Reoperative Pelvic Surgery (eBook)

Reoperative Pelvic Surgery 2
Preface 5
Contents 6
Contributors 8
Introduction and Overview: Principles of Reoperative Pelvic Surgery 12
Pelvic Anatomy 12
Timing of Reoperation 12
Patient Preparation 13
Conduct of the Surgery 13
Other Points to Consider During Surgery 13
Identification of Structures 13
Rectal Stump 13
Vaginal Identification 14
Prevention and Control of Pelvic Bleeding 14
Management of Bleeding 14
Specific Procedures and Reconstruction 14
Conclusion 14
References 15
Reoperations Within the First 30 Days After Pelvic Surgery 16
Anorectal Complications 16
Infection 16
Wound Healing Complications 16
Fecal Impaction 17
Reoperative Pelvic and Abdominal Complications 17
Infection 17
Wound and Fascial Dehiscence 18
Anastomotic Leak 19
Small Bowel Obstruction 20
Fistulous Complications 21
Early Stoma Complications 21
Postoperative Cholecystitis 22
Ureteral Injury 22
Compartment Syndrome 23
References 23
Reoperation and Management of Postoperative Pelvic Hemorrhage and Coagulopathy 26
Etiology 26
Incidence 26
Diagnosis 27
Coagulopathy 27
Acquired Platelet Dysfunction 27
Acquired Coagulopathy 28
Decision to Reoperate 28
Transcatheter Arterial Embolization 29
Reoperative Techniques 29
Space-Specific Surgical Techniques 30
Presacral Space 30
Obturator Fossa 31
Space of Retzius 31
Pelvic Floor 31
Abdominal Packing 31
Conclusion 31
References 31
Reoperative Considerations After Laparoscopic Pelvic Surgery 33
Expected Postoperative Course 33
Evaluation of Patients Who Deviate from the Expected Postoperative Course 33
Clinical Signs and Symptoms 33
Laboratory Studies 33
Radiologic Evaluation 34
Laparoscopic Management of Postoperative Complications 35
Postoperative Bleeding 35
Bowel Obstruction 36
Trocar Site Hernias 36
Adhesive Obstructions 37
Infectious Complications 37
Missed Enterotomies 37
Anastomotic Dehiscences 38
Pelvic Abscesses 38
Conclusion 38
References 39
Laparoscopic Reoperative Surgery for Incompletely Staged Gynecologic Malignancies 40
Endometrial Carcinoma 40
Ovarian Carcinoma 41
Cervical Carcinoma 44
Laparoscopic Lymphadenectomy Technique 45
Robotic Reoperative Surgery and Lymphadenectomy 47
Conclusion 49
References 49
Reoperation for Endometriosis and Ovarian Remnants 52
Endometriosis 52
Treatment 52
Recurrence 53
Complications of Surgery 53
Rectal Involvement with Endometriosis 54
Ovarian Remnant Syndrome 55
Diagnosis 55
Physical Examination 55
Management 55
References 56
Pelvic Exenteration for Recurrent Pelvic Cancer 58
Patient Selection 59
Counseling 60
Perioperative Management 61
Surgical Techniques 61
Exploratory Laparotomy 61
Periaortic Lymphadenectomy 61
Pelvic Lymphadenectomy and Assessment of Resectability 61
Abdominal Exenterative Phase 62
Perineal Exenterative Phase 63
Reconstructive Phase: Conduit Formation 63
Vaginal Reconstruction 64
Postoperative Care 65
Postoperative Complications 66
References 66
Reoperation for Bladder Cancer 69
Nephroureterectomy for Upper Tract Recurrence After Cystectomy 69
Surveillance 70
Risk Factors 71
Treatment 72
Nephron-Sparing Techniques 72
Open Nephroureterectomy 72
Operative Technique: Open Nephroureterectomy After Radical Cystectomy and Ileal Conduit Diversion 72
Complications 75
Survival Outcomes 76
Urethrectomy for Urethral Recurrence After Cystectomy 76
Presentation 76
Risk Factors 77
Surveillance 77
Treatment 78
Conservative Therapy 78
Urethrectomy 79
Operative Technique: Urethrectomy After Radical Cystectomy 79
Male Patients with Ileal Conduit Diversion 79
