Surgical Oncology, University of Berlin, Charité CampusMilte, Charite platz 1, 10 M7 Berlin, Germany. E-mail: [email protected]

245

June 9, 2009 14:7 B-601 ch34 FA

246 B. Rau and P. M. Schlag

The tendency of soft tissue sarcomas to metastasise depends onthe grade of the tumour. Low grade sarcomas are characterised mainlyby local invasive growth, but do not tend to metastasise. High gradetumours are more likely to disseminate. Therefore in these tumourssurgery is usually covered by a pre- and/or post-operative treatmentstrategy. However, complete resection and the grade of the tumourare the most important prognostic factors.

Surgery plays an important role in the treatment of soft tissuesarcomas and is a challenging procedure especially in retroperitonealtumours, because these are usually very large when detected. How-ever, the anatomical location of most retroperitoneal sarcomas pre-cludes complete surgical excision with tumour-free circumferentialmargin. Surgical excision should be aimed at removing all grosstumours with as much marginal tissue in the expected areas oflocal spread as is compatible with reasonable morbidity. Usually theretroperitoneal tumours are adjacent to, covered by or close to the bigvessels of the aorta and cava vein, kidney, adrenal gland, diaphragm,pancreatic head, corpus or tail, spleen, liver, colon, rectum,stomach, etc.

In the case of marginal excision of the tumour, additional radio-therapy should be considered, especially in high grade sarcomas, andthe surgeon should outline the margins of resection with clips. How-ever, any potential enhancement of local control by radiotherapy mustbe weighed against functional deficits and impairments in quality oflife induced by radiotherapy.

OPERATIVE TECHNIQUE

In retroperitoneal sarcomas, it is of major importance to resectthe tumour within gross tumour-free circumferential margins. Theaverage mean diameter of retroperitoneal tumours is often veryimpressive, so median laparotomy extends from the xiphoid processto pubic symphysis. Sometimes even lateral extension of the scar is

June 9, 2009 14:7 B-601 ch34 FA

Excision of Intra-Abdominal Sarcomas 247

necessary (be aware of the right angle of the incisions to each other,to avoid necrosis of the abdominal wall).

Retroperitoneal sarcomas are covered ventrally by the bowel (seeFig. 1) and the peritoneum, and dorsally by the retroperitoneal planeadjacent to the autochthonous muscles and the vertebra as well as thelateral abdominal wall. Usually, to achieve complete resection, multi-visceral en bloc resection has to be planned. Therefore the first step ofthe procedure should be dissection of the big vessels and a truncularcut through the mesenteric inferior and renal artery, if the kidney isinvolved. The same procedure has to be performed with the vein. Thesecond step is dissection of the tumour within the retroperitoneal fas-cia and the ventral part of the adjacent autochthonous muscles of theback. Sometimes the complete muscles have to be resected includingthe femoral nerve.

Preparation of the retroperitoneal space dorsal of the tumourcould be very difficult, because of the bad view. To reduce the bloodloss during the operation, especially in this part, sealing equipmentcould help.

If nephrectomy is necessary for achieving complete resection,retransplantation of the kidney could be an option for organ-savingsurgery. Then the cortex of the kidney has to be dissected outside thebody and retransplantation of the kidney can be performed easily.

DISCUSSION

The incidence of retroperitoneal sarcoma (RPS), a rare disease, appearsstable. Most patients who undergo surgery do not receive any adju-vant radiotherapy, and very few receive preoperative radiotherapy.The Swedish Council of Technology Assessment in Health Care anal-ysed the literature on radiation therapy for soft tissue sarcomas (STS).2

The review was based on data from 5 randomised trials, 6 prospec-tive studies, 25 retrospective studies and 3 other articles involving4579 patients.Again, prognostic factors for tumour-related death fromSTS re-confirmed the histological grade, tumour size and age. There

June 9, 2009 14:7 B-601 ch34 FA


FIGURE 1 � (a) A 54-year-old man was detected to have an incidental Grade 1 liposar-coma at the abdominal US. There was no evidence of metastatic spread. Radical surgi-cal excision was undertaken. (b) Specimen of en bloc excision of the large liposarcomawith the left colon.

June 9, 2009 14:7 B-601 ch34 FA


is strong evidence that adjuvant radiotherapy improves the local con-trol rate in combination with conservative surgery in the treatment ofSTS of extremities and the trunk in patients with negative, marginalor minimal microscopic positive surgical margins.2

For RPS no convincing studies exist which demonstrate the ben-eficial influence of adjuvant or neoadjuvant radiotherapy in thesepatients, mostly due to the radio-therapeutically induced toxicity. Onthe other hand, this leads to more sophisticated delivery methodsthat deliver high dose rates while sparing surrounding normal tissues.Preoperative radiotherapy for RPS demonstrated less local recurrenceand a low rate of induced toxicity. However, even for large retroperi-toneal tumours the data are still discussed to establish preoperativeradiotherapy for RPS.2

There is no randomised study comparing external beam radiother-apy and brachytherapy. The data suggest that external beam radio-therapy and low-dose-rate brachytherapy result in comparable localcontrol for high-grade tumours. Some patients with low-grade softtissue sarcomas benefit from external beam radiotherapy in termsof local control. The available data are inconclusive concerning theeffect of intraoperative high-dose-rate radiotherapy for RPS. Differ-ences in adjuvant radiotherapy that are related to demographic andgeographic factors suggest that at least some treatment variationsreflect differences in individual and institutional practice patterns.2

However, there remains no definitive prospective, randomised trialthat establishes the role of adjuvant or neoadjuvant radiation versusno radiation. Owing to significant radiation morbidity with adjacentorgans, especially the small bowel, there exists no consensus on radi-ation timing, delivery method or dosing.3,4

The weighting of surgery in the multimodal treatment setting iswidely accepted: complete resection of the sarcoma is the numberone prognostic factor. But complete resection of RPS is difficult and ispossible only in 50% of cases.1,5 Usually, incomplete resections overno resection have not shown a survival benefit. However, in selectedpatients with unresectable retroperitoneal liposarcoma, incomplete

June 9, 2009 14:7 B-601 ch34 FA


surgical resection can provide prolongation of survival and success-ful symptom palliation. Most likely to benefit are those patients pre-senting with primary tumours, which suggests that surgical resectionshould be attempted in the majority of patients.6

The use of intraoperative radiation therapy has also been exam-ined as a means of improving local recurrence rates, but may be asso-ciated with more radiation-related morbidity.7

To summarise the treatment strategies in RPS: surgery with com-plete resection is the most important factor for long term survival andrecurrence rate. However, every effort should be made to minimiselocal recurrence, but recurrence alone does not define the long termoutcome. The biology of the tumour seems to be the most importantprognostic factor; therefore our challenge remains to find effectivemultimodal treatment strategies for ameliorating the result. Furtherstudies are needed.

REFERENCES

1. Weiss SW, Goldblum J. (2001) Sarcomas in the retroperitoneum. In:Enzinger F, Weiss SW, editors, Soft Tissue Tumours, 4th ed. St. Louis,Mosby, pp. 37–44.

2. Strander H, Turesson I, Cavallin-Stahl E. (2003) A systematic overviewof radiation therapy effects in soft tissue sarcomas. Acta Oncol 42(5–6):516–531.

3. Tzeng CW, Fiveash JB, Heslin MJ. (2006) Radiation therapy for retroperi-toneal sarcoma. Expert Rev Anticancer Ther 6(8): 1251–1260.

4. Tzeng CW, Fiveash JB, Popple RA, et al. (2006) Preoperative radiationtherapy with selective dose escalation to the margin at risk for retroperi-toneal sarcoma. Chirurg 107(2): 371–379.

5. Erzen D, Novak J, Spiler M, Sencar M. (2007) Aggressive surgical treat-ment of retroperitoneal sarcoma: long-term experience of a single insti-tution. Surg Technol Int 16: 97–106.

6. Glass A, Wieand HS, Fisher B, et al. (1981) Acute toxicity during adju-vant chemotherapy for breast cancer: the National Surgical Adjuvant

June 9, 2009 14:7 B-601 ch34 FA


Breast and Bowel Project (NSABP) experience from 1717 patients receiv-ing single and multiple agents [prior annotation incorrect]. Cancer TreatRep 65: 363–376.

7. Pawlik TM, Ahuja N, Herman JM. (2007) The role of radiation inretroperitoneal sarcomas: a surgical perspective. Curr Opin Oncol 19(4):359–366.

June 9, 2009 14:7 B-601 ch35 FA

chap

ter35

Laparoscopic Adrenalectomyfor Tumours in the Adrenal Glands

Bergþór Björnsson∗,†, Guðjón Birgisson†

and Margrét Oddsdóttir††

INTRODUCTION

Laparoscopic adrenalectomy became the method of choice in theearly 1990s for the removal of adrenal glands with presumed benigntumours.1 The laparoscopic approach, with its magnification and del-icate instruments, was found to be ideal for the removal of these smallorgans deep in the retroperitoneum and in close proximity with thecaval vein, the renal vessels as well as the spleen. Several studies haveshown excellent outcomes with short hospital stays and low morbid-ity in comparison with the conventional open method.1 Malignantlesions of the adrenals are relatively rare. The laparoscopic approach isnot feasible for invasive adrenal malignancy. However, for suspectedmalignancy without apparent local invasion, laparoscopic adrenalec-tomy is considered appropriate.2,3

∗Corresponding author.†University of Iceland Medical School and Landspitali-University Hospital,Reykjavik, Iceland.††Landspitali-University Hospital, Reykjavik, Iceland.

253

June 9, 2009 14:7 B-601 ch35 FA

254 B. Björnsson et al.

TECHNIQUE

The adrenal glands can be removed using the laparoscope byeither the transperitoneal or the retroperitoneal approach. We preferthe transperitoneal route, and it is the technique more commonlyused.

