Extralevator Abdominoperineal Resection (APR) for Recurrent Anal Cancer With an En Bloc Total Abdominal Hysterectomy and Bilateral Salpingo-Oophorectomy and Total Vaginectomy With Permanent Colostomy Formation and Pelvic Floor Reconstruction Using a Right Rectus Abdominis Flap

CHAPTER 1

I'm Dr. Steve Wexner, the chair of the Department of Colorectal Surgery, and the director of the Ellen Leifer Shulman and Steven Shulman Digestive Disease Center at Cleveland Clinic, Florida in Weston. With me is Dr. Zoe Garoufalia. Yes, I'm Zoe Garoufalia. I'm one of the clinical fellows in the colorectal surgery department, and I'm also a general surgeon from Athens, Greece. And Dr. Garoufalia is gonna share the details of the patient who's operation you'll momentarily see. Yeah, so this case that you will see shortly, it's a case of a 53-year-old female patient that came to us with recurrent anal cancer. Her history begins about two years ago when she was first diagnosed with anal cancer. Her clinical staging back then was CT4 N0 M0. So she underwent a Nigro protocol. Her response was pretty good, and she was free from disease for two years. But then she started having some pain, some itchiness. She was diagnosed with the endovaginal fistula. We took some biopsies and did an MRI, and unfortunately, saw recurrence of her disease. Her MRI scan shows recurrence of the disease that takes up all the posterior wall of her vagina and abutting her urethra. We discussed the case in our multidisciplinary team meeting and based on the severity of the symptoms that the patient was experiencing, the pain, the fact that she couldn't evacuate anymore without doing enemas, we opted for surgical treatment of the disease. Yeah, the MRI clearly shows a T4 lesion. So it's invading not only into the vagina but bilaterally, more so on the right than on the left up into the labis majorum on the right and somewhat on the left, almost sort of going around and encroaching towards the urethra. So it's a very locally advanced tumor. But because there's no distant metastatic disease, the thought is that it is resectable for cure. And as you mentioned, we don't operate on anybody with a rectal carcinoma. And we've expanded that of course to colon and to anus as well through the National Accreditation Program for Rectal Cancer which we helped found back in 2011. And we were one of the first accredited centers in 2018 and have been re-accredited. And every single patient with rectal cancer is presented and discussed by a group of surgeons, radiologists, pathologists, medical oncologists, radiation oncologists, geneticists, and others as needed in this case, GYN oncology. There are other cases we might involve neurosurgery, spine surgery for tumors going the other way, or urology if anterior exenteration is necessary. That multidisciplinary team approach is key. And again, the MRI clearly shows why we need it. So in this instance, we're involving the urologist at the beginning to perform cystoscopy, be sure the urethra is clear and the bladder is not involved. Place bilateral urinary catheters because it's gonna be a a wide extra levator abdominal perineal excision with an en bloc total abdominal hysterectomy bilateral salpingo-oophrectomy, and total vaginectomy with a subsequent reconstruction. So the gyn oncologist will perform that part with us. And then one of our plastic surgeons is going to perform a rectus abdominis reconstruction of the perineum to close the entire perineum. So everything's gonna be gone. And you'll see how we work together as a team in this instance, urology, GYN oncology, colorectal surgery, and plastic surgery. The way we've elected to approach in this instance, because we need the rectus abdominis, it's going to be an open rather than a laparoscopic operation because the plastic surgeon needs a xiphoid-to-pubis incision to harvest the right rectus, allowing us to use the left permanent colostomy creation. A few technical differences from a standard, let's say a coloanal anastomosis. We don't need to mobilize the splenic flexure. Sometimes we don't even need to take the inferior mesenteric vein high, just the inferior mesenteric artery depends on the amount of redundancy and diverticular disease in the left colon. Secondly, we will do everything as if it was an abdominoperineal excision without the TAH BSO vaginectomy, and essentially leave the tumor hanging on the vagina and have done everything else, the high ligation, the total mesorectal excision, the extralevator dissection from below, and just leave everything for the gynecologic oncologist to then come and perform en bloc with us. And that's the specimen you're going to see, the uterus, ovaries, tubes, entire vagina, anterior, posterior, just leaving the urethra in place anteriorly the pubic bone, pelvic sidewalls. And we will routinely perform a coccygectomy as part of an extralevator abdominoperineal resection as well. So that's what you're going to see. So these cases should be performed only in high volume centers with highly experienced surgeons. The morbidity is high, and you need a very experienced team, not only surgical, but only the perioperative team should take care from physiotherapy, nutrition, making sure that every concern and every problem is addressed in a timely manner. So the patient, we can reduce the morbidity as much as possible.

