Acs0905 Gynecologic Considerations For The General Surgeon

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  • 1. © 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 9 CARE IN SPECIAL SITUATIONS 5 GYNECOLOGIC CONSIDERATIONS FOR THE GENERAL SURGEON — 1 5 GYNECOLOGIC CONSIDERATIONS FOR THE GENERAL SURGEON Edward S. Podczaski, M.D., F.A.C.S., and Paul R. Kramer, Jr., M.D. For many general surgeons, gynecologic surgery is not a major A negative serum β–human chorionic gonadotropin (β-hCG) component of practice. In a report published in 1995, surgical res- determination rules out an ectopic pregnancy. In hemodynamical- idents who graduated that year had handled, on average, only 1.6 ly stable patients, pelvic ultrasonography may establish a diagnosis gynecologic cases.1 Nevertheless, it is clear that some surgeons and permit expectant management even if some intraperitoneal devote a significant portion of their practice to treating gynecolog- bleeding has occurred. The appearance of hemorrhagic cysts on ic disorders. In a prospective registry of consecutive cases reported computed tomography depends on the age of the clot: blood from by seven rural general surgeons, 20% of the procedures were clas- an acute hemorrhage has a high attenuation value, whereas blood sified as gynecologic.2 Furthermore, in a National Survey of from a previous hemorrhage has an attenuation value approaching Ovarian Carcinoma published in 1993, 21% of the primary surgi- that of water. In an acute setting, CT typically demonstrates a cys- cal procedures for ovarian cancer were actually performed by gen- tic adnexal mass with areas of high attenuation at intramural and eral surgeons.3 At present, more than half of the general surgery intracystic sites. A hemoperitoneum may also be present, with residency programs in the United States offer no formal rotation high-attenuation clot and blood accumulating in the dependent in gynecology; accordingly, both residents and practicing surgeons pelvis. Laparoscopy may be useful when the diagnosis is uncertain may benefit from a discussion of basic gynecologic problems and or when a stable patient has a moderate hemoperitoneum. In their surgical management. In what follows, we consider the gyne- hemodynamically unstable patients, adequate volume and blood cologic conditions that are most commonly encountered by gen- replacement are initiated and emergency laparotomy is performed. eral surgeons.These conditions may be broadly classified as gyne- Once it is confirmed that the bleeding is from a ruptured cyst, con- cologic emergencies, outpatient gynecologic problems (e.g., pelvic servative therapy, consisting of removing the cyst and achieving masses and abnormal uterine bleeding), or squamous dysplasias hemostasis, is initiated. and gynecologic malignancies. ADNEXAL TORSION Abnormal enlargement of the adnexa, either by neoplasms or by Gynecologic Emergencies cysts, may predispose to torsion of the tube and the ovary around the infundibulopelvic ligament, resulting in vascular compromise. BLEEDING FROM OVARIAN CYSTS Adnexal torsion is a gynecologic emergency: if untreated, it will Each month, the ovary of a premenopausal woman undergoes a result in infarction of the adnexa with eventual peritonitis. cycle of hormonally driven changes characterized by follicular Although torsion can occur in postmenopausal women, it is most development, the emergence of a dominant follicle, ovulation, and common in patients of reproductive age. the formation of a corpus luteum. Cystic enlargement of one of The presenting complaint is severe pelvic pain of abrupt onset, these physiologic structures is relatively common and is considered often accompanied by nausea and vomiting of sudden onset. The functional rather than neoplastic. Approximately 7% of asymp- pain may be colicky or knifelike and is usually related to the degree tomatic women between the ages of 25 and 40 years have ovarian of vascular compromise. There may be a history of waxing and cysts larger than 2.5 cm.4 Functional ovarian cysts should not waning pelvic pain corresponding to previous episodes of partial cause pain unless accompanied by bleeding, rupture, or torsion. twisting and detorsion. Physical examination often demonstrates Follicular cysts are fluid-filled structures that arise from a nor- an acute abdomen with lower abdominal tenderness and guarding. mal follicle that fails to ovulate or does not undergo atresia. Pelvic examination usually demonstrates a mass that may be diffi- Rupture of follicular cysts may result in acute pain, which is usu- cult to assess because of tenderness. Low-grade temperature ele- ally of brief duration. Corpus luteum cysts arise from a mature, vations may be noted, but significant fevers are unlikely. In most well-vascularized corpus luteum and may be associated with pro- series, the accuracy with which adnexal torsion is diagnosed is longed secretion of progesterone. They tend to be larger than fol- approximately 70%.5 Ultrasonography demonstrates a mass in licular cysts and are more likely to cause clinical symptoms. nearly all affected patients. However, the presence of arterial flow Corpus luteum cysts range in severity from masses that cause no on Doppler ultrasonography does not exclude ovarian torsion: symptoms to ruptured cysts that cause catastrophic bleeding. Dull, early in the development of ovarian torsion, lymphatic and venous unilateral lower abdominal and pelvic pain is the typical presenting flow may be obstructed while arterial perfusion is preserved.6 CT complaint. Pelvic examination may show an enlarged, tender may demonstrate ovarian enlargement, smooth-wall thickening of ovary. Unruptured corpus luteum cysts are followed conservative- the mass or tube, and uterine deviation towards the affected ly. However, events such as coitus, exercise, or trauma may rupture adnexa. On occasion, a twisted vascular pedicle (torsion knot or the cyst, resulting in slight to significant intraperitoneal bleeding, whirling sign) or lack of contrast enhancement within the twisted in which case the patient usually experiences the sudden onset of ovarian mass may be observed. Prompt surgical intervention is severe lower abdominal or pelvic pain. The acute pain of a bleed- necessary to prevent adnexal infarction. ing corpus luteum cyst is indistinguishable from that of a ruptured In the past, adnexal torsion was commonly treated aggressively, ectopic pregnancy. with salpingo-oophorectomy. This approach continues to be war-
  • 2. © 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 9 CARE IN SPECIAL SITUATIONS 5 GYNECOLOGIC CONSIDERATIONS FOR THE GENERAL SURGEON — 2 ranted in perimenopausal and postmenopausal patients; however, Table 1 Recommended Outpatient and Inpatient a more conservative approach is now considered preferable for the Therapies for Pelvic Inflammatory Disease8 treatment of women of reproductive age who desire future fertili- ty. The traditional approach was based on two assumptions: first, that the twisted adnexum with vascular compromise was nonvi- Type of Therapy Regimen Agents and Dosages able, and second, that detorsion was potentially dangerous Ofloxacin, 400 mg p.o., once daily, for because it might cause thrombus to be released from the clotted 14 days* veins in the infundibulopelvic ligament.These assumptions proved or to be unfounded. Accordingly, current management begins with A Levofloxacin, 500 mg p.o., once daily, for 14 days* untwisting the adnexum and assessing its viability. Once the tor- with or without sion is unwound, the adnexum may demonstrate reperfusion or Metronidazole, 500 mg p.o., b.i.d., for 14 days infarction without vascular recovery. Only a gangrenous adnexum must be completely removed. Ceftriaxone, 250 mg I.M. in single dose Patients may be managed by means of either laparoscopy or or laparotomy, depending on the clinical circumstances. In a series Outpatient Cefoxitin, 2 g I.M. in single dose, and probenecid, 1 g p.o., administered that included 40 young women with adnexal torsion, all of the concurrently patients were successfully managed conservatively, with unwind- or ing of the torsion; laparotomy was performed in 26 of the 40 and B Another parenteral third-generation operative laparoscopy in 14.7 Ideally, cystectomy, along with cephalosporin (e.g., cefotaxime or ceftizoxime) removal of the cause of the torsion, should be done at the time of plus detorsion. However, cystectomy on an edematous and fragile Doxycycline, 100 mg p.o., b.i.d., for 14 days ovary may be technically difficult and may cause