Reoperative Pelvic Surgery

Anatomy and Pitfalls of the Reoperative Pelvis

The difficulty of pelvic surgery in general relates to the narrow and deep confines of this anatomical compartment that is rigidly bound by bone, connective tissue, and muscle and contains many vital structures in close proximity to one another that are at risk of inadvertent damage. The challenges of adequate visualization and precise dissection are compounded in the reoperative patient, as scarring from previous surgery often further limits exposure and obliterates the normal anatomical planes. In addition, structures such as the ureters, pelvic nerves, and blood vessels may be displaced into unusual positions where they are more prone to injury.

The reoperative surgeon's understanding of the fascial planes within the pelvis is critical for the success of any endeavor. The pelvis is lined by a parietal fascia, which then extends to cover the pelvic organs as the visceral fascia. Overlying the sacrum, the presacral fascia constitutes a thickening and condensation of the parietal endopelvic fascia, where it protects the underlying presacral venous plexus. The vast majority of pelvic surgeries should be conducted in a plane anterior to this presacral fascia between it and the parietal fascia investing the mesorectum. Only rarely is violation of the presacral fascia indicated in the resection of a locally advanced or recurrent rectal cancer that involves this layer. Dissection deep to the presacral fascia, often blunt and due to lack of exposure, will invariably result in injury to the presacral veins. These vascular structures are prone to bleed precipitously due to the fact that they are avalvular and communicate directly with the basivertebral veins. Controlling bleeding from the presacral veins is especially challenging, as injury often results in an end-on venotomy rather than one on the lateral wall of the vessel. The special techniques used to deal with this complication are discussed later in the chapter, but precise anatomical dissection and avoidance of presacral venous injury is the best approach. Even in the reoperative situation, the plane between the presacral fascia and the mesentery of the ileal J pouch or colonic neorectum is usually present and can be identified.

The anterior counterpart to the presacral fascia is the fascia of Denonvilliers. This fascial layer separates the rectum and the base of the bladder and serves to protect the underlying seminal vesicles, prostate gland, and parasympathetic nerves that are involved in sexual function. Damage to these nervi erigentes will lead to erectile dysfunction in the male patient. Only in the case of an anterior rectal tumor that is closely opposed to Denonvilliers fascia should this plane be knowingly violated to ensure a clear radial margin.

The distal half of the ureters are also at risk during reoperative pelvic surgery when they may be displaced medially due to prior mobilization or concealed by scar tissue. Injury can occur at any location but is most common where the ureter crosses the pelvic brim or close to its insertion into the bladder. Injury in the former location is usually due to overaggressive and early lateral dissection, whereas damage in the latter instance typically results from inadequate exposure and visualization. Ureter injuries are inevitable in a high-volume reoperative pelvic surgery practice, but the keys to minimizing their occurrence and consequence are the liberal use of ureteric stents and maintenance of a high index of suspicion so that injuries can be immediately recognized and repaired. Ureter injuries that are dealt with at the time of surgery rarely have adverse consequences, whereas those that go unrecognized and present later in the postoperative period often lead to significant morbidity. One of the first steps in a reoperative pelvic surgery should be identification of the course of the ureters, either by palpation of previously placed plastic stents or by dissection and tagging with vessel loops. In the case of overt injury, enlisting the aid of an experienced urologist for repair or reimplantation is vital. If occult injury is suspected, the administration of methylene blue or indocyanine green intravenously may aid in identification.

One of the most dramatic intraoperative complications of reoperative pelvic surgery is injury to the internal iliac artery or vein as they course along the pelvic sidewall. These injuries can be extremely difficult to control and may lead to massive and life-threatening bleeding. Less commonly, the common or external iliac vessels may be injured. This problem is even more difficult, as control of bleeding must not jeopardize perfusion to the lower extremities. In the event of significant bleeding from any of these vessels, the first step should be pressure at the bleeding site with either the surgeon's finger or a peanut sponge. The latter is preferable, as this can then be passed to the assistant, freeing the surgeon to gain proximal control of the vessel. The anesthesia team should be notified of impending blood loss so that blood products can be ordered and administered. Only when the patient is resuscitated and stabilized should an attempt be made to either ligate or definitively repair the vascular injury. Additional suction catheters can be useful to keep the field cleared of blood for adequate visualization. Blindly placed sutures are discouraged because they risk further vascular injury, especially in the case of venous bleeding or inadvertent ligation of the adjacent ureter. Obtaining the help of a vascular surgeon in this situation can be invaluable.

Finally, the surgeon must often deal with small bowel loops that are adhesed within the pelvis after previous proctectomy, hysterectomy, or in the worst scenario, cystectomy. The small bowel loops should be mobilized en masse from the pelvis using sharp dissection in a plane between the small bowel serosa or mesentery and the endopelvic fascia. Keeping the dissection flush with the small bowel will minimize the risk of injuring adjacent structures such as the ureter or pelvic sidewall vessels. Any serosal tears or enterotomies created should be either immediately repaired or tagged with sutures to facilitate identification and repair prior to completion of surgery.

