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25 Inammatory Bowel Disease
267
distal to the fascia recalling the dissection continues in a more anterior direction toward the levator hiatus following the curve of the distal sacrum.
Whenever massive presacral bleeding is encountered, the initial step is to achieve direct pressure
control of the bleeding site as well as notifying
the anesthesiologist and surgical team to prepare
for the possibility of profound bleeding. If the
bleeding site cannot be controlled in this manner,
the posterior pelvis is packed to halt the
hemorrhage. Once the patient is stabilized, blood
products are made available, and all personnel
are adequately readied, the pressure or pelvic
packing is removed. Bleeding from the veins of
the presacral venous plexus can be suture ligated,
but hemorrhage originating from a sacral basivertebral vein retracted into a sacral foramen requires
obliteration using a variety of techniques used
individually or in combination, such as biologic
tissue (e.g., the epiploic appendix, omental scrap,
rectus muscle) welding, directed coagulation
(e.g., an argon beam coagulator, electrocautery),
focal tamponade (e.g., bone wax, a hemostatic
sponge, a matrix hemostatic agent, rectus muscle/fascia), and occlusive pin (e.g., a thumb tack)
placement (Fig.25.2).
If sidewall or presacral bleeding cannot be con-
trolled after the above-outlined approaches or the
patient becomes unstable or coagulopathic, the
pelvis is packed to achieve hemostasis and the
abdomen is closed with plans to return to the operating room in 2–3 days after the patient is optimized. It is important to arrest all bleeding prior to
constructing any anastomosis because efforts to
control bleeding after an ileal pouch or neo-rectum
is in place can be more difcult and pelvic packing
potentially threatens future problems affecting the
bowel or low-lying anastomosis.
Early Postoperative Complications
Surgical Site Infections
Surgical site infections (SSIs) are one of the
potential complications associated with any surgical procedure, and their incidence after pelvic
surgery for IBD can vary based on several factors, including the patient’s overall health, the
type of procedure performed, the surgical technique used, and the hospital’s infection control
practices. Many of these variables have been discussed in other chapters, but a few aspects unique
to IBD-related surgery warrant mention. IBD is
an inammatory condition that can be complicated by malnutrition, stulas, and abscesses, and
these factors increase the incidence of postoperative SSIs. Moreover, many women with IBD are
being treated with corticosteroids, immunomodulators, biologic agents, and/or small molecule
medications prior to surgery, but only high-dose
corticosteroids—prednisone (at least 20 mg
daily) for at least 6 weeks—have been consistently shown to increase the risk of incisional and
organ/space infections, including anastomotic
leaks [4, 5].
Fig. 25.2 Rectus muscle/fascia sutured into position to
tamponade presacral bleeding from the basivertebral vein
Anastomotic/Pouch Leaks andPelvic
Abscesses
Women with IBD requiring pelvic surgery commonly wish to avoid a permanent stoma.
Individuals suffering from Crohn’s disease of
the large intestine are sometimes candidates for
segmental resection and creation of a low
268
S. A. Strong
colorectal anastomosis or proctocolectomy and
ileal pouch- anal anastomosis (IPAA) while
many patients requiring surgery for ulcerative
colitis elect to undergo proctocolectomy and
IPAA.A leak from an anastomosis or the ileal
pouch can be one of the more devastating complications (Fig.25.3). Construction of a diverting loop ileostomy at the time of the initial
operation does not necessarily decrease the risk
of anastomotic leak but does minimize its consequences. Another technique used to potentially reduce the risk of leak associated with an
IPAA employs close rectal dissection instead of
total mesorectal excision. In the former technique, the superior rectal artery and mesorectum are left intact and the dissection is
performed close to the muscular tube of the rectum. This close dissection is technically more
challenging but tends to be associated with
fewer anastomotic leaks, improved short-term
quality of life, and better fecal continence compared to the total mesorectal excision approach
[6, 7]. Lastly, long-term follow-up suggests that
close dissection might also lessen the risk of
chronic pelvic sepsis [8].
Fig. 25.3 Potential sites of leak from ileal pouch and
ileal pouch-anal anastomosis
Other locations prone to leak include the tip of
the J-pouch and the pouch body staple/suture
line. Both locations are relatively risk-free staple/
suture lines, but a leak can develop due to a technical error or insufcient blood supply, especially
at the tip of the J-pouch. Leaks from a low coloproctostomy, IPAA, or ileal pouch can manifest
themselves through a variety of symptoms (e.g.,
fever, ileus, pain, rigors) and signs (e.g., elevated
C-reactive protein, leukocytosis, tachycardia).