a further vascu- with or without lar insult to the remaining tissue. In such cases, it is advisable to Metronidazole, 500 mg p.o., b.i.d., for 14 days evaluate the patient 6 to 8 weeks after the acute episode. If an ovar- Cefotetan, 2 g I.V. q. 12 hr ian mass is still found at that time, ovarian cystectomy may be per- or formed via operative laparoscopy. A Cefoxitin, 2 g I.V. q. 6 hr PELVIC INFLAMMATORY DISEASE plus Doxycycline, 100 mg p.o. or I.V. q. 12 hr Pelvic inflammatory disease (PID) is an acute infection of the Inpatient upper female genital tract that involves the uterus, the fallopian Clindamycin, 900 mg I.V. q. 8 hr plus tubes, and the ovaries. It is a community-acquired disease and is B Gentamicin, 2 mg/kg I.V. or I.M. loading initiated by a sexually transmitted agent that results in the ascent dose, followed by maintenance dosage of of vaginal flora into the upper genital tract. The resulting polymi- 1.5 mg/kg q. 8 hr; once daily dosage may crobial infection (caused by a mixture of anaerobes, facultative be substituted anaerobes, and aerobic organisms) can lead to a wide spectrum of *Should not be used in patients at increased risk for infection with quinolone-resistant disorders, including endometritis, salpingitis, tubo-ovarian ab- N. gonorrhoeae. scess, and pelvic peritonitis. Lower abdominal pain is the most frequent complaint.The pain diagnosis of PID), a presumptive diagnosis of PID has a positive usually is bilateral, rarely is of more than 2 weeks’ duration, and predictive value of 65% to 90% 8 Unfortunately, many episodes of often begins with or follows menses. Approximately half of the PID go unrecognized and subsequently give rise to infertility, patients are febrile. Abdominal palpation demonstrates diffuse ectopic pregnancy, chronic pelvic pain, or tubo-ovarian abscesses. tenderness that is more pronounced in the two lower quadrants. PID treatment regimens are designed to provide broad-spec- Rebound tenderness and diminished bowel sounds are common. trum empiric therapy of likely pathogens, including N.gonorrhoeae, Pelvic examination reveals a purulent endocervical discharge with C. trachomatis, anaerobes, and gram-negative facultative bacteria. cervical motion and adnexal tenderness. Quinolone-resistant N. gonorrhoeae, prevalent in parts of Asia and Empiric treatment of PID should be initiated in sexually active the Pacific, is becoming increasingly common in California and young women or women at risk in the clinical setting of lower Hawaii; this and other geographic variables associated with PID abdominal tenderness, adnexal tenderness, and cervical motion may affect the choice of antimicrobial agents. The Centers for tenderness. Additional criteria supporting the diagnosis include Disease Control (CDC) has made specific recommendations for fever (oral temperature > 101° F), abnormal cervical or vaginal outpatient and inpatient (parenteral) antibiotic therapy [see Table mucopurulent discharge, the presence of abundant white cells on 1].8 Criteria for inpatient therapy include inability to rule out a saline microscopy of vaginal secretions, an elevated sedimentation surgical emergency (e.g., appendicitis), severe symptoms, high rate, an elevated C-reactive protein level, and documentation of fevers, failure to respond to oral antibiotics, and the presence of a cervical infection with Neisseria gonorrhoeae or Chlamydia tra- tubo-ovarian abscess. Patients who are initially treated with par- chomatis.8 The differential diagnosis includes adnexal torsion, enteral antibiotics are usually switched to oral therapy within 24 appendicitis, ectopic pregnancy, endometriosis, a hemorrhagic hours after clinical improvement. ovarian cyst, and urinary tract infection. Pertinent lab studies Tubo-ovarian abscess is the most serious manifestation of include determination of the serum β-hCG level (to rule out an PID.There are no standardized diagnostic criteria for this condi- ectopic pregnancy), microscopic examination of the vaginal dis- tion, and a clinical diagnosis presents the same difficulties as a charge, a complete blood count, endocervical nucleic acid ampli- clinical diagnosis of PID itself. Most women with a tubo-ovarian fication tests for N. gonorrhoeae and C. trachomatis, sedimentation abscess are young and desire future fertility. Fevers and pelvic rate, and urinalysis. Clinical diagnosis of acute PID remains pain are typical presenting complaints. Pelvic examination usual- imprecise. Compared with laparoscopy (the gold standard for ly demonstrates a mass or extreme adnexal tenderness. Many
  • 3. © 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 9 CARE IN SPECIAL SITUATIONS 5 GYNECOLOGIC CONSIDERATIONS FOR THE GENERAL SURGEON — 3 unruptured tubo-ovarian abscesses, unlike unruptured abscesses sonographers. If the transvaginal ultrasonogram is nondiagnostic, elsewhere in the body, can be successfully managed with antibi- a serum β-hCG test is performed to establish the serum level rela- otics alone. Ultrasonography is useful for diagnosis and follow-up tive to the discriminatory cutoff. If an intrauterine pregnancy is not of cases that are managed conservatively. Medical management of visualized above the discriminatory cutoff, the contents of the an unruptured abscess consists of administration of appropriate uterus are evacuated to distinguish an abnormal intrauterine ges- antibiotics, close monitoring, and, possibly, drainage via colpoto- tation from an ectopic pregnancy. If the initial β-hCG is below the my. Indications for surgical intervention include a questionable discriminatory cutoff, serial β-hCG measurements are required to diagnosis, rupture of the tubo-ovarian abscess (a true surgical document a viable or nonviable gestation. With a viable gestation, emergency), and failure of medical (i.e., antibiotic) therapy. the β-hCG level should rise by at least 53% in 2 days.9 A precipi- tous decline in the β-hCG level suggests a spontaneous abortion; ECTOPIC PREGNANCY however, if the β-hCG level does not decline by at least 21% to Pelvic pain and vaginal bleeding in the first trimester are the 35% in 2 days (depending on the initial value), an ectopic preg- complaints most commonly associated with ectopic pregnancy. nancy should be suspected [see Figure 1].9 Although hypotension, tachycardia, and guarding may be noted The clinical scenario of hypovolemic shock, an acute abdomen, and alert the clinician to impending tubal rupture, most patients and a positive pregnancy test usually establishes the diagnosis of a present with less alarming findings. Patients with a suspected ruptured ectopic pregnancy. The rupture of the ectopic gestation ectopic pregnancy are initially assessed by means of transvaginal through the tube is followed by the abrupt onset of pelvic pain lat- ultrasonography [see Figure 1]. Given the risk that an ectopic pre- eralized to the affected adnexa. The clinical manifestations of ganancy may be coexisting with an intrauterine one (estimated to hemoperitoneum ensue, including abdominal pain, diaphragmatic be between 1/4,000 and 1/15,000), the first task in the diagnostic irritation and syncope. If the site of tubal rupture is small or tam- evaluation is to exclude an intrauterine pregnancy. ponades itself, the physical findings may be more subtle. The pre- Critical to the diagnosis of a suspected ectopic pregnancy is the dominant symptom is pain, usually described as dull or cramping. concept of the so-called discriminatory cutoff,9 which is defined as A history of menstrual irregularity is usually present and may be the serum β-hCG level at which a normal intrauterine pregnancy accompanied by subjective symptoms of pregnancy. Current rapid can be ultrasonographically identified in nearly all patients.With a urine β-hCG assays have a sensitivity of 20 to 25 mIU/ml and are transvaginal approach, the discriminatory cutoff is usually between readily available to confirm the diagnosis in a patient with an acute 1,500 and 2,500 mIU/ml; however, this value can be affected by abdomen. the equipment used and by the experience (or inexperience) of the Once the diagnosis of a ruptured ectopic pregnancy is made, Patient presents in early pregnancy with pain and bleeding; ectopic pregnancy is suspected Perform transvaginal ultrasonography. Sonogram reveals normal Sonogram reveals abnormal Sonogram is nondiagnostic Sonogram reveals uterine pregnancy uterine pregnancy ectopic pregnancy Obtain serum β-hCG level. Manage expectantly. Manage expectantly, or perform Treat as appropriate. dilatation and curettage, or administer misoprostol intravaginally. -hCG level is higher than -hCG level is lower than discriminatory cutoff discriminatory cutoff Evaluate uterine contents. Perform serial β-hCG If chorionic villi are absent, treat determinations. as ectopic pregnancy. -hCG level shows normal rise (≥ 53% in 2 -hCG level shows normal fall -hCG level shows abnormal days), suggesting viable gestation (minimal decline of 21% to 35% in rise or fall 2 days, depending on initial level), suggesting spontaneous abortion Evaluate uterine contents. Perform ultrasonography when β-hCG level rises above discriminatory cutoff. If chorionic villi are absent, treat No treatment is necessary. as ectopic pregnancy. Figure 1 Algorithm illustrates evaluation of patients with suspected ectopic pregnancy.9