CHAPTER 2

Alright, so we're in the bladder, and... There's some elevation of the floor of the bladder, but that's really about it. It appears - no epithelial lesions. So that looks all normal. The urethra itself appears normal. Excellent. But on palpation, it's a little hard around the lateral walls. Okay, the ureteral orifice is here. It looks normal. Catheters go up nicely. That's good. And on this side, same thing. A little elevated, so this appears like there's some posterior displacement of the bladder, probably from the tumor, but other than that, nothing remarkable. This one goes up easy as well, one, two, three, four, five. Okay, that's it. Now by manual examination, I feel a lot of disease on the labia, vaginal sidewalls anteriorly feel softer. It's mainly lateral sidewall and posterior is indurated, but clear anteriorly. Okay? Thank you. So you can kind of feel like a "U" and up top it's soft. Okay? You have the catheter? Okay. There we go. Okay, that's it.

CHAPTER 3

Okay, incision at 1:32. Thank you. Okay.

CHAPTER 4

There you have it. Around here.

CHAPTER 5

So, yeah, we should have enough for colostomy with that. Yes, it's enough. I don't think you need to take more. Okay, that's good. So first thing we wanna do is just get the ureter down here, the retroperitoneum. Okay, that's good. Okay. Okay, so let's continue on this plane here. Bovie for Dr. Meyer. Okay. Let's flip this over here. Right ureter is here, yep. Okay. Do two and then slide in two more. I need a new blue handle. The blue. The blue one. Just be sure the ureter is out. It is, okay. Okay. So we do two, then slide towards the colon and do two more. Yep. So I double these. I do two doubles just to help for hemostasis. You can maybe do three here, I dunno. And then cut, okay. so that's the inferior mesenteric artery. Now she has a lot of left colonic redundancies. Is my headlight on? Is my headlight on? Yes. Maybe it's not focused on the area. Okay. Oh, you're in mesentery, you wanna stay in that clear stuff. Yeah, here. Okay. Towards kidney. On my finger, right here. Right here. You can see here it's a... Okay. This is the line of Toldt here, guys. FYI. Okay, so this should get us plenty of length for sigmoid colon so we can, you know, and the rest is gonna be removed. So I can make a window here. Take the vessel. This vessel, yeah. This way. No, this. Yeah. Use your hands so you can feel the window. Which way are you going, Dave? 'Cause you wanna make the seal longer that direction, right? So you're kind of upside down. Here. That's right here. Oh no, what I want you to do, maybe I'm not communicating it well, but start here. You mean move down? Yeah, exactly. 'Cause the way the points were, it looked like you were going the other way. Okay. So this is fine. This should easily come as a nice sigmoid colostomy. If we need to mobilize any more, we can take the inferior mesenteric vein. Okay, come from you down. Yep, exactly. No other way. Okay. Down. Do you have a GIA 100 blue ready? Yeah. Okay, here take this. I got it, take that. I think we may be okay on length for a stoma. Yes? Yes. Okay, GIA 100 blue, please. Where's Martine? There, okay. Okay, I think this will be fine guys. Without taking the vein. Okay. So if we needed more length, we would next take the inferior mesenteric vein, which you can see here, okay? This is the vein here coming up to the duodenum. And we would go above the level of the left colic, or if this was rectal cancer, which just it's not. So we'd go above the level of the left colic to here. But we can leave it be. It's all fine. You get a hair more length right here, Dave, just to... You don't need too much... huh? No, we're good. Okay, hold that for me, Rachel.

