Nongynecological conditions encountered by the gynecologists surgeon

Case report A 68 yrs. old (G9L6Ab1D2) Menopause from 25yrs ago Chief complain: abdominal pain Referred for: laparotomy Past medical history: hypertension, respiratory dysfunction (sleep apnea syndrome) , CVA Past surgical history: hysterectomy Drug History: Atenolol ,Losartan, Prednisolone

Laboratories test CA125>500 Alpha feto protein =1.71 B hcg=0.06

Pre-surgery diagnosis: pelvic cyst Post-surgery diagnosis: recto sigmoid cancer Surgery type: partial colectomy hartman colostomy Surgery description: Abdomen was opened with low midline dissection , a perforated recto sigmoid mass was seen which was opened in abdomen wall, tumor was freed, sigmoidal branch of colon was closed, appropriate margin was dissected . Hartman colostomy was pasted.

Introduction: In the majority of patients proceeding to the operating room for surgery in the pelvis, an accurate diagnosis has been made preoperatively. Advances in imaging should reduce the number of unanticipated findings intraoperatively for the pelvic surgeon. This is commonly a problem in obese patients and elderly patients with atypical or ill-defined pelvic pathology and requires methodical consideration of the differential diagnosis preoperatively to appropriately triage and plan for these unanticipated findings. Te linde’s 2015

Appendicitis If appendicitis is in the differential diagnosis preoperatively, laparoscopy should be performed. If the appendix is grossly inflamed and dilated in the absence of other pathology, the appendix should be removed. If there is gross purulence due to perforation, the area should be copiously irrigated with saline prior to cl obscure. If a phlegmon is encountered in the right lower quadrant and the cecum is involved, it is reasonable to abort the procedure and treat the appendicitis with intravenous antibiotics and percutaneous drainage if an abscess develops. Surgery in this setting is associated with higher morbidity. If an organized abscess is seen, placement of a drain at the time of surgery is suggested; in the case of a phlegmon, no drain is recommended. Te linde’s 2015

Diverticular Disease Diverticulosis is common among Americans, with prevalence rates up to 45%. Diverticulitis is inflammation of the diverticulum, usually occurring in the sigmoid colon, and it is generally managed nonoperatively. Only when the attacks become recurrent and frequent enough to affect lifestyle is elective sigmoid resection entertained. Complicated diverticulitis generally requires surgery . When a contained abscess is seen on CT imaging, percutaneous drainage is attempted . Surgery is ideally performed a few weeks after drain removal in an effort to avoid an end or diverting stoma. Patients with an acute perforation will present with an acute abdomen and require emergency surgery. Te linde’s 2015

If the patient has acute diverticulitis or chronic smoldering diverticulitis, it is reasonable to consider a sigmoid resection. Diverticulitis with an abscess involving the adnexa can sometimes be mistaken for a tuboovarian abscess, and this should always be in the differential diagnosis of a pelvic mass in the older female patient. In such cases, moderate elevation of CA-125 is common secondary to inflammation, which can further complicate the diagnostic challenge. Te linde’s 2015

STEPS IN THE PROCEDURE Sigmoid Resection for Diverticulitis Retract the sigmoid colon medially and separate the colon from the white line of Toldt and Gerota fascia. Identify and protect the left ureter and ovarian vessels. Mobilization of the splenic flexure may be necessary if there is not a natural redundancy in the colon. Divide the mesentery to the sigmoid colon, staying close to the bowel wall. This is done with right angle clamps and ligatures in the open technique and with a vessel-sealing device in the laparoscopic technique. Identify and transect the upper rectum with a TA stapler. Identify and transect the descending colon. Secure the anvil of the circular stapler into the proximal lumen with a purse-string suture. Perform a tension-free end-to-end stapled anastomosis using a circular stapler Te linde’s 2015

Colorectal Cancer Cancers of the colon are common with over 100,000 new diagnoses in the United States every year If a cancer of the colon is unexpectedly encountered intraoperatively, a decision should be made as to whether to proceed with bowel resection immediately or close the abdomen and perform the definitive surgery at a later date. The most frequent tumors unexpectedly encountered by the gynecologic surgeon are cecal or rectosigmoid in location. Due to locations, these can often be mistaken for an adnexal mass. Techniques for each are described in the “Steps in the Procedure” boxes. Te linde’s 2015

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Right Colectomy Technique for Cecal Cancer Explore for resectability (omentum, peritoneum, liver, duodenum, superior mesenteric vessels). Retract the colon medially and separate the colon from the white line of Toldt and Gerota fascia. Identify and protect the ureter, gonadal vessels, and duodenum. Dissect the gastrocolic ligament to complete the mobilization of the hepatic flexure. Identify the appropriate vessels. Divide the ileocolic, right colic, and right branch of the middle colic vessels near their origins. Complete the mesenteric dissection. There is an expectation that at least 12 lymph nodes (LNs) are harvested because of a known survival advantage associated with increasing number of LNs. Wait for the demarcation of the bowel after vessel ligation, and then transect the terminal ileum and the transverse colon. Perform a side-to-side anastomosis using either a stapled or hand-sewn technique Te linde’s 2015

