Laparoscopic radical hysterectomy for cervical cancer

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摘要

The description of the laparoscopic radical hysterectomy for cervical cancer covers all aspects of the surgical procedure used for the management of cervical cancer.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: exploration, opening of spaces, lymphadenectomy, parametrium treatment, freeing of pelvic ureter, posterior step, vaginal step/closure.
Consequently, this operating technique is well standardized for the management of this condition.

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2002-12

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WeBSurg.com, Dec 2002;2(12).
URL: http://www.websurg.com/doi-ot02en279.htm

Laparoscopic radical hysterectomy for cervical cancer

1. Introduction

Laparoscopy was first used in the management of cervical cancer 15 years ago. Initially, pelviscopic pelvic lymph node dissection was used before a vaginal radical hysterectomy, the so-called Shauta's operation (Dargent, 2001; Childers et al., 1992). Thereafter, laparoscopy was mainly used to convert a radical abdominal hysterectomy to a radical vaginal hysterectomy. The main advocates of this procedure were Dargent and Querleu (Dargent and Mathevet, 1992; Dargent and Mathevet, 1995; Querleu, 1993). Following these reports, many series on the procedure were published. Radical hysterectomy performed entirely by laparoscopy has been described by Canis (Canis et al., 1990) and Nezhat (Nezhat et al., 1992; Nezhat et al., 1993). This operation, at the beginning of the author's experience, was time-consuming and the radicality of the procedure was questioned. Few surgical teams reported on series about complete laparoscopic radical hysterectomy.

Over the past decade, a few reports on a limited number of patients have shown the feasibility of a radical resection by laparoscopic surgery, and have documented an equivalent number of pelvic nodes harvested by laparoscopy and open surgery (Canis et al., 1995; Spirtos et al., 1996). The largest series of laparoscopic radical hysterectomy to date was presented by Spirtos (Spirtos et al., 2002). This chapter describes a technique of type III Piver-like radical laparoscopic hysterectomy (Piver et al., 1974) for operable, non-bulky (less than 4 cm) cervical tumors with no evidence of node involvement in imaging studies (MRI or CT-scan) (Pomel et al., 1997).

2. Anatomy

• Uterus

The uterus is maintained in the pelvic space by the following ligamentous structures:
1. Cardinal ligament, still referred to as parametrium or paracervix, laterally;
2. Utero-sacral ligaments, posteriorly;
3. Round ligament superiorly and anteriorly;
4. Adnexal pedicles superiorly and posteriorly.

• Surgical spaces

1. Paravesical fossa
2. Vesicouterine space
3. Bladder pillars
4. Pararectal fossa
5. Rectovaginal space
6. Uterosacral ligaments
7. Cardinal ligament
The paravesical fossa is separated from the vesicouterine space by the bladder pillar or vesicouterine ligaments. The pararectal fossa is separated from the rectovaginal space by the rectovaginal and uterosacral ligaments. The cardinal ligament separates the pararectal and paravesical fossae.

• Arteries and veins

1. External iliac artery
2. Internal iliac artery
3. Uterine artery
4. Umbilical artery
5. Ovarian artery
6. Artery of the round ligament
Main arteries:
The uterine arteries usually arise from an internal branch of the umbilical artery, or sometimes branch directly off from the internal iliac artery.
Secondary arteries:
Blood is supplied to the uterus via the arteries of the round ligament, which branch off from the external iliac network.
The uterus is then supplied by the ovarian arteries via the utero-ovarian ligament.
Veins:
There are usually 4 uterine veins on each side of the uterus. They course along the cardinal ligament.
The secondary veins run parallel to the arteries of the same name.

• Ureter

1. Ureter
2. Parametrium
The ureter courses posteriorly to anteriorly below the uterine artery, in the superior portion of the cardinal ligament, and passes through the bladder pillar.