CHAPTER 6

Okay, you got the ureter under your finger? I do not. Okay, here. Okay, so here's nerve. It's a good example of the pelvic nerve here coming down. And we're gonna drop, you can see that nerve drop down. Dr. Meyer's finger right here. Watch it drop down, right here. So we preserve her nerve. St. Mark's here, So we go in the presacral space, but we're gonna stop higher than usual 'cause he's gonna do a hysterectomy. So we're not gonna separate this plane as much as we normally would. Yeah, that's about the level we wanna stop and leave everything en bloc. Feel that. Hold this here. Yeah, I don't wanna go any lower than that because we were, anteriorly put your finger in the cul-de-sac and you can see where it kind of merges. So here posteriorly, there. Pull hard, and you can see there's the presacral space. Okay. Now we don't have a, it's not sewn shut and there's no mushroom, right? No mushroom. That's fine. Can you feel my finger down at the posterior? Yeah. No, it's down. Further down. Yeah. Further distal, distal, distal. I want you to feel how distal I am? Yeah... Skin, right? Right, exactly. Okay, so we dissect down till we're pretty much at skin. Gonna do a bit more lateral here. She needs her levators to come en bloc. Oh yeah, it's gonna come. I just wanna make it so everything we need to do from above is done. And then while he's working above, we'll go below and we'll start... Okay, so we're now gonna leave this for the gynecologist, the GYN oncologist. So he can en bloc, do a TAH BSO with the posterior vaginal wall. And he's gonna have to preserve the bladder as he works here. So we can put a lap, and down below we've gone all the way down to the levators here. Hold this, Rachel. Give me a... Here I'll show you. So here's ureter, on the left. Pelvic nerve on the left, branching beautifully. And on the right hand side, pelvic nerve here, that wishbone you see coming here. And the right ureter you wanna see as well, but it's under here. You can kind of... I can feel it anyway, but that wishbone is classic for the pelvic nerve. So give me a lap pad to pack the pelvis. And a long DeBakey. Open please. So we'll let him work. So that's it. I'm gonna work from below. No, I want to do below now. This blue handle needs to get changed. Yeah. So we're gonna go below and do our part and stop anteriorly for this part.

CHAPTER 7

And we're gonna stop about there for Cardenas. See he's gonna continue here. This side's okay. Yeah. But this side for sure. We got that lone star? We're not done with the Bovie yet guys. Okay. The Bovie is okay, we don't have suction here. It stopped working but it started again. This is an extralevator APR, There are different types of dissections, you could do an interesting carrot, not for cancer, here, you can do a standard cylindrical APR or you can do what we're doing today, extralevator because of the extent of the tumor. Now the tumor is pretty much circumferential. So I may take the coccyx too. Coccyx is here. Yeah. I can feel it. Huh? You feel it? I went to feel it like... Yeah, you want the coccyx to be in the front, which it is here. Okay. Yeah. And then you're gonna go in the sacrococcygeal joint. Let's have the Bovie extender please. Do we have the lone star yet? Yeah, yeah... This is why you need them laid on the table. Coccyx is right there. Can you raise the table, please? And head down if she doesn't slip? Okay, let's put the lone star. It's gonna help us see. Keep going? Yes, please. And then we're gonna need an Adson-Beckman at some point. Okay, let's have the lone star hooks. I'm just gonna do the posterior and lateral parts. I did everything up top, and I left it en bloc right at the point where it touches the vagina. And I'm gonna do here posterior and lateral, and I just came up the sides here. But I'm gonna leave this for you, inside for you. So I think we're in here. Dave, do you want to go above and take a feel? Sure. Okay, so why don't you work here first. Can you please turn the Bovie to 80. Do you have that Adson-Beckman? The retractor? Okay. So that's the stump of the part, of the S5, sacrococcygeal joint. Yeah. Yeah, here Dave. Here's me. Yeah. Trying to get some vaginal stuff. I think we'll stop there 'cause I don't wanna violate the oncologic planes. Yeah, I mean he can cut across above this. The whole thing's gonna fall out now. Yeah, it's in good shape, feel it, two hands. Dave, you do the same. Feel, two hands. Okay.