  • 4. © 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 9 CARE IN SPECIAL SITUATIONS 5 GYNECOLOGIC CONSIDERATIONS FOR THE GENERAL SURGEON — 4 treatment consists of surgical removal of the ectopic gestation; Outpatient Gynecologic Problems there is no role for medical management (e.g., methotrexate) in the PELVIC MASS treatment of this condition. It should be kept in mind that not all ruptured ectopic gestations necessitate laparotomy. Hemodynam- The differential diagnosis of a pelvic mass is determined by the ically stable patients can often be treated laparoscopically, depend- viscera occupying the pelvis and their potential pathologic alter- ing on the clinical situation, the physical characteristics of the ations.The most common cause of an adnexal mass is an enlarged patient, and the equipment available. Diagnostic laparoscopy is an ovary. During the reproductive years, the majority of ovarian mass- excellent tool for both diagnosis and treatment in such patients. es are functional cysts. Such cysts range in size from a few cen- The patient’s desire for future fertility must be considered timeters to 8 to 10 cm in diameter and usually disappear in 1 to 3 before surgical intervention is initiated. For patients who wish to months. A premenopausal woman with a cystic adnexal mass less bear children in the future, conservative, tube-sparing surgery than 8 cm in diameter is usually followed for at least one menstru- has been recommended. Linear salpingosotomy is performed by al cycle; the majority of such masses undergo spontaneous regres- making an incision in the antimesenteric aspect of the tube over- sion. Transvaginal ultrasonography may be particularly useful for lying the bulge of the ectopic gestation.The products of concep- establishing the size of the mass, as well as for distinguishing a sim- tion are removed, hemostasis is achieved through electrocauter- ple cyst from a complex mass. A premenopausal patient with a ization, and the tubal defect is left open to heal by secondary large (> 8–10 cm), predominantly solid, fixed, or irregular mass intention. In cases of ectopic pregnancies at the distal or fimbri- should be surgically evaluated. A postmenopausal patient with a al portion of the fallopian tube, fimbrial expression with extru- simple unilocular cyst measuring less than 5 to 6 cm in diameter sion of the products of conception has also been performed. can be followed expectantly, provided that the CA 125 level is nor- Patients undergoing conservative surgery should be followed mal. In an autopsy study of 234 postmenopausal women who died with serial β-hCG determinations to ensure that there is no of nongynecologic causes, 15% had ovarian cysts, and 3.8% had residual trophoblastic tissue. For patients who are hemodynam- an ovarian cyst between 2 and 5 cm in diameter.11 A post- ically unstable or who have no further desire of pregnancy, sal- menopausal patient with a large, suspicious (i.e., bilateral, irregu- pingectomy is the procedure of choice. Salpingectomy may also be lar, fixed, solid, or accompanied by ascites), or complex mass necessary for adequate hemostasis after an unsuccessful attempt requires surgical intervention. at salpingostomy. Endometriosis is a benign, progressive disease defined as the presence of ectopic endometrial glands and stroma in aberrant loca- VULVAR HEMATOMA tions in the pelvis. Hemorrhage may occur within the glandular tis- Vulvar hematomas are usually the result of blunt trauma (e.g., sue, followed by fibroblastic proliferation.The ovaries are the most from straddle injuries, automobile accidents, or physical assault). common site of involvement, and ovarian involvement often results The most important task in the management of a child with a vul- in obvious endometriotic cysts. Approximately 10% of cases may var hematoma is to determine the full extent of the problem. involve the rectosigmoid as well, and, depending on the degree of Management is usually conservative unless the hematoma is rapid- scarification, such involvement may be difficult to distinguish from ly expanding. If the hematoma is not expanding after a minimum a primary bowel neoplasm. Symptoms include pelvic pain and of 4 hours of observation, if the patient is able to void clear urine, infertility. Medical therapy with nonsteroidal anti-inflammatory and if the hematoma is not large enough to cause undue distress, drugs (NSAIDs), combined oral contraceptives, progestins, or nonsurgical treatment is indicated.10 Administration of analgesics long-acting gonadotropin-releasing hormone (GnRH) agonists and application of ice packs and pressure to the affected vulva for may be considered. The goals of conservative therapy are removal 8 to 12 hours after the event typically yield considerable sympto- of gross endometriosis, lysis of adhesions, and restoration of normal matic improvement. If the hematoma is expanding, is causing con- anatomy. Definitive surgical treatment with hysterectomy and bilat- siderable pain, or is obstructing the urethra, it should be incised eral salpingo-oophorectomy is reserved for patients who experience and evacuated with the patient under anesthesia. Any actively intractable pain and who are no longer desirous of bearing children. bleeding vessels should be ligated, and the cavity should be closed The majority of adnexal masses in women of childbearing age in layers. If the bed of the hematoma continues to ooze, a pack can can be managed with cystectomy and ovarian preservation. be placed to tamponade any residual bleeding. Laparoscopic aspiration of an adnexal cyst as an isolated proce- dure is not recommended, because of the frequency of recurrence BARTHOLIN GLAND ABSCESS and the absence of any definitive pathology. Persistent cysts, cys- Simple incision and drainage of a Bartholin gland abscess usu- tadenomas, dermoids, and endometriomas may be managed with ally achieves prompt relief of symptoms, but it may increase the cystectomy, which removes the epithelial cyst lining and provides a risk of later recurrence.The preferred approach has been to create tissue diagnosis. In a premenopasusal patient with an adnexum a fistulous tract so as to marsupialize the gland cavity. To perform that is not salvageable or is suspicious for malignancy, a salpingo- a marsupialization, a small elliptical incision is made in the vestibu- oophorectomy may be performed. In a postmenopausal patient lar mucosa overlying the wall of the abscess.The elliptical piece of with a mass, the entire ovary and tube should be removed for mucosa is removed, exposing the wall of the Bartholin abscess.The pathologic assessment. In carefully selected cases (e.g., patients wall of the abscess is then entered, and the contents of the abscess with a negative CA 125 determination or a small, benign-appear- are evacuated. A portion of the wall underlying the elliptical ing mass), removal of the ovary and tube can be done laparoscop- mucosal defect is excised, and the wall of the cyst is approximated ically. Laparotomy is still considered the standard of care for the to the edge of the mucosa with a few 3-0 absorbable sutures. evaluation of potentially cancerous masses. A solid mass in a post- Alternatively, the Bartholin abscess may be stabilized manually and menopausal woman, the presence of ascites, and bilateral disease entered via a stab incision.The contents are evacuated, and a Word are all suggestive of malignancy. The two major concerns regard- catheter is inserted into the cavity.The balloon is then inflated and ing the use of laparoscopy in the management of ovarian cancers left in place for drainage of the cyst. Marsupialization is accom- remain the risk of tumor spillage and the delay in initiating defini- plished by epithelializing the catheter tract. tive treatment.
