Modified Posterior Exenteration "The way how I do it"


Patient position and Retroperitoneal Access
  • Ensure adequate exposure and patient position (modified lithotomy) for vaginal access.

  • Opening avascular pelvic spaces.

  • Start from Frozen to unfrozen pelvis

  • Step by step devascularisation: IP ligament and uterine artery.

  • Use proper instruments: bipolar scissors, monopolar cautery. Use of advance bipolar sealer is a good idea in these large surgeries in order to achieve good heamostasis and reduce  blood loss.


Recto-sigmoid Resection

 

 

  • Tailoring bowel resection place: take care not to leave a diverticulosis sigmoid.
  • Ligate the inferior mesenteric artery or sigmoid artery.
  • Open presacral space by following both hypogastric  nerves down to the mesorectum. 

Bladder Dissection

 

 

  • Fill the bladder with 250 cc saline.
  • Identify uracus as a landmarck for removing bladder peritoneum.
  • Insert swab on a sponge forceps in the vagina: this is mandatory.

  • Dissect ureteric tunnel as in radical hysterectomy: this step is needed most of the times to remove the cancer en Block and avoid ureteric injury. 


En block Resection of Cancer

 

  • Open vagina using vaginal sponge forceps.

  • Open posterior vagina from the recto-vaginal space, not from Pouch of Douglas.

  • Follow the hypogastric nerve and plexus as best landmarks while dissecting mesorecto and utero-recto-sacral ligament.

  • Dissect as much as possible the rectovaginal space in order to facilitate anastomosis.

  • For tension free anastomosis this steps should be followed:

    1- Cut the IMA at the aorta level.

    2- Dissect and release large colonup to splenic colon flexure.

    3- If needed, cut the inferior mesenteric vein at Treitz angle.