CHAPTER 8

Open here and here. Open this space. Don't get too close here. Get in this space. More dissection here. Okay, come this way. Okay, good. Okay. Open parallel now. Good. Excellent. That's good, that's good. Go over here. Okay, open this space here. Do you see this? Ureter is here. Yeah. External iliac artery there, ureter here. Create a window. Here's the ovary. So the ovary's right here. So the window is gonna be more proximal? Okay. Open the space to isolate IP. Here. I'll come up to here. But we're not taking the IP, right? Yes, we are doing, we're removing the uterus to the ovaries. Oh, okay. Perfect. Lemme just create a window here. Close to this one. Parallel. Close. No, closer. Closer. Good. It's too much. You pull back, pull back, pull back, more and more. Yeah. Divide. Tie with a free tie on a pass. Free tie on a pass, please. 0 Vicryl on a needle, next. Don't, it was too much. Switch your scissors please. 0 Vicryl on a CT-1 needle, just put above. Okay. Through the middle and make a loop around, yeah. Needle's out. Needle back. I'm gonna make your life easier. Yeah, don't pull too much. It's ripping there. Instrument back. I'll have a dry lap, please. Thank you. Now we took down the IP now we're gonna take the round ligament, don't sell please. Hold this just one second. Bovie, one second. I'm just gonna modify something here. Yeah, go ahead. Lets do the bladder flap. Pickups to me as well please. Do the bladder flap. So we took down the round ligament, the right round ligament. Now we're gonna do the bladder flap. We're separating the bladder from the lower aspect of the uterus and the cervix. Keep going in the middle. Good. Fat doesn't belong to us. Fat needs to go up. Staying close. Right there. Right here, here's the plane. Yep, I see it. Good, keep dissecting here. Keep taking this. Yeah. Is my light on, or? Okay, go ahead. Take, just on the side, just the... Good. Okay, do more bladder flap. Go here. Good. Excellent. Take this. Yeah, this one. So we're gonna take the whole vagina, anterior and posterior. Yeah. Dissect down the bladder. We can do also from below. Okay, keep dissecting all the way to as much as you can. Great. Thank you. Keep dissecting. Okay, good. A long cervix. A long cervix. It is, yeah. Now take that posterior. Next step is we're gonna take the posterior broad ligament. Babcock clamp, please. Down. Good. So just take the broad ligament. The ureter is here. So I want you to come down like this up here. Yeah. The peritoneum... You're right, that's peritoneum. So here's the Uterine vein. When you feel, no, let me see, hold it. Good. Drop down the... I think we can go with the... Just like drop the ureter a little bit more, posteriorly bring the... Okay, just the peritoneum. Yeah, just the peritoneum. Don't get into the vessel. Nope. More lateral. A little more lateral. Excellent. That's great. You don't have a Z-clamp, right? Zeppelin clamps. Zeppelin, you have any? It's just this one, it's fine. Go ahead, LigaSure. Go ahead LigaSure. LigaSure. 0 Vicryl on a CT-1 is next. Yeah, buzz more... Two times. And I'm gonna buzz it a little bit more proximal. Okay. I would do it this way. Right there, okay? You're not clamped there, right? Do one more. Good. Needle back. Do you feel like it's draining? How much is in the Foley? 300. 300. Okay. But the bladder here looks full. It's very distended, the bladder. Do we have that Z-clamp? I do. Straight. This is too curved Straight Z-clamp. Okay, put the clamp here, same thing what you did on the other side. Yep. Ureter is down, right? The ureter is here. See that? Okay. They took already the IP. See this here? The ureter is here. Here's this ureter here. They took the IP already. Just go with the LigaSure here. Okay. Right, do you agree? Why are we gonna isolate? I think so. Yeah, just go with the LigaSure. Okay. Hold this for you. One second. Yeah. A little higher. A little higher. Ureter is here. Good? Yeah. Until I meet the window. So the left infundibulopelvic ligament was taken down already. So we are just removing the remaining of the IP, connect the dot. Higher, move the nose up. Now take the round ligament. No, I didn't throw back in or whatever you think. Okay. You said, but she has two only. I don't know... I'll be back. Thank you. Stay there, stay there. Just stay there. You're gonna put the stitch. Yeah. 0 Vicryl is next, 0 Vicryl on a needle is next please. Do you see any change? I don't see any change yet, but let me check. Okay. Can I have a curved Mayo. 0 Vicryl on a CT-1 is next. Good. Just cut this time, it;s too small. Needle back. You will cut, okay? Otherwise I'm gonna... Yeah. Cut. Can you expose the back, please. Let's turn back to you. Bouncer, please. Feel it? Scissors, instrument back to you. I can feel it right here. Okay. Hold this for me, please. You stay there. Don't move. Stay there. Show me that. Same thing over here. Yeah. So you have two curved Zeppelins. You have two? So all this vagina is gonna come out in one, feel, this is the cancers. Yeah, I know. But that's from below, right? Yeah, I'm gonna go down. You stay here, please. Yeah. Before you take the uterus, you're going to... Vaginally. Okay. Did you divide the colon already? Yeah, we wanted to take everything like en bloc. En bloc, yeah. No, no, you're fine. Just holding on the - great stuff. It's almost done on each part. I'm gonna go down. I see you gonna take it out en bloc. Yeah. Yeah. Throw me this exposure. It's a great exposure. This is on pelvic sidewall. The ureter is here, coming down here. Okay, move like this. We're gonna dissect here. Okay. Yeah, right there. Here's where the tumor starts. See that, this is tumor. I just don't see where it starts. I mean the tumor is in the rectum. Right here. Can you give me this exposure? Yeah, of course. Yeah, that's all as far as we can go. Here's where the tumor is. Go, like this way real quick. Yeah, right there, okay. Can you retract even more of this? Meet up like that? But I wanna dissect this. Okay, so... Perfect, right there. This is all bladder. Perfect. Good length. Yeah. Yeah, that's where that start seeing desmoplastic reaction due to tumor. Perfect. See, right there. Yeah, that's actually... Yeah, right there. Same thing. I'm gonna dissect the... Yeah. I saw along the cervix. Cervix is still ongoing. Yeah. Can you feel it vaginally? I'm gonna do it. It's so freaking long. Look how long we are already. I know. You see this? That's why like, let me feel it. Okay. Remember, to this? I wonder if it just ended here. You know there's a small cervix. Right there. Excellent exposure. Okay, I'm gonna go down. Okay. Alright, I'm gonna start vaginally. Can you feel my finger in the back of the, where we did a dissection posteriorly? Yeah, let me go... So I can't tell what is the cervix? So this