Sigmoid Colectomy Technique for Cancer Explore for resectability (omentum, peritoneum, liver) Retract the colon medially and separate the colon from the white line of Toldt and Gerota fascia. Identify and protect the left ureter and gonadal vessels. Mobilization of the splenic flexure may be necessary if there is no redundancy in the colon. Identify the appropriate vessels. Divide the inferior mesenteric vessels just beyond the takeoff of the left colic vessels and divide the sigmoidal branches. Complete the mesenteric dissection. There is an expectation that at least 12 LNs are harvested because of a known survival advantage associated with increasing number of LNs. Wait for demarcation of the bowel after vessel ligation to ensure adequate perfusion to the bowel outside the planned lines of resection. Identify and transect the upper rectum with a TA stapler Identify and transect the descending colon. Secure the anvil of the circular stapler into the proximal lumen with a purse-string suture. Perform a tension-free end-to-end stapled anastomosis using a circular EEA stapler. Te linde’s 2015

Crohn Disease Crohn disease is a chronic recurring inflammatory disorder that can affect the entire gastrointestinal tract. The most common site of midgut involvement is the ileum. Intraoperatively, the surgeon may find inflammation of the ileum and cecum with the classic “creeping fat” along the antimesenteric side of the bowel. If this is found,it is best to close the abdomen and refer to gastroenterology for consideration of medical treatments. However, if the inflammation is associated with a proximal obstruction, a surgeon with experience treating inflammatory bowel disease should assist with ileocecal resection to grossly negative margins or stricturoplasty. . Te linde’s 2015

Carcinoid Tumors Carcinoids are neuroendocrine tumors and may be found in the GI tract, lungs, and kidneys. Carcinoid tumors are the most common neoplasms of the appendix. When a small mass at the tip of the appendix is found, a formal appendectomy as described earlier is appropriate. If the carcinoid is greater than 2 cm or located at the base of the appendix, a right hemicolectomy would ideally be performed. Carcinoids of the small intestine can be associated with extensive mesenteric lymphadenopathy and a small-bowel resection with careful mesenteric dissection is required. Te linde’s 2015

Meckel Diverticulum Meckel diverticulum is the most common congenital abnormality of the GI tract. It is most commonly located in the ileum within 2 feet of the ileocecal valve and appears as an outpouching of the bowel at the antimesenteric border. If a Meckel's is encountered, it should be palpated. If there are any masses palpable within the lumen of the Meckel's, our practice is to resect. Te linde’s 2015

Small-Bowel Lymphoma Surgery is not generally first-line therapy for this broad group of tumors, so a specialist should be consulted to determine if the patient should be closed or resection performed ... Te linde’s 2015

Small-Bowel Adenocarcinoma Localized adenocarcinomas of the small bowel are treated with resection of the primary tumor and the draining mesentery. Adjuvant therapy is often given, but no survival advantage has been shown. In patients with carcinomatosis, debulking therapy and intraperitoneal chemotherapy have been described. Te linde’s 2015

Intussusception Intussusception refers to the invagination of a part of the intestine into itself, essentially an “internal prolapse.” If this is identified in the operating room in an adult patient, the surgeon should search for a lesion If a lead point is seen, a small-bowel resection should be performed..” Colonic intussusception is caused by cancer until proven otherwise. Te linde’s 2015

Gastrointestinal Stromal Tumor Gastrointestinal stromal tumors (GISTs) are tumors of the GI tract. These tumors are often hemorrhagic and involving the antimesenteric portion of the small bowel.Because of the small- bowel mobility, they often drape down into the pelvis and present as pelvic masses easily confused with adnexal tumors on exam and imaging. Segmental bowel resection is the preferred surgical approach. Te linde’s 2015

Epithelial Tumors of Appendiceal Origin This includes a spectrum of lesions from mucoceles to pseudomyxoma peritonei (PMP). It is not possible to differentiate a benign mucocele from a cystadenocarcinoma by imaging, so we recommend performing an appendectomy if a cystic lesion is identified in the appendix. If a malignancy is identified, a right hemicolectomy should follow. Treatment of PMP is surgical debulking with or without adjuvant therapy. Te linde’s 2015

Fistulae The fistula should be treated according to the suspected cause. If malignancy is suspected, an en bloc resection is required. If the fistula is associated with an inflammatory or infectious disease, it is generally safe to finger fracture the organs apart, resect the segment of offending bowel, and repair the recipient side of the fistula. Te linde’s 2015

Best surgical practices If the diagnosis is uncertain, consider preoperative preparation with stent, bowel enemas, stoma marking, and appropriate consent. Assess the entire abdomen and pelvis, running the intestine from the ligament of Treitz to the rectosigmoid junction. This affects the choice of incision. Consult the expert when in doubt. Do not biopsy or attempt resection of any retropritoneal mass.