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Pelvic exenteration was initially performed in palliative situations, but the indications now extend to situations with a curative objective.1 2
Total pelvic exenteration is an ultra-radical surgery reserved for gynecological pathologies that have recurred, most often in an irradiated area, making the surgical procedure more complex and the post-operative course more risky.3
In order to obtain negative margins, pelvic exenteration comprises an en bloc radical hysterectomy at the level of the pelvic wall combined with colpectomy, bladder resection (anterior exenteration), rectum resection (posterior exenteration), or both (total exenteration). This procedure can also be classified according to the line of resection in relation to the levator ani muscles as supra- or infralevator.4
We describe in a video a total pelvic exenteration with total vulvectomy and anorectal resection in 10 steps divided into two phases, the abdominal phase and pelvic phase. Figure 1 shows a still image from the video.
Video still image: Dissection of the left parametria after the opening of retroperitoneal spaces.
Abdominal resection
Step 1 : Paravesical and pararectal spaces dissection
Step 2 : Ureterolysis and ureteral section
Step 3 : Retzius dissection and ligation of Santotini’s plexus
Step 4 : Parametrial section
Step 5 : Presacral and retrorectal space development
Step 6 : Rectal section
Step 7: Endopelvic fascia opening
Perineal resection
Step 8 : Surgical margins
Step 9 : Operative specimen closure
Step 10: Levator ani muscles sections
As regards the anterior exenteration, we chose to control Santorini’s plexus during the abdominal phase in order to avoid bleeding that is difficult to control during the perineal phase. This plexus runs along the neck of the bladder behind the pubic symphysis, and we recommend tying it off after opening the Retzius space.
In the posterior stage, the patient had a recurrence of infiltrating vulvar cancer after concurrent chemo-radiation therapy, with progression reaching the anus and urethra. In this case, it was essential to remove the entire mesorectum with section of the rectal artery passing in front of the sacrum.
During the perineal phase, we opted for 2 cm skin margins to ensure that we obtained negative skin, urethral, and anal margins. We also chose to close the vulva after detachment of the subcutaneous tissues in order to minimize the risk of dissemination when handling the surgical specimen.
The stages of urinary (Briker), digestive (colostomy), and pelvic (filling the pelvic defect with a deep inferior epigastric perforator flap) reconstruction are not shown in this video.
Supplementary video
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Footnotes
X @egauroy, @Alejandra
Contributors AM is the main surgeon, TM managed the reconstruction, EC made the anatomical board, JS is the voice on the video, EG is the 2nd surgeon, prepared and edited the video, wrote the manuscript and is responsible for the overall content as guarantor.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
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