Pelvic Exenterationjaffe

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Pelvic ExenterationJaffe
Summary of Procedures
Position

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Modified dorsolithotomy with Allen stirrups

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Incision

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Midline longitudinal, perineal

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Special instrumentation

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Vital View, ABC may be helpful; EEA, GIA, TA staplers; Robo-retractor or similar devices

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Unique considerations

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Full and thorough mechanical and antibiotic intestinal prep.
NG tube placement intraop.
SCD and minidose heparin intraop for VTE prophylaxis.
Preop PFTs.
Consider preop Greenfield IVC filter placement to avoid PE for high-risk patients.
Consider intraop radiation of tumor bed and/or of resection margins. Abort case if extrapelvic metastases and/or tumor extension to pelvic sidewalls noted.

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Antibiotics

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Cefotetan 2 g iv preop and continue q 12 h for 3 days. Alternatively, a combination of ampicillin (1 g), gentamicin (80 mg), and metronidazole (500 mg) may be given.

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Closing considerations

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Abdominal drains; colostomy; ureteral stents; urostomy; intraop radiation therapy.
Triple-lumen central line placement. Copious irrigation of the operative sites.

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EBL

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1200–4000 mL

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Postop care

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ICU: 2–3 d. Correction of electrolyte imbalance. Extensive peritoneal raw surfaces → intraperitoneal fluid 3rd-spacing. Patients require good hydration to maintain intravascular volume. SCDs and heparin VTE prophylaxis. Consider concentrated albumin infusion to maintain intravascular volume. Early and aggressive use of TPN is important. Maintain Hct in the low 30s, as concentrated blood may → sludging and contribute to flap necrosis and wound breakdown. Remove ureteral stents 1–2 wk postop, when the edema at the ureterointestinal site has subsided.

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Respiratory

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Usually not significant unless there is Hx of smoking or lung disease. Ask about prior chemotherapy.

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Tests: resp

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Consider CXR; others as indicated from H&P.

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Cardiovascular

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Exercise tolerance should be assessed. Underlying CAD or CHF should be medically optimized preoperatively. Any exposure to cardiotoxic chemotherapy should be investigated and may require further tests, such as an ECHO.

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Tests: cardiac

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Consider ECG; others as indicated from H&P.

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Neurological

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Any Hx of stroke, Sz, carotid artery disease, or other neurologic disease should be evaluated and documented.

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Endocrine

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Any endocrine disease, such as diabetes, should be optimized in consultation with the patient's primary care physician or endocrinologist. Ask about recent corticosteroid use.
Tests: Fasting blood sugar in the diabetic; others as indicated from H&P.

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Gastrointestinal

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Patients should have iv hydration if given a bowel prep.

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Hematologic

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Many patients will be anemic from chronic disease and malnutrition. Consider preop transfusion PRBC to ↑ Hct > 30%.

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Tests: hema

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CBC, PT, PTT

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Laboratory

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LFTs

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Premedication

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Consider midazolam 1–2 mg iv. Detailed explanation about the procedure and the potential for postop events including intubation and mechanical ventilation worthwhile.

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Intraoperative
Anesthetic technique:

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GETA ± supplemental epidural anesthesia.

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General anesthesia:
Induction

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Standard induction
Keep in mind possibility surgery could be significantly shortened if metastatic tumor found during initial ex lap.

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Maintenance

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Balanced anesthetic technique based on comorbidities, use of concomitant epidural anesthesia and likelihood of needing ICU postop. Epidural anesthetic or epidural narcotic (morphine or hydromorphone) can be given to reduce anesthetic requirements when using inhalation agents.

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Emergence
If patient is hemodynamically stable, with favorable oxygenation and pulmonary function, normothermic, and responsive at the end of surgery, ? may be appropriate

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extubation may be appropriate

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Any patient who is unstable, hypothermic, has high-oxygen requirements, significant edema of the face or airway, or ongoing excessive fluid requirements should be admitted to ICU and remain intubated. Due to the ?

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large fluid shifts and significant complication rates, postop monitoring in the ICU is appropriate.

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Epidural
Consider epidural for intraop and/or postop use:what meds given for post op pain control in epidural?

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2% lidocaine (10–15 mL), with or without hydromorphone (0.3–0.8 mg), may be given in the epidural for postop pain control.

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epidural Intraop use may ?

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↑ hemodynamic instability in setting of ↑ bleeding and fluid shifts.

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epidural Post op efficacy may be limited if patient

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remains intubated > 1 day.

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Ventilation ?-? cm H2O PEEP may help prevent atelectasis. [check mark]ABGs during surgery. Adjust ventilation to keep normocarbic.

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5–7

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Give ? for metabolic acidosis when pH < 7.20 and treat underlying cause.

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HCO3

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Blood and fluid requirements Potential large blood loss
IV:
NS/LR at

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14–16 ga × 2
10–15 mL/kg/h

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Colloid solutions
Renal ultrafiltration .

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improved by NS/LR, bowel edema ↑'d

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LR useful when

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acidosis occurs.

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? is better when giving blood products or when metabolic alkalosis is present.

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NS

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Rapid-infuser should be available. Strive to maintain euvolemia based on what vs?

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BP, HR, UO, ABG, invasive monitoring (CVP, CO, art line tracing), and estimates of ongoing EBL and fluid shifts.

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Hetastarch
Consider PRBCs when Hct <

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30%

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Use of 6% hetastarch should be limited to ?ml due to potential coagulopathy with larger volumes.

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1,000 mL

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Maintain UO of .

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0.5–1 mL/kg/h

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Ionized Ca++ Measure ionized Ca++ and K+ after rapid administration of

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blood products; replace Ca++ as necessary.

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FFP/Plt
Plt or FFP

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for coagulation abnormalities. Monitor values during case periodically.

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Monitoring Standard monitors (see p. B-1). Consider ± catheters usually helpful in these cases which are of very long duration, and associated with major bleeding, fluid shifts, ICU postop, and potential need for vasoactive infusions.

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Arterial line
Consider CVP/PA catheter
Foley catheter Invasive hemodynamic monitoring with arterial and PA

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± TEE TEE allows

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intraop assessment of myocardial function and may be appropriate in selected patients.

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Positioning

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

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* NB: peroneal nerve compression at lateral fibular head →

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foot drop.

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Complications

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Hypothermia: Use forced air and fluid warmers and monitor temperature.
VTE
Coagulopathy
Trauma to kidney
Watch for hematuria or ↓UO.
Bleeding:Monitor hemoglobin and coagulation status periodically during long surgery. Keep adequate reserve blood products available.
Peripheral nerve injury Prolonged surgery, carefully pad, secure, and monitor all extremities.

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Postoperative
Pain management Epidural or iv opiates See p. C-2.

Tests CBC, chemistry panel, coags, ABG Others as indicated from postoperative course. Patient will likely need ongoing critical care/ICU management.

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Complications
Bleeding [check mark]Hct and coags periodically. Be prepared for continued increased fluid requirements for 24 h postop.
Fluid overload
Hypothermia:Maintain euvolemia, if significant fluid gain occurs, consider ICU postop ventilation.
PONV If extubated.
VTE See p. B-7.
Peripheral nerve injury For prolonged surgery, carefully pad, secure, and monitor all extremities.