The patient is placed in a lateral decubitus position. The brakingpoint of the table should be at or just above the pelvic rim of the patient.The table is flexed to provide as much space as possible betweenthe costal margin and the iliac crest (Fig. 1). The whole table is thenadjusted so that the upper part is almost horizontal, but with the lowerpart sloping downwards. The legs are slightly bent, with a pillowbetween them. A small roll is placed in the axilla facing the table andthe contralateral arm secured on an arm table. The patient is securedin this position with tape or stabilisers. It is convenient to mark theanterior and mid-axillary line while the patient is supine. The firsttrocar is placed at the anterior axillary line, 2–5 cm below the costalmargin. We usually place the first trocar by the open technique anduse a 30◦ laparoscope. This incision can later be enlarged if necessaryto deliver the specimen out of the abdomen. Once the intra-abdominalpressure is 15 mmHg, a 5 mm trocar is placed below the costal margin

FIGURE 1 � Patient position for laparoscopic left adrenalectomy.

June 9, 2009 14:7 B-601 ch35 FA

Laparoscopic Adrenalectomy 255

at the mid-clavicular line. Another 5 mm trocar is then placed justbelow the costal margin, just lateral to the mid-axillary line. On theright, the third 5 mm trocar is placed in the epigastrium for the liverretractor. Sometimes, the third 5 mm trocar is needed on the left sidefor additional retraction. On the left side, it may be necessary to takedown the lateral attachments of the left colon flexure to accommodatethis trocar. On the right, an additional trocar (5 mm) is placed in theepigastrium for a liver retractor. Sometimes, yet another 5 mm trocaris needed on the left side for retraction. The placement may either be inthe epigastrium or posterolateral to the lateral 5 mm trocar, dependingon the operative field.

In general, we use a combination of electrocautery and ultrasonicscissors for dissection. The adrenal veins are controlled with titaniumclips, but if they are large we prefer vascular staplers. It is important tohandle the adrenal glands with care, so as to keep their fragile capsuleintact.

Left Adrenalectomy

The lienocolic ligament is divided and the left colon flexure ismobilised away from the spleen. The proximal part of the left colonmay need to be mobilised from the lateral abdominal wall to give agood view of the area behind the spleen. The lateral attachments ofthe spleen are divided, starting below the inferior pole and continuingup to the diaphragm, where the attachments of the superior pole aredivided. If the tip of the pancreas is noted, the dissection is continueddorsal to it. When fully mobilised the spleen falls medially withoutretraction and the area behind it is now visualised as “an open book”.The dissection is adequate when the medial edge of the adrenal glandis exposed. The inferior and medial border of the gland is mobilised,and as one dissects the medial-dorso-inferior part of the gland, theleft adrenal vein comes into view (Fig. 2). Once around the vein itis secured with clips and divided. As one carries out the dissectionsuperiorly, an additional branch may be found that needs attention.

June 9, 2009 14:7 B-601 ch35 FA


FIGURE 2 � Exposure of the right adrenal gland and the right adrenal vein.

The gland is now mobilised by freeing all its edges and then from theunderlying retroperitoneum.

Right Adrenalectomy

The lateral liver attachments and the triangular ligament aredivided. With a retractor the liver is retracted. The dorsal peritonealattachments to the liver are divided until the upper edge of the adrenalgland comes into view. The lateral edge of the caval vein and themedial side of the adrenal gland are carefully separated. Once theright adrenal vein is seen and isolated with a right angle dissector, itis secured with clips and divided (Fig. 3). The gland is fully mobilisedby freeing its edges circumferentially and dividing the retroperitonealattachments.

June 9, 2009 14:7 B-601 ch35 FA

Laparoscopic Adrenalectomy 257

FIGURE 3 � Exposure of the left adrenal gland and the left adreanal vein.

An impermeable plastic bag is used for retrieval of the gland. It istaken out through the initial incision, which may need to be enlargedto deliver the specimen intact.

DISCUSSION

Laparoscopic adrenalectomy is the standard of care for the removalof adrenal tumours confined to the adrenal gland.4,5 For a suspectedmalignant lesion of the adrenal gland, it is generally considered safe touse the laparoscopic approach.6,7 However, very large tumours andobvious signs of invasive tumour growth are indications for opensurgery.

June 9, 2009 14:7 B-601 ch35 FA


REFERENCES

1. Lee J, El-Tamer M, Schiffner T, et al. (2008) Open and laparoscopicadrenalectomy: analysis of the National Surgical Quality ImprovementProgram. J Am Coll Surg 206: 953–959.

2. Cobb WS, Kercher KW, Sing RF, Heniford BT. (2005) Laparoscopicadrenalectomy for malignancy. Am J Surg 189: 405–411.

3. Sturgeon C, Kebebew E. (2004) Laparoscopic adrenalectomy for malig-nancy. Surg Clin North Am 84: 755–774.

4. Bjornsson B, Birgisson G, Oddsdottir M. (2008) Laparoscopic adrenalec-tomies: a nationwide single-surgeon experience. Surg Endosc 22: 622–626.

5. Parnaby CN, Chong PS, Chisholm L, et al. (2008) The role of laparoscopicadrenalectomy for adrenal tumours of 6 cm or greater. Surg Endosc 22:617–621.

6. McCauley LR, Nguygen MM. (2008) Laparoscopic radical adrenalectomyfor cancer: long-term outcomes. Curr Opin Urol 18: 134–138.

7. Adler JT, Mack E, Chen H. (2007) Equal oncologic results for laparoscopicand open resection of adrenal metastases. J Surg Res 140: 159–164.

June 9, 2009 14:7 B-601 ch36 FA

chap

ter36

Isolated Limb Perfusion

Harald J. Hoekstra∗

INTRODUCTION

Isolated limb perfusion (ILP) is performed in the limb salvage treat-ment of locally advanced melanoma or sarcoma.1,2 The theory behindregional chemotherapy is that a high drug uptake may be achievedwithout systemic toxicity. The delivery of chemotherapy within theILP setting has three major advantages: the “first pass” effect, whichresults in an increased drug uptake; hyperthermia, which facilitatesdrug uptake through increased blood flow and permeability of thecell membrane; and the use of cytostatic agents, which cannot be usedoutside the ILP setting due to the high systemic toxicity.3

PERFUSION LEVEL

Upper limb perfusions may be performed at two levels — axillary orbrachial — and lower limb perfusions at three levels — iliac, femoral orpopliteal (Fig. 1). The level of perfusion is determined by the involved

∗Division of Surgical Oncology, Department of Surgery, Groningen UniversityHospital, University of Groningen, PO Box 30.001, 9700 RB Groningen, TheNetherlands. E-mail: [email protected]

259

June 9, 2009 14:7 B-601 ch36 FA

260 H. J. Hoekstra

FIGURE 1 � Five different perfusion levels for regional perfusion of the extremities.

part of the limb and the kind of disease, e.g. skin malignancies versussarcomas. For skin malignancies the most proximal site of cannulationis the best choice, since the whole limb is at risk. In sarcomas the levelof perfusion is determined by the distinct part of the limb containingthe tumour.

PERFUSION TECHNIQUE

After dissection of the appropriate artery and vein and ligation ofthe collateral vessels, to control collateral flow and prevent leakage,the patient is heparinised systemically (heparin 3.3 mg/kg BW). Thelimb is isolated from the systemic circulation by an esmarch bandagetwisted around the root of the limb and fixed around a pin insertedinto the head of the humerus (axillary perfusion) or iliac crest (iliac per-fusion). An inflating tourniquet (300–400 mm Hg) is used for brachialor popliteal perfusions. The artery and vein are exposed, cannulatedwith 14–16 F catheters and connected to an extracorporeal circulationsystem. Thermister probes are placed in the subcutaneous tissue andmuscle for continuous temperature monitoring. The limb is wrappedin a thermal blanket (Fig. 2).

June 9, 2009 14:7 B-601 ch36 FA

Isolated Limb Perfusion 261

FIGURE 2 � Schematic drawing of a regional perfusion circuit for an iliac perfusion ofthe lower extremity: an esmarch bandage around the hip with a Steinman pin insertedin the iliac crest, arterial and venous perfusion catheters connected to the arterial andvenous line, membrane oxygenator, heat exchanger, roller pomp, continuous leakagemonitoring with a scintillation detector placed over the heart, a warm water mattressand thermoprobes for skin and muscle temperature.

The extracorporeal circulation perfusion system consists of a rollerpump, a membrane oxygenator, a heat exchanger and systems for con-tinuous data monitoring of the temperature of the perfusate, the meanarterial and venous pressure in the perfusion canules, the mean arte-rial pressure in the system, and the venous saturation and electronicbalance of the perfusion volume.

The perfusate consists of 250 ml of Isodex in 0.9% saline, 250 mlof white-cell-reduced (filtered) packed red cells and 30 ml of 8.4%NaHCO3; 0.5 ml of 5000 IU/ml heparin is oxygenated by a membraneoxygenator (DIDECO, Mirandola, Italy) with a gas mixture of air andoxygen. Leakage into the systemic circulation is continuously mon-itored with radioactive tracers. A small calibration dose of radioac-tive iodine-131-labeled human serum albumin (RISA 0.5 MBq) and adose of radioactive technetium-99m-labeled human serum albumin(RtcSA 10 MBq) are administered into the systemic circulation afterthe isolation of the limb is accomplished. The day before surgery the

June 9, 2009 14:7 B-601 ch36 FA

262 H. J. Hoekstra

thyroid is saturated through the oral administration of iodine. A ten-times-higher dose of RISA (5 MBq) is injected in the perfusion circuit.The 364 keV gamma rays emerging from the RISA and the 140 keVgamma rays from the RtcSA are measured with a NaI detector overthe precordium. The risk of leakage is less than 3% (Fig. 2).4,5

Cytostatic agents are added into the arterial line to the limb whenthere is no leakage, and a limb temperature of 38◦C is reached. Per-fusions are flow- and pressure-regulated to achieve adequate tissueperfusion. Adjustments of the flow rate and pressure in the perfusioncircuit by the perfusionist, as well as the blood pressure of the patientby the anaesthesiologist, together with an optimal isolation of the limbby the surgeon, ensure a stable and optimal perfusion. When there isan increase leakage to the systemic circulation (losing), the flow rateshould be reduced and the systemic blood pressure increased, andeventually the tourniquet tightened, while with a loss of the systemiccirculation into the perfusion circuit (gaining) the tourniquet shouldbe tightened, the flow rate increased and the outflow “occluded.” Incase of too much leakage, losing or gaining, the perfusion should beterminated for technical reasons to prevent loco-regional or systemiccomplications.