  • 5. © 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 9 CARE IN SPECIAL SITUATIONS 5 GYNECOLOGIC CONSIDERATIONS FOR THE GENERAL SURGEON — 5 In an open cystectomy, the ovary is immobilized, and the ovari- causes necrosis and shrinkage of the myomas. an capsule is incised with a scalpel near the base of the cyst. Hysterectomy is the most commonly performed major nonob- Traction is placed on the incised ovarian capsule, and a stetric operation in the United States, with approximately 600,000 Metzenbaum scissors is used to dissect the areolar tissue between done each year. Although hysterectomies can be performed via a the cyst wall and the capsule. After the cyst is removed, hemosta- vaginal or a laparoscopic approach, more than 60% are performed sis is obtained in the bed of the cyst cavity. To reduce the risk of abdominally, especially for the treatment of leiomyomata.12 An adhesions, the ovary usually is not sutured together. In a laparo- abdominal hysterectomy follows a clamp, cut, and tie approach scopic cystectomy, the utero-ovarian ligament is held so as to and proceeds in a lateral-to-medial direction.The round ligaments expose the antimesenteric aspect of the ovary.The ovarian capsule are divided early in the procedure. Access to the broad ligament is is incised with a monopolar scissors, and the cyst wall is exposed; gained by dividing the infundibulopelvic ligaments and performing the cyst wall is then bluntly separated from the ovarian capsule. salpingo-oophorectomy or by dividing the proximal tube at the The presence of an intact cyst wall facilitates the dissection. utero-ovarian ligament and preserving the adnexa.The vesicouter- Eventually, the cyst is aspirated, and the remaining cyst wall is sep- ine fold is transversely divided in an area where the bladder flap arated from the ovarian capsule by means of a 5 mm grasper. appears mobile.The bladder is reflected below the level of the uter- Repeated twisting of the cyst wall around the grasper (the so-called ine cervix, and the uterine arteries are skeletonized. Each uterine hair-curler technique) allows the cyst wall to be pulled away from artery pedicle is clamped adjacent to the cervix, then cut and tied, the ovarian capsule. The collapsed cyst is then removed through and the cardinal ligaments are serially transected. Each pedicle is one of the port sites and inspected for interior papillations or nodu- clamped, divided, and ligated medial to the previous purchase of larities.The bed of the excision is inspected for hemostasis.To min- tissue. Eventually, the vagina is entered, the specimen is amputat- imize adhesions, the edges of the ovary are not approximated with ed from the vaginal apex, and the open vaginal tube is closed. sutures. Potential urinary tract morbidity includes injury to the bladder In a postmenopausal patient with an ovarian mass, salpingo- (resulting in fistulas) and ureteral damage, most often occurring oophorectomy is preferred, with the entire adnexum submitted for with clamping of the gonadal vessels (i.e., the infundibulopelvic lig- pathologic evaluation. In an open salpingo-oophorectomy, the ament) or clamping of the uterine arteries. broad ligament is entered by dividing the round ligament or by ABNORMAL UTERINE BLEEDING dividing the peritoneum lateral to the infundibulopelvic ligament. After the ureter is identified, the infundibulopelvic ligament is Abnormal uterine bleeding is one of the most frequent com- skeletonized, clamped, and ligated. The adnexum is mobilized plaints expressed by patients seeking gynecologic care. Such bleed- toward the uterus, where the proximal fallopian tube and the ing is not in itself a diagnosis but, rather, a symptom that warrants utero-ovarian ligament are clamped, cut, and ligated. In selected evaluation.The term abnormal uterine bleeding includes excessive postmenopausal patients with adnexal masses, salpingo-oophorec- uterine bleeding (menorrhagia), bleeding between menses, and any tomy can be accomplished laparoscopically with bipolar elec- combination of the two, as well as postmenopausal bleeding. trodesiccation, suture ligation, or automatic staplers for control of Excessive uterine bleeding has been quantitatively defined as either the infundibulopelvic ligament. menses persisting for longer than 7 days or a total menstrual blood loss that exceeds 80 ml. It is better, however, to define excessive LEIOMYOMAS bleeding in terms of the degree to which the abnormal bleeding Leiomyomas, or myomas, arise as benign tumors from the deviates from a particular patient’s established menstrual pattern— myometrium and are the most common tumors of the uterus. for example, an increase of two or more in the number of sanitary Leiomyomas are often multiple and are grouped according to their pads used daily or menses that persist for 3 or more days longer location within the uterus; intramural, subserosal, and submucos- than normal. The differential diagnosis includes systemic disease al sites are the most common locations. Symptoms include pres- (e.g., coagulopathies, hypothyroidism, and cirrhosis), reproductive sure from an enlarging uterus, abnormal uterine bleeding, dys- tract disease (e.g., complications of pregnancy, benign disorders, menorrhea, and adverse pregnancy outcomes. The majority of and malignant lesions), iatrogenic causes (e.g., an intrauterine women with myomas, however, are asymptomatic. In general, the device [IUD]), and dysfunctional uterine bleeding. Dysfunctional severity of the symptoms is determined by the size and number of uterine bleeding can only be established by excluding the other the fibroids, as well as by their location. The diagnosis of myomas causes of abnormal uterine bleeding; it usually represents noncyclic is typically made through palpation of an irregular, enlarged bleeding resulting from disordered hormonal interaction. uterus, though other causes of uterine enlargement or asymmetry The most important function of the history and the physical must also be considered. Difficult cases may be resolved by examination is to determine the source and the cause of the bleed- employing ultrasonography or MRI to examine the uterus. ing. A thorough examination is necessary to assess the lower geni- Small, asymptomatic leiomyomas may be managed with obser- tal tract, the cervix, the size of the uterus, and the status of the vation once a stable uterine size has been established.The need for adnexal structures. If the patient is of reproductive age, determi- intervention is determined on the basis of interval growth, lesion nation of the urinary or serum β-hCG level should be considered location, and patient symptoms. Rapid growth or enlargement of at an early stage of evaluation. Serum β-hCG levels may remain the uterus is another indication for surgical treatment because of elevated for as long as 38 days after a first-trimester abortion.13 the possibility of a uterine sarcoma, as well as an increased risk of Complications of pregnancy (e.g., threatened or incomplete abor- operative complications. Women with symptomatic leiomyomas tions, ectopic pregnancies, retained placental tissue, or trophoblas- may be treated with myomectomy, hysterectomy, or, as is now tic disease) are an important cause of abnormal uterine bleeding in becoming more common, uterine artery embolization.The choice women of childbearing age. An endometrial biopsy should be per- between myomectomy and hysterectomy is usually determined by formed in women who have risk factors for endometrial cancer the patient’s age, parity, and, most important, desire for future (e.g., obesity, chronic anovulation, or unopposed estrogen thera- childbearing.The therapeutic effect of uterine artery embolization py), women with menorrhagia who are older than 35 to 40 years, is thought to result from irreversible postembolic ischemia that and postmenopausal women who experience uterine bleeding.The
