Jafferadicalvulvectomy

Front 1

Radical Vulvectomy
Surgical Considerations
Position

Back 1

Modified dorsolithotomy in Allen universal stirrups

Front 2

Radical Vulvectomy
surgical Considerations
Incision

Back 2

Bull's head, from iliac crest to iliac crest and along labia-crural folds
2 separate groin incisions from iliac crest to pubic tubercle; 1 vulvar incision
1 or 2 separate groin incisions from iliac crest to pubic tubercle; vulvar incision

Front 3

Radical Vulvectomy
Surgical Considerations
Special instrumentation

Back 3

Argon Beam Coagulator

Front 4

Radical Vulvectomy
Surgical Considerations
Antibiotics

Back 4

Cefotetan 2 g iv; then 2 g iv q 12 h × 72 h

Front 5

Unique considerations
⇐ ⇐

Back 5

Two-team approach to minimize surgical time.
Preop bowel prep and constipating medications (e.g., Lomotil) to ↓postop bowel movements.

Front 6

Surgical time

Back 6

3–4 h en bloc dissection
2–3 h hemivulvectomy

Front 7

Closing considerations for en bloc dissection, hemivulvectomy, 3 incision

Back 7

Possible skin graft; vulvar and groin suction drains

Front 8

EBL

Back 8

500–1000 mL=en bloc and 3 incsion
250–1000 mL hemi

Front 9

Postop care

Back 9

PACU or ICU, if necessary; aggressive local wound care. VTE prophylaxis

Front 10

NB: trauma to femoral vessels at time of groin lymph node dissection increases risk of

Back 10

thrombophlebitis and PE.

Front 11

Anesthetic Considerations
Preoperative
Patients with vulvar carcinoma are usually elderly. Consider and evaluate coexisting medical conditions, including

Back 11

HTN, CAD, and diabetes.

Front 12

Radical vulvectomy is performed for invasive tumor that has not

Back 12

metastasized to distant sites.

Front 13

Respiratory
The presence of ?? should be discussed with the patient preop.

Back 13

lung disease and smoking Hx

Front 14

Respiratory
Consider ?? for patients with significant respiratory disease.

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CXR and PFTs

Front 15

Cardiovascular
There is an increased incidence of ?? in these patients

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HTN and atherosclerosis

Front 16

Cardiovascular
A ? is indicated for angina, recent MI, CHF, or heart murmurs.
Renal

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cardiology consultation

Front 17

Cardio
Review recent ECG for patients >.

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50

Front 18

renal
In old age, ? is decreased 2° ↓renal mass, but ? remains unchanged because of decreased muscle mass.

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creatinine clearance
serum creatinine

Front 19

Gastrointestinal
Patients should have ? preop if given bowel prep overnight.

Back 19

iv hydration

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Neurological
Document a ? if Hx of stroke, Sz, or other neurologic disease.

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neurological exam

Front 21

Neurological
Hx of peripheral neuropathy or autonomic dysfunction should be assessed in ? patients.

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diabetic

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Endocrine
3 co morbidities are common in this patient population.
g

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Diabetes, obesity, and hypothyroidism

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endocrine
Tests:

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Fasting blood sugar; thyroid function; others as indicated from H&P.

Front 24

Hematologic
Chronic ? may be present.
Tests:

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anemia
Hb/Hct; Plt count

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Laboratory

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LFTs, if indicated.

Front 26

Premedication

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Consider midazolam iv 1–2 m

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Intraoperative
Anesthetic technique:

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GETA or regional anesthesia, alone or in combination.

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General anesthesia:
Induction
Maintenance
Emergence

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Standard induction
Standard maintenance
No special

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Regional anesthesia:
Epidural

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2% lidocaine ± epinephrine 1:200,000 (10–20 mL) or 0.5% bupivacaine (10–20 mL) are used; then at ~3–5 mL/h.

Front 30

Narcotics such as ? in the epidural for postop pain control.

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morphine (2–4 mg)

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Spinal

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Tetracaine (12 mg) or bupivacaine (12–15 mg), preservative-free morphine (0.1–0.2 mg) → T8 sensory level.

Front 32

Blood and fluid requirements
IV:
NS/LR at
UO >

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16–18 ga × 2
6–8 mL/kg/h
0.5 mL/kg/h
Warm iv fluids

Front 33

Occasionally, ? vessels may be injured, requiring rapid blood replacement.

Positioning [check mark] and pad pressure points
[check mark] eyes
Antiembolism stockings and SCD

Postoperative
Complications Hypothermia
Bleeding
PONV See p. B-6

VTE See p. B-7

Pain management PCA (p. C-3)
Epidural or spinal narcotics (p. C-2)
Incisions may be left open to granulate in, or be covered with skin grafts. Epidural analgesia allows earlier ambulation with less sedation in elderly patients.
Tests Tests as indicated from postop clinical findings

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femoral

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Consider PRBCs for Hct < ? in healthy patients and < ? in patients with cardiac or pulmonary disease.

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21%
25–30%

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Monitoring Standard monitors
±

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± Arterial line
± CVP line
Foley catheter

Front 36

? monitors indicated for patients in poor condition or with cardiovascular or respiratory disease.

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Invasive monitors

Front 37

An ? catheter is useful for drawing labs in surgery to check Hct, coags, glucose, or ABGs.

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arterial