After the perfusion the limb is washed out with 4–6 l of saline andfilled with 250 ml of white-cell-reduced (filtered) packed red cells. Thevessels are restored, heparin is antagonised with prothrombin, anda fasciotomy is performed. Patients perfused with TNFα are moni-tored during a period of 24 h in the intensive care unit, while patientsperfused with melphalan are observed on the ward. No prophylac-tic antibiotics are prescribed. Patients receive subcutaneous low-dosemolecular heparin till a full mobilisation is achieved.

CYTOSTATIC AGENTS

Cytostatic agents used in ILP must have appropriate pharmacoki-netic profiles, and steep dose-response curves without requiringmetabolic activation (Fig. 3). A variety of cytostatic agents besidesmelphalan have been used: darcarbazide (DTIC), actinomycin-D,

June 9, 2009 14:7 B-601 ch36 FA


FIGURE 3 � Appropriate pharmacokinetic profiles for cytostatic agents used in ILP.

thiotepa, mitomycine-C, doxorubicin, cisplatin and carboplatin. Themajority of these agents were ineffective, the duration of response wasquite limited, or local toxicity hampered further application.

Melphalan (Alkeran�, GlaxoSmithKline Pharmaceuticals, Res-earch Triangle Park NC) is the most effective drug in ILP formelanoma. The dose calculation of melphalan was in the past per-formed on body weight (lower limb 1.0–1.5 mg/kg BW and upperlimb 0.5–0.7 mg/kg BW). Today the dosage is based on the perfusedlimb volume (lower limb 10 mg/L, upper limb 13 mg/L). Dosesgreater than 150 mg per limb result in regional toxicity.

Tumour necrosis factor–alpha (TNFα; Boerhinger-IngelheimGmbH, Vienna, Austria) is used together with melphalan in the treat-ment of locally advanced melanoma and sarcoma of the limb.1,2 TNFα

attacks the neovascular endothelial cells, in particular the tumour vas-culature, causing increased vessel permeability and facilitating mel-phalan uptake in the tumour cells.6 The dosage of TNFα for the upperlimb and popliteal perfusion is 3 mg; for the lower limb, 4 mg. “TNFpriming time” of 15–30 minutes prior to the intra-arterial delivery ofmelphalan seems appropriate. The clinically used perfusion time for

June 9, 2009 14:7 B-601 ch36 FA

264 H. J. Hoekstra

Table 1 Wieberdink’s Acute Regional Toxicity Grading System.

Grade I No reactionGrade II Slight erythema and/or oedemaGrade III Considerable erythema and/or oedema with

some blistering; slightly disturbed motility permissibleGrade IV Extensive epidermolysis and/or obvious damage

to the deep tissues, causing definite functional disturbances;threatening or manifest compartmental syndrome

Grade V Reaction which may necessitate amputation

melphalan alone is 45–60 minutes; for the combined TNF–melphalanperfusion, 60–90 minutes.7

TREATMENT TOXICITY

The effects of the perfusate on normal tissues are recorded according toWieberdink’s criteria and vary widely between individuals (Table 1).8

Melphalan may cause skin toxicity, erythema and blistering. Thisresolves in general within a month with regard to the accompanyingprocedures, e.g. tumour resection or radiation. A small proportionof patients undergoing ILP for melanoma will have long-term limbsymptoms (5–8%), without severe impairment.9 After ILP for sarcomaimpairment of limb function is not related to the ILP, but to the extentof surgery with or without adjuvant irradiation.10

Another risk factor in ILP is the vascular status of the (elderly)patient. Manipulation, cannulation and tight occlusion of scleroticvessels might cause embolic events, arterial stricture after vesselrepair, or arterial thrombosis, requiring reoperation or even ampu-tation of the perfused limb. Deep venous thrombosis is sometimesencountered due to cannulation of the vein or the thrombogenic sideeffect of melphalan.

SUMMARY

ILP is a technically demanding procedure that delivers safe and effec-tive high doses of cytostatic agents in the limb-saving treatment oflocally advanced melanoma or sarcoma.

June 9, 2009 14:7 B-601 ch36 FA


REFERENCES

1. Hoekstra HJ. (2008) The European approach to in-transit melanomalesions. Int J Hyperthermia 24: 227–237.

2. van Ginkel RJ, Thijssens KM, Pras E, et al. (2007) Isolated limb perfusionwith tumor necrosis factor alpha and melphalan for locally advancedsoft tissue sarcoma: three time periods at risk for amputation. Ann SurgOncol 14: 1499–1506.

3. Guchelaar HJ, Hoekstra HJ, de Vries EG, et al. (1992) Cisplatin and plat-inum pharmacokinetics during hyperthermic isolated limb perfusion forhuman tumours of the extremities. Br J Cancer 65: 898–902.

4. Daryanani D, Komdeur R, Ter Veen J, et al. (2001) Continuous leakagemeasurement during hyperthermic isolated limb perfusion. Ann SurgOncol 8: 566–572.

5. Van Ginkel RJ, Limburg PC, Piers DA, et al. (2002) Value of continuousleakage monitoring with radioactive iodine-131-labeled human serumalbumin during hyperthermic isolated limb perfusion with tumor necro-sis factor–alpha and melphalan. Ann Surg Oncol 9: 355–363.

6. Nooijen PT, Manusama ER, Eggermont AM, et al. (1996) Synergisticeffects of TNF-alpha and melphalan in an isolated limb perfusion modelof rat sarcoma: a histopathological, immunohistochemical and electronmicroscopical study. Br J Cancer 74: 1908–1915.

7. de Wilt JH, Manusama ER, van Tiel ST, et al. (1999) Prerequisites foreffective isolated limb perfusion using tumour necrosis factor alpha andmelphalan in rats. Br J Cancer 80: 161–166.

8. Wieberdink J, Benckhuysen C, Braat RP, et al. (1982) Dosimetry in iso-lated perfusion of the limb by assessment of perfused tissue volume andgrading of toxic tissue reactions. Eur J Cancer Clin Oncol 18: 905–910.

9. Olieman AF, Schraffordt Koops H, Geertzen JH, et al. (1994) Functionalmorbidity of hyperthermic isolated regional perfusion of the extremities.Ann Surg Oncol 1: 382–388.

10. Hoven-Gondrie ML, Thijssens KM, Geertzen JH, et al. (2008) Isolatedlimb perfusion and external beam radiotherapy for soft tissue sarcomasof the extremity: long-term effects on normal tissue according to theLENT-SOMA scoring system. Ann Surg Oncol 15: 1502–1510.

June 9, 2009 14:7 B-601 ch37 FA

chap

ter37

Cone and Wedge Resection in RenalCell Carcinoma

Frederik C. Roos∗,† and Joachim W. Thüroff†

INTRODUCTION

Nephron sparing surgery (NSS) is the treatment of choice for patientswith localised renal cell carcinoma (RCC) when preservation of renalparenchyma is mandatory, such as in bilateral RCCs, RCC in a solitarykidney and in chronic renal failure (imperative indication).1

Elective NSS is defined as treatment of a single, safely resectableRCC in a patient with a normal contralateral kidney. Several reportshave shown that NSS provides equivalent oncological2 and betterrenal functional results than radical nephrectomy (RN) for thesepatients.3

Long-term renal functional outcomes are better in patients under-going NSS than RN; Lau et al.3 reported that progression to chronicrenal failure (defined as a serum creatinine level of > 2.0 mg/dL) at 10years occurred in 22.4% of patients after RN, versus 11.6% after NSS.

Recent data suggest that NSS is safe for tumours up to 7 cm, andelective NSS is a reasonable option for all patients with a clinical T1renal tumour.4,5

∗Corresponding author.†Department of Urology, Johannes Gutenberg-University Mainz Medical School,Germany. E-mail: [email protected]

267

June 9, 2009 14:7 B-601 ch37 FA

268 F. C. Roos and J. W. Thüroff

INTRAOPERATIVE PROCEDURE

We generally prefer the extraperitoneal flank incision through the 10thor 11th intercostal space. After opening Gerota’s fascia, the kidney iscompletely mobilised, leaving the perirenal fat only attached at thesite of the tumour. The renal vessels are exposed and secured by ves-sel loops. Clamping of the artery may not be necessary for excisingsmall peripheral tumours. When cold renal ischaemia is required, thekidney is placed into a bowel bag, which is loosely tied around therenal hilus and has its bottom excised to be filled with slush ice. Tenminutes before clamping the renal artery, 1.2 mg of enalapril and man-nitol 20% 1 ml/kg bw are administered intravenously. The fibrousrenal capsule is incised at a 2–4 mm distance from the tumour ineither a circle (cone resection) or an ellipse (wedge resection), dependingon the size and location of the tumour and its intraparenchymal orexophytic extension (Fig. 1). A minimum of about 2 mm of normalrenal parenchyma should be removed around the tumour. The cone

FIGURE 1 � Illustration of cone (white scattered) and wedge resection (black scat-tered line).

June 9, 2009 14:7 B-601 ch37 FA

Cone and Wedge Resection in Renal Cell Carcinoma 269

resection (black dotted line) allows maximal preservation of renalparenchyma while the wedge resection (grey plotted line) allows eas-ier re-approximation of the renal parenchyma after tumour resection,especially in the mid-portion of the kidney.

Using brain spatulae, the renal parenchyma is sharply and bluntlyseparated in the renal cortex and only bluntly in the medulla alongthe parallel structures of the tubules and collecting ducts of the renalpapillae (Fig. 2). Small vessels are coagulated and large vessels areoversewn with 4/0 polyglycolic acid, which does not melt during afollowing coagulation. Major vessels at the base of the resection areclamped and ligated.