  • 6. © 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 9 CARE IN SPECIAL SITUATIONS 5 GYNECOLOGIC CONSIDERATIONS FOR THE GENERAL SURGEON — 6 Table 2 Bethesda System for Reporting and istration of estrogens to stabilize the endometrium and terminate Interpreting Results of Pap Smear bleeding; subsequently, after 24 hours of I.V. estrogen therapy, the patient is switched to an oral contraceptive. Excessive blood loss with ovulatory cycles can be managed with NSAIDs, an oral con- Section of Report Explanation traceptive, the levonorgestrel IUD, or surgical intervention (i.e., endometrial ablation). In one study, use of the levonorgestrel IUD This section is where a "normal" result (the desired outcome) is reported. Abnormal find- resulted in an 87% reduction in menstrual blood loss after 3 Negative for ings not related to cancer risk are reported months and a 95% reduction after 6 months, compared with intraepithelial in two subcategories: (1) organisms (e.g., lesion or blood loss recorded during pretreatment menses.14 evidence of Trichomonas, fungal, herpesvirus, malignancy or some other infection) and (2) other nonneo- plastic findings (e.g., evidence of injury and Squamous Dysplasias and Gynecologic Malignancies response to injury). This section is to alert the physician that cells SQUAMOUS DYSPLASIAS OF LOWER GENITAL TRACT Endometrial cells present in woman from the lining of the uterus are present when Infection with low-risk human papillomavirus (HPV) types, 40 years of age they normally should not be. It is a check on the status of the uterus and endometrium such as HPV 6 and HPV 11, results in condylomas of the lower or older rather than the cervix. genital tract. Infection with high-risk types, such as HPV 16 and This section is where abnormalities associated HPV 18, may result in dysplasias that have the potential to with the risk of developing cancer are reported. progress to invasive disease.The majority of sexually active women These abnormalities occur over a spectrum eventually become infected with high-risk HPV types. In most ranging from slight changes to definite cancer. They are initially classified into squamous cell women, however, this infection proves transient: at 12 months’ fol- changes and glandular cell changes. low-up, 70% of HPV-infected women are HPV negative, and at 24 Squamous cell abnormalities months’ follow-up, 91% are HPV negative.15 Those women who Atypical squamous cells (ASC): cellular experience persistent infections are at highest risk for the subse- abnormalities that qualitatively or quantita- tively fall short of definitive diagnosis of quent development of significant cervical dysplasias. squamous epithelial lesion The Papanicolaou (Pap) smear is a screening test used to iden- ASC of undetermined significance (ASC-US) tify women who may have cervical dysplasia (also referred to as ASC for which HSIL or high-grade changes cervical intraepithelial neoplasia [CIN]) and early invasive disease. cannot be excluded (ASC-H) Epithelial cell Low-grade squamous intraepithelial lesion Patients with abnormal smears as determined by the Bethesda sys- abnormalities* (LSIL): encompasses HPV infection, CIN I, tem [see Table 2] undergo outpatient triage with colposcopy. This and mild dysplasia technique uses a bright light source and magnification to examine High-grade squamous intraepithelial lesion the cervix after the application of dilute acetic acid, which acts as a (HSIL): encompasses CIN II and III, moder- ate dysplasia, severe dysplasia, and mucolytic agent and accentuates epithelial and vascular changes carcinoma in situ suggestive of dysplasia. Small biopsies are obtained from abnor- Squamous cell carcinoma (SCC): character- mal-appearing areas to allow mapping of potential areas of dyspla- ized by tumor diathesis (blood and necrotic debris), prominent macronuclei, and sia. Expectant management is recommended for patients with parachromatin clearing mild squamous cell dysplasia (i.e., CIN I); treatment aimed at Glandular cell abnormalities eliminating the dysplasia is usually recommended for patients with Atypical glandular cells (AGC) (endocervical, more significant lesions (i.e., CIN II or CIN III). In the past, many endometrial, or not otherwise specified) patients with cervical dysplasia were treated with ablative therapies, AGC favoring neoplasia (endocervical or not otherwise specified) such as cryotherapy or laser vaporization. Currently, a loop elec- Endocervical adenocarcinoma in situ (AIS) trocautery excision procedure (LEEP) is often employed to treat Adenocarcinoma (endocervical, endometrial, extrauterine, or not otherwise specified) This section is where any malignant tumors Table 3 International Federation of Other malignancies other than primary SCC and glandular adeno- carcinoma are reported. Gynecology and Obstetrics Surgical Staging System for Endometrial Carcinoma * Patients with LSIL, HSIL, SCC, persistent ASC-US, ASC-US with high-risk HPV types, ASC-H, AGC, AIS, or adenocarcinoma undergo outpatient evaluation with colposcopy. Stage Description ectocervix is cleansed with antiseptic solution, and a flexible plas- tic catheter containing an obturator is advanced into the uterine IA Tumor is limited to endometrium cavity. The obturator is withdrawn, and tissue fragments are aspi- I IB Tumor invades ≤ 50% of myometrium rated into the plastic catheter. Patients who are unable to tolerate IC Tumor invades > 50% of myometrium this procedure may be evaluated by means of transvaginal ultra- IIA Tumor involves endocervical glands II sonography. An endometrial stripe thinner than 5 mm is unlikely IIB Tumor invades cervical stroma to represent an endometrial cancer. IIIA Tumor invades uterine serosa or adnexa, peritoneal cytology Treatment of abnormal uterine bleeding depends on the under- is positive, or both lying cause. Patients with demonstrated organic pathology are III IIIB Tumor metastasizes to vagina managed as appropriate for the specific condition present. IIIC Tumor metastasizes to pelvic or para-aortic lymph nodes Excessive uterine bleeding resulting from anovulation can be man- IVA Tumor invades bladder or bowel mucosa aged with cyclic progestins or an oral contraceptive. Acute severe IV IVB Tumor metastasizes to distant sites, including intra-abdominal menorrhagia (often accompanied by hemodynamic instability) can or inguinal lymph nodes initially be managed with volume support and intravenous admin-
  • 7. © 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 9 CARE IN SPECIAL SITUATIONS 5 GYNECOLOGIC CONSIDERATIONS FOR THE GENERAL SURGEON — 7 Superior Vesical Artery Bladder Round Ligament Round Ligament Paravesical Space Uterus Lateral Cervical Ligament Uterine Artery Hypogastric Artery Pararectal Space Figure 2 Depicted are the retroperitoneal spaces of the pelvis (i.e., the pararectal and paravesical spaces). Dissection of the pararectal and paravesical External Iliac Artery spaces demonstrates the base of the cardinal ligament separating the two spaces. In this representa- tion, the superior vesical artery Infundibulopelvic has been mobilized from the lat- Ligament Ureter eral wall of the bladder and relo- cated to a lateral position.25 Cut Edge of Peritoneum the dysplasia, as well as to submit tissue for pathologic analysis. response modifier in cream form that is currently used in the treat- Cold-knife cervical conization may be performed as an alternative ment of condyloma. Lesions in hair-bearing areas and confluent to LEEP; it avoids creating thermal artifacts and may be more use- lesions (often seen in postmenopausal women) are best treated ful in patients who have glandular dysplasias or appear to be at risk with wide local excision. Large unifocal confluent lesions may con- for early invasive disease. tain occult invasive foci that are identifiable only through excision Women who have undergone a total hysterectomy for benign and careful pathologic evaluation. The lesion, along with a 4 to 5 disease may discontinue Pap smear screening. Women who have mm margin of normal tissue, is incised with a scalpel and dissect- undergone a hysterectomy and have a history of a significant cer- ed away from the underlying dermis with an electrocautery. The vical dysplasia (CIN II or CIN III) should continue annual Pap superficial defect is closed in one layer with interrupted sutures; a smear screening until three consecutive satisfactory negative cytol- rhomboid flap may be required for more sizeable defects. ogy results have been obtained, at which point routine cytology ENDOMETRIAL CANCER screening can be discontinued. Women who have had high-grade squamous dysplasias of the cervix may also experience the devel- Endometrial carcinoma is the most common gynecologic malig- opment of vaginal dysplasia after hysterectomy. nancy and accounts for more than 95% of uterine cancers. Vaginal dysplasia is asymptomatic and typically is detected only Although the majority of these carcinomas occur on a sporadic after an abnormal Pap smear. Initial evaluation consists of col- basis, an endometrial cancer can also be the initial manifestation of poscopy with directed biopsies of abnormal-appearing vaginal the Lynch syndrome (hereditary nonpolyposis colorectal cancer mucosa. Significant dysplasias may be either ablated with superfi- [HNPCC]) [see 5:14 Hereditary Colorectal Cancer and Polyposis cial laser vaporization or excised. Excision with partial vaginecto- Syndromes]. The lifetime risk of endometrial cancer for women my is definitive treatment from a pathologic perspective, but it may with the Lynch syndrome is 40% to 60%, which equals or exceeds be associated with a higher rate of complications. their risk of colorectal cancer.16 In the United States, approximate- Vulvar dysplasia may be visible in the form of discrete, slightly ly 40,000 new cases of endometrial cancer are diagnosed each raised (papular), often pigmented lesions. Biopsy of the lesion year, of which 7,000 prove fatal. About 75% of these cases involve establishes the diagnosis and rules out obvious invasive disease. postmenopausal women, with the remaining 25% involving pre- Multifocal disease involving non–hair-bearing areas (often seen in menopausal women; only about 5% of cases involve women young patients) can usually be treated with superficial laser vapor- younger than 40 years. Endometrial cancers are adenocarcinomas ization or with topical application of imiquimod, an immune and usually resemble the glands of the endometrial lining; howev-
