This is a lecture note on surgical principles of gynecologic malignancies.

1. Surgical Principles
of
Gynecologic Malignancies
Hale Teka, OB-GYN Year 2 Resident
Mekelle University,
College of Health Sciences
Wednesday, May 30,
2018
Hale T., M.D., Resident Physician 1

2. • Contents
– Objectives
– Introduction
– Technical Aspects of Gynecologic Surgery
– Surgical Management of Gyencologic
Cancer
– The Future of Gynecologic Oncology
– Summary
Hale T., M.D., Resident PhysicianWednesday, May 30,
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3. Objectives
1. To appreciate and understand the
surgical principles of gynecologic
oncology
2. To understand the multimodality and
multidisciplinary nature of
management of gynecologic
oncology
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4. Introduction
• Some cancers can be cured by surgery or
chemotherapy alone
•In majority of cases, however, management
of human cancer requires a multimodal
approach
•In this presentation we will focus on role of
surgery in gynecologic cancers
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5. Technical Aspects Surgery
• Decision of whether or not to utilize
surgical therapy
• Preoperative and postoperative
management
• Proper technique
– For the student
•Actual practice in tying knots, manipulating
instruments, and suturing
– For the accomplished surgeon
•Sufficient case load must be maintained
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6. • Anatomy
– No amount of surgical skill or knowledge
of cancer therapy can compensate for
the lack of this knowledge
– Familarity with the anatomy of pelvis,
abdomen, retroperitoneum and the
lymphatic drainage of the female genital
tract
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8. Hale T., M.D., Resident Physician
The pelvic and paraaortic
lymph nodes and their
relationship to the major
retroperitoneal vessels.
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11. • The lymphatic drainage from both the
uterine corpus and the ovaries follows
one of three routes
– (a) along the uterine arteries in the broad
ligaments to the pelvic nodes,
– (b) in channels following the round
ligaments to the inguinal lymph nodes, or
– (c) along the ovarian lymphatics in the
infundibulopelvic ligaments directly up to
the paraaortic nodes
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12. • The paracaval, interaorto-caval, and
paraaortic (left side) are sampled in
the surgical staging of gynecologic
malignancies
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13. • The gynecologic cancers can spread
across upper abdominal structures
such as the diaphragm, liver,
pancreas, and spleen
• Debulking of tumors from these cytes
improves optimal cytoreduction
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14. Hale T., M.D., Resident Physician
Peritoneal reflections of the liver: the lesser omentum (hepatogastric and
hepatoduodenal ligaments) and its relation to the coronary ligament of the liver
and diaphragm
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15. • Patient positioning
– Important for exposure
– Low lithotomy position using Allen stirrups
•Simultaenous excess to the perineum and
abdomen
•Examples
– Ovarian cancer cytoreduction
– Radical hysterectomy
– Pelvic exenterative procedures
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17. • Abdominal Incisions
– Should be highly individualized
– 3 basic incisions for intraperitoneal exposure
•Midline incision
•Maylard incision
•Pfannenstiel incision
– For extraperitoneal access to the pelvic
and paraaortic nodes
•J-shaped incision
•Sunrise incisionWednesday, May 30,
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Entry into the abdominal cavity can
be made by three basic incisions:
(1) the midline incision;
(2) the transverse Maylard-type
incision ; and
(3) the Pfannenstiel incision.
Pfannenstiel incision can be
converted to a Cherney-type
incision for improved exposure
For the patient for whom later
exposure of the upper abdominal
cavity is necessary, a midline upper
abdominal incision can be
separately used

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The “sunrise” incision:-
In the center, the incision
is approximately 6 cm
above the umbilicus
The incision is carried
laterally in a downward
fashion to the level of the
iliac crests.

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The Maylard incision
The deep inferior
epigastric vessels are
located on the lateral and
posterior borders of the
rectus muscle
They are bluntly dissected
from this position by the
finger of the operator,
isolated, clamped,
sectioned, and tied. Only
after they are tied should
the rectus muscle be
incised.

21. • Lymph Node Dissection
– Transperitoneal approach
•Ovarian tumor
•Endometrial cancer
– Retroperitoneal approach
•Pretreatment surgical staging
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Starting at the
bifurcation of the
common iliac
vessels, the loose
areolar tissue over
the vein is excised
from cephalad to
caudad. Clips
should be used at
the bifurcation of
the common iliac
to avoid
troublesome
bleeding.