The excised tumour is sent for frozen sections for diagnosis andchecking of margins of resection. If the tumour extends into the renalhilum, additional biopsies should be taken from tissue at the groundof resection to ensure complete resection. Intraoperative 7.5–12 MHzultrasound is especially useful for identifying intraparenchymallyembedded tumours and to outline central tumour extension. Whileobtaining negative surgical margins is imperative, the width ofexcised normal parenchyma around the tumour margin does notaffect the likelihood of recurrence.7

FIGURE 2 � Resection of the tumour by clamping the vessels at the tumour ground.

June 9, 2009 14:7 B-601 ch37 FA


If there is a positive margin, nephrectomy may not necessarilybe required in all patients with a normal contralateral kidney.8 Inpatients with imperative indications (solitary kidney, chronic renalfailure, bilateral RCCs), immediate extension of the resection or radi-cal nephrectomy followed by dialysis may be elected. If renal calycesand/or renal pelvis had been opened, reconstruction is performedwith 6/0 polyglycolic acid sutures. When drainage of the collectingsystem is required, an 8–12 F nephrostomy catheter is inserted andfixed by a 5/0 polyglytone purse-string suture.6

An argon-beam laser or an infrared sapphire coagulator maybe used for coagulation. Both instruments provide the requiredhaemostasis for parenchymal bleeding. The non-contact argon laserdoes so by superficial tissue carbonisation, while the infrared contactcoagulator provides heat necrosis of 1–3 mm of tissue, depending onthe selected exposure time (1–5 s), with little carbonisation and tis-sue adherence. Hence, infrared coagulation may be used not only for

FIGURE 3 � Use of an argon-beam laser and/or an infrared sapphire coagulator in thecoagulation of the tumour bed.

June 9, 2009 14:7 B-601 ch37 FA


haemostasis but also for non-surgical extension of the safety margin ofresection (Fig. 3). With application of either instrument, most monofil-ament sutures may melt, so that braided sutures should preferably beused for ligation or oversewing.

The renal fibrous capsule is closed with a running monofilamentmattress suture using 5/0 poly p-dioxanone; this is an important stepin providing haemostasis by compression (Fig. 4). Cone resection ofsmall tumours may be performed with or without renal clamping.In small exophytic renal tumours, the ground of resection usuallydoes not reach the renal sinus and collecting system, rendering asuperficial shallow defect of the parenchyma. When a shallow defectcannot be closed by adaptation of the renal capsule, a free patchof adjacent peritoneum or dexon cluster may be used to cover thedefect.9

FIGURE 4 � Suture of the renal capsular before releasing the arterial closure in orderto maintain haemostasis.

June 9, 2009 14:7 B-601 ch37 FA


COMPLICATION MANAGEMENT

In case of haemodynamically relevant postoperative bleeding, diag-nostic angiography with an option of superselective embolisation ofan arterial bleeding is required. If there is no arterial bleeding, con-servative management is preferable to surgical revision. A urinaryfistula or a urinoma is verified by examining the creatinine concen-tration in the fluid from the perirenal drain. Useful imaging modal-ities of a leakage are nephrotogram (if a nephrostomy catheter isavailable), IVP, CT or retrograde pyelography, which may be com-bined with insertion of a ureteric catheter or double-J (JJ) stent fordrainage of the collecting system. When a JJ stent is placed, a con-tinuous bladder catheter is required to prevent reflux. Large urino-mas must be drained percutaneously by ultrasonographically guidedplacement of a drain. In all cases of urinary extravasation, antibiotictreatment is mandatory. Acute renal failure secondary to renal tubu-lar ischemia requires temporary haemodialysis in cases of solitarykidneys or when chronic renal failure is pre-existent. Obstruction ofthe upper urinary tract may be caused by blood clots in the urine.If the patient is symptomatic (fever, pain), drainage by means of aureteric catheter or a JJ/single-J stent and antibiotic treatment arerequired.

REFERENCES

1. Fergany AF, Saad IR, Woo L, Novick AC. (2006) Open partialnephrectomy for tumor in a solitary kidney: experience with 400 cases.J Urol 175: 1630–1633.

2. Lerner SE, Hawkins CA, Blute ML, et al. (1996) Disease outcome inpatients with low stage renal cell carcinoma treated with nephron sparingor radical surgery. J Urol 155: 1868–1873.

3. Lau WK, Blute ML, WeaverAL, et al. (2000) Matched comparison of radicalnephrectomy vs nephron-sparing surgery in patients with unilateral renalcell carcinoma and a normal contralateral kidney. Mayo Clin Proc 75: 1236–1242.

June 9, 2009 14:7 B-601 ch37 FA


4. Becker F, Siemer S, Hack M, et al. (2006) Excellent long term cancer controlwith elective nephron-sparing surgery for selected renal cell carcinomasmeasuring more than 4 cm. Eur Urol 49: 1058–1064.

5. Pahernik S, Roos F, Röhrig B, et al. (2008) Elective nephron sparing surgeryfor renal cell carcinoma of larger than 4 cm. J Urol 179: 71–74.

6. Pahernik S, Gillitzer R, Thüroff JW. (2004) Surgical atlas: cone/wedgeresection of renal cell carcinoma. BJU 93: 639–654.

7. Castilla EA, Liou LS, Abrahams NA, et al. ( 2002) Prognostic importanceof resection margin width after nephron-sparing surgery for renal cellcarcinoma. Urology 60: 993–997.

8. Permpongkosol S, Colombo JR, Gill IS, et al. (2006) Positive surgicalparenchyma margin after laparoscopic partial nephrectomy for renal cellcarcinoma: oncological outcomes. J Urol 176: 2401–2404.

9. Lane BR, Novick AC. (2007) Nephron-sparing surgery. BJU 99: 1245–1250.

June 9, 2009 14:7 B-601 ch38 FA

chap

ter38

Transperitoneal Laparoscopic RadicalNephrectomy

Hugh F. O’Kane†, Alex MacLeod†, Christopher Hagan†

and Thiagarajan Nambirajan∗,†

INTRODUCTION

Since the first report in 1991,1 laparoscopic radical nephrectomy hasbecome the mainstay of surgical treatment in the majority of patientsrequiring nephrectomy for malignant disease.2 Traditionally, opensurgical removal of the kidney has been carried out through a midline,flank or lumbar approach. These large surgical incisions often result insignificant post-operative wound pain leading to a prolonged recov-ery time.

The majority of published series demonstrate clear advantagesof laparoscopic nephrectomy over open surgery with regard todecreased post-operative pain, analgesic requirements, shorter hospi-tal stay and reduced time to full recovery.3,4 Other advantages includefewer wound complications, improved cosmesis and reduced intra-operative blood loss. The laparoscopic approach was initially used forsmall T1–2 renal tumours, and as experience has grown, the indicationfor it has been extended to include more challenging, larger tumours.

∗Corresponding author.†Department of Urology, Belfast City Hospital, Lisburn Road, Belfast, NorthernIreland. E-mail: [email protected]

275

June 9, 2009 14:7 B-601 ch38 FA

276 H. F. O’Kane et al.

With the introduction of any new technique, initial capital costsand a longer operating time as a result of the learning curve are citedas disadvantages. However, these issues have largely been resolvedwith time. In order for laparoscopic nephrectomy to be accepted as atreatment comparable to open surgery, the sound oncological princi-ples of removal of the intact kidney and surrounding Gerota’s fascianeed to be maintained. The two standard laparoscopic approaches,namely transperitoneal and retroperitoneal, when carried out cor-rectly, adhere to these principles.

TECHNIQUE

Pre-Operative Workup

Pre-operative staging of renal tumours is performed with comput-erised tomography (CT) of the chest, abdomen and pelvis. Thepatients are cross-matched for two units of blood and have the side ofthe tumour marked on the skin prior to leaving for theatre. Patients areconsented for the very small risk of conversion to open surgery (∼1%)in addition to specific laparoscopic complications, including bowelinjury and post-operative shoulder tip pain related to CO2 insuffla-tion. The correct tumour side is reaffirmed in theatre with CT filmsand with a urethral catheter inserted.

Transperitoneal Approach

The patient is positioned in the lateral decubitus position at an angleof 40◦–50◦, with slight elevation of the kidney bridge. Careful posi-tioning and pressure point padding prevents neuromuscular injury.The patient is strapped to the table to allow rotation if necessary toachieve an ergonomically comfortable position for the operating sur-geon. Peritoneal access allowing establishment of the pneumoperi-toneum is under direct vision via the Hassan approach, which is saferthan the blind or “closed” Veress needle method.5

June 9, 2009 14:7 B-601 ch38 FA

Transperitoneal Laparoscopic Radical Nephrectomy 277

The primary laparoscope trocar is a 12 mm port inserted adja-cent to the umbilicus. Two further 5–10 mm trocars are inserted underdirect vision in the subcostal and iliac fossa positions. Port site place-ment follows the principle of triangulation to allow maximal accessto the renal hilum, where the majority of the dissection takes place,but will also allow ureteric dissection. An additional 5 mm port maybe required, particularly for right-sided nephrectomies which mayneed liver retraction (Fig. 1). Avariety of laparoscopic instruments areavailable for tissue dissection and coagulation, including monopolarelectric cautery, bipolar vessel electro-thermal sealers and ultrasonicshears (Harmonic scalpel, Ethicon endo-surgery).

Dissection begins with an incision along the line of Toldt, allowingmedial retraction of the colon. The ureter is identified and mobilised tohelp with retraction of the kidney and to guide the dissection cepha-lad towards the renal hilum. Careful dissection of the hilar vesselsis achieved with the combination of a right angle dissector, suctionand the harmonic scalpel. The renal artery which is usually found

FIGURE 1 � Port placement for right transperitoneal laparoscopic radical nephrec-tomy. Note the preoperative arrow marking operative side and 4th 5 mm port toallow liver edge retraction.

June 9, 2009 14:7 B-601 ch38 FA


posterior to the vein is ligated first, followed by the vein with partic-ular care to avoid any unseen lumbar veins entering the renal veinposteriorly (Fig. 2).