  • 8. © 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 9 CARE IN SPECIAL SITUATIONS 5 GYNECOLOGIC CONSIDERATIONS FOR THE GENERAL SURGEON — 8 er, approximately 10% have a nonendometrioid (i.e., papillary complaints. Not surprisingly, 60% to 70% of patients have serous or clear cell) histology, a pattern associated with a biologi- advanced (stage III or IV) disease at diagnosis. Detection of ovari- cally aggressive behavior. Abnormal vaginal bleeding or post- an cancer is further hindered by the fact that there is no effective menopausal bleeding is the most common presenting complaint. screening test. The tumor-associated antigen CA 125 is expressed Outpatient endometrial biopsy with aspiration of tissue from the by more than 80% of ovarian epithelial cancers; however, though uterine cavity often establishes the diagnosis. If the tissue obtained CA 125 levels are employed in following up patients with docu- is insufficient or the patient cannot tolerate outpatient evaluation, mented disease, they are not useful for screening purposes. In a dilatation and curettage (often with hysteroscopy) is performed group of 1,110 women at increased risk for ovarian cancer, annu- with the patient under anesthesia. al surveillance with serum CA 125 determinations and additional Approximately 75% of patients with endometrial cancer have transvaginal ultrasonography was unable to detect tumors at an early disease. Therapy typically consists of hysterectomy, bilateral early enough stage to influence the prognosis.20 salpingo-oophorectomy, procurement of peritoneal specimens for Surgical intervention serves three purposes in the setting of cytologic examination, and staging. The regional lymph nodes are ovarian epithelial cancer: diagnosis, staging, and tumor debulking the most frequent site of occult metastatic disease. Accordingly, the (cytoreduction). The staging of ovarian cancer is based on the surgical staging criteria [see Table 3] emphasize the pathologic status pathologic findings at surgery [see Table 4]. Only a minority of of the regional lymph nodes with selective pelvic and para-aortic women have stage I disease at diagnosis, and the decision whether lymphadenectomy. Although there are direct lymphatic channels to employ paclitaxel and carboplatinum chemotherapy is predicat- from the uterus to the para-aortic area, it is uncommon to find pos- ed on the surgical extent of the disease. Unfortunately, thorough itive para-aortic nodes in the absence of pelvic nodal involvement. intraoperative staging is not always performed. In a series of 785 Selective pelvic lymphadenectomy removes the lymphatic tissue women found to have ovarian cancer in 1991, lymphadenectomy from the anterior and medial surfaces of the iliac vessels and from was not done in 66% of the patients with presumptive stage I or II the obturator fossa superior to the obturator nerve. Sampling of disease.21 the pelvic lymph nodes is facilitated by developing the pararectal In patients who appear to have early rather than advanced dis- and paravesical spaces in the retroperitoneum of the pelvis [see Figure 2].The pararectal space is developed by means of blunt dis- section between the ureter medially and the internal iliac (hypogas- tric) artery laterally. Dissection through the loose areolar tissue Table 4 International Federation of proceeds caudomedially toward the coccyx. The paravesical space Gynecology and Obstetrics is developed by sweeping the obliterated superior vesical artery and Surgical Staging System for Ovarian Cancer the bladder medially.The space is bordered by the pubic symphy- sis anteriorly and the obturator internus laterally. Development of the spaces provides the exposure necessary for skeletonizing the Stage Characteristics iliac vessels and the obturator nerve. Selective para-aortic lym- Tumor growth is limited to ovaries. phadenectomy consists of removing precaval and aortic lymphatic IA Tumor is limited to one ovary; there is no ascitic fluid tissue from the level of the inferior mesenteric artery to the middle containing malignant cells; there is no tumor on external of the common iliac artery bilaterally. Sampling of the para-aortic surface; capsule is intact lymph nodes is then accomplished via either a direct or a lateral IB Tumor is limited to the two ovaries; there is no ascitic fluid I containing malignant cells; there is no tumor on external approach.With a direct approach, an incision is made into the peri- surface; capsules are intact toneum overlying the right common iliac artery and extended over IC Tumor is either stage IA or IB, but (a) there is tumor on the aorta.With a lateral approach, an incision is made in the later- surface of one or both ovaries, (b) capsule is ruptured, or al paracolic gutters, with the right or left colon reflected medially. (c) ascitic fluid containing malignant cells is present or peri- toneal washings are positive In one study, a median of 11 pelvic and three para-aortic lymph nodes were obtained at selective lymphadenectomy.17 Tumor involves one or both ovaries, with pelvic extension. IIA Tumor extends or metastasizes to uterus or Fallopian tubes OVARIAN CANCER IIB Tumor extends to other pelvic tissues II IIC Tumor is either stage IIA or IIB, but (a) there is tumor on Of all the reproductive tract malignancies, ovarian cancer poses surface of one or both ovaries, (b) one or both capsules the greatest clinical challenge. Although ovarian cancers can arise are ruptured, or (c) ascitic fluid containing malignant cells from germ cells, sex-cord cells, or stromal cells, approximately is present or peritoneal washings are positive 85% arise from the coelomic epithelium and thus are termed Tumor involves one or both ovaries, with peritoneal implants epithelial cancers.The peak incidence of invasive ovarian epithelial outside pelvis, positive retroperitoneal or inguinal nodes, or cancers is between 56 and 60 years of age. Approximately 5% to both. Superficial liver metastasis equals stage III. Tumor is limited to true pelvis, but with histologically proven malignant 10% of these cancers have a hereditary component; women with extension to small bowel or omentum. BRCA1/BRCA2 or Lynch syndrome (HNPCC) germline muta- IIIA Tumor is grossly limited to true pelvis, with negative nodes tions are at increased risk. Prophylactic salpingo-oophorectomy in III but with histologically confirmed microscopic seeding of abdominal peritoneal surfaces patients with BRCA1/BRCA2 mutations virtually eliminates the IIIB Tumor involves one or both ovaries, with negative nodes risk of ovarian and tubal cancer and reduces the risk of breast and but with histologically confirmed implants on abdominal primary peritoneal cancer.18,19 peritoneal surfaces, none of which are > 2 cm in diameter Ovarian cancer is the second most common gynecologic malig- IIIC Abdominal implants > 2 cm in diameter are present, retroperitoneal or inguinal nodes are positive, or both nancy, but it has the highest fatality-to-case ratio of any reproduc- tive tract cancer. Ovarian epithelial carcinomas spread primarily Tumor involves one or both ovaries, with distant metastasis. If through exfoliation of cells, which places the entire peritoneal cav- IV pleural effusion is present, cytologic test results must be obtained to assign a case to stage IV. ity at risk for metastases. Moreover, early recognition is difficult Parenchymal liver metastasis equals stage IV. because the majority of patients have only vague and nonspecific