Male or Female Patients with Orthotopic Neobladder Diversion 80
Total Urethrectomy with Conversion to Incontinent Cutaneous Diversion 81
Subtotal Urethrectomy with Perineal Urethrostomy 82
Complications 82
Survival 82
Completion Cystectomy for Recurrence After Partial Cystectomy 82
Patient Selection 83
Operative Technique of Completion Cystectomy 83
Treatment Outcomes 83
Pelvic Recurrence 83
Risk Factors 83
Presentation 84
Treatment 84
Treatment Outcomes 84
Operative Techniques for Pelvic Recurrence 84
Conclusion 85
References 85
Reoperative Surgery for Prostate Cancer 88
Radical Prostatectomy After Surgery for Benign Prostatic Hyperplasia 88
Technical Challenges 88
Oncologic Outcomes 89
Complications and Functional Outcomes 90
Timing and Technical Modifications 92
Surgery After Failed Local Therapy 92
Salvage Radical Prostatectomy 92
The Role of PSA in Salvage Radical Prostatectomy 92
Morbidity 93
Predictors of Survival 93
Oncologic Outcomes After Salvage Radical Prostatectomy 95
Functional Outcomes 95
Technical Challenges and Surgical Modification 96
Salvage Radical Surgery for Bulky Local Recurrence After Radical Prostatectomy 97
References 97
Introduction to Reoperative Pelvic Surgery for Rectal Cancer 100
Risk Factors and Prevention 100
Prognostic Factors 102
Management of Recurrent Rectal Cancer 103
Phase 1 103
General Evaluation, Risk Assessment, and Initial Staging 103
Determining Resectability 105
Phase 2 106
Preoperative Multimodality Treatment 106
Phase 3 107
Surgical Resection and Intraoperative Radiotherapy 107
Surgical Resection 107
MSKCC Experience 108
Intraoperative Radiotherapy 110
Palliative Therapy for Advanced Recurrent Rectal Cancer 112
Summary: Reoperative Treatment of Locally Recurrent Rectal Adenocarcinoma 114
Recurrent Squamous Cell Carcinoma of the Anus 114
References 115
Recurrent Pelvic Organ Prolapse 119
Risk Factors Associated with Prolapse 119
Anatomy and Pathology 121
Surgical Management of Apical Prolapse 122
Apical Prolapse Using Uterosacral Ligaments 123
McCall Culdeplasty 123
Uterosacral Vaginal Vault Suspension 123
Sacrospinous Ligament Fixation 125
Iliococcygeus Vaginal Vault Suspension 128
Abdominal Sacrocolpopexy 129
Tension-Free Vaginal Mesh Kit Procedures 130
Obliterative Procedures 132
Colpectomy and Le Fort Colpocleisis Procedures 132
Anterior Wall Prolapse 134
Anterior Colporrhaphy 134
Paravaginal Repair 134
Graft Augmentation 136
Posterior Wall Prolapse 139
Posterior Colporrhaphy 139
Site-Specific Defect Repair 140
Graft Augmentation 141
Sexual Function and Posterior Repair 143
Conclusion 143
References 144
Recurrent Rectal Prolapse 150
Etiology 150
Symptoms and Physical Findings 150
Evaluation 151
Choice of Operative Repair 152
Operative Technique: Abdominal Approach 153
Rectopexy 153
Resection and Rectopexy 153
Operative Technique: Perineal Approach 154
Delorme 154
Perineal Proctectomy 154
Conclusion 154
References 156
Suburethral Sling Failures and Complications 157
Evaluation of Sling Failures 157
Recurrent Stress Urinary Incontinence After Sling 157
Complications of Slings 159
Visceral Perforation 159
Bleeding 160
Bladder and Urethral Perforation 160
Voiding Dysfunction 160
Urethral Erosion 161
Vaginal Erosion/Extrusion 162
Infection and Abscess 162
Obstruction 162
Evaluation And Intervention 162
Treatment 164
Incision of Sling 164
Urethrolysis 164
Conclusion 165
References 165
Reoperative Surgery for Anal Incontinence 168
Redo Anterior Sphincteroplasty 168
Postanal Repair 170
Gluteoplasty 171
Graciloplasty 172