The two most commonly used methods for securing the renal ves-sels are endovascular linear staplers and non-polymer ligating clips(Hem-O-Lok, Weck closure system, Telelflex medical). Both meth-ods are widely used (see video). Occasionally a large renal vein mayrequire the placement of a loop around the vessel to “shrink” the veinso as to facilitate placement of the Hem-O-Lok clip.6 This manoeu-vre is infrequently required, after the introduction of extra-large clips(Hem-O-Lok XL). Although surgeons’ preference, experience andtraining strongly influence the choice of the haemostatic method, allcurrently available techniques risk mechanical malfunction and usermisuse.

Once the hilar vessels have been ligated, the kidney is dissectedfree of its remaining attachments. For left-sided nephrectomy, atten-tion is paid to avoiding splenic and pancreatic injuries. On the rightside, particular care is given to the short adrenal vein.

FIGURE 2 � An excellent view of the hilar vessels during transperitoneal laparoscopicradical nephrectomy. The renal artery is about to be clipped with a Hem-O-Lok clip.

June 9, 2009 14:7 B-601 ch38 FA

Transperitoneal Laparoscopic Radical Nephrectomy 279

FIGURE 3 � Wounds following retrieval of the specimen.

After the ureter has been clipped and divided, the specimen isplaced in a retrieval bag prior to removal via a muscle-splittingincision created by extending the iliac fossa trocar site (Fig. 3). Thepractice of specimen morcellation to allow extraction through asmaller incision is not popular, as this prevents optimal histopatho-logical assessment and carries a small risk of tumour seeding.

DISCUSSION

There is overwhelming evidence to support the use of laparoscopicnephrectomy over the open approach due to reduced post-operativeanalgesic requirements, a shortened hospital stay, improved cosmesisand an earlier return to normal activities. The majority of this evi-dence has been obtained from cohort studies, although one small,randomised study has been reported.7 Long term oncological datahave also confirmed an outcome comparable to that of open radi-cal nephrectomy.8 Laparoscopic radical nephrectomy is a standardtreatment modality for T1–3a renal cell carcinoma patients. It is also

June 9, 2009 14:7 B-601 ch38 FA


technically feasible for treating patients with T3b disease (tumourwithin renal vein) or N1–2 disease, and as a cytoreductive treatmentfor patients with metastatic disease.9

There have been very few randomised studies comparingthe transperitoneal and retroperitoneal approaches to laparoscopicnephrectomy. One prospective randomised study failed to demon-strate any difference between the transperitoneal and retroperitoneo-scopic approaches in terms of operative difficulty, complications orpost-operative recovery time.10

REFERENCES

1. Clayman RV, Kavoussi LR, Soper NJ, et al. (2002) Laparoscopic nephrec-tomy. J Urol 167(2, Pt 2): 862.

2. Fenn NJ, Gill IS. (2004) The expanding indications for laparoscopic rad-ical nephrectomy. BJU Int 94(6): 761–765.

3. Gill IS, Meraney AM, Schweizer DK, et al. (2001) Laparoscopic radicalnephrectomy in 100 patients: a single center experience from the UnitedStates. Cancer 92 (7): 1843–1855.

4. Dunn MD, Portis AJ, Shalhav AL, et al. (2000) Laparoscopic versus openradical nephrectomy: a 9-year experience. J Urol 164(4): 1153–1159.

5. Bonjer HJ, Hazebroek EJ, Kazemier G, et al. (1997) Open versus closedestablishment of pneumoperitoneum in laparoscopic surgery. Br J Surg84(5): 599–602.

6. Li SK, Hou SM, Fung B, et al. (2004) Safe control of the renal vein duringlaparoscopic nephrectomy using the “loop around the vein” technique.BJU Int 93(3): 420–421.

7. Burgess NA, Koo BC, Calvert RC, et al. (2007) Randomized trial of laparo-scopic v open nephrectomy. J Endourol 21(6): 610–613.

8. PortisAJ, Yan Y, Landman J, et al. (2002) Long-term followup after laparo-scopic radical nephrectomy. J Urol 167(3): 1257–1262.

9. Ono Y, Hattori R, Gotoh M, et al. (2005) Laparoscopic radical nephrec-tomy for renal cell carcinoma: the standard of care already? Curr OpinUrol 15(2): 75–8 (review).

10. Nambirajan T, Jeschke S, Al Zahrani H, et al. (2004) Prospective, random-ized controlled study: transperitoneal laparoscopic versus retroperito-neoscopic radical nephrectomy. Urology 64(5): 919–924.

June 9, 2009 14:7 B-601 ch39 FA

chap

ter39

Radical Prostatectomy for LocallyAdvanced Prostate Cancer

Marc Claessens∗,†, Steven Joniau† and Hendrik Van Poppel†

INTRODUCTION

Locally advanced prostate cancer (T3) is defined as cancer that hasextended beyond the prostatic capsule with invasion of the pericap-sular tissue or seminal vesicles, but without lymph node involvementor distant metastases.1 According to the 2002 TNM classification, T3ais an extracapsular extension either unilaterally or bilaterally and T3binvolves invasion of seminal vesicles.2

According to the guidelines of the European Association of Urol-ogy, radical prostatectomy can be performed in patients with locallyadvanced CaP, PSA serum levels <20 ng/mL, ≤cT3a, biopsy Gleasonscore ≤8 and a life expectancy more than 10 years.3 MRI can be usedto improve the detection of seminal vesicle or sphincter involvement,which excludes patients from surgery.

Although still controversial, it is increasingly evident thatsurgery has a place in treating locally advanced disease with excel-lent 5-, 10- and 15-year CSS rates of 95–99%, 90–92% and 79%,respectively.4,5

∗Corresponding author.†University Hospital Leuven, Department of Urology, Leuven, Belgium. E-mail:[email protected]

281

June 9, 2009 14:7 B-601 ch39 FA

282 M. Claessens et al.

TECHNIQUE

General Preparation and Positioning of the Patient

General or locoregional anesthesia can be used. The authors pre-fer a spinal anesthesia, combined with an epidural catheter forpostoperative pain control. The patient is placed in a supine posi-tion, with a slightly overstretched abdomen and pelvis. A 20F Foleycatheter is placed after the patient is draped.

Incision and Exposure of the Pelvis

A midline lower abdominal incision is performed. The peritoneumis mobilized from the Retzius space up to the iliac bifurcation. Toattempt an extended lymph node dissection, it may be necessary todivide the vas deferens bilaterally, which allows further retractionof the peritoneum up to the aortic bifurcation, resulting in a bettervascular exposure.

Pelvic Lymph Node Dissection (Fig. 1)

Heidenreich et al. advocated extended resection of the iliac lymphnodes in prostate cancer patients who are at high risk for lymph

FIGURE 1 � Extended lymph node dissection. (1) External iliac artery; (2) external iliacvein; (3) internal iliac artery; (4) obturator nerve.

June 9, 2009 14:7 B-601 ch39 FA

Radical Prostatectomy for Locally Advanced Prostate Cancer 283

node involvement.6 The boundaries for an extended lymphadenec-tomy are: laterally, the upper limit of the external iliac vein; caudally,the femoral canal; cranially, the bifurcation of the common iliac artery;medially, the lateral wall of the bladder; and inferiorly, the floor of theobturator fossa and internal iliac vessels.7

Incision of the Endopelvic Fasciaand Lateral Dissection

All fatty tissue covering the endopelvic fascia should be cleared. Theendopelvic fascia is incised and the incision is extended posteriorlyusing curved scissors. The levator muscle is then gently dissected offthe lateral prostate with the aid of a peanut dissector. The endopelvicfascia is further incised anteriorly until the apex of the prostate can bevisualised and the apicourethral angle can be clearly recognised.

Division of the Puboprostatic Ligaments

The puboprostatic ligaments are isolated using a right-angled clampbefore being sectioned with electrocoagulation.

Control of the Dorsal Vein Complex

The dorsal vein complex is ligated by passing a blunt right-angledclamp underneath, just anterior to the urethra. This manoeuvre isperformed under digital control by the thumb and middle finger ofthe left hand. The right-angled grasps a 1-0 ligature that is tied, whilethe assistant is pushing the prostate posteriorly, enabling the knotto be tied as far caudally as possible. A 2-0 stitch is placed throughthe anterior commissure of the prostate to prevent extensive back-bleeding. Transection of the dorsal vein complex is then done usingelectrocautery. Finally, the dorsal vein complex stump is oversewnusing a 2-0 running-suture.

June 9, 2009 14:7 B-601 ch39 FA


Dissection of the Apex and NeurovascularBundles and Division of the Urethra

Under identical digital control, a right-angled clamp is passed under-neath the urethra just anterior to the rectum. A vessel loop is placedbehind the urethra, enabling a correct dissection of the prostatic apexbefore transection of the urethra.

The tissue lateral to the urethra (consisting of the remnants of theendopelvic fascia covering the dorsal vein complex and the externalurethral sphincter fascia) is dissected off the urethra using the dissec-tion scissors inserted close to the urethra at the prostatourethral angle.After these paraurethral structures are clipped and divided bilaterally,the prostatic apex is completely freed and well visualised. The urethracan now be transected with the 20 F Foley catheter in place (Fig. 2).

Posterior Release

The recto-urethral muscle is transected horizontally. Then the planebetween the prostate and rectum is developed bluntly with the indexfinger up to the base of the seminal vesicles. In patients with a well-developed rectourethralis muscle however, it can be hard to distin-guish it from the rectal muscular layer and an initial sharp dissectionmay be necessary.

FIGURE 2 � Transection of urethra. (1) Prostate; (2) urethra; (3) pubic bone.

