Anaesthesia for pelvic exenteration surgery

Question 1

Indications for pelvic exenteration

Answer 1

• Malignancy- rectal, anal, sarcoma, ovarian, cervical, vaginal and bladder
• Pelvic abscess with persistent sepsis

Question 2

Contraindication for pelvic exenteration

Answer 2

• Poor baseline functional status usually assessed with frailty scoring systems
• Inability to achieve complete resection of tumour
• Metastatic disease is a relative contraindication depending on where the metastases are

Question 3

What are the five pelvic compartments

Answer 3

• Anterior: the urogenital organ and pubic bones
• Central: all the major pelvic organs
• Lateral x2: Major blood vessels to lower limbs and bony sidewall of the pelvis
• Posterior: Sacrum and associated nerve roots

Question 4

Types of pelvic exenteration

Answer 4

• Extended resection includes on pelvic compartment with partial resection of an adjacent compartment
• Pelvic exenteration is the complete resection of two or more contiguous compartments
• Total pelvic exenteration includes urethra, bladder, rectum, anus, internal reproductive organs and assoc muscles and ligaments

Most often involves a laparotomy with a possible perineal approach but some centres are moving to laparoscopic and robotic work

Question 5

Intraoperative Radiotherapy

Answer 5

Allows for highly targeted radiotherapy of the tumour bed following resection. Reducing chances of local recurrence. This can be done by…
- Electron beam therapy
- Ortholavage systems
- Brachytherapy
This may involve the transfer of the anaesthetised patient intra-op to a radiation bunker.

Question 6

Pre-operative Assessment for Pelvic Exenteration

Answer 6

Aims:
- Identify functional status
- Optimise comorbidities
- Identification of factors that increase complications

Tests:
- U&Es, LFTs, FBC, haematinics, cross-match
- ECG, ECHO
- CPET
- BMI
- Albumin

Patient education and pre-hab are key, psychological support should be offered

Question 7

Intra-operative management for Pelvic Exenteration

Answer 7

Monitoring
- Arterial line, wide bore PVC, CVC
- Urinary catheter
- Temperature monitoring
- Consider invasive cardiac output monitor- LiDCO (may not be feasible as needs to sit in femoral artery), PA catheter
- Oesophageal doppler

Analgesia
- Chronic pain is a common problem in this cohort as is regular opioid use
- Multimodal- paracetamol, lidocaine, ketamine, magnesium, a2-agonist
- Neuraxial and epidural placement- tend to not be used until op is finished due to sympathetic blockade this causes

Fluid and Blood Management
- Bowel prep pre-op causes dehydration
- High insensible losses from large incisions
- Should provide goal-directed fluid therapy
- Aim Hb 70-100 with normal coagualtion

Question 8

Potential complications from the supine position

Answer 8

• Pressure damage to heels, sacrum, posterior scalp
• Possible nerve pressure injuries if inadequate padding

Question 9

Potential complications from lloyd-davies position

Answer 9

• Compression to iliac vessels resulting in ischaemia and risk of VTE
• Impaired lower limb perfusion leading to compartment syndrome
• Femoral, obturator and sciatic nerve injury due to compression

Question 10

Potential complications from lithotomy position

Answer 10

• Compression to iliac vessels resulting in ischaemia and risk of VTE
• Impaired lower limb perfusion leading to compartment syndrome
• Femoral, obturator and sciatic nerve injury due to compression

Question 11

Potential complications from the prone position

Answer 11

• Movement, kinking or displacement of ETT
• Eye injury- ischaemic optic neuropathy, chemosis
• Brachial plexus injuries
• Cervical spine injuries

Question 12

Potential complications from the lateral position

Answer 12

• Movement, kinking or displacement of ETT
• V/Q mismatches and shunt
• Spine and neck injuries
• Pressure injury to the dependent ear, eye etc.

Question 13

Potential complications from Trendelenberg position

Answer 13

• Risk of patient slipping off table and traction injuries if fixed limbs
• Movement, kinking or displacement of ETT
• Facial and periorbital oedema
• Laryngeal oedema
• Raised ICP- confusion on waking

Question 14

Potential complications from reverse Trendelenberg position

Answer 14

• May cause a reduction in pre-load and decreased cardiac output
• May improve ventilation

Question 15

Postoperative management for Pelvic Exenteration

Answer 15

• ICU or surgical HDU care
• Can be extubated at the end of surgery depending on clinical variables such as risk of SIRS, need for large transfusion or need for repeat surgery
• Operative complications: massive haemorrhage, urinary leaks, stoma ischaemia, fistula formations, wound dehiscence, deep space infections, Ileus, AKI, VTE