  • 9. © 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 9 CARE IN SPECIAL SITUATIONS 5 GYNECOLOGIC CONSIDERATIONS FOR THE GENERAL SURGEON — 9 a b c d Figure 3 Shown is a retroperitoneal approach to a large, fixed ovarian mass that is adherent to adjacent struc- tures. (a) The mass is drawn medially, and the peritoneum lateral to the infundibulopelvic ligament is divided (dotted line) to afford entry into the retroperitoneum of the pelvis. (b) The ureter (arrow) is identified on the medial leaf of the broad ligament in a location below the infundibulopelvic ligament. (c) An opening is made below the infundibulopelvic ligament and superior to the ureter, and the primary blood supply to the ovarian mass is thereby isolated. (d) The gonadal vessels are clamped, cut, and ligated. The mass is then dissected from the adja- cent tissues in view of the ureter. ease, the emphasis is on accurate staging. At least 30% of patients toneum is entered laterally along the surface of the psoas muscle. whose disease is seemingly confined to the pelvis show some evi- The procedure is initiated by either dividing the round ligament or dence of upper abdominal or nodal spread. A midline incision is entering the peritoneum lateral to the infundibulopelvic ligament. made, and upon entry into the peritoneal cavity, any free abdomi- Upon entry into the retroperitoneal space, the infundibulopelvic nal fluid is submitted for cytologic evaluation. If no abdominal fluid ligament, the ureter, and the great vessels are identified. The is present, pelvic washings are done with 50 to 100 ml of saline, and pararectal and paravesical spaces may be developed to facilitate the the saline is recovered and submitted for cytologic evaluation. The removal of locally advanced pelvic disease [see Figure 2]. If the dis- ovarian tumor should be removed intact (if possible) and submitted ease involves the bowel, its mesentery, or both, resection and for frozen-section analysis. The intra-abdominal surfaces and the reanastomosis may be necessary, either to remove an obstruction or viscera are systematically inspected. Any suspicious areas or adhe- to achieve optimal tumor debulking. Small bowel resection may be sions are subjected to biopsy. Random peritoneal biopsies are per- required to achieve optimal cytoreduction in as many as 10% of formed on the lateral upper and lower paracolic gutters, the blad- patients.23,24 der flap, the cul-de-sac, and the pelvic sidewalls. Sterile tongue Primary peritoneal and tubal cancers are relatively rare malig- depressors are used to obtain cytologic specimens from both infra- nancies whose presentation may include a mass, malignant ascites, diaphragmatic surfaces. An infracolic omentectomy is performed. or pain. These tumors are more frequent in patients with The regional nodes are palpated, and any enlarged lymph nodes are BRCA1/BRCA2 mutations, and they bear a histologic resemblance removed. Finally, the pelvic and para-aortic nodes are sampled to to, as well as behave as, ovarian epithelial carcinomas.Treatment is allow detection of any occult spread. identical to that of ovarian cancer, with initial surgical intervention Because the majority of patients with ovarian epithelial cancers establishing the diagnosis and the disease stage. After tumor present with advanced disease, the main goal of surgical interven- debulking, paclitaxel and carboplatinum chemotherapy is adminis- tion is often tumor debulking. The purpose of cytoreduction is to tered. Patients with tubal cancers should undergo hysterectomy remove the primary cancer, as well as any metastases. If complete and bilateral salpingo-oophorectomy. If there is no evidence of resection of metastases is not feasible, the aim is to reduce the bulk gross tumor spread, a staging procedure is performed that includes of the residual disease to, ideally, a diameter of 1 cm or less (so- sampling of the pelvic and para-aortic lymph nodes, infracolic called optimal debulking). Optimal cytoreduction enhances the omentectomy, and procurement of peritoneal specimens for cyto- response to I.V. paclitaxel and carboplatinum chemotherapy, and logic examination through multiple peritoneal biopsies. patients with minimal residual disease have a distinct survival CERVICAL CANCER advantage over those with more substantial residual disease. Furthermore, current data indicate that patients who have under- Although cervical cancer is only the third most common gyne- gone optimal debulking may be candidates for intraperitoneal, as cologic malignancy in the United States, it is the most common opposed to I.V., chemotherapy.There is evidence to suggest that the genital tract cancer in the world. Patients with early invasive carci- use of intraperitoneal chemotherapy may improve survival rates.22 nomas may present with nothing more than an abnormal Pap The removal of pelvic disease is accomplished via a retroperi- smear, but most complain of postcoital bleeding or a bloody vagi- toneal approach [see Figure 3]. Although ovarian cancers common- nal discharge.With early disease, colposcopy or conization may be ly involve and distort peritoneal surfaces, they usually do not have required to establish the diagnosis; however, the majority of a significant effect on the retroperitoneal anatomy. The retroperi- patients have a gross cervical lesion, and punch biopsy is usually
  • 10. © 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 9 CARE IN SPECIAL SITUATIONS 5 GYNECOLOGIC CONSIDERATIONS FOR THE GENERAL SURGEON — 10 Table 5 International Federation of Gynecology a simple hysterectomy for benign disease, the vascular pedicles are and Obstetrics Surgical Staging System for placed close to the uterus and the cervix. A radical hysterectomy dissects out the lower aspect of the ureters, allowing wider clear- Cervical Cancer ance of the central specimen and the adjacent adventitial tissues (e.g., cardinal ligaments and parametria). At an early point in the Stage Characteristics procedure, the pararectal and paravesical spaces are developed [see Figure 2]. If the disease appears to be limited to the central speci- IA Tumor is invasive carcinoma that can be diagnosed only men, the uterine artery is divided at its point of origin from the by microscopy IA1: Tumor has measured stromal invasion of ≤ 3 mm superior vesical artery and mobilized over the ureter. The parame- and extension of ≤ 7 mm tria, lying between the pararectal and paravesical spaces, are divid- IA2: Tumor has measured stromal invasion of > 3 but ed. The ureters are separated from the medial peritoneum of the < 5 mm and extension of ≤ 7 mm posterior leaf of the broad ligament, then dissected out to the point I IB Tumor is clinically visible lesion limited to cervix or micro- where they insert into the bladder. Once the distal ureters have scopic lesion more extensive than stage IA been mobilized, clamps are placed into the paravaginal tissues, and IB1: Tumor is clinically visible lesion with maximum an extra margin of lateral tissue is removed. The rectovaginal sep- diameter of ≤ 4 cm tum is also developed to allow division of the uterosacral ligaments IB2: Tumor is clinically visible lesion with maximum diameter of > 4 cm closer to their point of origin at the sacrum.The upper 2 cm of the vagina is removed in continuity with the rest of the specimen. A sys- Tumor invades beyond uterus but does not reach pelvic wall tematic pelvic lymph node dissection is then performed, with skele- or lower third of vagina. II IIA Tumor does not obviously involve parametrium tonization of the common iliac artery, the external iliac artery, the IIB Tumor obviously involves parametrium external iliac vein, and the obturator nerve. Patients who have more advanced disease (stage IIB or higher) or Tumor extends to pelvic wall. On rectal examination, there is are unable to undergo surgery are treated with radiotherapy and no cancer-free space between tumor and pelvic wall. Tumor involves lower third of vagina. All cases with chemotherapy as a radiation sensitizer. Initially, protracted, fraction- hydronephrosis or a nonfunctioning kidney are included ated external beam radiotherapy is administered. By using a number III unless known to be attributable to another cause. of fields, external beam treatment distributes radiation to the central IIIA Tumor involves lower third of vagina, with no extension tumor and the pelvic lymph nodes in a relatively homogeneous fash- to pelvic wall IIIB Tumor extends to pelvic wall, hydronephrosis is present, ion. External radiotherapy is followed by intracavitary radiotherapy, or kidney is nonfunctioning in which a radioisotope is placed into the uterus, the cervix, and the upper vagina.The radiation delivered by intracavitary radiotherapy is Tumor extends beyond true pelvis or involves mucosa of blad- der or rectum (as proved by biopsy). Bullous edema per se distributed according to the inverse square law: a substantial amount IV does not permit case to be allotted to stage IV. is delivered to the central tumor, but the dose falls off rapidly in adja- IVA Tumor spreads to adjacent organs cent tissues as the distance from