Wertheim-Meigs operation

The Wertheim-Meigs operation (based on Ernst Wertheim and Joe Vincent Meigs ) is a surgical procedure for the surgical treatment of cervical cancer .

Scope and indication

The Wertheim-Meigs operation is used from stage IA2 (according to the FIGO classification ) of cervical carcinoma . It is one of the most extensive gynecological interventions. It consists of the following individual measures:

• radical hysterectomy ; in older women or adenocarcinomas additionally with adnexa .
• Lymphadenectomy with removal of the connective and adipose tissue, including the lymphatics and pelvic lymph nodes on both sides over the artery et common iliac vein , artery et external iliac vein and artery et internal iliac vein .
• Removal of the (paracolpic) tissue surrounding the vagina in the obturator fossa down to the pelvic floor .

Depending on the stage, or depending on its size, the tumor is resected using a more or less large vaginal cuff .

Surgery problems

The current standard surgical therapy for cervical cancer in the form of the Wertheim-Meigs operation is, of course, based on historical ideas about the anatomy of the female pelvis and the local tumor spread. Despite the radical operation, many patients with histopathologically proven risk factors require additional radiation therapy or chemoradiotherapy after the operation . Nevertheless, a locoregional recurrence rate of 10–15% is to be expected. The rate of treatment- related moderate and severe morbidity is high at 30%, since the pelvic autonomic nerves are ignored in surgical anatomy and the boundaries to the rectum and bladder compartments are not clearly defined. These problems should no longer exist in the future with total mesometrial resection of the uterus (TMMR), a surgical method developed in 1998. However, the method has not yet been investigated in prospective randomized or multicenter studies for morbidity and mortality.

Anaesthesiological aspects

The Wertheim-Meigs operation is a great engagement of the abdomen, if possible, in combination anesthesia (general anesthesia in combination with a thoracic epidural anesthesia is performed). The potentially large shifts and losses of fluid as well as the often pre-existing anemia make differentiated monitoring (possibly invasive blood pressure measurement , central venous catheterization ) and volume therapy as well as, if necessary, transfusion of blood reserves necessary. In patients without previous cardiac diseases, controlled hypotension can reduce blood loss. Post-operatively, care in a guard or intensive care unit is often necessary. Patients can be offered (peridural or intravenous ) patient-controlled pain therapy .

Gynecological operations, especially hysterectomy, are associated with significantly higher rates of postoperative nausea and vomiting (PONV, in up to 80% of patients) compared to other operations . Whether the intervention is a specific cause for this is controversial, but based on the current data, it is rather rejected. The high incidence is probably mainly due to the risk profile of the patients, since the female gender factor per se is associated with two to three times the rate of PONV. For the prophylaxis and treatment of postoperative nausea, there are a number of treatment options such as performing a total intravenous anesthesia and administering various antiemetics ( dexamethasone , Setrone, etc.).

history

The Austrian gynecologist Ernst Wertheim developed the radical surgical method using an abdominal incision in 1898, which was later further developed by the American Joe Vincent Meigs , as the route using an abdominal incision was too risky in earlier times. In the Wertheim radical surgery, up to 74 percent of the patients initially died, due to the size and duration of the operation. At that time, a scientific debate about better surgical techniques for cervical cancer broke out between Ernst Wertheim and his former teacher Friedrich Schauta . Schauta favored the vaginal radical hysterectomy ( Schauta-Stoeckel operation ) developed by him . In a direct comparison of the two methods, vaginal surgery was associated with a lower mortality rate , but also less radical, as lymph node groups could not be reached. By reducing the risks associated with open stomach surgery, the importance of Schauta's surgery in favor of Wertheim's surgery decreased.

Individual evidence

1. ↑ M. Höckel, N. Dornhöfer: The Hydra phenomenon of cancer: Why tumors recur locally after microscopically complete resection. Cancer Res, 65: pp. 2997-3002, 2005 PMID 15833823
2. ↑ M. Höckel: Total Mesometrial Resection: A New Radicality Principle in the Surgical Therapy of Cervical Carcinoma. Oncologist 12: pp. 901-907, 2006
3. ^ MW Beckmann, S. Ackermann: Closing words (discussion). Deutsches Ärzteblatt 102, A3351, 2005 pdf
4. ↑ Rossaint, Werner, Zwissler (Ed.): Die Anästhesiologie. General and special anesthesiology, pain therapy and intensive care medicine. Springer, Berlin 2008, 2nd edition, ISBN 978-3540763017
5. ↑ CC Apfel, N. Roewer: Postoperative nausea and vomiting. Anesthetist. 2004 Apr; 53 (4): 377-89 Review. PMID 15190867
6. ^ O. Käser, FA Iklé: Atlas of the gynecological operations. Georg Thieme Verlag, Stuttgart 1965, 263-307
7. ↑ G. Reiffenstuhl: The vaginal radical operation according to Schauta-Amreich for the treatment of collum carcinoma. Archives of Gynecology and Obstetrics 242 (1987), p. 36 doi : 10.1007 / BF01783015

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