is my finger. Yeah, that's your finger. So okay, we are in the back. Yeah. So that's gonna come in in total, right? This is so freaking hard. You almost, 'cause that's the end of the cervix. All right, so I'm gonna go... Okay. This is all up to here. It's all the way up to here. See, this is tumor, right? Yeah. You feel it? So I'm gonna come up here. Get here and feel it. Here. So now I'm gonna go this way here. Okay. We will come on up the muscles here. This is the bulbocavernosus muscle here. Okay. Are you gonna choose the LigaSure on top again or no? Can I have a Babcock clamp here, to hold like this? Can you hold this one? Babcock clamp. Babcock. Thank you. With your Bovie, can you come here? This is the pubic bone, which you can feel, you hold this for me. I need the LigaSure. Can I choose that LigaSure? I think they said they're not gonna use it. Okay, I take it. Thank you. Let me give it flat. This is your margin, right? This is your margin, so I'm gonna... Can you feel my finger from above? You feel my finger? Yeah, I touched your finger here. Okay. So I'm gonna... Did you feel my finger? Yeah. Hold this here, like this. Like this. Can you feel my finger now? I just wanna make sure I'm in the pelvis already. Yeah, I feel your fingers. Okay, good, good. Is it already... I'm in the pelvis already? Yes. Perfect. Okay. So now I just need to connect the dots here then. I'm in the pelvis and outside the bowel, right? Yeah. Where is my finger in relationship to the ureter? I can feel you. My finger, is it? Medial, I feel it. It is not close, right? No, you have 10. Nope. Okay. I have my finger here on the sidewall where the ureter is, and I... Okay. But I would stay close here to where my finger is. Medially, right? Yeah, medial, yeah. Yeah. Because I can't really feel the... This is my finger. Yeah. So we are almost done anteriorly. See this here? Okay, so what is that tumor? It's here, right? Yeah. You're pulling thing down, yeah. Yeah. So now I'm okay on this side. Just gonna go to the other side. But this is the posterior vagina. New lap please. So I took already a portion of the vulva here. I took... Here's the vagina. This is the bulbocavernosus muscle. We are connecting already with the top of the vaginal apex here. Where is the uterus here? Here, right? The uterus, yep. This is my finger. Yeah. Yeah. Yeah, ureter is up. So this is all out already. It's gonna peel it off. I'm gonna separate the bladder from the vagina now. So we're in this right plane, I think. Yeah, it's gonna continue here. This is not much. See this here. Less than here for sure. So I'm gonna connect here, this way here. Putting my finger here. Can you feel my finger? Oh, it's right here. Can you feel my... My finger is already inside, you see? Inside, but... In the peritoneum. Can you check? Yeah. Yes, you are on the left side of the patient. Yeah, the tumor comes all the way up here. See this? Yeah. See? I have to go... You really have to go anteriorly and posteriorly. So at least go very high. Here... Yeah. The tumor is going to the patient's left vagina and moving towards anteriorly as well. Yeah. I'm gonna go this way and very high. Here's not much. You move towards you, this side. This is a battle. That's what we do, we battle against cancer. Okay. Are you feeling okay? What? Are you feeling okay? Yeah. Okay. Give me a 2 Vicryl on a small needle, please. No. Suture scissors, please. Can I have the vaginal retractor please? Yeah, either is fine. See, look at the tumors going anteriorly as well. Yeah, yeah. Hard to tell. That's a great exposure. That's what I need. It's going really high. All this area needs to go. Have a Deaver, please. Yeah, one of those wide... Yeah. Please Bovie me here. Actually I'll do it. Do you feel my finger? It's right here, it's already here. Can you feel my other finger, and the finger anteriorly? Right here, I feel you. Here, right? And what is between this finger and this one? Is the ureter around? Here. Yeah, yeah. That's a pelvic sidewall. So you have to like go more medial, right here. You see where my finger is? Yeah. This is like... I just don't wanna get too medial because I feel the tumor. Yeah. I see here. It's the sidewall. Yeah, it should be okay. Okay, stay there. This is all out. Can you show me here, please? I just wanna take this, I'm gonna go above. So everything is out in terms of this side. This side. Now it's all about anterior vagina. See this? And the reason I don't wanna take that is because you can see the tumor is extending... Yeah, you can see that. See that? Yeah. Actually I have a nice shot here. Show me here, this one. What is this? This is the uterosacral ligament. No. No, it's going medially. How can it be the stent very posteriorly? This band, this band here. This... This here. It's impossible to be the stent. Hold this. So the tumor is going all the way to the anterior vagina as well. Okay, so you gotta take... Yeah. I'm taking the whole thing here. So now... Right. Finally, I was able to mobilize, everything is detached. Patient left side. Right. Right side is gone. Yeah. The uterus is included. I just have to peel it off the anterior vagina. And that's it. Yeah. Beautiful. You see this, right? Oh, I see. It's going... It's unbelievable. Yeah. It's... But I think we got margins all around it. I went close to the pubic bone here. I wanna make sure... Yeah. What I'm gonna dictate is pubic bone, pubic bone here. There's not much to remove. That's the... It's the ischium, yeah. Yeah. Like a pubic bone and the is ischium, yes. Yes. I'm gonna go... We took the coccyx. The back, we went back. Yeah, we take everything. Yeah, I'm just gonna go anteriorly to peel this off safely. This is anterior vagina, ureter. That's it. Yep, okay. Yeah, okay. I'm gonna go anteriorly. Can you stay here? Can you feel my finger from? Perfect. Here's my finger. It's already. Yeah. Yeah. It's here. Yeah. Okay. This is for you. See that? Yeah. This is tumor too? No, that's not. That's just bladder. Almost over. Yeah, don't open. It's just here. See this? Right there. Don't open the LigaSure. You agree it's not bladder, right? No, particularly with the growth. Okay, you got it? You take it out. Oh, yeah. One sec, one second. No, I think it's better from here. Look, look. One minute. My finger is here. Okay, yeah. One more shot. One second. Your finger is here. One second, one second. No, no, no, no, one sec. Let me take the clamp off. One second. Go ahead. Now you can pull it out. Yeah. Yes. This is for you. This is pretty cool. Removing everything en bloc, right? Everything. So let me... Can I have a lap, please? My re-phrase. Uterus, cervix, uterus, fallopian tube, ovaries, cervix. Total vagina. And do you wanna get a...? Lemme see if I can show here. Can I have a clean lap please? A clean lap.

