Cystectomy - Intraoperative High Yield
See here for general information about cystectomy
CONDUIT PROTOCOL
1. midline incision into abdomen
2. identify appendix, ileocecal valve
3. mark 15cm from the ileocecal valve
4. make a incision in mesentery in between arcades (point light down)
5. use ligature to free up to the bowel and proximal on mesentery to have sufficient freedom and mark this end with suture
6. make incision ~15cm from the distal end of urostomy and use ligature as previously
7. use 60mm GIA stapler to resect both ends of loop
*make the side to side anastomosis with 2 staple runs on the antimesenteric boarder, then use the GI stapler on the ends of the intestine and cut off the little remaining border
*oversow this with imbricating sutures
*through a couple of stitches imbricating the middle part of the anastomosis (end of staple line) that is not on the mesentery side to give more support to the staple line.
8. close the mesentery, in proper orientation
9. make a window and bring left ureter behind L sigmoid colon
10. cut end off of distal ostomy, milk out and irrigate junk out
11. pass yankhauer into urostomy and open this end, pass the yankhauer (or make the hole big enough for a thumb)
12. incise distal end of ureter 1.5cm
13. suture 2 sutures to the ureter/urostomy using 3-0 monocryl
14. pass stent up to kidney
15. finish anastomosis out to in suturing
16. clamp skin, bring up and cut urostomy site
17. cut down to fascia, make sure 1 finger easily can exit.
18. to suture ostomy to skin, pass a stitch through the skin, into the urostomy under the skin level and then through the top of the rosebud
19. repeat circumferentially, some like 4 quadrant stiches like this, then skin/rosebud top only
PELVIC LYMPH NODE DISSECTION
STANDARD BOUNDARIES (LEVEL 1)
Proximal: bifurcation of common iliac
Lateral: genitofemoral nerve to include obturator fossa
Inferior: internal iliac lymph nodes, floor of pelvis
Posterior: sacrum
EXTENDED BOUNDARIES (LEVEL 2)
Proximal: bifurcation of aorta, others same as above
SUPEREXTENDED BOUNDARIES (LEVEL 3)
Proximal: Aorta at the origin of the IMA
CONDUIT PROTOCOL
1. midline incision into abdomen
2. identify appendix, ileocecal valve
3. mark 15cm from the ileocecal valve
4. make a incision in mesentery in between arcades (point light down)
5. use ligature to free up to the bowel and proximal on mesentery to have sufficient freedom and mark this end with suture
6. make incision ~15cm from the distal end of urostomy and use ligature as previously
7. use 60mm GIA stapler to resect both ends of loop
*make the side to side anastomosis with 2 staple runs on the antimesenteric boarder, then use the GI stapler on the ends of the intestine and cut off the little remaining border
*oversow this with imbricating sutures
*through a couple of stitches imbricating the middle part of the anastomosis (end of staple line) that is not on the mesentery side to give more support to the staple line.
8. close the mesentery, in proper orientation
9. make a window and bring left ureter behind L sigmoid colon
10. cut end off of distal ostomy, milk out and irrigate junk out
11. pass yankhauer into urostomy and open this end, pass the yankhauer (or make the hole big enough for a thumb)
12. incise distal end of ureter 1.5cm
13. suture 2 sutures to the ureter/urostomy using 3-0 monocryl
14. pass stent up to kidney
15. finish anastomosis out to in suturing
16. clamp skin, bring up and cut urostomy site
17. cut down to fascia, make sure 1 finger easily can exit.
18. to suture ostomy to skin, pass a stitch through the skin, into the urostomy under the skin level and then through the top of the rosebud
19. repeat circumferentially, some like 4 quadrant stiches like this, then skin/rosebud top only
PELVIC LYMPH NODE DISSECTION
STANDARD BOUNDARIES (LEVEL 1)
Proximal: bifurcation of common iliac
Lateral: genitofemoral nerve to include obturator fossa
Inferior: internal iliac lymph nodes, floor of pelvis
Posterior: sacrum
EXTENDED BOUNDARIES (LEVEL 2)
Proximal: bifurcation of aorta, others same as above
SUPEREXTENDED BOUNDARIES (LEVEL 3)
Proximal: Aorta at the origin of the IMA