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A vein retractor is used to retract the
external iliac veins anterior and lateral to
expose the obturator space. Lymphatic
tissue is gently teased from the psoas
muscle. The entire lymphatic bundle is
clamped, sectioned at its caudal end, and
ligated at the pelvic sidewall. With the use
of the Singley forceps, the lymphatic
bundle is bluntly dissected from the
obturator nerve and mobilized superiorly.
Often, the obturator vein and artery must
be sacrificed to obtain access to tissue
posterior and lateral to the nerve. Once
the tissue is mobilized superiorly, all
areolar tissue is cleaned off the
hypogastric vessels to the level of the
bifurcation of the common iliac artery. The
large tissue bundle is clamped and
removed en bloc

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25. • Radical Hysterectomy
– Key principles in classification of radical
hysterectomy
•Extent of parametrial resection
•Most recent and acceptable classification
– Type A
– Type B
– Type C1
– Type C2
– Type D
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29. • Cancer Debulking
– To remove all or as close as possible to all
grossly visible and palpable tumor
– What does removal of tumor bulk offer?
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30. • Continent Urinary Diversion
– Indiana or miami pouch
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An approximately 1-cm
segment of ureter is brought
into the pouch. For ease of
ureterointestinal anastomosis,
the ureter should be secured
posteriorly to the pouch by
suturing the adventitial tissue of
the ureter to the seromuscular
layers of the pouch with 3 or 4
permanent 3-0 sutures. The
ureter is spatulated to increase
the lumen diameter. The ureter
is sutured directly to the colon
and is not tunneled. This is a
full-thickness approximation of
the colon and ureter. Once both
ureters have been sutured into
the pouch, 2 #8 French

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The site for the ileal stoma is
selected on the anterior abdominal
wall and then incised through all
abdominal tissue layers
The stoma is created for
catheterization and the #14 French
catheter should exit the pouch
through this stoma
It is critical that the ileal segment be
at a 90° angle with the abdominal
wall so that catheterization is a
“straight shot.” The pouch may be
sutured to the abdominal wall to
accomplish this. All stents and
drainage tubes are brought out
through the anterior abdominal wall
and secured
The pouch may also be anchored
posteriorly (i.e., to the sacrum

34. • Abdominal Closure
– Midline incision is preferable
– Running mass closure
– No 2 monofilament polypropylene suture
– Fascial closure
•Closed in suture length to wound lenth ration
of at least 4:1
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35. Surgical Management of Gynecological Cance
• Gynecologic Oncologist must
– Evaluate a woman with a genital
tract malignancy
– Direct her management
– Perform necessary surgical
procedures
– Supervise her postoperative care
and surveillance
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36. • Early Diagnosis and Preventation
– Understanding the significance of cancer
precursors
•Abnormal Pap smear result
•Endometrial hyperplasia
•Surgical removal of tubes, ovaries and uterus
after childbearing is complete in high risk
women
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37. • What determines therapy for
gynecologic oncology?
– Anatomic site
– Histologic type
– Histologic grade (differentiation)
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38. • Surgery as Primary Therapy
– Preinvasive diseases
– Local diseases
– Advanced diseases
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39. • Surgery combined with other therapies
– Adjuvant therapy
•Chemoradiotherpay after surgery
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40. • Surgery as a Salvage Therapy
– Surgery after failure of other therapies
•Surgery with limitations of function
– Bladder function
– Sexual function
– Anal and rectal function
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41. • Surgery for Metastatic Disease
– Surgical resection of metastatic lesions
– Example: Lung, Liver, Spleen
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42. • Surgical Procedures for Specialized
Care
– Placement of intravenous access
– Intracavitary tubes
– Intraarterial devices
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43. • Surgery for Reconstruction
– To correct complications of treatment
•Closure of defects from improper wound
healing, radiation necrosis, or tissue loss after
ectravasation of chemotherapeutic agen
– Vulvar reconstruction
– Vaginal reconstruction
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44. • Surgery for Palliation
– Resection of tumor to relieve symptoms
– Pain relief
– Diversion or bypass of portions of the GIT
or urinary tract to prolong life or provide
comfort
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45. • Diagnosis and Staging
– Surgical biopsy
•Instrumental biopsy
•Excisional biopsy
•FNAC
•Surgical exploration
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47. 1. Vulval Carcinoma
• Incidence
– Rare
– 1.7 / 100,000 females
– Accounts 3-5% of genital malignancies
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49. • Surgical Management
– Prophylactic
• Simple vulvectomy in postmenopausal women
with VIN
– Definitive
• Microinvasion
– > 1mm
» Radical vulvectomy with bilateral groin node
dissection in all cases of stromal invasion
– < 1 mm
» Wide local excision with or without ipsilateral groin
lypmphadenectomy
» No lymph gland involvement
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50. • Frank Invasion
– Radical vulvectomy with bilateral
inguinofemoral lymphadenectomy
– 3 separate incisions Vs en-block
approach
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51. Bartholin's Gland Carcinoma
• Surgical Management
– Same as vulval carcinoma
– + Remove
• Part of the lower vagina
• Levator ani muscle
• Ischiorectal fat
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52. 2. Vaginal Carcinoma
• Incidence
– Very rare
– 0.6 / 100,000
– It accounts about 1% of genital
malignancies
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54. • Surgical Management
– Stage I
• Radical hysterectomy
• Partial vaginectomy
• Bilateral pelvic lymphadenectomy
– Stage II-IV
• Pelvic exenteration operation
– If radiation therapy fails
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55. • Clear Cell Adenocarcinoma
– Radical hysterectomy
– Vaginectomy with
– Pelvic lymphadenectomy
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56. 3. Carcinoma Cervix
• Incidence
– Most common gynecologic cancer in
women
– Occurs in younger population of women
– 3rd among all malignancies in women
– 85% in developing countries
– Economically advanced countries: 3.6%
of new cancers
– Within the US, cervical cancer is the third
most common gynecologic cancer and
the 11th most common solid malignant
neoplasm among women
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Hispanic Latino  Black  White  American Indian  Asian American

