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cerning anal discharge, pain, or bleeding. An anal Pap smear with high-
resolution anoscopy is performed, followed by a digital rectal exam and
inguinal lymph node palpation. Further treatment is based on Pap smear
findings (Figure 6.4) [13,50].
Unfortunately, optimal follow-up for other, lower-risk groups (such as
heterosexual men and women with anal condyloma) are not defined. Pro-
spective studies in these groups are much more difficult, the numbers of
affected individuals are fewer, and medical follow up is less likely. Even so,
a number of possibly high-risk subgroups, including women diagnosed
with cervical dysplasia and prostitutes, may benefit from this algorithm as
well.
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6. Investigation and Management of Malignant Anal-Canal Tumours 131
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134 N.N. Mahmoud and R.D. Madoff
7
Difficult Intraoperative Problems
in Pelvic Surgery
Finlay J.M. Curran and Nigel A. Scott
1. Introduction
Colorectal surgery in the pelvis is directed at removing a neoplastic or
inflammatory process from the confines of the pelvic cavity and/or recon-
structing intestinal continuity to the anal canal. Both types of pathological
processes, unrestrained by anatomical planes, can involve adjacent pelvic
viscera, the pelvic nerves, the musculature of the pelvic floor, pelvic vessels,
and the bony pelvis in an unpredictable fashion. Intraoperative problems
and dilemmas in the pelvis are posed by the complexity of the structures
that are involved by the pathology compounded by the narrow confines and
restricted access of the true pelvis. In addition, the restoration of rectal and
genitourinary function along with wound reconstruction presents a wide
range of technical intraoperative challenges [1].
The best approach to difficult intraoperative pelvic problems in colorec-
tal surgery is anticipation of the problem and its planned management
to optimise patient outcomes. Preoperative planning involves meticulous
imaging and detailed patient discussion, assembly of an experienced
multiprofessional team, and appropriate operating room and preoperative
resources.
2. Preoperative Planning
For the colorectal surgeon, difficulties in the pelvis are compounded by
unexpected tumour or inflammatory involvement of vascular structures,
genitourinary structures, and pelvic musculoskeletal components. Loss of
tissue planes due to previous pelvic surgery and/or radiotherapy exacer-
bates these surgical difficulties (Figure 7.1). Anticipation of anatomical
problems is based on a comprehensive preoperative imaging strategy might
include the processes in Table 7.1.
Having delineated the extent of the pelvic pathology and established the
feasibility of excision, detailed involvement of the patient and relatives in
135
136 F.J.M. Curran and N.A. Scott
Table 7.1. Preoperative imaging strategy.
Inflammatory Process Neoplastic Process
Physical, including pelvic examination Physical, including pelvic examination
under anaesthetic under anaesthetic
Lower gastrointestinal endoscopy Lower gastrointestinal endoscopy
Cystoscopy Cystoscopy
Computed tomography of the pelvis Computed tomography of the pelvis
Magnetic resonance imaging of the Magnetic resonance imaging of the pelvis
pelvis
Gastrointestinal contrast series Transrectal ultrasound
Intravenous pyelogram Staging computed tomography chest and abdomen
Excretion renogram Positron emission tomography scan
Intravenous pyelogram
Excretion renogram
Figure 7.1. Magnetic resonance imaging of a rectal-cancer recurrence.
the operative strategy is essential. Excisional pelvic surgery has a range of
potentially devastating mental and physical consequences for the patient.
Addressing these concerns preoperatively considerably simplifies the man-
agement of problems encountered intraoperatively (Table 7.2).
The final aspect of preparedness for complex pelvic surgery and associ-
ated intraoperative problems is the identification of the resources and per-
sonnel required for the planned procedure and anticipated intraoperative
problems. Multidisciplinary team operating is a skill that is developed by
frequent practice. Consultants that commonly operate together develop
intraoperative patterns of working that are difficult to emulate in ad hoc
surgical teams summoned to the operating room on an urgent unplanned
basis.Although not all are applicable to the majority of cases, access to the
resources listed in Table 7.3 should be considered in the planning of a
complex colorectal pelvic case.
It is mandatory that a complex colorectal procedure be conducted with
the correct personnel and within the correct environment. Senior theater
nurses with an extensive colorectal experience are essential for difficult
pelvic surgery to both anticipate problems and manage the technical
requirements of a multidisciplinary surgical team. Junior surgical trainees
are not suitable sole assistants for complex pelvic surgery. Senior trainees,
colorectal specialist surgical assistants,and/or joint consultant operating are
more appropriate.
Exposure of the pelvic operative field can present a problem. While the
pelvis of a thin female allows easy, direct visualisation of the procedure, the
obese male pelvis is a much more difficult environment to operate within.
The majority of colorectal pelvic surgery is conducted in the Lloyd Davis
position (Figure 7.2). Careful attention has to be paid to the positioning of
the lower limbs to avoid compression of the lateral popliteal nerve and
7. Difficult Intraoperative Problems in Pelvic Surgery 137
Table 7.2. Potential mental and physical consequences
of excisional pelvic surgery for the patient.
Loss of anorectal function and stoma formation
Loss of bladder function and stoma formation
Loss of sexual function
Postoperative morbidity including nonhealing perineum
Postoperative mortality
Adjuvant morbidity
Risk of noncurative procedure
Table 7.3. Identification of the resources and personnel that should be considered
in the planning of a complex colorectal pelvic case.