These leaks are generally diagnosed with crosssectional imaging that includes delivery of intravenous, oral, and transanal contrast and/or lower
endoscopy. Some are only identied on routine
transanal contrast imaging performed prior to
ileostomy closure in a patient that had an uneventful postoperative recovery.
Treatment of a pelvic abscess or leak will
depend on the clinical status of the patient, preexisting diversion, and the location of the abscess
and/or leak. Patients should receive broadspectrum antibiotics directed against anaerobic
and Gram-negative bacilli bacteria, and an undiverted anastomotic leak causing pelvic sepsis is
likely to require fecal diversion, abdominopelvic
washout, and extensive drainage. An isolated pelvic abscess can usually be managed by percutaneous transgluteal drainage, but sometimes they
are too small or not accessible; most abscesses
less than 4–5 cm in size can be sterilized with
antibiotic therapy alone. Repeat laparoscopy/
laparotomy is rarely warranted in the diverted
patient, except for a large inaccessible abscess
that is causing signicant sepsis.
Anastomotic leaks with or without an associated abscess are best managed in the operating
room by placing a suitably sized Pezzer catheter
through the anastomotic defect via the anus. The
drain is passed to the height of the associated cavity/tract, secured with a suture to the proximal
bowel at the site of the defect, and trimmed 5cm
beyond the anal verge. Most cavities will quickly
collapse around the drain catheter as evidenced
by a drain injection study performed 4–6weeks
later. The catheter can be replaced by a smallercaliber drain that is passed only halfway along
the tract every 4–6weeks after imaging to conrm shortening of the tract. The drain is ulti-
25 Inammatory Bowel Disease
269
mately discontinued, and the defect is saucerized
when the residual tract measures only 2–3cm in
length. If the tract does not shorten as anticipated,
a septotomy can be performed if the tract is less
than 4–5cm in length using an energy device or
mechanical stapler. Longer tracts or selected
short tracts may require advancement of the
proximal bowel and construction of a neoanastomosis. Vacuum-assisted devices like those
commercially available outside the United States
can be pieced together, placed through an endoscopically reachable anastomotic defect, used to
expedite the collapse of a cavity, and may be
linked to improved pouch function and a lower
risk of pouch loss compared to more conventional management [9].
Percutaneous drainage of an abscess arising
from an anastomotic leak has the potential to
cause an extrasphincteric stula, but this rarely
materializes [10]. This approach can be coupled
with efforts at endoscopic or transanal suture closure of the anastomotic defect prior to discontinuation of the percutaneous drain. Abscesses caused
by leaks from the tip of the J-pouch or body of the
ileal pouch commonly require percutaneous
drainage for source control and fecal diversion if
not already in place. Endoscopic closure of the
defect can be subsequently attempted but the success rate is low, especially with leaks from the tip
of the J-pouch, which typically require mobilization of the upper pouch and amputation of the culprit segment or ileal pouch excision and
construction of a neo-ileal pouch [11]. That operation is usually scheduled to occur no sooner than
6months after the last abdominal operation.
IPAA and are commonly predated by early postoperative sepsis. Other risk factors include preoperative high-dose corticosteroid usage,
technical problems encountered during proctectomy or ileal pouch creation, and a postoperative
diagnosis of Crohn’s disease. These stulas are
typically diagnosed with contrast-enhanced
imaging studies and lower endoscopy studies and
their management can range from observation for
simple asymptomatic stulas to pouch excision
and creation of a permanent ileostomy for unsalvageable situations with debilitating symptoms.
Patients with stulas linked to Crohn’s disease
complicated by inammation of the ileal pouch
or anal canal are best treated with medical therapy and are generally not operative candidates.
Most other cases suitable for operative repair will
begin with fecal diversion and drainage of the stula when possible. An ileostomy is created using
a segment of the bowel located more proximally
than usual in case construction of a neo-ileal
pouch is required during the next operation.
Fistulas arising from a stapled IPAA extending to the perineum can be treated with transanal
or transabdominal ileal pouch advancement and
construction of a neo-IPAA (Figs.25.4 and 25.5).
