reference to those chapters.

The repair of these defects can range from simple closure to complex vaginoplasty. In cases that involve either obligate (for margin) or inadvertent resection of the vaginal wall, early engagement of the gynecologic oncologist and/or plastic and reconstructive surgery team provides the greatest chance for a good functional outcome. Upper vagi­nal injuries can often be resolved with hysterec­tomy and incorporation of the injury in the resection specimen. Injuries occurring in the lower third of the vagina are most problematic owing to their implications for vaginal stenosis at or near the introitus and its impact on sexual intercourse. Figure26.2 depicts a breakdown of a primary vagi-

nal repair following abdominal perineal resection for rectal cancer that resulted from negative pres­sure wound therapy in a dehiscent perineal inci­sion. Ultimate reconstruction with skin graft and gluteal advancement ap is shown in the panels. Mid-vaginal injuries are a gray area and must be assessed on an individual basis taking into consid­eration the precise location and extent of the injury, the length of the vaginal remnant and the patient’s desire to engage in sexual intercourse. More com­plicated vaginal reconstruction using a skin graft or vascularized transposition aps can be fashioned from the epidermal components of planned trans­position aps mobilized to ll the pelvic void cre­ated by radical extirpation. This subject is covered in greater detail in Chap. 41. Figure26.3 demon­strates vaginal reconstruction using the preserved skin from a vertical rectus myocutaneous ap employed to ll the pelvis in a thin patient with a bulky lower rectal tumor that invaded the vagina.

to minimize bladder injury. Maintenance of one intact ureter allows such reconstructive options as well as others like uretero- ureterostomy or wet colostomy, which

clearly. This is rarely necessary but is a useful tool As in real estate, injury to the bladder and its man-

Bladder injury during pelvic dissection is easy to

separating the ureter from the bladder at that level and reimplantation over a stent. Resection of the dome of the bladder to mitigate injury or achieve margin is possible as long as there is no signi­cant reduction in bladder volume. As injury extends more distal in the bladder or more length needs to be bridged with a bladder ap, the risk of microbladder increases.. The bladder is forgiv­ing and will tolerate tension and ischemia more readily than the gut. Simple cystotomy can be oversewn in two layers with an absorbable suture to approximate the mucosa and interrupted sero­muscular sutures to reinforce the repair. A drain should be left in place in the rare event that a leak does occur in the postoperative period and should be assayed for creatinine prior to removal. A foley catheter should remain in place for at least 7 days following repair and, as a precaution, the drain should be removed only after the patient demonstrates the ability to void normally.

Finally, when utilizing a lower mid-line inci­sion, one must always be cognizant of the risk of bladder injury as the incision extends towards the pubic symphysis. Extra care must be taken in the obese and reoperative patient as the planes of the anterior abdominal wall and bladder may be fused and difcult to separate. Bladder injury of this nature at the very outset of an anticipated complex and difcult planned procedure is particularly dis­satisfying and, needless to say, should be avoided. Consideration of the possibility of such injury and close supervision of trainees as the pelvis is exposed is usually sufcient to prevent it.

Vascular injury during resection of pelvic tumors usually occurs at the sharp end of a metal instrument such as a ne scissor or scalpel, which are frequently utilized to dissect a solid tumor away from surrounding named blood ves­sels. Blunt and/or blind dissection deep in the female pelvis can also lead to signicant venous hemorrhage as side branches arising from the hypogastric vein are easily avulsed. We use the small- jawed Maryland Ligasure dissector (MedTronic, Inc. St. Paul, MN) deep in the pel­vis, following the pelvic sidewall closely to minimize risk of avulsion. This bipolar surgical instrument is better suited to insinuate between tumors and the pelvic sidewall than its larger counterpart and is capable of sealing named and unnamed venous tributaries as large as 7mm. A word of caution is in order at this time: use of the larger “Impact” Ligasure device reduces precise visualization of the entire length of the active jaws, especially in tight spaces. As such, there is risk of unintended and or unrecognized “side biting” of the named deep pelvic vessels (Fig.26.5). This area of sealing may be initially hemostatic but can result in catastrophic blow­out at any point, especially when venous return increases with resuscitation, normal positioning and normalization of the blood pressure in the postoperative period. Inammation and abscess formation in the early postoperative period can also weaken an already compromised lengthy vascular seal and lead to dehiscence. Extreme caution should be exercised bearing this specic complication in mind when using this partially blind technique in mobilizing deep attachments of pelvic tumors. Figure26.6 shows a bulky pel-

reminds the surgeon of its presence with each beat of the patient’s heart and the relief felt in the heart of both the patient and surgeon is unmistak­able. Compromise of arterial inow to the lower extremity in the setting of arterial injury and repair should be ruled out using Doppler ultra­sound anywhere distal to the repair in the arterial tree. Venous injury as described abovethat isrec­ognized in the recovery room or beyond is likelycatastrophic and must be approached as a traumatic injury for there to be any hope of

size (8½) surgical glove can be inserted into the perineal defect and packed with lubricated laparotomy packsor Kerlix gauze to exert pres-

packs can be removed at the bedside or in the OR once the coagulopathy is corrected. The perineal defect can then be closed without having to re­enter the peritoneal cavity.

Decits resulting from traction and compres­sion of the nerves during surgery can result in various degrees of pain, paresthesia, and/or weakness, depending on the severity of injury. In most cases their recognition is delayed and usu­ally managed with physical therapy, with resolu­tion of symptoms over time. Entrapment v can be a major source of pain and may require decom­pression of the involved nerve.