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.
- 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.
- 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.