CHAPTER 9

Colon, rectosigmoid, anus. That is crazy. It looks great. Here's the anus here. Total. No. Here is the uterus with the ovaries. Body of the uterus. Cervix, anteriorly, you have the anterior vagina. This is anterior vagina. In the back is the posterior vagina. Yeah, I know. From up here, it's pretty impressive. With the tumor. Ureter here, you can see them both here. Yeah. Yeah. Yeah. Oh, this is vulva too. Yeah. So I hope it's not tumor here. So vagina is here. This is the vulva. Here is vulva. Vulva. This is vulva too. The tumor is inside. This is tumor, tumor, tumor. Yeah. Anterior vagina. Lateral vagina. This is the right side, left side. Posterior. Are we okay with hemostasis? Yeah... Okay, gonna just take a quick look, make sure I'm not leaving anything behind. So pubic bone, ramus here. This is the... This is an exenteration basically. Yeah. Here is the bladder. Here's the bladder see that? This the bladder mucosa, the stent - I'm gonna check the stents here. Well, that's impressive. What do you think about the stents? The stent are okay. Right. We didn't get into the stents. - No, no, no. Yeah. Right here. And I was trying to follow it. So here's the Foley balloon. I think this is the entry here. Yeah, I can feel the stent here. Yeah, oh we're good. You feel this stent here? This is stent, stent. Yeah, good. The other stent. This side is pretty good. Oh, really? Yeah, good. I'm glad you feel good. Stent keeps coming here. No, it's non-lateral Yeah. Say again. We're ready. He already did. They dissected almost to the pubic bone. We're done. Is there anything suspicious left behind, or it feels good? It feels good. It feels good. It was just close to the ramus of the bone. It was close, but there's nothing more to resect. No. It could be just desmoplastic reaction as well. Yeah, hopefully, make sure we got a good margin. Yeah, absolutely. Are you okay with hemostasis or you want me to? Yeah, we can put a stitch or two in. Yeah, you're right.