Sacral Nerve Stimulation 174
Artificial Bowel Sphincter 175
Gynecologic Approaches to Fecal Incontinence 176
Bias Toward Obstetrical Surgical Experience 176
Lack of Experience with Sonographic and Functional Assessment Tools 176
Absence of Colorectal Expertise in Many Communities 177
Reparative Surgery 177
Alternate Surgical Approaches 177
Colostomy 177
Conclusion 177
References 178
Gastrointestinal Fistulas 182
Rectourinary Fistulas 182
York Mason Approach to Genitourinary Fistulas 182
Clinical Scenario 182
Preparation and Position 182
Incision 182
Fistula Repair 182
Postoperative Care 183
Perineal Approach to Rectoprostatic Fistulas 184
Clinical Scenario 184
Preparation and Position 186
Incision 186
Dissection 186
Fistula Repair 186
Postoperative Care 187
Rectovaginal Fistulas 187
Clinical Scenario 187
Definition 188
Obstetrical Trauma 188
Crohn’s Disease 189
Operative Trauma 189
Radiation and Cancer 189
Evaluation 189
Transanal Flap Repair 189
Traumatic Cloaca Repair 189
Preparation 189
Incision 190
Repair 190
Postoperative Care 190
Other Techniques Used for Complex Rectovaginal Fistulas 191
Vesicoenteric Fistulas 192
Colovesical 192
Diverticular Colovesical Fistula 192
Malignant Enterovesical Fistula 193
Rectovesical Fistulas 193
Rectovesical Fistula in a Hostile Pelvis: Repaired Using a Transcystic Approach 193
Enterocutaneous Fistulas 194
Etiology 194
Management of Enterocutaneous Fistulas 194
Resuscitation 194
Investigation 194
Surgical Management 194
Fistula in Ano 195
Clinical Scenario 195
Definition 195
History 195
Inspection 195
Palpation 195
Anoscopy and Proctosigmoidoscopy 195
Natural History of Fistula-in-Ano 195
Imaging 195
Management 196
Fistulotomy 196
Fibrin Glue Injection 196
The Role of Setons 196
Cutting Setons 196
Drainage Setons 196
Long-Term Drainage Setons 196
Short-Term Drainage Setons 197
Marking Setons 197
Dermal Advancement Flaps 197
Transanal Anorectal Advancement Flap 197
Fistulectomy and Primary Closure 198
Anal Fistula Plug 198
Fistula and Carcinoma 198
Fistula in Crohn’s Disease 198
Fistula in Infants 198
Recurrent Anal Fistula 198
References 200
Urogenital Fistulas 202
Etiology and Epidemiology of Urogenital Fistulas 202
Vesicovaginal Fistula 202
Surgical VVF 202
Obstetric VVF 202
Radiation VVF 202
Other VVF 203
Urethrovaginal Fistula 203
Vesicouterine Fistula 203
Ureterouterine Fistula 203
Ureterovaginal Fistula 203
Evaluation and Diagnosis of Urogenital Fistulas 203
Presentation 203
Physical Examination 204
Cystoscopy 204
Imaging 204
Urodynamics 204
Surgical Principles of Fistula Prevention 204
Management of the Vesicovaginal Fistula 205
Conservative Management 205
Surgical Repair: General Principles 205
Timing of Repair 205
Preoperative Issues 205
Surgical Repair: Minimally Invasive Approaches 206
Sealants 206
Thermal Ablation 206
Cystoscopic Intervention 206
Surgical Repair: Open Techniques 207
Surgical Principles 207
Abdominal Versus Vaginal Approach 207
Transabdominal Technique for Vesicovaginal Fistula Repair 207
Transvaginal Technique for Vesicovaginal Fistula Repair 207
Surgical Outcomes Following Open Repair of Vesicovaginal Fistula 208
Open Versus Laparoscopic Approach 209
Surgical Repair, Tissue Interposition 209
Martius Flap 210
Peritoneal Flap 210
Omental Flap 211
Muscular Flaps 211
Postoperative Issues 211
Management of Additional Urogenital Fistulas 211
Urethrovaginal Fistula 211
Vesicouterine Fistula 211
Ureterouterine Fistula 212
Ureterovaginal Fistula 212
Conclusion 212
References 213
Complications of Urinary Diversion 216