58. • Risk Factors
– Lack of regular Pap Screening  the
greatest risk
– HPV
•HSV 2 has a concurrent causative role
•99.7% of cervical ca associated with
ongogenic HPV strain
•RR for different histologic forms
– SCC: 189x
– Adenocarcinoma: 110x
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59. – 90% of cervical Ca cases were linked to
12 oncogenic HPVs
•HPV 16  57% of Cervical Cas
– Mostly SCC
•HPV 18  16% of Cervical Cas
– Mostly Adenocarcinoma
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60. – Vaccination
•Incidence  decreased by 95%
•Persistence  decreased by 100%
•Effective duration of vaccine not known
•Ultimate goal of lowering cervical ca rate yet
to be determined
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61. – Lower socioeconomic Predictors of Lower
Screening
•Lower educational attainment
•Older age
•Obesity
•Smoking
•Neighborhood poverity
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62. • Cigarette Smoking
– Past, current, active and passive smokers
are all at risk
– 2-3 fold increased risk
– SCC is increased
– Alters infection and clearance
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63. • Reproductive Behavior
– Early coitarche
•Before 20 years  increased risk
•After 20 years  tendency to increase
– Multiple sexual partners
•> 6 life time partners
– Parity
•Para 1-2  2x
•Para 7  4x
– COC use
•4x fold increased risk
•Risk eliminated after cessetion of use > 10
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64. • Pathophysiology
– Infection with HPV infection
•Most of them clear
•Some persist  Dysplasia  Cervical Ca
– Early genes  Replication
•Oncogenic products E1 and E2
– Late genes  Transformation
•Oncogenic products E6 (Binds to  P53) and
E7 (binds to Rb)
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65. • Tumor Spread
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67. • Surgical Treatment
– Radical Hysterectomy
• Remove
– Uterus
– Tubes
– Ovaries
– Upper half of vagina
– Parametrium
– Draining primary cervical lymphnodes
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68. – Pelvic Exenteration
• Anterior exenteration
• Posterior exenteration
• Complete or total
• Laparascopic radical hysterectomy with pelvic
and aortic lymphadenectomy
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69. Endometrial Carcinoma
• Surgical Treatment
– Stage I
• Peritoneal washing
• Exploration
• Suturing of the cervix and fimbrial ends
• TAH-BSO
• Lymphnode sampling
• Vaginal hysterectomy
• Laparascopic hysterectomy
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71. – Stage II
• Radical hysterectomy +
• Pelvic and para-aortic lymphadenectomy
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72. – Stage III and IV
• Extended hysterectomy 6 weeks later
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73. Gestational Trophoblastic Diseaseses
• Surgical Treatment
– Stage I
• Hysterectomy
– High risk or resistant
– Family size compeleted
– Stage II and III
• Hysterectomy
– Low risk
» Family completed
• High risk or resistant
– To reduce tumor mass
– Stage IV
• Hepatic resection, craniotomy and hysterectomy ...
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75. Sarcoma Uterus
• Surgical Treatment
– Total hysterectomy with BSO
– + External Pelvic radiation
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76. Sarcoma Botryoides
• Surgical Treatment
– Local resection of the disease
– + Chemoradiation
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77. Carcinoma Fallopian Tube
• Surgical Treatment
– TAH + BSO + Omentectomy
– + Platinium based combination
chemotherapy
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78. Malignant Ovarian Tumors
• Surgical Treatment
– Primary Surgery
– Early Stage Disease
• Young women
– Unilateral oophorectomy
• Elderly women
– TAH-BSO
– Advanced Stage Disease
• Exploratory laparatomy
• Secondary Surgery
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81. • They Future of Gynecologic Oncology
– Multidimodality and
– multidisciplinary approach
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82. • Changes in the indication for Surgery
– Laparoscopic surgery
– Robotic surgery
– Computerized anesthesia machines
– Transesophageal ultrasound
– Safe anesthetic agents
– New generations of antibiotics
– New cardiovscular medications
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83. • Multidisciplinary Therapy and Primary
Care
– Gynecologist oncologists are trained to
be accomplished abdominopelvic
surgeons, medical and radiation
oncologists
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84. ReferencesReferences
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85. ReferencesReferences
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86. Thank you for listening!
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