Staging laparotomy

staging laparotomy

1. Staging laparotomy. Prakat c. Aryal Intern Department of OBG

2. A procedure in which a particular body region is surgically examined to assess the extent of disease with the purpose of determining the stage or extension of a cancer.

3. Can be used for various intraabdominal malignancies. Ovarian carcinoma; endometrial carcinoma ; Hodgkin's lymphoma; colorectal carcinoma. Only procedure of ovarian carcinoma is discussed here with.

4. Modern gynecologic oncology demands accurate staging of cancer patients in order to determine the most effective method of treatment. The noninvasive techniques formerly required for staging are being expanded to include extensive exploratory laparotomy. A significant percentage of patients may have more advanced disease than was noted with noninvasive clinical staging procedures.  The purpose of the operation is to gain detailed knowledge of the extent of metastasis of the pelvic malignancy. It is difficult to perform this procedure through a lower transverse incision because adequate exposure to the upper abdomen is compromised.

5. Early-stage cancer  — Stage I and II disease are considered early-stage ovarian cancer Advanced-stage disease In stage III disease, the cancer is confined to the abdomen and the abdominal lymph nodes. In stage IV disease, the cancer has spread to distant sites such as the liver or lungs.

6. Frozen section: During the frozen section procedure, the surgeon removes a portion of the tissue mass. This biopsy is then given to a  pathologist . The pathologist freezes the tissue in a  cryostat machine , cuts it with a  microtome , and then stains it with various dyes so that it can be examined under the microscope. The procedure usually takes only minutes. The result is typically limited to malignant or not malignant. The surgeon then can continue with the procedure. Can be used to asses the border of malignancy, ascertain the malignancy of the tissue being removed.

7. Procedure of surgical staging The patient is placed in the supine position or the dorsal modified lithotomy position with the hips slightly abducted, the thighs parallel to the floor, and the knees flexed in obstetric stirrups. The incision should extend from the symphysis pubis to well above the umbilicus and, in many cases, up to the xiphoid. If malignancy is unexpectedly discovered in lower transverse incision; rectus muscles can be divided or detached from pubis ; or incision can be converted in to j shape.

8. Any ovarian tumor should be removed intact; if possible frozen section should be obtained. Any free fluid in the pelvic cul de sac should be submitted for cytological evaluation. If no free fluid is present ; peritoneal washings should be obtained by installing and recovering 50 -100 ml of normal saline from cul de sac; each paracolic gutter and beneath each hemidiaphragm. Systematic exploration of all intra abdominal surfaces and viscera is performed.

9. Clock wise fashion Cecum cephalad  along the paracolic gutter ascending colon to the right kidney liver and gall bladder the right hemidiaphragm the entrance to the lesser sac at para aortic area across the transverse colon to the left hemidiaphgram  down the left paracolic gutter to the descensing colon to the rectosigmoid colol  small intestine and its mesentery from treitz ligament should be inspected.

10. Any suspicious areas or adhesions on the peritoneal surfaces should be biopsied. If there is no evidence of disease , multiple intraperitoneal biopsies should be performed Tissue from peritoneum of cul de sac ; both paracolic gutters , peritoneal bladder and intestinal mesenteries should be taken for biopsies. The omentum should be resected from from the transverse colon a procedure called an infracolic omentectomy. The retroperitoneal spaces should be explores to evaluate pelvic and para aortic lymph nodes.

11. If studding is found under either the left or the right diaphragm, biopsy of the small lesions should be done.

12. The exploration of the retroperitoneal space is begun by excising the peritoneum in the area of the cecum and terminal ileum. The peritoneum is incised parallel to the right common iliac artery. The incision is then advanced up the aorta until the third portion of the duodenum is encountered.

13. At the third portion of the duodenum, the ligament of Treitz is noted and mobilized along with duodenum to allow adequate exposure to the renal vessels. Lymph node excision is begun at the level of the left renal artery and vein, the origin of the right and left ovarian vessels. Adequate lymph sampling is performed along the aorta.

14. Any enlarged pelvic / paraaortic lymph nodes should be resected and submitted for frozen section. If no metastases are present a formal pelvic lymphadenectomy should be performed.

15. The peritoneum overlying the aorta is closed with 3-0 synthetic absorbable sutures .

16. RESULT Metastases in apparent stage I and II ovarian cancer occurs in as many as 3 in 10 patients; whose tumor appear to be confined to pelvis, but have occult metastasis in the upper abdomen of retroperitoneal nodes. Importance for careful initial surgical staging is emphasized by findings of a national study of 100 patients with apparent stage I and II disease. 28% of patients with stage I were upstaged 43% of patients with stage II were upstaged 77% were upstaged to actual stage III disease.

17. Low risk High risk Low grade High grade Intact capsule Growth through capsule No surface excrescences Surface excrescences No ascites Ascites + Negative peritoneal cytology for malignancy Peritoneal cytology positive for malignant cells Unruptured/ intraop rupture Pre op rupture No dense adherence Dense adherence Diploid tumor Aneuploid tumor Stage I low risk: surgery( TAH with BSO ; with adequate surgical staging fertility can be preserved in younger patient by doing unilateral salphingo oophorectomy after surgically staged to grade I A Stage I high risk : TAH with BSO with chemotherapy ; Advance stage : Primary cytoreductive surgery(surgical process with goals to reduce tumor to residual of < 1 cm max diameter.) ; followed by chemotherapy. Recurrent diseases may require secondary and tertiary cytoreductive surgery.

18. Summary Staging laparotomy is of vital importance should be done early for proper staging of disease and more precise then non invasive staging techniques. Staging laparotomy should be a part of definitive surgery of the disease. Staging of disease is mandatory for planning further treatment and prognosis of ovarian cancer Improper staging of disease may lead to undertreatment of disease ultimately resulting in decreased survival of the patient.

19. References William’s gynaecology : 3 rd edition Te Linde’s operative Gynecology: 11 th edition Berek and Novak’s gynecology 15 th edition http://atlasofpelvicsurgery.com/10MalignantDisease/1StagingofGynecologicOncologyPatientsWithExploratoryLaparotomy/cha10sec1.html https://jamanetwork.com/journals/jamasurgery/article-abstract/584474?redirect=true https://jamanetwork.com/journals/jama/article-abstract/388955

20. Thank you