CHAPTER 10

They don't like to do this because the ring retractor doesn't hold. Okay, so we're gonna have to go into this. We're gonna leave some behind. So which is the strength layer? Let's see, where do we want to go into this? Here. Yeah. I go in this way, bring this over this way. Yeah, that's probably the best. Alright, so that's where we're gonna start going in. Can I please see a right angle clamp? Grab a pickup and grab that. I'll take an Adson. Thank you. So you got the anterior sheath. You see the anterior sheath there? Right. Allis clamp, please. Can I see a right angle retractor? Let's go back up here, let's do this way. Yeah. Could you take the Bovie down to, Oh, take it down to 35. Let me know when the bipolar is up. Thank you. So let's start right around here. Put one here and put one here. Another one? Did we have some more Allises for this? I don't think so. We might with the... I'm just making do... Yeah, we do. Okay. We have some over here. Two of 'em with the... Okay. With the drapes. Okay. Take that off, come on up. Inscription. Tearing. Bring it down here. Straight up, thanks. Can we see a Babcock? Thank you. So you want to put a little tension on this, you want to grab this and you're gonna get the posterior sheath there as well. So you're not gonna avulse it or anything. It's just a little tension, that's all. Just bring it up here. I'm gonna need some number 1 Vicryl suture please. CT-1. Yeah, well you can, drop that. Reach around with this hand, and draw this to me. LigaSure. LigaSure. Can I have a Ray-Tec, please? Some irrigation and a small Kelly. Irrigation, sorry. Thank you. Please take the Bovie down to 25, two fiver. Thank you. Thank you. You want me to adjust? Yeah. Babcock. Change hands. This way I can get in there. Okay. One second. Can I see an Allis? Is that intercostal? It's gotta be right? Yeah. Hold this like this. Table down please. All right, right there. Can I have head down? I need a St. Mark's retractor please. That's good. No twisting, no turning. Looks good. Can I have a... Babcock off that field? Grab that muscle with the Babcock. Just the edge, just the edge. Good. Clamp, drop. Good. Change my glove. Okay, so let me have the Vicryl. You can put it back in the neutral position. Move it up. Is that neutral? No, that's not neutral. Yeah, take a look up here though. Give her a suture scissor. That's getting better, thank you. Thank you. Cut this right there. Hemostat or Kelly. Grab that. Pickup with teeth. Thank you. Is this diastasis? Let me get a 19 drain please. And a 0 silk suture. I believe I'll need one more Vicryl as well please. Downstairs, I'm gonna need a number 1 looped PDS. I'm gonna need a bunch of 0 Vicryl pop-offs. Like about three, four packs. Yeah, that should be it for now. Maybe some chromics, I'll let you know. 4-0 Chromics, yeah. Gimme some of those. Cut this one. Cut that one. Hold this one up. Cut it right there. Cut everything. Let me get a 15 blade.

CHAPTER 11

Where's my tips? Crisscross. Be a little more aggressive. I'll take a 0 silk suture. Needle back. Thank you.

