Dr Qamar Shahzad Joia General Surgeon

critical view of safety

the Classification of Chronic Venous Disorders (CEAP Classification)

🔬 RETROPERITONEAL SARCOMA — SURGICAL TECHNIQUE, TIPS & TRICKS

The single most important sentence in this disease: the best chance of cure is at the FIRST operation. There is no second first chance.

📌 THE GOVERNING PRINCIPLE

The modern standard is frontline extended (liberal multivisceral) resection — removal of the tumour en bloc with adherent organs and structures even when they are not overtly infiltrated, as a single specimen.

Why: microscopic infiltration of adjacent organs (parenchymal or pericapsular/perivisceral) has been documented in up to 60% of resected organs. What looks "free" at surgery frequently is not.

In experienced centres this policy delivers complete gross resection in ~95%, with 5- and 10-year overall survival of 67% and 46% (TARPSWG, 1007 patients).

⚠️ A grossly incomplete (R2) resection is of questionable benefit and potentially harmful. If you cannot deliver a complete resection, do not start — refer.

🧭 1. BEFORE THE KNIFE — PREOPERATIVE ESSENTIALS

1. CT chest / abdomen / pelvis with IV contrast is the standard staging study.

2. Image-guided percutaneous coaxial core needle biopsy (14–16 G) is strongly recommended. Needle-track seeding risk is minimal and is not a reason to skip biopsy.

3. Never do a laparotomy or open biopsy for a suspected RPS.

4. Assess the contralateral kidney functionally (contrast CT or differential renal scan) — you are planning to take one kidney in roughly half of these cases.

5. Read the CT like a surgeon, not a radiologist: define the asymmetry of retroperitoneal fat, the relation to great vessels, degree of IVC luminal obstruction, and the presence of venous collaterals. These change the operation.

6. Plan in a multidisciplinary sarcoma board. Histology drives the extent of surgery.

💡 Tip: In low-grade liposarcoma, intraoperative frozen section is useless — the tumour looks exactly like normal fat. Your resection map must come from the preoperative CT.

🗺️ 2. THINK IN BARRIERS, NOT IN ORGANS

The retroperitoneum is not a true compartment, but four structures behave as natural barriers to tumour spread:

Posteriorly → muscle sheaths (psoas fascia, quadratus lumborum)

Medially → adventitia of the great vessels

Anteriorly → the peritoneum itself

Where no barrier exists → an organ becomes the margin (colon, mesocolon, distal pancreas)

Dissect OVER the barrier, leaving it on the specimen. This reproduces the logic of compartmental resection in the extremity.

🔪 3. STANDARD OPERATIVE STEPS

Access: midline laparotomy; extend transversely, obliquely, or thoraco-abdominally for exposure — vascular control is critical and a cramped field is the commonest cause of disaster.

First step: colo-epiploic separation, then division of the transverse colon.

# # # 🔵 Right-sided RPS

1. Divide the distal ileum; divide right colic and ileocolic vessels close to the SMA/SMV.

2. Generous Kocher manoeuvre for full access to the IVC.

3. Separate duodenum / pancreatic head from the supero-medial aspect of the tumour, staying very close to the duodenal wall. If a strip of the lateral duodenal wall must go, repair primarily or with a jejunal patch.

4. The right lobe of the liver is usually just elevated. Liver resection is never indicated unless directly invaded; a sub-capsular dissection of the inferior/posterior surface is more often what is needed — with vascular control ready.

# # # 🔴 Left-sided RPS

1. Ligate the inferior mesenteric vein at the lower border of the pancreas.

2. Ligate the IMA; divide the sigmoid at the recto-sigmoid junction.

3. Detach the mesocolon from the great vessels.

4. Tumour below the transverse mesocolon → sweep distal pancreas and spleen off the top of the tumour.

5. Tumour extending into the upper left retroperitoneum → divide the distal pancreas, ligate splenic artery and vein, mobilise the spleen en bloc with the upper pole of the tumour.

# # # ⚙️ Common to both sides

6. Sub-adventitial dissection of the great vessels from the iliac vessels up to the diaphragmatic hiatus. Ligate and divide aortic/caval collaterals — renal, gonadal, adrenal.

7. Keep the ipsilateral adrenal on the specimen to clear the upper retroperitoneal space.

8. Laterally: incise the parietal wall and leave the peritoneum (± the inner layer of the abdominal side wall) on the tumour.

9. Posteriorly: carry the dissection to the psoas. Identify the femoral nerve just above the inguinal ligament after opening the psoas fascia; detach the fascia from the vertebrae and leave it on the back of the tumour.

10. Superiorly: peel the diaphragmatic peritoneum and leave it on top of the tumour.

Final specimen: tumour + kidney + adrenal + ipsilateral colon and mesocolon anteriorly; psoas aponeurosis (or whole psoas) posteriorly; abdominal wall peritoneum laterally/inferiorly; diaphragmatic peritoneum superiorly.