3. Indications

Ideally, preoperative staging includes an MRI, which determines the exact size of the tumor and its relationship to the neighboring organs.
This procedure is intended for operable, FIGO stage 1a2 or 1b1 cervical cancer (tumor less than 4 cm in diameter)(FIGO, 1994). Tumors less than 2 cm without metastastic foci are subject to surgical treatment alone. We perform preoperative radiation therapy for tumors larger than 2 cm or those that have metastatic foci on the biopsy or conization specimen.
The procedure begins with an external iliac lymphadenectomy with extemporaneous analysis of the pelvic lymph nodes. In our team, laparoscopic radical hysterectomy is performed in patients whose lymph nodes are not invaded.
Preservation of the ovaries is proposed for women under the age of 40 with tumors less than 2 cm without vascular invasion.

4. Operating room set-up

• Patient

1. Supports
- Trendelenburg position with a 15° to 25° tilt;
- buttocks placed at the distal edge of the table;
- shoulder supports used to prevent the patient from sliding;
- thighs and legs stretched apart, with a slight flexure;
- both arms alongside the body;
- gastric tube and urinary catheter;
- warming device.

• Team

The team is in the following position throughout the procedure:
1. Surgeon: to the left of the patient
2. First assistant: to the right of the patient
3. Second assistant: seated between the legs of the patient
4. Scrub nurse: on the surgeon’s left
5. Anesthesiologist: at the patient’s head

• Equipment

1. Anesthetic unit
2. Laparoscopic unit facing the legs
3. Electrocautery: behind the surgeon
4. Operating table
5. Instrument table
The operating table must enable both an abdominal and perineal approach. It is advisable to use a table that can be easily adjusted laterally, in Trendelenburg and reverse Trendelenburg, allowing for easy perineal exposure.
A 3CCD camera is recommended.
A high output (>= 9 L/min) insufflator should be used to electronically monitor pressures. Its inertia should be low to make up for losses in carbon dioxide (induced or not).

5. Trocar placement

We use 4 trocars:
- two 5 mm trocars positioned in each iliac fossa, lateral to the epigastric artery, at the level of the anterior superior iliac spines,
- two 10 mm trocars, one positioned in the umbilicus and the second positioned halfway between the pubic symphysis and the umbilicus.
For ergonomic purposes, the mid-trocar is ideally positioned above the level of the lateral trocars.

6. Instruments

1. 10 mm, 0° laparoscope
2. Two atraumatic grasping forceps
3. Bipolar cauterizing grasper
4. Disposable scissors
5. Suction-irrigation system for peritoneal lavage
- monopolar cauterization cable
- atraumatic uterine cannulation with endocervical uterine manipulator that screws in, to avoid using more aggressive Pozzi-type forceps.

7. Exploration

The exploration involves:
- the upper abdomen, diaphragmatic surface, hepatic capsules;
- the retroperitoneal contours facing the lumbo-aortic axis;
- the pelvis.
The main purpose of the exploration is to detect secondary lesions, an abnormality that was not detected by the imaging studies or a suspicious ovarian pathology. Peritoneal cytology is performed.

8. Opening of spaces

• Lateral peritoneum

1. External iliac artery
2. External iliac vein
3. Umbilical artery
4. Lumbo-ovarian pedicle
The incision of the peritoneum is performed just above the external iliac vessels, from the paracolic fossa lateral to the ovarian vessels, to the round ligament of the uterus, which is divided.

• Pelvic ureter

1. Pelvic ureter
2. Divided round ligament
The adnexa must be retracted medially with an atraumatic grasper. The pelvic ureter is identified on the deep surface of the peritoneum. The ureter is not dissected at this stage of the procedure.

• Paravesical fossa

1. External iliac artery
2. Paravesical fossa
3. Umbilical artery
4. Pararectal fossa
The umbilical artery is dissected and then retracted medially with an atraumatic grasper.
The paravesical space is opened using simple divergent traction of the graspers, one toward the external iliac vessels and the other toward the umbilical artery. This plane is usually easy to find. The dissection requires no cauterization, as it is performed in a bloodless plane. It is continued to the latero-vesical pelvic wall, ie the plane of the levator ani muscles and overlying pectineal ligament. This step can be facilitated by placing the uterine fundus under tension by retracting it cranially, anteriorly and toward the opposite side with the uterine manipulator.
Posteriorly, dissection of the umbilical artery is pursued down to its origin on the internal iliac artery.