Similar stulas involving the vagina may resolve
with observation if they are diagnosed in the
early postoperative period but will require surgi-
Late Postoperative Complications
Anastomotic/Pouch Fistulas
Although most women undergoing a proctocolectomy and creation of an IPAA experience
acceptable functional outcomes and satisfactory
quality of life, complications such as ileal pouchrelated stulas (e.g., pouch-perineal stula,
pouch-vaginal stula) occur in 1.5–12% of cases
[12]. They usually occur several months after
Fig. 25.4 A stula extending from ileal pouch-anal anastomosis to the posterior vagina
270
abc
S. A. Strong
cal repair if they persist or develop later, although
the underlying Crohn’s disease must always be
excluded. In women who are candidates for
repair, the integrity of the anal sphincter must be
assessed and concomitant sphincteroplasty is
generally indicated if a sphincter defect is noted
Fig. 25.5 A stula from ileal pouch-anal anastomosis to
the vagina repaired by mucosectomy, ileal pouch advancement, and creation of neo-ileal pouch-anal anastomosis
in addition to the stula (Fig. 25.6). The repair
can be performed as described for a stula to the
perineum, but a transvaginal approach can also
be considered. Pouch-vaginal stula repair can
be further buttressed using an interposed tissue
such as a Martius ap or the gracilis muscle, but
this is often reserved for a repeated attempt at
repair (Fig.25.7).
Enterocutaneous stulas caused by leaks from
the tip of the J-pouch were discussed earlier.
Similar stulas from the body of the ileal pouch
require mobilization of the ileal pouch and usually disconnection of the IPAA, repair of the
defect or creation of a neo-ileal pouch depending
upon the condition of the affected pouch, and creation of a handsewn neo-IPAA.
Transabdominal redo ileal pouch surgery is
warranted for several other indications such as
obstruction, dysfunction, pouchitis, prolapse, and
neoplasm, and the conduct of that operation is
predicated upon the underlying problem, condition of the existing ileal pouch, and integrity of
the existing anastomosis [13].
A recent systematic literature search of women
with ileal pouch-vaginal stulas has identied 34
relevant studies and suggested that a repeat IPAA
Fig. 25.6 Repair of stula from ileal pouch-anal anastomosis to the vagina with concomitant anal sphincteroplasty
25 Inammatory Bowel Disease
ba
Fig. 25.7 Repair of stula from ileal pouch-anal anastomosis to the vagina with a Martius ap
271
procedure is associated with the lowest recurrence
rate (42%), while the transanal ileal pouch
advancement operation had the highest risk of
recurrence (57%) [12]. It was also noted that
Crohn’s disease is responsible for one in four
pouch-vaginal stulas. When considering redo
ileal pouch surgery for all indications, a new
pouch is created in 41% of patients, the short- term
anastomotic leak rate is 8%, and 20% of individuals are expected to experience redo IPAA failure
after a median follow-up of 7years with pelvic
sepsis developing after redo ileal pouch surgery as
the primary predictor of pouch failure [13].
Overall functional outcomes and quality of life
scores are acceptable following a redo operation.
Infertility
The effect of surgery on infertility and pregnancy
outcomes was assessed in a recent Cochran
review [14]. Nine studies compared patients with
and without a history of prior IBD-related surgery, and another study contrasted women undergoing open versus laparoscopic IPAA.
Unfortunately, all the studies showed a high risk
of bias in at least two domains. They reported
that IBD surgery may increase the likelihood of
infertility at 24months [(relative risk (RR) 3.59,
95% condence interval (95% CI) 1.32–9.73;
190 participants; 1 study)] while the incidence of
infertility seems comparable in women who
undergo open compared to laparoscopic restorative proctocolectomy at 12 months (RR 0.70,
95% CI 0.38–1.27; 37 participants; 1 study). IBD
surgery may also adversely affect pregnancyrelated outcomes including miscarriage (odds
ratio (OR) 2.03, 95% CI 1.14–3.60; 776 pregnancies; 5 studies) and usage of assisted reproductive
technology (RR 25.09, 95% CI 1.56–403.76; 106
participants; 1 study) but not the incidence of
stillbirth (RR 1.96, 95% CI 0.42–9.18; 246 pregnancies; 3 studies), preterm birth (RR 1.91, 95%
CI 0.67–5.48; 194 pregnancies; 3 studies), low-
272
ba
S. A. Strong
birth-weight babies (RR 0.61, 95% CI 0.08–4.83),
or small-for- gestational- age infants (RR 2.54,
95% CI 0.80–8.01; 65 pregnancies; 1 study).
While assisted reproductive technology is safe
and effective in patients with IBD, that efcacy is
reduced in women who had previously undergone Crohn’s disease-related surgery and others
experiencing pouch failure [15].
