Jaffeinterstitial Perineal Implants

Front 1

Summary of Procedures
Position

Back 1

Laparotomy-Guided Laparoscopy-Guided both Modified dorsolithotomy; Allen stirrups

Front 2

Incision

Back 2

Laparotomy-Guided Midline longitudinal abdominal
Laparoscopy-Guided Vertical infraumbilical and multiple small transverse incisions at the pubic hairline

Front 3

Special instrumentation

Back 3

Laparotomy Syed-Neblett or MUPIT systems, or modifications thereof
Laparoscopy⇐+ videolaparoscopy equipment, preferably with a 3-chip camera

Front 4

Unique considerations

Back 4

Laparotomy MRI and/or CT scans + information from physical exam are used to preplan implant with a computer dosimetry program. Patients require thorough preop mechanical and antibiotic bowel prep. Preop epidural placement or postop PCA (see p. C-3) may prove helpful for pain control. Foley catheter needs to be inserted through an opening at the top of the clear plastic template prior to implant positioning.
Laparoscopy Adhesions of variable severity may be present from prior surgery or radiation. Care should be taken to avoid possible bowel injury at time of trocar insertion. Patient needs to be in steep Trendelenburg position for duration of procedure.

Front 5

Antibiotics

Back 5

Cefotetan 2 g iv; then q 12 h × 3 doses ⇐

Front 6

Surgical time
EBL

Back 6

1.5–3 h ⇐
150–350 mL Minimal

Front 7

Closing considerations

Back 7

Laparotomy-GuidedSuture template to perineum. Perform rectal exam and adjust any needles that are too close to, or have protruded through, the rectal mucosa. Pack any space between template and perineum with Vaseline gauze. Obtain A-P and lateral orthogonal localization films with the patient in the supine bed-rest position. Insert Hypaque dye into Foley catheter balloon before localization films. Consider insertion of a large Foley into the rectum, and attach to a drainage bag. Consider NG tube placement.
Laparoscopy-Guided⇐+ Release the pneumoperitoneum completely. Consider insertion of 1 L heparinized LR to cause the bowel to float and remain mobile, thus minimizing the risk of radiation injury.

Front 8

Postop care ⇐

Back 8

Patient is confined to bed while interstitial implants are in place. SCDs and minidose heparin for DVT prophylaxis. Vigorous use of incentive spirometry. Consider constipating medications (e.g., Lomotil). Patient must be placed in a shielded room. Visitors and medical personnel should interact with patient from behind a lead shield until radiation sources have been removed.

Front 9

Respiratory

Back 9

Usually not significant unless underlying lung disease is present.

Front 10

Cardiovascular
Tests: ECG if age ≥ 50; others as indicated from H&P.

Back 10

Many patients with pelvic tumors are elderly and prone to cardiovascular disease.

Front 11

Hematologic
Laboratory

I

Back 11

Tests: CBC, consider PT/PTT if at risk for coagulopathy
Renal panel

Front 12

Premedication

Back 12

Consider midazolam 1–2 mg iv

Front 13

ntraoperative
Anesthetic technique:

Back 13

Regional or GA, depending on site involved. A postop epidural is useful for pain management.

Front 14

Induction
Maintenance

Emergence

Back 14

Standard
Consider PONV prophylaxis (see p. B-6)

Front 15

Blood and fluid requirements Small blood loss
IV:
NS/LR at
Monitoring Standard monitors (see p. B-1).

Back 15

18–20 ga × 1
2–4 mL/kg/h

Front 16

Positioning

Back 16

May be necessary to keep patient motionless during implant insertion.
[check mark]and pad pressure points.
[check mark]eyes.
Antiembolism stockings and SCD.

Front 17

Postoperative
Pain management

Back 17

Epidural narcotics (see p. C-2).
PCA (see p. C-3).
Consider ketorolac 15–30 mg im/iv q 6 h for breakthrough pain. Implants are associated with significant discomfort.