Timing of Surgery

The proper timing of reoperative pelvic surgery may be one of the most critical components for its success. It is our practice to wait a minimum of 6 months from the last laparotomy before attempting procedures such as redo ileal pouch- or coloanal anastomosis and Hartmann reversal. In the interim and if necessary, pelvic sepsis can usually be controlled with percutaneous drains. If proximal fecal diversion is necessary, then a limited upper abdominal laparotomy will usually allow the creation of a loop jejunostomy or ileostomy while avoiding the hostile lower abdomen or pelvis. Such patients can then be maintained on total parenteral nutrition until reoperation is safe. In cases where the previous laparotomy was extremely difficult due to dense adhesions, delaying reoperation for 12 months may be wise. A crude but effective method to determine whether the patient is ready for reoperative surgery is the “abdominal mobility test.” With the patient lying supine and relaxed, abdominal wall palpation should reveal movement of the intraabdominal contents, independent of the abdominal wall. This is a highly subjective measure and must be informed by experience, but it can be quite useful and is commonly employed by us. Other criteria that should be met prior to reoperation are restoration of the patient's nutritional status and resolution of sepsis. Abdominal wounds should also be healed.

On the other hand, if an anastomotic complication has been recognized in the early postoperative period, then surgery may be undertaken for repair at that time since intraabdominal adhesions are not usually limiting within the first 7 to 10 days. Early recognition and treatment of complications can alleviate the disability associated with the complication and the need for prolonged courses of parenteral nutrition, wound care, and skilled nursing facility stays.

Preparation for Surgery

Measures taken to prepare for reoperative pelvic surgery involve both the patient and the surgeon. Patients should undergo a thorough preoperative medical clearance evaluation in order to identify and correct any underlying cardiopulmonary risk factors. In some extremely high-risk patients, the patient and surgeon may choose to manage the existing complication conservatively rather than embark on a high-risk reoperative procedure. In these circumstances, the patient's current quality of life must be weighed against the chances for success, the degree of potential improvement, and the inherent risks of surgery. Patients must have a thorough understanding of the magnitude of the surgery, length of hospital stay, risk of complications, and the possible need for rehabilitation after hospital discharge. The preoperative consent process should also include a realistic and clear discussion of the goals of surgery. Bowel function, risk of sexual dysfunction, and anticipated quality of life should all be clearly articulated so that expectations are realistic. Patients should also understand that in some cases the goals of surgery cannot be achieved without undue risk and that the operation may need to be aborted.

Records related to previous surgery should be thoroughly reviewed so that the surgeon has an understanding of the anatomical alterations that may be encountered. If unclear, abdominopelvic computed tomography (CT) scans and/or contrast studies of the pelvic viscera may be helpful. In cases of recurrent cancer, a positron emission tomography (PET) scan to exclude extrapelvic metastatic disease and a pelvic magnetic resonance imaging (MRI) to delineate involvement of adjacent structures and determine resectability should be obtained. Endoscopy is often performed to exclude occult neoplasia and to examine the length and condition of the rectal stump in the case of Hartmann reversal or to assess the size and health of the ileal J pouch in the case of a redo ileal pouch–anal anastomosis (IPAA).

Sufficient time should be scheduled for the operation, and it may be best to avoid additional surgical cases on these days. Any subspecialists that may be needed should be informed. It is much better to have a urologist, gynecologist, or vascular surgeon listed on the operative schedule and not needed than to be left scrambling for an intraoperative operative consult late in the day.

Immediately prior to surgery, the patient should be marked for a stoma in all four quadrants of the abdomen, blood products should be reserved, and appropriate antibiotics and deep venous thrombosis prophylaxis should be administered. Reoperative pelvic surgery cases are usually prolonged and contaminated affairs, and the patients are subsequently at high risk for thromboembolic complications and wound infections.

Surgical Technique

Patient Positioning and Equipment

Proper patient positioning is critical in reoperative surgery cases. The surgeon should always have access to the perineum, and therefore the legs should be elevated and spread in the modified lithotomy position ( Fig. 180.1 ). We routinely use yellow fin stirrups for this purpose and take great care to provide sufficient padding to the posterior and lateral aspect of the calf near the fibular head. Prolonged pressure at this point can result in superficial peroneal neuropathy with resultant loss of dorsiflexion and eversion of the foot. Injuries to the sciatic and femoral nerves have also been described after lithotomy positioning. The latter may occur after improper placement of a pelvic Balfour or Bookwalter retractor. The lower edge of the buttocks should also protrude slightly from the bottom of the operating table to provide adequate access to the perineum. As steep Trendelenburg position is frequently required to facilitate pelvic exposure, we prefer to secure the patient to the table with a chest strap or beanbag to prevent them from sliding cephalad. After adequate intravenous access has been established, the arms should be tucked at the patient's side. Leaving the arms extended outward on arm boards can sometimes limit the surgeon's mobility when working in the pelvis. The skin should be prepared from the nipple line to the perineum, and in cases in which vascular reconstruction is anticipated, the groins should be prepared bilaterally. Draping should maintain access to the perineum.

Several pieces of equipment are especially useful during reoperative pelvic surgery. A foot pedal Bovie control coupled with the extender tip will provide adequate reach into the deepest pelvis. Likewise, long instruments such as forceps, needle drivers, and clamps along with suction catheter tips are essential. A set of lighted deep pelvic retractors is crucial for gaining adequate exposure, and a headlamp can also be complementary. The retractor set pictured in Fig. 180.2 contains a lighted BriteTrac (VitalCor Inc., Westmont, Illinois), along with Deaver and curved deep pelvic retractors with narrow, medium, and wide blades (Electrosurgical Instruments, Rochester, New York). The Deaver retractor is typically used to elevate the bladder and provide anterior exposure early in the pelvic dissection. The BriteTrac provides anterior retraction of the rectum and mesorectum for dissection of the mesial rectal plane and is also useful for exposing the anterolateral junction of the perirectal tissues and the pelvic sidewall and seminal vesicles. The curved deep pelvic retractors are used for both posterior and anterior exposure in the deepest phase of pelvic dissection.