History 216
Complications 216
Metabolic Derangements 216
Nutritional Abnormalities 216
Metabolic Consequences 216
Ileum 217
Jejunum 217
Colon 217
Osteomalacia 217
Drug Reabsorption 218
Urolithiasis 218
Pyelonephritis 219
Stomal Complications 219
Parastomal Hernias 219
Ureterointestinal Anastomotic Complications 220
Bowel Complications 221
Renal Function 221
Secondary Neoplasm 221
References 222
Complications of Transurethral Surgery 225
Transurethral Resection of the Prostate 225
Intraoperative Complications 226
Bleeding 226
Transurethral Resection Syndrome 226
Prostatic Capsule Perforation 227
Injury to the Ureteral Orifices 227
Injury to the External Sphincter 227
Postoperative Complications 228
Failure to Void/Urinary Retention 228
Hematuria 228
UTI and Epididymitis 228
Irritative Voiding Symptoms 228
Late Postoperative Complications 228
Urinary Incontinence 228
Urethral Stricture and Bladder Neck Contracture 228
Ejaculatory Dysfunction 229
Erectile Dysfunction 229
Retreatment 229
Transurethral Resection of Bladder Tumor 229
Hemorrhage 230
Bladder Perforation 230
Other Concerns 230
Conclusion 230
References 231
Reoperative Management of Fissure and Hemorrhoids 233
Anal Fissure 233
Definition and Epidemiology 233
Etiology 233
Management 234
Medical Management 234
Nitrates 234
Calcium Channel Blockers 234
Botulin Toxin 234
Surgical 235
Anal Dilatation 235
Sphincterotomy 235
Fissurectomy 236
Anal Advancement Flaps 236
Summary 236
Anal Stenosis 237
Definition and Epidemiology 237
Etiology 237
Management 237
Nonoperative 237
Surgical 237
Mucosal Advancement Flaps 237
V-Y or Y-V Advancement Flap 237
Diamond or House Flap 238
Rotational S-Plasty 238
Summary 239
Recurrent Hemorrhoidal Disease 239
Rate of Recurrent Hemorrhoidal Disease 240
Management of Recurrent Disease 241
Summary 241
References 241
Reoperative Surgery for Inflammatory Bowel Disease 245
Crohn’s Disease 245
Small Bowel Disease 245
Surgery 245
Colonic Disease 246
Surgery 247
Technique of Rectal Resection 250
Perineal Resection of the Anus and Distal Rectum 252
Perianal Disease 253
Reoperative Surgery for Crohn’s Disease 254
Recurrent Disease 255
After Ileocolectomy 255
After Segmental Colectomy 256
After Small Bowel Resection or Stricturoplasty 256
Specific Complications 256
Anastomotic Dehiscence/Fistula 256
Anastomotic Stricture 257
Presacral Hemorrhage 257
Pelvic Abscess 257
Perineal Hernia 258
Cancer 258
Unhealed Perineal Wound 259
Chronic Ulcerative Colitis 259
Total Proctocolectomy and Standard (Brooke) Ileostomy 260
Reoperations Following Total Proctocolectomy 260
Delayed Perineal Wound Healing 260
Stoma Problems 260
Subtotal Colectomy and Ileorectal Anastomosis 260
Specific Complications 261
Anastomotic Leakage 261
Continuing Proctitis/Dysplasia 261
Secondary Proctectomy 261
Total Proctocolectomy and Continent Ileostomy 261
Complications of Continent Ileostomy 262
Early Postoperative Complications 262
Hemorrhage 262
Suture Line Dehiscence 262
Early Fistulas 262
Ischemia 263
Ischemia of the Outflow Tract 263
Ischemic Necrosis of the Valve 263
Late Complications 264
Valve Slippage 264
Valve Revision 264
Valve Repair 264
Valve Reconstruction 264
Late Fistulas 265
Repair of Valve Fistula 265
Skin-Level Stenosis 265
Double Z-Plasty 265
Valve Prolapse 267
Repair of Valve Prolapse 267
Restorative Proctocolectomy 267
Restorative Proctocolectomy Complications 268
Pelvic Sepsis 268
Pouch Ischemia 268
Pouch Suture Line Leak 268
Pelvic Abscess 269
Ileal Pouch-Anal Anastomosis Leak 269
Ileal Pouch-Anal Anastomosis Perineal Fistula 269