Sexual Dysfunction
Sexual dysfunction is common among women
with IBD as demonstrated by a systematic review
and meta-analysis that included 18 studies where
their prevalence of sexual dysfunction was 53%
(95% CI 50–55%, P<0.001) and even higher in
individuals undergoing operation [odds ratio
(OR), 1.33, 95% CI 1.22–1.45, P<0.001)], suffering from depression (OR 6.14, 95% CI
3.51–10.76, P <0.001), experiencing increased
disease activity (OR 2.73, 95% CI 1.32–5.64,
P = 0.007), aficted with comorbidities (OR
3.21, 95% CI 2.06–5.00, P<0.001), or requiring
corticosteroid therapy (OR 2.62, 95% CI
1.48–4.66, P=0.001) [16]. Of women undergoing a proctectomy for inammatory bowel dis-
ease, their total Female Sexual Function Index
score and category-based assessments (i.e.,
desire, arousal, lubrication, orgasm, satisfaction,
pain) do not signicantly change after surgery.
However, subgroup analysis suggests women
undergoing an IPAA tend to experience some
improvement but not to a degree that is statistically signicant [17].
Unhealed Perineal Wound
A signicant proportion of patients (37%–79%)
experience delayed perineal wound healing following proctectomy for IBD, and it occurs more
commonly in patients with Crohn’s disease
undergoing proctectomy than in those with
ulcerative colitis (Fig.25.8). While past studies
[18] have reported that several factors were asso-
ciated with delayed healing (e.g., age, the presence of a high-lying anorectal stula, sex,
perioperative corticosteroid usage, degree of
contamination at operation, wound management), more recent studies [19, 20] have suggested that the presence of preoperative perineal
sepsis and ileal pouch complications are the
principal culprits. Accordingly, fecal diversion
Fig. 25.8 Methods for managing excision of the sphincters for patients with inammatory bowel disease (left: intersphincteric; right: extrasphincteric)
25 Inammatory Bowel Disease
Fig. 25.9 An unhealed perineal wound following proctectomy for Crohn’s disease (patient lying in the left lateral decubitus position)
alone is initially recommended followed by subsequent proctectomy or ileal pouch excision
with excision or unroong of all stula tracts
once the local sepsis is adequately controlled.
The close rectal dissection discussed earlier
actually increases the risk of perineal complications, and, thus, total mesorectal excision is recommended [21].
The management of an unhealed perineal
wound—a wound that has failed to heal after
6 months—depends upon the features of the
wound and whether a presacral sinus tract is present (Fig.25.9). A simple wound must be opened
to sufciently expose its depths and then allowed
to close by secondary intention, skin grafting, or
local ap closure. Presacral sinuses are more difcult to manage because they are associated with
a long tract lined by a biolm that will not heal by
secondary intention. In this instance, a transabdominal or transperineal procedure is usually
required with the harvesting of an omental or
muscular ap to ll the pelvis after all aspects of
the perineal wound and sinus tract are thoroughly
debrided.
Entrapped Ovary (Inclusion Cyst)
Pelvic cysts can develop several years after proctectomy for IBD, and the cause is likely due to
descent of the ovary from an intraperitoneal loca-
273
tion to an extraperitoneal position [22]. This condition may be avoided by performing a simple
oophoropexy procedure that xes the ovaries to
the lateral wall of the peritoneum with nonabsorbable mattress sutures placed at the time of
proctectomy. Affected women typically present
with symptoms due to compression of contiguous structures by the enlarging cyst(s), and crosssectional imaging generally shows cystic masses
in the retroperitoneum. Simple cyst aspiration is
associated with a high rate of recurrence that
occurs soon after the procedure. Instead, the cyst
should be excised, and the ovary dissected free
and xed within the peritoneal cavity. If the cyst
walls cannot be removed without injury to vital
structures, partial resection or marsupialization is
recommended along with xation or removal of
the ovary.
Summary
Pelvic surgery for Crohn’s disease and ulcerative
colitis can be associated with intraoperative complications such as injury to the surrounding structures and bleeding from the vessels located along
the pelvic sidewalls or presacral veins. The most
bothersome early postoperative complications
are infection-related while late complications can
result from these infections in the form of a stula or chronic sinus. Infertility, sexual dysfunction, nonhealing perineal wound, and pelvic cysts
are other problems that can manifest themselves
months or years after proctectomy for inammatory bowel disease.
