Rectal Sparing in Modified Posterior Exenteration: Description of the Technique in 10 Steps

BACKGROUND To achieve complete cytoreduction in ovarian carcinoma, rectal resection may be necessary in the case of gastrointestinal tract involvement.1 Posterior resection surgeries were described by Eiseinkopt and Bristow who modified Hudson's pelvic peritonec-tomy.2The concept of digestive sparing has been developed for several years. We propose a modified surgical approach of posterior resection by combining three principles (Hudson- type dissection, pushed Douglasectomy, and first stapling of the rectum) to optimize rectal sparing.3 4METHODVideo 1 shows an 10- steps 'en bloc' pelvic peritonectomy combined with digestive resection, illustrating the first stapling of the rectum. We associated other digestive resection during this procedure not present RESULTS The surgical procedure is divided into 10 steps: Step 1: Supra- pelvic and intra- peritoneal approach Step 2: Pelvic and retro- peritoneal approach Step 3: Uterine vessel ligature Step 4 : Ureterolysis Step 5 : Pre- vesical peritonectomy Step 6: Para- rectal space dissection Step 7: 'Hanging' en bloc specimen Step 8: Retrograde dissection of rectovaginal septum and Douglas pouch dissection Step 9: First rectal stapling Step 10: Proximal bowel division CONCLUSIONS In our experience, the first section of the rectum is always feasible if the three principles are combined (Hudson- type dissection, advanced Douglasectomy, and first stapling of the rectum). The advantages of rectal sparing are that it allows an anastomosis to be made on the upper rectum, avoids lowering the left colonic angle, makes it very easy to combine other digestive resections 'en bloc', and facilitates repeat rectal resections in the case of recurrence. Standardization of this procedure will help young surgeons to learn the methodology and better grasp the steps involved.