June 9, 2009 14:7 B-601 ch39 FA


Resection of the Neurovascular Bundlesand Division of the Pedicles

The resection of the neurovascular bundles can be done using curvedscissors after a 135◦ angle clamp is passed behind them and clippingof the tissue is done using large clips with the same-angled clippingforceps. The neurovascular bundle at the tumor bearing side can-not be spared. In selected patients with smaller unilateral and non-apical T3a prostate cancer, a contralateral nerve-sparing RP can beattempted, using small clips for the perforating vessels and nervefibers. Sokoloff and Brendler suggested that absolute contraindica-tions of nerve-sparing are T3b tumors and palpable lesion at the apex.8

The dissection is continued up to the lateral aspect of the seminal vesi-cles. To divide the pedicles gradually, a 135◦ clamp is passed throughthem, and the pedicles are clipped with large clips.

Resection of the Seminal Vesicles

The Denonvilliers fascia is divided sharply between both the vasa def-erentia reaching the posterior bladder wall. The ejaculatory complexis encircled by using curved dissection forceps, and the index finger isplaced behind it. The top of the seminal vesicles is reached via peanutdissection and the vessels at their apex are clipped and divided. Bothvasa deferentia are clipped with large clips. The prostate and seminalvesicles are now completely mobilised posteriorly as well as laterallyup to the bladder neck.

Bladder Neck Dissection

For extracapsular cancers, it is better to resect the bladder neck startinganteriorly9,10 (Fig. 3). The bladder is opened and the Foley catheter isgrasped and pulled out of the bladder, in order to enable traction onthe prostatovesicular block. The posterior bladder neck is sectioned,care being taken not to harm the ureteral orifices. A racket closure ofthe bladder neck with eversion of the mucosa is performed. For apical

June 9, 2009 14:7 B-601 ch39 FA


FIGURE 3 � Resection of bladder neck. (1) Prostate; (2) 20 F Foley catheter; (3) bladderneck; (4) bladder.

T3 tumours, the intraprostatic bladder neck can usually be preserved,enabling a more anatomic reconstruction of the bladder neck.

Anastomosis

Haemostasis is performed by using clips and/or a haemostatic sealant(e.g. FloSeal® or Tachosil®) prior to finalising the anastomosis betweenthe bladder and urethra.

The quality of the vesicourethral anastomosis will directlyinfluence urinary leakage, stricture formation and preservation ofcontinence. The principle of the anastomosis is to obtain a perfectadaptation of the urethra with the reconstructed bladder neck, with-out compromising the integrity of the external sphincter.11 A 16 FFoley (silicone) catheter is inserted and proceeded into the recon-structed bladder neck. The balloon is not inflated in order to avoidinadvertent damage during anastomosis. A swab-on-a-stick is placedjust posteriorly to the urethra, pushing the rectum downwards. Fourstitches are sufficient for a good anastomosis. The first suture is placedat the 7 o’clock position, outside-in at the urethra and inside-out at thebladder neck. The second suture is started outside-in at the bladderneck at the 5 o’clock position and inside-out at the urethra. The thirdand the fourth sutures are placed at the 2 and 11 o’clock position in the

June 9, 2009 14:7 B-601 ch39 FA


same way as the second. Then the balloon is inflated. Gentle tractionon the catheter brings the bladder neck down to the urethral stump.The four sutures are tied and the bladder can be rinsed.

Two suction drains are inserted to keep the Retzius space dry. Thepatient can be discharged at postoperative day 4. The Foley catheteris left for 10 days. Pelvic floor physiotherapy is started immediatelyafter withdrawal of the Foley catheter.

DISCUSSION

The goals of surgery for locally advanced prostate cancer are a moreradical tumor extirpation including:

— An extensive lymph node dissection. This might necessitate divi-sion of the vas deferens bilaterally, resulting in a better vascularexposure up to the aortic bifurcation

— Good visualisation and complete resection of the apex.— Broad neurovascular bundle resection at least at the tumor bearing

side.— Complete resection of the seminal vesicles.— Resection of the bladder neck in most cases, instead of a bladder

neck sparing approach.

REFERENCES

1. Boccon-Gibod L, BertacciniA, BonoA, et al. (2003) Management of locallyadvanced prostate cancer: a European consensus. Int J Clin Pract 57(3):187–194.

2. Sobin LH, Wittekind C. (2002) TNM Classification of Prostate Cancer, 6thed. New York, Wiley-Liss.

3. Heidenreich A, Aus G, Abbou CC, et al. (2007) Guidelines onProstate Cancer. http://www.uroweb.org/fileadmin/user_upload/Guidelines/break 07_Prostate_Cancer_2007.pdf

4. Ward JF, Slezak JM, Blute ML, et al. (2005) Radical prostatectomy forclinically advanced (cT3) prostate cancer since the advent of prostate-specific antigen testing: 15-year outcome. BJU Int 95: 751–756.

June 9, 2009 14:7 B-601 ch39 FA


5. Hsu CY, Joniau S, Oyen R, et al. (2006) Outcome for clinical unilat-eral T3a prostate cancer: a single-institution experience. Eur Urol Suppl5(2): 213.

6. Heidenreich A, Varga Z, Von Knobloch R. (2002) Extended pelvic lym-phadenectomy in patients undergoing radical prostatectomy: high inci-dence of lymph node metastasis. J Urol 167: 1681–1686.

7. Bader P, Burkhard FC, Markwalder R, Studer UE. (2002) Is a limitedlymph node dissection an adequate staging procedure for prostate can-cer? J Urol 168: 514–518.

8. Sokoloff M, Brendler C. (2001) Indication and contraindication for nerve-sparing radical prostatectomy. Urol Clin North Am 28(3): 535–543.

9. Van Poppel H. (2005) Surgery for clinical T3 prostate cancer. Eur UrolSuppl 4: 12–14.

10. Hsu CY, Joniau S, Van Poppel H. (2005) Radical prostatectomy for locallyadvanced prostate cancer: technical aspects of radical prostatectomy.EAU Update Ser 3: 90–97.

11. Gillitzer R, Thuroff JW. (2003) Technical advances in radical retropubicprostatectomy techniques for avoiding complication. Part II: vesi-courethral anastomosis and nerve-sparing prostatectomy. BJU Int 92:178–184.

June 9, 2009 14:7 B-601 ch40 FA

chap

ter40

Flap Technology and ReconstructiveTechniques in Urology

Milomir Ninkovic† and Gustavo Sturtz∗,†

Failure in healing of perineal or pelvic wounds is common in the pres-ence of infection, dead spaces, fistulas, chemotherapy or irradiation.Large soft tissue defects resulting from trauma or ablative operationscontinue to be a challenging problem, particularly when complicatedby radiation. Previously radiated skin does not mobilise easily anddoes not tolerate tension. Ideally, the coverage of such defects shouldinclude the use of flaps of relatively uninvolved tissue with reliableblood supply. Such patients are usually ill and debilitated, so a single-stage reconstruction with a minimal donor defect is optimal. Recon-struction following resection of malignant tumours or treatment ofcongenital anomalies often requires a multidisciplinary approach,comprising specialists in urology, gynaecology, plastic surgery andoncology. The surgical treatment can involve repair, reconstruction orcompensation of dysfunctional tissue.

Skin grafts provide ideal coverage for shallow wounds in whichno major structures, such as arteries, veins, nerves or tendons, areexposed. Split-thickness skin grafts can be applied directly ontoabdominal viscera, but they lack the resistance to provide adequate

∗Corresponding author.†Department of Plastic, Reconstructive, Hand and Burns Surgery, Hospital Bogen-hausen – Technical University Munich, Munich, Germany. E-mail: [email protected]; [email protected]

289

June 9, 2009 14:7 B-601 ch40 FA

290 M. Ninkovic and G. Sturtz

protection to the viscera and are frequently unstable. The skin, inaddition, adheres firmly to the surface of the gastrointestinal tract,making a subsequent operation difficult and treacherous.

A defect with missing muscle and skin may benefit from a muscleor musculocutaneous flap to improve contour as well coverage. If theavailable local tissue is inadequate, regional flaps, such as a rectusabdominis flap or free tissue transfer, may provide additional tissuefor reconstruction. All pedicled local or regional flaps have their limi-tations in terms of the arc of rotation, size, tissue volume and mobilityrestriction with functional and aesthetic disadvantages for the donorsite. Another difficulty is that the well-perfused proximal part of theflap does not reach the defect, so that the defect is covered by poorlyperfused parts of the flap or the flap cannot reach the defect at all.

When the local flaps are unavailable or insufficient, free microvas-cular tissue transfer is the procedure of choice for complex anatom-ical and/or functional requirements. The transfer of a free flap is awell-established method and provides tissue with a rich blood sup-ply. Good perfused tissue improves wound healing and allows earlyrehabilitation.

PELVIC FLOOR RECONSTRUCTION

The pelvic floor consists of a number of individual anatomical struc-tures (the pelvic diaphragm, the lower urinary tract, the reproductiveorgans, the colorectal system and the anal sphincter) with specificfunctions. Surgical treatment for pelvic floor disorders can involverepair, reconstruction, or compensation for replacement of the dys-functional tissue, and these procedures can involve a vaginal, supra-pubic, laparoscopic or mixed approach. The goal of reconstructionis to restore structural integrity by providing well-vascularised soft-tissue coverage and active support, protection and retention of theinternal organs. The reconstructive surgeon must use tissue that hasenough strength and stability to prevent hernia formation and thatalso has sufficient volume to fill or eliminate dead space. The proper

June 9, 2009 14:7 B-601 ch40 FA

Flap Technology and Reconstructive Techniques in Urology 291

selection of flaps is based on the requirements of each patient, consid-ering the age; the cause, size, shape and depth of the defect; the donorsite morbidity; the patient’s general condition; and the condition ofthe vascular supply of adjacent regions.

The problem of small-bowel placement in the pelvic cavitydenuded of peritoneum is still one of the most taxing and potentiallytroublesome problems in radical pelvic surgery. In addition, intesti-nal fistulas and small-bowel adhesive obstructions are not very rare aspostoperative complications or as an effect of radiotherapy. Syntheticabsorbable mesh or autologous materials such as omentum or peri-toneal flaps have been used as substitutes for pelvic reconstruction.