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C, Cacciottola L, Boissel N, Liebenthron J, Pellicer
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9. Wasmann KA, Reijntjes MA, Stellingwerf ME,
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11. Holubar SD, Rajamanickam RK, Gorgun E, Lightner
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Complications ofResection
ofRetroperitoneal Tumors
intheFemale Pelvis
EmmanuelZervos andNasreenA.Vohra
26
Introduction
Tumors oftheFemale Pelvis
Outside of genitourinary pathology, rectal cancer
is by far the most common tumor of the female
pelvis occurring in about 19,000 women per year
in the United States [1]. Rectal adenocarcinoma
arises from the mucosa or polyps of the rectum
and is, thereby, less conspicuous on axial imaging
than most other pelvic pathology. Occasionally,
nodal metastases in the mesorectum may manifest
as a “pelvic tumor” but these are quickly characterized once the mucosal-based primary reveals
itself through symptoms (obstruction or hematochezia) or endoscopy. Less frequently, gastrointestinal stromal tumors (GIST) and carcinoid
tumors can also arise from their associated components of the rectum with about 6% of approximately 1500 GISTS in the US each year occurring
in the colorectum [2]. GISTs arise from specialized cells within the GI tract known as the interstitial cells of Cajal and, although common in the
more proximal GI tract, are relatively rare in the
rectum [3]. Rectal carcinoid tumors arise from
enterochromafn (Kulchitsky) cells found in the
crypts of Lieberkuhn and are the second most
E. Zervos (*) · N. A. Vohra
Surgery, Division of Surgical Oncology, ECU Health
Medical Center, East Carolina University,
Greenville, NC, USA
e-mail: ZERVOSE@ecu.edu; VOHRAN@ecu.edu
common rectal pathology behind adenocarcinoma
[4]. The rectum is the most common site of GI
carcinoid tumors and their incidence is rising representing about 3500 cases per year in the United
States [5].
Sarcoma is the most common pelvic tumor that
does not arise from the rectum. Sarcomas can originate in any of the soft tissue components of the
pelvis including: fat (liposarcoma); muscle (leiomyosarcoma); bone (rhabdomyosarcoma); blood
vessels (angiosarcoma) and nerve tissue (neurobroma, neurobrosarcoma). Most pelvic sarcomas
extend into, or out of the pelvis with few conned
to the true pelvis. Modern high- resolution imaging
(either thin slice CT or MRI) can often distinguish
the origin of these tumors based on imaging characteristics and anatomic relationships.
Beyond rectal tumors and sarcomas, all other
non-GU pelvic tumors are comparatively rare.
Chordomas arise from remnant cells of the embryologic notochord most commonly anterior to the
spinal cord at the sacrum. About 33 women are
diagnosed each year with sacral (pelvic) chordoma
in the United States [6]. Neurobromas although
rare are the most common pelvic tumor in individuals carrying the NF gene mutation and, with
the exception of aneurysmal disease, tumors of
vascular origin arising from the pelvic vessels are
exceedingly rare. Figure26.1 outlines and characterizes non- urogynecological pelvic masses based
on location and malignant potential.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Hoffman et al. (eds.), Major Complications of Female Pelvic Surgery,
https://doi.org/10.1007/978-3-031-66772-5_26
275
276
E. Zervos and N. A. Vohra
Benign
Peritoneal cysts
Lipoma
Mesenteric cysts
Impacted stool
Diverticulitis
Abscess
Schwannoma
Paraganglioma
Extragonadal
teratoma
Leiomyoma
Intraperitoneal
Non-urogynecological pelvic
Malignant
Colon/rectal
cancer
Adeno
Neuroendocrine
Sarcoma
GIST
LMS
Desmoid
masses
Benign
Hind gut cysts
Diverticulitis
Abscess
Impacted stool
Schwannoma
Paraganglioma
Extraperitoneal
Malignant
Rectal cancer
LMS
Liposarcoma
GIST
Desmoid
Chordoma
Fig. 26.1 Differential diagnosis of non-urogynecological pelvic masse
The primary treatment for the majority of
tumors originating in the pelvis is surgical resection even when they represent locally advanced
unresectable or metastatic manifestations of latestage disease. The narrow connes of the pelvis
and symptoms imparted on the daily activities of
micturition, defecation and occasionally sexual
intercourseby bulky tumor masses often mandate
the complications associated with the surgical
management of these tumors are similar for all
tumor types. Most are described in detail in other
chapters of this book and will be described very
supercially in this chapter with references to
those other chapters. As such, we will focus on
those complications that are most common and
not covered elsewhere in this textbook.
some type of surgical intervention to facilitate
these functionsand mitigate symptoms. Tumors
arising from or invading the pelvic sidewall or
sacrum (generally above S3) are usually managed with fecal and or urinary diversion for
Complications ofResection ofNon-
gynecologic Tumors intheFemale
Pelvis
symptom relief as these are generally unresectable with curative intent due to neurogenic consequences and instability of the pelvis resulting
from sacrectomy above that level. In that regard,
The complications of the removal of these tumors
can be broadly separated into three categories: (1)
Vascular; (2) solid organ and (3) Neurologic. We