the central lesion increases. IVB Tumor spreads to distant organs VULVAR CANCER performed to establish the diagnosis. As a result of the necrotic Vulvar cancers arise from the epidermis of the vulva and are usu- debris and blood, cytology yields false negative results in as many ally of squamous histology. Approximately 30% to 40% of vulvar as 50% of invasive cervical carcinomas.When a gross cervical lesion cancers are related to exposure to HPV, usually in younger patients is present, biopsy and histologic evaluation are mandatory. and those with preexisting vulvar dysplasia. In the majority of The staging of cervical cancer is based on the clinical findings and patients, however, no clear cause can be identified.Vulvar carcino- takes into account the results of pelvic examination, chest radiogra- mas spread by embolization along lymphatic channels, which ter- phy, and intravenous pyelography (IVP) [see Table 5]. Stage I cervi- cal cancer denotes disease that is limited to the cervix itself. It may be subdivided into stages IA (microscopic disease) and IB (more Table 6 Characteristics of advanced or grossly visible disease). The assignment of a cervical Complete and Partial Moles cancer to stage IA requires that cervical conization be done to assess the depth and lateral extent of stromal invasion. Microinvasive car- cinoma is a tumor that invades the cervical stroma to a depth of 3 Parameter Complete Mole Partial Mole mm or less, without lymphovascular space involvement. Stage II No fetus or fetal parts cancer denotes disease that involves the upper two thirds of the vagi- Anatomy Fetus or fetal parts present present na or parametrial disease that has not reached the pelvic sidewall. Focal trophoblastic prolifer- Stage IIIB cancer denotes parametrial disease that has reached the Generalized villous swel- ation and villous swelling; pelvic sidewall or results in ureteral obstruction. Histology ling; diffuse trophoblastic villous scalloping and proliferation prominent trophoblastic Treatment of cervical cancer is predicated on the patient’s suit- inclusions ability for surgery and on the stage and bulk of the tumor.Young patients with early, genuine microinvasive carcinomas and a desire Diploid, usually 46 XX Karyotype (all genetic material is Diandric triploidy for future childbearing may be followed conservatively after coniza- paternal) tion with negative margins. For the majority of patients with microinvasive cancers, definitive treatment consists of simple Uterus large for dates; pre- Presentation eclampsia; hyperthyroid- Missed or incomplete abdominal or vaginal hysterectomy; the risk of pelvic nodal metas- ism; theca-lutein cysts abortion tasis is lower than 1%. Patients with stage IA2, IB, and IIA disease may be treated with radical hysterectomy. This surgical procedure Natural history 20% chance of requiring 3% to 4% chance of requir- chemotherapy ing chemotherapy differs from simple abdominal hysterectomy in several respects. In
  • 11. © 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice 9 CARE IN SPECIAL SITUATIONS 5 GYNECOLOGIC CONSIDERATIONS FOR THE GENERAL SURGEON — 11 GESTATIONAL TROPHOBLASTIC DISEASE minate at the inguinofemoral lymph nodes. Superficial and medial lymph nodes are the ones most commonly involved. The pelvic Gestational trophoblastic disease is a blanket term for a range of lymph nodes are rarely involved unless the ipsilateral inguinal placenta-derived neoplasias that include hydatidiform mole, inva- nodes contain metastatic disease. sive mole, gestational choriocarcinoma, and placental site tumor. Treatment must take into account both the primary vulvar Of these conditions, the one most frequently encountered is hyda- lesion and the possibility of inguinal node metastasis. Historically, tidiform mole, or molar gestation. In the United States, moles radical vulvectomy with bilateral groin dissection was the stan- occur in approximately one of every 1,000 to 1,200 pregnancies. dard of care for the treatment of vulvar cancers. Currently, the Patients present with vaginal bleeding, passage of mole tissue emphasis is on performing the most conservative surgical proce- through the vagina, a uterus that is large for the gestational age (as dure that is consistent with cure of the disease. Radical local exci- determined on the basis of the last menstrual period), or medical sion with surgical evaluation of the inguinal nodes has become the complications deriving from the mole.The diagnosis is established modern standard of care for most patients. The vulvar lesion is through ultrasonographic examination of the uterus.Therapy con- excised with margins of at least 1 cm.The incision is carried to the sists of evacuation of the uterine contents (ideally by suction curet- inferior fascia of the urogenital diaphragm, which is coplanar with tage) and subsequent serial serum β-hCG determinations, with the fascia lata of the thigh and the fascia over the pubic symphy- adequate contraception during the follow-up period. Moles usual- sis. If more than 1 mm of stromal invasion is noted, surgical eval- ly are complete but sometimes are partial (i.e., occur with fetal tis- uation of the inguinofemoral lymph nodes is required. Bilateral sue or even a fetus). The distinction between complete and partial groin dissections are not necessary unless the lesion is on the clit- moles, though initially regarded as little more than a medical oris, the anterior labia minora, or the perineum or lies within 1 cm curiosity, actually reflects identifiable differences in anatomy, his- of the midline. If the extent of stromal invasion is 1 mm or less, tology, presentation, and natural history [see Table 6]. node dissection is not necessary, because the risk of groin metas- If β-hCG levels rise or plateau or there is evidence of metastatic tasis is low. disease, further therapy for postmolar malignant gestational tro- Surgical evaluation of the inguinal nodes has also evolved over phoblastic neoplasia is required. Before effective chemotherapy time.The current surgical options are (1) a superficial inguinal node became available, it was common practice to perform hysterecto- dissection that removes the lymphatic tissue above the fascia lata my, allowing pathologic assessment of the uterine contents (persis- and the cribriform fascia and (2) a complete inguinofemoral node tent mole, invasive mole, or choriocarcinoma). dissection that removes both the superficial nodes and the deep Currently, most women with gestational trophoblastic disease nodes lying below the cribriform fascia and medial to the femoral can be successfully managed by means of chemotherapy, without vein. Advocates of the first option view the superficial inguinal nodes risk to the reproductive organs. Patients are evaluated for metas- as the sentinel lymph nodes of the groin and consequently maintain tases with various radiologic studies and are stratified according to that a more extensive dissection is generally not required. prognostic risk factors (as assessed by criteria developed by the Patients found to have positive inguinal nodes at groin dissection National Institutes of Health, the International Federation of receive adjuvant radiotherapy. Patients with advanced, unresectable Gynecology and Obstetrics, or the World Health Organization). primary disease, who in the past were treated with exenteration, Sites of metastatic disease are documented; however, to avoid the now are treated with radiation and chemotherapy as a radiation risk of a major hemorrhage, they are not subjected to biopsy. sensitizer. Local (perineal) recurrences are treated with wide local Therapy is governed by the level of risk present. Single-agent ther- resection. Unfortunately, recurrences in the inguinal nodes after apy (with methotrexate or actinomycin D) is given to patients with primary therapy usually are refractory to further therapy and often low-risk disease, and aggressive multiagent therapy is given to prove fatal. patients with high-risk disease. References 1. Boberg JT, ex-sec. Surgical Operative Log Project: Sexually transmitted diseases treatment guide- ine device in the treatment of menorrhagia in 1994–1995, Residency Review Committee for Sur- lines, 2006. MMWR Recomm Rep 55(RR- Chinese women: Efficacy versus acceptability. gery. Accreditation Council for Graduate Medical 11):1, 2006 Contraception 51:231, 1995 Education, Chicago, 1995 9. Seeber BE, Barnhart KT: Suspected ectopic preg- 15. Ho GY, Bierman R, Beardsley L, et al: Natural 2. Landercasper J, Bintz M, Cogbill TH, et al: nancy. Obstet Gynecol 107:399, 2006 history of cervicovaginal papillomavirus infec- Spectrum of general surgery in rural America. tion in young women. 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