Well-vascularised tissue could lead to primary healing and verygood protection from secondary complications (postradiation fistula,small-bowel obstruction, pelvic sidewall adherence). The suggestedtechnique of using a rectus abdominis muscle flap after radical pelvicsurgery is a very simple and efficient method of making a well-vascularised barrier and support for the small intestine. The trans-posed rectus abdominis muscle acts as a bed for the abdominal cavityand the small bowel is held out of the pelvic basin. The rectus musclesare carefully retracted downwards and the edges are sutured posteri-orly to the promontorium and laterally around the linea terminalis. Toavoid abdominal wall weakness, a precise abdominal closure using asynthetic mesh has to be performed.

The reconstruction of full-thickness pelvic floor defects can bedone with variably designed local flaps such as thigh or gluteal flaps.If the available local tissue is inadequate, regional flaps, such as therectus abdominis, may provide additional tissue. However, if theseflap tissues are unavailable or insufficient, free tissue transfer may benecessary.

The available tissue from an amputated limb can be used as apedicled-in-continuity fillet flap or a free microvascular fillet lowerleg flap. This technique can be used to repair defects of the lower trunkwithout the need for vascular anastomosis and without incurringdonor site morbidity. The oncological safety of using ipsilateral lower

June 9, 2009 14:7 B-601 ch40 FA


extremity tissue must be considered in each case. Free microvasculartissue transfer from the lower leg, filleted from the tibia and fibulaand supplied by the popliteal vessels, is a second option for obtaininga large amount of soft tissue for complex pelvic reconstruction.

VAGINAL RECONSTRUCTION

Many techniques have been described for vaginal reconstruction inpatients with congenital vaginal agenesis or in those undergoinganterior exenteration for malignant disease. They include Frank’stechnique (non-surgical autodilatation), the McIndoe procedure, therectus abdominis flap method the gracilis flap technique, the puden-dal thigh flap method and the free jejunal flap technique. An imme-diate partial or total vaginal reconstruction is frequently proposedin cases of exenterative or extended radical pelvic surgery for can-cer treatment. Probably the most common method for constructing avagina in patients with Mayer–Rokitansky–Kuster–Hauser syndromeis the technique popularised by McIndoe and Banister in 1938 usingsplit-thickness skin grafts. The undesirable complication is the latecontraction of the neovagina. The vulvoperineal fasciocutaneous flap(Malaga flap) is safe and reliable for complete neovaginal plasticreconstructions in patients with Mayer–Rokitansky–Kuster–Hausersyndrome. Vaginal reconstruction can be performed as an elective sur-gical procedure when adequate lining of the whole rectovesical cavityor partial reconstruction of the vaginal wall is needed. A method ofvaginoplasty using de-epithelialised vulvar transposition flaps hasbeen used to enlarge the width of narrow vaginas.

VESICOVAGINAL FISTULA REPAIR

Surgeons will often be required to adapt their approach and techniqueto the individual patient. When tissue interposition is desired, as inthe case of failed previous repairs, the traditional Martius flap method

June 9, 2009 14:7 B-601 ch40 FA


is not ideal for proximal fistulas. In these cases, peritoneum is readilyavailable for tissue interposition and it provides a well-vascularisedlayer without the need for other incisions or extensive dissection. Con-sequently, a peritoneal flap is used for proximal fistulas and a Martiusflap is used for distal fistulas. A full-thickness labial flap is reservedfor cases of insufficient vaginal epithelium.

Chronic postoperative pouch-vaginal and vesicovaginal fistulasafter hysterectomy and irradiation do not respond to conventionaltreatment. A synchronous vaginoabdominal approach using a verti-cal myocutaneous distally based rectus abdominis myocutaneous flapcan be used successfully to close a pouch-vaginal fistula and simulta-neously reconstruct the posterior vaginal wall.

The endorectal advancement flap is a surgical procedure used inthe treatment of anorectal and rectovaginal fistulas. It has been usedto treat fistulas of various causes, including cryptoglandular disease,obstetric injury, trauma and inflammatory bowel disease. It has beenused sucessfully in the treatment of both anorectal and rectovagi-nal fistulas. This flap consists of mucosa, submucosa and variableamounts of circular muscle. The distal portion of the flap is excised,the fistular tract curetted and the internal opening closed by apposi-tion of the surrounding smooth muscle with absorbable sutures. Theflap is then lowered to cover the internal opening and is sewn intoplace, without tension, using absorbable sutures.

RECTOURETHRAL FISTULA REPAIR

Fistulas between the lower rectum and the urethra may be congenital,with a constellation of pelvic floor malformations, or acquired afterinflammation, infection, neoplasia or trauma. Iatrogenic rectourethralfistulas may follow the treatment of prostatic cancer. Gracilis muscletransposition is an effective surgical treatment (Figs. 1 to 3).After mus-cle harvesting the patient is turned to the prone jackknife position. Ahorizontal incision is made between the anus and the scrotum, and isdeepened in the space between the urethra and the rectum. The rectal

June 9, 2009 14:7 B-601 ch40 FA


FIGURE 1 � Defect on the pelvic floor after anorectal resection.

FIGURE 2 � Intraoperative view of the gracilis flap with a distal skin island. The muscleis turned at its pivot point to fill the pelvic floor defect.

defect is then closed primarily or with an advancement flap and theurethral defect may be closed with interrupted absorbable suturesover the indwelling catheter. The subcutaneous tunnel between theperineum and the thigh is then approached through the perineal side,

June 9, 2009 14:7 B-601 ch40 FA


FIGURE 3 � Postoperative view 10 days after the surgery.

and the gracilis is rotated and placed in the space between the rectumand the urethra.

A scrotal dartos flap is well vascularised and easy to mobilise.After the bulbospongiosum has been detached from the perineal body,the impulse of the 8 F catheter in the fistula is carefully palpated.The fistula is dissected circumferentially and then excised completely.The rectum and the urethra are closed separately. The tip of the V-shaped perineal skin flap is incised to produce an island flap andthen carefully de-epithelialised. The de-epithelialised dartos flap istaken to the undersurface of the urethra to cover the urethral closure.The perineal skin is reapproximated using a Y–V recession technique.

Successful repair can be achieved in the majority of patients, withminimal morbidity, a short length of stay and a good post-operativequality of life.

PENILE AND URETHRAL RECONSTRUCTION

Single-stage penile reconstruction is performed routinely. Advancesin microsurgical flap transfer techniques permit harvesting of thinand pliable flaps, which are large enough to create a penis with

June 9, 2009 14:7 B-601 ch40 FA


normal dimensions and an acceptable appearance. The anastomosisof sensory nerves can provide protective and erogenous sensation,enabling an erectile prosthesis to be implanted one year after com-pletion of the phalloplasty. Many of these ideal requirements are metby using the radial forearm flap. The major disadvantage of this flapis the donor site morbidity. In patients who refuse a radial forearmflap, a pedicle anterolateral flap is the authors’ procedure of choice.The urethra is folded with full-thickness skin graft and adhered to theflap with fibrin glue. It is beyond the scope of this chapter to give acomplete overview of all the possible flaps that can be used in penileand urethral reconstruction.

FUNCTIONAL BLADDER AND ABDOMINALWALL RECONSTRUCTION

The abdominal wall protects and surrounds the contents of theabdominal cavity and participates in a great variety of functions,such as posture, standing, walking and bending. The abdominal wallmusculature aids in lifting and straining during urination, defecation,childbirth, vomiting and coughing.

Bladder acontractility or permanent detrusor dysfunction is adebilitating disorder affecting a large number of relatively young peo-ple. The underlying abnormality may be due to damage to the detru-sor muscle itself, its autonomic nerve supply, the spinal micturitioncentre or the upper motor neurone system.

Latissimus dorsi muscle has a reliable and suitable anatomy (ade-quate size, volume and length of the neurovascular pedicle) and anappropriate muscle configuration to meet the functional needs of theabdominal wall reconstruction or functioning detrusor myoplasty.The latissimus dorsi muscle transferred to the abdominal wall orwrapped around the acontractile bladder is innervated by coapta-tion of the thoracodorsal nerve to the lowest intercostal motor nervessupplying the rectus abdominis muscle. This leads to abdominalwall stability, voluntary contraction and bladder emptying. Follow-ing reinnervation and adequate muscle training, the transplanted

June 9, 2009 14:7 B-601 ch40 FA


latissimus dorsi muscle provides sufficient capacity and strength toreplace the missing urinary detrusor muscle. In the authors’ expe-rience, functioning free muscle transplantation was able to restorevoluntary voiding in 35 of 39 patients who had previously dependedon long-term catheterisation. The latissimus dorsi detrusor myoplastytechnique in combination with tissue engineering could be the key-stone for complete autologous bladder reconstruction.

CONCLUSION

Functional repair, patient satisfaction, early rehabilitation and qual-ity of life are the goals for the reconstruction of urogenital organs.The keystone for complete bladder reconstruction could be the latis-simus dorsi detrusor myoplasty technique in combination with thenew technology of tissue engineering. In contrast to the traditionalapproach to pelvic surgery, managed by different surgical specialities,there is increasing recognition that optimal functional and anatom-ical reconstruction can be obtained through the interdisciplinaryapproach.

REFERENCES

1. Ninkovic M, Kronberger P, Harpf C, et al. (1998) Free innervated latis-simus dorsi muscle flap for reconstruction of full thickness abdominalwall defects. Plast Reconstr Surg 101: 971–978.

2. Horch RE, Gitsch G, Schultze-Seemann W. (2002) Bilateral pedicledmyocutaneous vertical rectus abdominis muscle flaps to close vesico-vaginal and pouch-vaginal fistulas with simultaneous vaginal and per-ineal reconstruction in irradiated pelvic wounds. Urology 60: 502–507.

3. Ninkovic M, Stenzl A, Schwabegger A, et al. (2003) Free neurovasculartransfer of latissimus dorsi for the treatment of bladder acontractility. II:Clinical results. J Urol 169: 1379–1383.

4. Ninkovic M, Strasser H, SchwabeggerA, et al. (2000) The concept of func-tioning free skeletal muscle transfer in combination with tissue engineer-ing for bladder substitution. World J Urol 18: 359–363.