CHAPTER 12

Yeah, can I give you a pathology? Pathology. Okay. Pathology, that's right. Bring the - the legs down a little bit. We need two Army-Navy's, Kelly. I need a clean lap. But don't open it, please. And I need a Kocher, please. Kelly. Kelly or something? Babcock next. Can I have a lap, please. Do you have that basically? Babcock back, needle back. It's secure. Yeah. It's bigger. Let me get a number 1 PDS please. And a large needle. Well it's not small. Let me know when the PDS is up. Thank you. Behind you. Oh, a looped PDS, okay. Yeah, it's okay. Hold that up for me. Thanks. You can drop it Lucy. I think it's okay now. May I have 4-0 chromic suture please. Okay, do you want the chromic on an SH, or an RB-1? How about an RB-1? Okay. Thank you. No problem. Okay. Can chromic that. I can't bring that forward any, that's really where it is. Us closing the abdominal wall, or are you? Yes, please. You... No, go for it. Can do it. You see on the other side how I have anterior, posterior together? Yes. So you just come through anterior, posterior across, and anterior, posterior across. When you get down to... Drain in the area. There's a drain in there. Yeah. And the sheath, or that's in the pelvis? No, the sheath, I perforated the posterior erector sheath. So it'll drain into the abdomen. When you get down like below the arcuate line, just grab anterior. Okay. Okay. Alright. Sorry. I think Wexner wanted to look before we started closing. Okay. He said he wanted to confirm the orientation of the mesentery. So he can come. And don't forget the Seprafilm. Oh, yeah. Of course. Do you have Seprafilm? Seprafilm? We will. Michelle? Yes. Can you please? Do you know if Wexner is in the other room? Do you need the Seprafilm? Yes. And also, do you know if Wexner is in the other room? Yes, he is. Can you ask him if he wants to see, or we can start to close. And let us know. Let him know you guys are ready to close. We are ready to close. If he wants to see or if we can start. You can tell him we are closing. Yeah, maybe... Can I see the chromic? Thank you. You're welcome. She no longer has a vaginal canal? Correct. Do we have another chromic, please? Oh, I don't know, maybe around another 15 minutes. We'll cut it. Can I get one more chromic? Yep. Cut here. Hold this gently up here. Mosquito. Hold this, gently, don't... So, this is all straight? Yes, sir. Alright, I might do a nice Brooke elephant. So we wanna make sure the stoma and mesentary are straight. So we look inside and see the mesentery going just like that out to the colostomy. We've got our drain in the pelvis and we're gonna put in our Seprafilm and close and mature the stoma. Okay. Excellent. Yes. Fabulous, carry on. Cutting or...? Cut. Okay. Leave a tail. Chromic back if you have any more. You don't have any more do you? Here's a PDS. Yeah, I like that RB. Okay. Can I have a PD and another Seprafilm, please. Whenever you get the chromic, let me know. Alright, I'll take the next Seprafilm. Don't forget the Seprafilm, like a hot dog in a bun. This is simple chromics, you see this? We have another one. This is the last one? I still have another. Right down in the middle. Cut this over here. This you can hold up and you can just take these down. Just edge to edge. See this edge here? Yep. Alright. This edge here. PDS. Yeah. This is skin, mucosa, that's soft tissue. So you're doing skin to skin or skin to mucosa. So just put in a bunch of chromics across from this layer here to the skin layer. Let me put one or two more in just to show you, to get the layers approximated. Okay. So that's the skin up on top. And that's the skin there. Yeah. And then you gotta put some in the middle. Okay. Can I cut this one? It'll help you. Okay. You might want to hold it up with one hand. Okay. While you sew with the other. Yeah. Mucosa to the skin. And if you need more chromics, just get more chromics. Solid closure, all the way. All the way as far back as you can go. Yes. Okay. And then Vicryls, hold on. Yeah. Okay, so. You got a good lap count right now? Yeah. Let's cut that right here. That'll remind you the layers, but it'll have to be replaced. Okay. Hey, I'm gonna give you a needle. I'm gonna give you another needle. I'm going to give you a tenotomy, a needle driver, a staple gun, a lap pad, and a pickup with teeth. Bacitracin ointment when you're done, all the way up here, just make sure that it's closed. Otherwise she'll pee into the empty space. Okay. You're gonna close, right? Yeah. Chromic and Vicryl. I'll start with the chromic. Probe this area here. See where the spaces are. See where the layers are. Right here. Don't press too hard. So I'll go... All the way to here. Now that's the urethra you're touching, right? Give me the scissor. This is the urethra here. Right. Where the stent is. Right. This is the urethra. You don't want to go into that. I already put one in there. Okay. So just... Side to side. Skin to skin as far back. There and there. Yep. And then Vicryls. Okay. Got it. Thank you. I'll take the chromics. Sign out. No specimen. Did what I said I was gonna do. Any questions? No. Alright.

CHAPTER 13

Abram started doing a 5.8. Abram started a 12, 2, five, seven. Five, seven. 11 and then we close things up. Okay? And start with 2 and 11 and 5, and... Hemostat, please, and scissors. Another suture, please.