Transanal Ileal Advancement 270
Pouch Advancement 270
Fibrin Sealant/Anal Fistula Plug 271
Pouch Vaginal Fistula 271
Transanal Repair 271
Transvaginal Repair 271
Pouch Advancement 271
Interposition Flap 271
Pouch Redo 271
Secondary Mucosectomy 272
Ileal Pouch-Anal Anastomosis Stricture 272
Obstructed Defecation/Pouch Prolapse 272
Cancer Following Restorative Proctocolectomy 273
Pouch Excision 273
References 273
Complications of Surgery After Pelvic Radiation 279
General Principles of Radiation Therapy 279
Radiation Therapy Techniques 279
Acute and Late Toxicities by Organ with Pathophysiology 280
Rectum 281
Bladder 281
Ureters 281
Reducing Incidental Radiation 281
Complications of Surgery After Pelvic Radiation 281
Salvage Prostatectomy 281
Surgical Considerations of Salvage Prostatectomy 282
Salvage Cystectomy 283
Urinary Diversion 283
Surgical Considerations of Salvage Cystectomy 284
Surgical Considerations After Radiation for Cervical Carcinoma 285
Conclusion 285
References 285
Reoperation for Diverticular Disease 287
Re-Resection for Recurrent Diverticulitis After Previous Colon Resection 288
Reoperation After a Previous Hartmann’s Procedure 288
Conclusion 289
References 289
Reoperative Surgery for Gastrointestinal Stomal Problems 291
Stomal Complications and Risk Factors 291
Emergent Versus Elective Stoma Creation 291
Ischemia and Necrosis 292
Prolapse 293
Retraction 294
Stenosis 294
Parastomal Hernia 295
Symptoms 296
Diagnosis 296
Nonoperative Therapy 297
Surgical Repair 297
Operative Techniques 297
Local Repair with Sutures 297
Parastomal Subcutaneous Repair 297
Onlay Mesh Repair 297
Relocation 298
Intraabdominal Mesh Repairs 298
Laparoscopic Repair 299
Abdominoplasty and Contouring 299
Loop Ostomy Hernias 299
Results of Parastomal Hernia Repair 299
Summary of Parastomal Hernias 300
Bleeding and Peristomal Varices 300
Trauma and Perforation 300
Abscess and Fistula 301
Obstruction 301
Parastomal Pyoderma Gangrenosum 301
Miscellaneous Problems 302
Mucosal Implantation 302
Fungal Infections 302
Allergic Reactions 303
High-Output Ostomy and Dehydration 303
Stomal Polyps and Carcinoma 303
Conclusion 304
References 304
Reoperative Pelvic Surgery for Late Bowel Obstruction (After 30 Days) 308
Differential Diagnosis and Diagnostic Workup 308
Preoperative Considerations 310
Distorted Anatomy and Loss of Normal Tissue Planes 310
Potential Pitfalls and Complications 310
Preoperative Adjuncts 311
Operative Technique 311
Specific Situations and Management 312
Malignant Bowel Obstruction from Local Recurrence or Carcinomatosis 312
Reversal of Hartmann’s/Stoma Closure 313
Gynecologic Malignancy 313
Conclusion 314
References 314
Suggested Readings 308
Reoperations for Bleeding 317
Gastrointestinal Bleeding 317
Etiologies 317
Initial Assessment, Resuscitation, and Stabilization 317
Radionuclide Imaging 318
Colonoscopy 318
Angiography 318
Newer Diagnostic Methods 320
Operative Therapy 320
Perioperative Hemorrhage 321
Preoperative Preparation 321
Intraoperative Considerations 322
Splenic Injury 323
Pelvic Hemorrhage 323
Laparoscopic Surgery 324
Anastomotic Hemorrhage 324
Anorectal Procedures 324
Postoperative Care 325
Postoperative Hemorrhage 325
Conclusion 326
References 326
Reoperative Surgery for Constipation or Dysmotility 328
Always Start Over with the History 328
Physical Examination 328
Further Testing 329
Conservative Treatment 329
Surgical Treatment 329
Slow Transit Constipation 329
Obstructed Outlet Defecation 330
Conclusion 330
References 331
Index 333