5. Birch C, Frynes MM. (2002) The role of synthetic and biological prosthe-ses in reconstructive surgery. Curr Opin Obstet Gynecol 14: 527–535.

June 9, 2009 14:7 B-601 ch40 FA


6. Codeiro PG, Pusic AL, Disa JJ. (2002) A classification system and recon-structive algorithm for acquired vaginal defects. Plast Reconstr Surg 110:1058–1065.

7. Seccia A, Salgarello M, Sturla M, et al. (2002) Neovaginal reconstructionwith the modified McIndoe technique: a review of 32 cases. Ann PlastSurg 49: 379–384.

8. Huang WC, Zinmann LN, Bihrle W. (2002) Surgical repair of vesicovagi-nal fistulas. Urol Clin North Am 29: 709–723.

9. Sonoda T, Hull T, Piedmonte MR, Fazio VM. (2002) Outcomes of pri-mary repair of anorectal and rectovaginal fistulas using the endorectaladvancement flap. Dis Colon Rectum 45: 1622–1628.

10. Ninkovic M, Daberning W. (2003) Flap technology for reconstruction ofurogenital organs. Curr Opin Urol 13: 483–488.

11. Hoefter E, Holm C, Dornseifer U, et al. (2005) Der freie und gestielteMuskeltransfer als Therapieotion in der urologischen Chirurgie. Urologe[A] 44: 743–750.

12. Monstrey S, Ceulemans P. (2006) Perineogenital reconstruction. In Perfo-rator Flaps Anatomy, Technique and Clinical Applications (Quality MedicalPublishing), pp. 903–915.

13. Ninkovic M, Sturtz G, Stenzl A. Analysis of the free neurovasculartransfer of latissimus dorsi muscle for treatment of bladder acontrac-tility. In Proc. ASPS/PSEF/ASMS Annual Scientific Meeting (Oct. 2006, SanFrancisco).

14. Stenzl A, Ninkovic M, Kölle D, et al. (1998) Restoration of voluntaryemptying of the bladder by transplantation of innervated free skeletalmuscle. Lancet 351(9114): 1483–1485.

Regional and Free Flaps Urological Reconstructions

Regional Flaps:Lower Abdominal Wall Rectus Abdominis

ThoracoepigastricExternal Oblique Muscle or

MyocutaneousTensor Fascia LataGroin Flap

June 9, 2009 14:7 B-601 ch40 FA


Sacral Area Gluteus Maximus MuscleSuperior Gluteal Artery PerforatorLumbar Artery PerforatorParassacral Artery PerforatorLateral Intercostal Artery Perforator

Ischial Area Deep Femoral (posterior thigh) ArteryPerforator Flap

Posterior Gluteal ThighInferior Gluteal Artery Perforator (IGAP)

Trochanteric Area Lateral Circumflex Femoris ArteryPerforator

Superior Gluteal Artery Perforator (SGAP)Deep Femoral (posterior thigh) Artery

Perforator Flap

Perineogenital Area Transverse/Vertical Rectus AbdominisMyocutaneous

Pudendal Artery ThighInternal Pudendal ArteryOmentumGracilis MuscleAnterolateral Thigh (free or pedicled)Gluteal FoldRectal Advancement FlapDartos Flapvulvoperineal fasciocutaneous flap

(Malaga flap)Martius flap

June 9, 2009 14:7 B-601 ch40 FA


Penile Reconstruction Forearm FlapDeep Inferior Epigastric

Perforator (DIEP)Anterolateral Thigh FlapLateral Arm Flap

Distant/Free Flaps:Deep Inferior Epigastric

Perforator (DIEP)Transverse/Vertical Rectus

Abdominis MyocutaneousThoracodorsal Artery Perforator

(TAP)Latissimus Dorsi (defect

coverage and functionaltransfer)

Jejunal/Gastric FlapAnterolateral ThighForearm Flap

(penis reconstruction)Tensor Fascis Lata

Recipient Vessels for Free Flaps:Superior Gluteal vesselsInferior Gluteal VesselsSuperficial Femoral Vessels

(or side branches)Inferior Epigastric Vessels

Recipient Nerves:Ilioinguinal Nerve (sensitive)Dorsal Clitoral or Penile

(sensitive)Lower Intercostals (motor for

Bladder and Abdominal Wall)

June 17, 2009 14:52 B-601 index FA

Index

ablation, 133–135adrenal tumour, 257anastomosis, 195–198, 201, 202anatomy, 209, 210anterior approach, 79, 80, 82–84anterior resection syndrome, 203anterograde and retrograde nerve

preparation, 36atypical resection, 142, 143, 146

bladder reconstruction, 296, 297breast cancer, 1, 2, 25breast reconstruction, 7, 10, 13, 14, 17Breslow thickness, 219

capsular dissection technique, 43cardia, 117, 118, 120, 121, 123central neck dissection, 48, 50, 52chemotherapy, 113, 114coloanal anastomosis, 203–207colonic J pouch, 203–205coloplasty, 203–205colorectal, 179, 180, 183, 184colorectal cancer, 157, 162, 163colorectal liver metastases, 142colostomy construction, 171complication, 272cytoreductive surgery, 229cytostatic agents, 259, 262–264

deep lobe resection, 37defect filling, 37dose calculation, 263

en bloc resection, 247esophageal carcinoma, 103esophagogastrostomy, 105excision, 219, 220excision margin, 220extended cervical mediastinoscopy, 89,

90extended liver resection, 151

familial adenomatous polyposis, 195flaps, 289–296

gastric cancer, 109, 110, 112, 113gastroesophageal junction, 104, 107gluteal fold flap, 215–217groin, 223, 226

HIPEC, 229, 232, 233, 235

identification of the facial nerve, 35ileoanal pouch, 195, 202ileostomy construction, 171ilioinguinal, 223, 228immediate breast reconstruction, 19inflow control, 146intraperitoneal chemotherapy, 229, 233,

234IPMN, 126, 127, 130isolated limb perfusion, 259isolated perfusion, 157, 161Ivor Lewis operation, 103

J pouch, 203–207

301

June 17, 2009 14:52 B-601 index FA

302 Index

laparoscopic, 275–277, 279, 280radical transperitoneal

nephrectomy, 275laparoscopic adrenalectomy, 253, 257laparoscopy, 238, 240, 242laryngeal cancer, 55, 56, 60, 61laryngectomy, 55–57latissimus dorsi flap, 11, 13left-sided oesophagectomy, 100liver metastases, 162liver resection, 141, 142, 144liver surgery, 149lobectomy, 71–73, 75–77locally advanced, 281, 287lumpectomy, 25, 28lung cancer, 63, 71–73lymph node, 45–50, 109–114lymphadenectomy, 63, 64, 68, 69, 95, 96,

98, 99, 101, 223, 227

mastectomy, 7–10, 12, 14–16mediastinoscopy, 87–90mediastinum, 65, 68melanoma, 223mesorectum, 187, 188, 190–192metastases, 134, 136, 137microsurgery, 295monitoring, 34multivisceral resection, 247

nephron sparing surgery, 267non-palpable, 25, 26

oesophageal cancer, 95, 117, 118, 123

palliative, 179, 180, 182–184pancreas, 110, 114pancreatic cancer, 126pancreatic resection, 126, 129, 130parasternal mediastinotomy, 88, 89parathyroid gland, 49, 51, 52perfusate, 261, 264perfusion level, 259, 260perfusion technique, 260perineal reconstruction, 216peritoneal carcinomatosis, 229, 230

peritoneal mesothelioma, 229, 235peritonectomy, 230–232, 234, 235posterolateral neck dissection, 48, 52prevertebral route, 104, 105primary melanoma, 219proctocolectomy, 195–198prostate cancer, 281, 282, 285, 287pseudomyxoma peritonei, 229, 231pulmonary, 71, 72, 74, 75

radical nephrectomy, 275, 279, 280laparoscopic transperitoneal, 276

radical prostatectomy, 281radiochemotherapy, 114radiofrequency, 133–135, 137radiotherapy, 221rectal cancer, 187, 192, 203rectum, 195, 197, 199recurrent laryngeal nerve, 49, 51, 53renal cell carcinoma, 267, 279

radical laparoscopic nephrectomy,275, 279

resection margin, 141, 142retroperitoneal sarcoma, 246, 247retrosternal route, 104, 105right-sided oesophagectomy, 97robotic colorectal surgery, 169ROLL, 26, 27

sentinel node, 1skin incision, 35skin/nipple sparing mastectomy, 19small renal tumours, 271spinal accessory nerve, 48spleen, 114stapling, 193stent, 117–123stent placement, 117, 118, 120–123stenting, 179, 181–184subclinical, 25superior laryngeal nerve, 49superior sulcus tumours, 79, 80, 84surgery, 84, 110, 114, 246, 247, 249, 250surgical procedure, 245surgical techniques, 55, 142

June 17, 2009 14:52 B-601 index FA

Index 303

technique, 118thoracodorsal bundle, 2thoracoscopic lobectomy, 71, 72thyroid carcinoma, 45–47thyroidectomy, 41, 43, 44tissue expander, 7, 10, 11TME, 187, 188, 192total exenteration, 209, 210, 214total pancreatectomy, 125, 129, 131total protectomy, 203toxicity, 259, 263, 264TRAM flap, 7, 14–17transcervical extended mediastinal

lymphadenectomy (TEMLA), 91transhiatal esophagectomy, 103–105transthoracic oesophagectomy, 95tumour, 133–136, 138, 139

tumour necrosis factor alpha, 263two-field lymph node dissection, 107

ulcerative colitis, 195–198utility thoracotomy, 72, 73

video-assisted lobectomybasic considerations, 71for lung cancer staging, 71–73indications, 73lymphadenectomy, 77technique, 73

video-assisted mediastinoscopiclymphadenectomy (VAMLA), 91

video-assisted thoracoscopic surgery,91

videothoracoscopic lobectomy, 71

Documents

Atlas of Procedures in Surgical Oncology