📊 Typical organ yield in modern series: ipsilateral kidney 55%, colon 25–33%, psoas 27%, spleen 16%, distal pancreas 12%, diaphragm 13%, abdominal wall 12%, iliac vein/IVC 10%. Pancreaticoduodenectomy is required in only 4–5% of right-sided tumours.

🦵 4. PSOAS AND THE RETROPERITONEAL NERVES

Partial or complete psoas resection is needed in ~30% of cases. Know what lies behind it.

Behind the psoas fibres: lumbar arteries and veins, and the L2–L4 roots of the femoral and obturator nerves.

Femoral nerve — the main motor nerve of the retroperitoneum; found postero-laterally on the psoas, just proximal to the inguinal ligament. Long-term functional loss after femoral nerve sacrifice is the one truly disabling morbidity of this operation.

Genitofemoral nerve — on the anterior surface of the psoas; usually has to be divided even for partial psoas/fascial resection → numbness of the anterior thigh. Warn the patient before surgery.

Iliohypogastric nerve — carries motor fibres to the lateral abdominal wall; division produces a permanent bulge (relaxatio) of the abdominal wall.

Lateral femoral cutaneous and ilio-inguinal nerves are purely sensory.

⚠️ Sensory disturbance of thigh, groin or ge***al region is reported long-term by 76% of patients. Consent for it explicitly.

🩸 5. MAJOR VASCULAR INVOLVEMENT — WHEN TO RESECT, WHEN TO PEEL

Vascular resection is required in 10–14% of primary RPS — mostly leiomyosarcomas arising from veins.

Decision rule:

Attempt sub-adventitial dissection of the tumour off every major vessel — unless the vessel is widely encased or overtly infiltrated.

The adventitia, left on the tumour side, is a genuine oncological barrier and a safe dissection plane. Systematic vascular resection has never been shown to improve local control or survival, and it roughly doubles the risk of severe postoperative adverse events.

⚠️ Trap: peri-tumoural inflammation and desmoplastic reaction are frequently indistinguishable from true wall invasion. Also, a vessel that is merely pushed and thinned may need resection simply to avoid or control a catastrophic tear.

# # # Arterial reconstruction

Primary anastomosis is rarely possible after an oncological resection → orthotopic prosthetic graft (ring-reinforced PTFE, or Dacron) is standard; patency >90%.

Reversed great saphenous vein is an option for visceral/iliac arteries.

If colon or bowel is resected in the same operation: consider an extra-anatomic route (cross-femoral or axillo-bifemoral bypass), silver- or antibiotic-impregnated grafts, and always interpose omentum between graft and viscera.

SMA encasement is generally a marker of unresectability; segmental SMA resection is exceptional.

# # # Venous / IVC reconstruction

Partial wall defect,

7 Common Laparoscopic Port Placements Every Surgery Resident Should Know

Port placement isn't random-it's what determines your ergonomics, triangulation, exposure, and ultimately the ease of the operation.

In this carousel, you'll learn the standard port set ups for some of the most commonly performed laparoscopic procedures.

Whether you're preparing for your next OT, assisting for the first time, or revising for exams, save this as a quick reference.

Randhawa Scoring System

The Randhawa Scoring System is a preoperative scoring system used to predict the difficulty of laparoscopic cholecystectomy (LC). It is based on clinical history, physical examination, and ultrasonographic findings. The parameters include age >50 years, male s*x, previous hospitalization for acute cholecystitis, body mass index (BMI), previous abdominal scar, palpable gallbladder, gallbladder wall thickness >4 mm, pericholecystic collection, and impacted gallstone. The total score ranges from 0 to 15. A score of 0–5 predicts an easy laparoscopic cholecystectomy, 6–10 indicates a difficult procedure, and 11–15 predicts a very difficult operation with a higher likelihood of conversion to open cholecystectomy. This scoring system helps surgeons anticipate operative difficulty, counsel patients appropriately, optimize operative planning, and allocate experienced surgical assistance when necessary.

The Heaney maneuver:

The Heaney maneuver is performed by clamping both the suprahepatic and infrahepatic inferior vena cava while simultaneously applying the Pringle maneuver (Fig. 10.3 ). During the Heaney maneuver, clamping of the inferior vena cava can lead to cardiac arrest because of the sudden decrease in cardiac preload. It is crucial that central pressures are monitored and that fluid replacement is adequate. The aorta should not be clamped. Doing so will result in worsening acidosis. Once you have control of the inferior vena cava and portal vein, there is less than one hour to repair the injury. Begin by taking down the falciform and right triangular ligament as well as freeing the liver posteriorly from the diaphragm.
Occasionally, the right hepatic artery may arise from the superior mesenteric artery (replaced right hepatic). The right hepatic lobe is freed up from the diaphragm and rotated medially away from the diaphragm, exposing the small hepatic veins from segment one communicating directly into the inferior vena cava.Each of these small veins should be ligated. In
extreme deceleration injuries, the small veins are avulsed from the anterior surface of the inferior vena cava creating a linear laceration.

𝗥𝗲𝗳:Operative Techniques
for Severe Liver Injury, Springer