The curriculum asks for knowledge of 'elective laparoscopic and open procedures on the uterus'.
The topic appeared as an SAQ in 2018 (34% pass rate) in the guise of open surgery for ovarian malignancy.
Examiner feedback was fairly scathing: generic answers which lacked both specificity for the question and the practical elements of anaesthesia for such a patient.
The exact type of surgery performed for gynaecological cancer naturally depends on the nature of the cancer itself
In most cases surgery is performed laparoscopically, including robotic surgery, although there is an appreciable conversion rate to open (e.g. 3.9% for laparoscopic hysterectomy)
Epidemiology
Second commonest cancer in women; incidence 8.4/100,000
Screening programme has improved diagnosis, access to management and prognosis
80 - 90% are SCC, the remainder are epithelial or mesenchymal in origin
Directly via obturator fascia to other pelvic organs e.g. bladder and rectum
Haemtologically to lung, liver and bone
Management
Simple hysterectomy if early disease
If late disease, radical hysterectomy involves removal of uterus, vagina (25%), uterosacral and utero-vesical ligaments, parametrium and pelvic nodes
Age-standardised mortality 2.3%, 5yr survival 66%
Epidemiology
Commonest cancer of the female genital tract; 20.3/100,000
Most commonly adenocarcinoma; other types include adenosquamous, serous papillary, clear-cell or undifferentiated
Risk factors
Hormone-related
High BMI
Diabetes
Low physical activity
Smoking
Spread
Local invasion
Via Fallopian tube to become peritoneal metastases
Via lymphatics
Haematogenous (lung, liver, brain, bone)
Management
TAH + BSO + pelvic lymphadenectomy
Age-standardised mortality 4%, 5yr survival 77%
Epidemiology
Incidence 17.1/100,000
90% epithelial histologically
Late presentation often leads to poor survival
Risk factors
Familial (BRCA1/2)
Obesity
Nulliparity
Spread from other primary (bowel/breast)
PCOS
PID
Spread
Malignant cells slough off and spread:
To other intra-abdominal organs and may require large numbers of abdominal organs being removed at surgery e.g. pelvic exenteration resulting in ureteric division and colostomy formation
Via lymphatic system to areas above the diaphragm
Via haematological system to lung parenchyma and pleura, CNS, bone and skin
Peritoneal carcinomatosis
Management
Neo-adjuvant chemotherapy for debulking of tumour mass with paclitaxel and cisplatin
Complex surgery (laparoscopic/open)
Post-operative chemotherapy common too
Age-standardised mortality 9.1%, 5yr survival 43%
Epidemiology
Rare: incidence of vulval cancer 2.5/100,000 and vaginal cancer 0.6/100,000
Majority of cases are secondaries from other pelvic cancers
Risk factors
Advanced age
Diethylstilbesterol
HPV
Sexual history
Smoking
Management
Management depends on stage, but includes:
Vaginal cancer: partial vaginectomy and lymphadenectomy
Vulval cancer: block dissection of vulva/groin and LN’s
Age-standardised mortality <1% and 5yr survival 58%
Perioperative management of the patient with gynaecological malignancy
Airway & Respiratory
May have chronic smoking-related lung pathology e.g. COPD
Increased intra-abdominal pressure due to ascites can increase risk of reflux
Ascites can also cause massively reduced FRC due to basal atelectasis and consequent V/Q mismatching
Pleural effusions (transudative)
Investigate presence via clinical examination and imaging
Assess exercise tolerance and lung function
May require pre-operative drainage
Pre-operative management involves a full history, examination, review of imaging (CXR, CT), investigation and optimisation of airways disease, and consideration of drainage of ascites, pleural effusion(s) or both
Cardiovascular
May have co-existing cardiovascular disease due to history of smoking and obesity
Anticipate difficult venous access due to chemotherapy/previous use although may have long-term indwelling lines
Assess for cardiotoxic effects of chemotherapeutic agents
Pre-operative management involves standard history taking and cardiovascular examination, ECG and consideration of a TTE to look for cardiac dysfunction ± paraneoplastic pericardial effusions
Renal
Multiple reasons for renal impairment including:
Nephrotoxic chemotherapeutic agents
Effect of diuretics for ascites
Reduced oral intake due to chemotherapy-induced nausea/vomiting
Dehydration from pre-operative bowel prep ± fasting rules
Direct compression or invasion of urinary tract
Pre-operative management involves checking U&E
Gastrointestinal
Risk of liver dysfunction from:
Metastatic spread
Chemotherapeutic agents
Cholestasis from massive ascites
Malnutrition and dehydration risk from:
Reduced oral intake due to chemotherapy-induced nausea/vomiting
Dehydration from pre-operative bowel prep ± fasting rules
Pre-operative management involves checking LFTs, optimising fluid status pre-operatively and considering the need for dietetic input pre-operatively
Haematological
Higher risk of VTE (up to 45%) due to:
Pro-coagulant state of malignancy
Venous return impaired by ascites/intra-abdominal mass
Surgical inflammation
Conversely, there may be higher bleeding risk due to:
Liver disease causing deranged clotting function
Large areas of dissection intra-operatively
May be anaemia due to chronic disease, chemotherapy-induced bone marrow suppression or bleeding from genital tract
Pre-operative management involves checking full blood count, clotting profile, ensuring cross-matched blood available and appropriate perioperative VTE prophylaxis
Immunology
Bone marrow suppression from chemotherapy renders patient high risk for infections
Pre-operative management involves assessing for the presence of active infection pre-operatively and suitable measures to reduce perioperative infection risk
Pharmacological considerations
Paclitaxel and cisplatin cause bone marrow suppression, renal and liver injury and cardiotoxicity
May be taking diuretics to deal with massive ascites, and therefore may have electrolyte derangement
May already be taking anti-emetics due to chemotherapy-induced nausea/vomiting; should ensure uninterrupted administration peri-operatively
May already be taking opioids for abdominal pain; factor this in when prescribing peri-operatively
Consider single dose of gabapentin 600mg pre-operatively
Airway & Respiratory
Intubate patient as major, prolonged, abdominal surgery with head-down position and higher risk of reflux due to intra-abdominal mass
Reduced FRC so requires induction in ramped position, adequately pre-oxygenation
Arterial blood gas monitoring to ensure adequate ventilation
May have high airway pressures due to large abdomen ± intra-operative positioning
Cardiovascular
Two large bore cannulae due to significant risk of bleeding
Arterial monitoring, for invasive blood pressure monitoring and rapid checking of electrolytes, and monitoring of lactate/BE
Central venous access
Consider cardiac output monitoring due to massive fluid shifts from ascites and tissue removal
Analgesia
Paracetamol and NSAIDs may be contra-indicated if there are renal and liver injuries
May require higher doses of opioids if already taking them pre-operatively
Avoid renally-excreted opioids if kidney injury
Use regional anaesthesia e.g. thoracic epidural, rectus sheath catheters
Use adjuncts such as magnesium
Consider ketamine if history of chronic pain or opioid tolerance
Renal
Catheterise to monitor UO to help manage intra-operative fluid balance
Use drugs who do not require renal clearance if there is acute renal impairment e.g. remifentanil, atracurium
Haematological
Significant blood loss due to ooze; use rapid testing for haemoglobin and POC visco-elastic assays
Diaphragmatic surgery relies on complete mobilization of liver through resection of the falciform and round ligaments
If there is invasion near hepatic veins, clamping of supra-hepatic and infra-hepatic vena cava, hepatic vein and hilum may reduce bleeding
Other
Prolonged surgery so meticulous approach to positioning and padding
Antibiotics as per protocol and scrupulous asepsis during procedures (e.g. CVC insertion) due to bone marrow suppression
Temperature monitoring and management with warmed mattress, forced air blankets and fluid warmers
Intra-operative VTE prophylaxis with TEDS and IPCs
Consider postoperative care location; likely to need HDU (level 2) care but possibly level 3
Although day-case laparoscopic TLH is possible this is usually reserved for non-malignant indications
Analgesia
Optimised pain management using a multi-modal approach and pain team input
Regular simple analgesia + opioid PCA + LA infusions e.g. rectus sheath catheters for open procedures
Supportive care
Ongoing oxygen therapy, especially if opioid PCA used
Empirical 2hrs HFNO post-op. improves P:F ratio but not clinical outcomes such as respiratory rate, degree of dyspnoea or POPC rate at 30 days (BJA, 2023)
Ongoing monitoring to titrate fluid therapy accordingly
VTE prophylaxis to include mechanical measures, LMWH and early mobilisation
Re-establish enteral nutrition but may require parenteral nutrition if delayed