Consultant Surgical Operating Room Resource Perioperative Care
Personnel
Colorectal surgeon Three-session day MPT discussion
Urologist Three scrub teams Stoma care
Gynaecologist Two consultant anaesthetists Preoperative clinic
Neurosurgeon (spinal) Image intensifier, epidural placement Bowel preparation
Plastic surgeon Repositioning (Lloyd Davies, prone, Blood bank on site
Vascular surgeon supine) HDU bed provision
Cell Saver® access ITU bed provision
Figure 7.2. (A) Overall view: Lloyd Davis position with head down. (B) St. Mark’s
retractors.
A
B
lower-leg compartment syndrome. For removal of the anal canal,the coccyx
must be advanced beyond the edge of the operating table. When a muco-
sectomy or intersphincteric dissection is contemplated, it is helpful to
retract the buttocks of an obese patient with adhesive tape. A posterior
approach to the sacrum necessitates intraoperative repositioning of the
patient into the prone jackknife position.
The dissection techniques used for a malignant process differ funda-
mentally from those used for an inflammatory mass. An inflammatory
process is pinched off adjacent to the involved structures in the expectation
that removal of the inflammatory focus will be followed by resolution of
the inflammation. By contrast, a malignant process must never be trans-
gressed by the dissection—malignancy must be removed intact within a
block of normal structures for local cure to be effected.The pelvis is cleared
of small bowel loops by positioning the patient head down. Early in the
process of defining a malignant pelvic mass, loops of small bowel adherent
to the mass should be divided across with a 55-mm stapling gun. Similarly,
the sigmoid should be divided from the rectum and all the abdominal
viscera packed away from the pelvis into the upper abdomen.
Access and retraction is greatly assisted by using a mechanical retractor
such as the Omnitract. Two short blades are used to retract the abdominal
wall laterally and the large fence retractor placed over packs keeps the
small bowel out of the pelvis. Finally, the lipped retractors can be used to
retract the bladder or the vagina and uterus anteriorly away from the
rectum. Standard theater lighting can be adequate for illuminating the gen-
erality of the operative field, but detailed dissection on the pelvic floor
requires lighting directed into the pelvis. Headlamps offer a consistently
high standard of pelvic illumination. An alternative is a lighted retractor,
which is useful for dissection deep onto the pelvic floor.
Difficult intraoperative pelvic problems consist of (a) vascular or uro-
genital collateral damage, (b) specific excisional problems, and (c) pelvic
visceral and soft tissue reconstruction.
3. Collateral Damage
3.1. Intraoperative Pelvic Haemorrhage
Colorectal pelvic surgery can be complicated by difficult intraopera-
tive haemorrhage. Haemorrhage during surgery in the pelvis can be a life-
threatening event and usually arises from either the presacral venous plexus
or from branches of the internal iliac vessels on the pelvic sidewall.
3.1.1. Presacral Venous Haemorrhage
There are two separate systems of veins in the presacral space and each is
a potential source of bleeding [2]. The presacral venous plexus forms one
7. Difficult Intraoperative Problems in Pelvic Surgery 139
system and this communicates with the internal sacral venous drainage by
a series of basivertebral veins.The adventitia of the valveless basivertebral
veins is continuous with the sacral periosteum as the vein enters the sacral
foramen. The damaged the veins can retract into the sacral foramina and
form a second potential source of major presacral bleeding.
Presacral bleeding in the majority of cases is due to performing the dis-
section of the mesorectum posterior to the rectum in the wrong plane [3].
The correct plane for mesorectal excision is through loose areolar tissue,
which is almost completely avascular. If this plane is not defined correctly
by sharp dissection, the surgeon can begin to remove the presacral fascia,
particularly if conducting a blunt dissection behind the rectum with the
hand or a swab on a stick. Such a blunt stripping disrupts the hypogastric
plexus and exposes the lumbosacral disc, the sacral periosteum, and the very
thin-walled veins of the presacral plexus. Continued blunt stripping of the
presacral fascia tears these veins and initiates torrential venous bleeding.
Haemorrhage from the presacral plexus will not improve by placing the
patient in a steep Trendelenburg position, as this increases the pressure
within the basivertebral veins, facilitating further bleeding. The best initial
manoeuvre is to stop operating and use the pressure of a pack accurately
placed over the bleeding point to stem the blood loss. Keep the pressure
applied with your hand to ensure that you have control while you consider
your options. Do not waste time and circulating blood volume by sucking
at a bleeding field that you cannot define due to the torrential loss of blood.
Do not take the pack in and out frequently to be greeted by severe blood
loss—be prepared to sustain the pressure with the help of an assistant for
30 minutes or so.
While gaining control of the bleeding by pressure,inform the anaesthetist
that you have a significant problem with pelvic bleeding. Give the anaes-
thetist time to consider the following while you maintain haemorrhage
control by pressure: (a) immediate blood and/or fluid infusion if clinically
appropriate, (b) arranging for cross-matched units to be brought to theatre,
(c) arranging for further cross-match units, or (d) arranging for a Cell
Saver® (Haemonetics), if available.
You should also consider the personnel, equipment, and manoeuvres you
may need to employ to stop the presacral bleeding. Do you have a suitable
assistant to help you visualise the bleed and deal with it? If not, consider
sending for more experienced help, including a fellow consultant, at this
stage. Is the lighting adequate? Would a lighted retractor or a headlight
improve the view? Do you need two suckers to clear the operative field for
a good view when the packs are removed?
What technique might arrest the haemorrhage?
• Pressure alone with haemostatic Surgicel (Johnson & Johnson)
• Diathermy with spray on
• Argon beam plasma coagulation
140 F.J.M. Curran and N.A. Scott
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