• Pararectal fossa

1. Paravesical fossa
2. Pararectal fossa
3. Bifurcation of umbilical artery and uterine artery
4. Internal iliac artery
5. External iliac artery
6. Ureter
This opening is facilitated by the identification of the iliac arterial bifurcation. The dissection begins medial to the contours of the internal iliac artery, which is followed to the floor of the levator ani muscles. Cauterization of the small arteries arising directly from the internal iliac artery is sometimes required. As for the opening of the paravesical fossa, this step can be facilitated by placing the uterine fundus under tension by retracting it toward the opposite side with the uterine manipulator.

9. Lymphadenectomy

• Lymphadenectomy

1. External iliac artery
2. External iliac vein
3. External iliac lymph node chain retracted medially
4. Umbilical artery
Three external iliac lymph node groups are involved.
The external lymph node chain lateral to the external iliac artery is dissected using simple traction. This dissection is pursued to the iliac bifurcation.
The surgeon dissects the internal surface of the external iliac vein, followed by its superior surface. The internal and inferior surfaces of the external iliac vein are then dissected. The dissection is pursued to the pelvic wall. This frees the superior surface of the lymph node chain. The mobilization of these lymph nodes permits the identification of the obturator nerve, which represents the inferior limit of the lymph node dissection.
The entire lymph node chain is mobilized medially to expose and dissect the posterior attachments to the iliac bifurcation.

• Lymph node chain

1. External iliac artery
2. External iliac vein
3. Lymph node chain
4. Umbilical artery
The lymph nodes are extracted in a retrieval bag to avoid contamination of the wall. Each lymph node group is sent for frozen section in separate bags.

10. Parametrium treatment

• Uterine artery division

1. Division of the uterine artery
2. External iliac vein
3. Obturator nerve
4. Umbilical artery
5. Paravesical fossa
6. Pararectal fossa
The uterine fundus is retracted cranially, anteriorly and toward the opposite side. This step opens the dissection spaces.
At the superior limit of the parametrium, the uterine artery is identified. It is clipped or cauterized at its origin, and then divided.

• Division of parametrium

Piver type III classification:
1. Division of the distal parametrium
2. Umbilical artery
3. Parametrium
4. Paravesical fossa
5. Pararectal fossa
6. External iliac vein
The parametrium is isolated between the paravesical fossa anteriorly and laterally, and the pararectal fossa posteriorly and medially.
The base of the parametrium is then cauterized against the pelvic wall with the bipolar grasper before being divided. After its division, the paravesical and pararectal fossae are no longer separate. This step is performed while maintaining the parametrium under tension.

11. Freeing/pelvic ureter

• Dissection of the bladder

1. Opening of the vesicouterine space
2. Uterus
3. Bladder wall
4. Division of the external bladder pillar
5. Ureter
6. Parametrium
7. Paravesical fossa
The uterine fundus is placed in median and posterior position.
The surgeon opens the vesicouterine space, identifies the external bladder pillar and divides it. The anterior border of the parametrium is thereby freed from the bladder wall.

• Parametrial ureter

1. Uterus
2. Parametrium
3. Ureter
4. Bladder peritoneum
The uterine fundus is retracted cranially, anteriorly and toward the opposite side.
The parametrial ureter is first freed laterally, and is then freed from its attachments to the parametria.

• Juxtavesical ureter

1. Bladder
2. Left ureter
3. Right ureter
4. Vagina
5. Uterus
6. Internal bladder pillar
The ureter is dissected down to its entry into the bladder.
The internal bladder pillar is identified and divided.

12. Posterior step

• Rectovaginal space

This step involves opening the rectovaginal space and laterally freeing the uterosacral ligaments on each side at a distance from the uterus. It enables the surgeon to cauterize and divide the paravaginal attachments.

• Uterosacral ligaments

1. Left ureter
2. Uterosacral ligaments
3. Rectum
The surgeon then divides the uterosacral ligaments 2 cm from the posterior surface of the uterus.

13. Vaginal step/closure

• Colpotomy

1. Vaginal incision
The vaginal incision is performed laparoscopically or transvaginally more than 2 cm from the cervix or the tumor. It permits extraction of the uterus and parametria en bloc. The operative specimen is sent for frozen section verification of the integrity of the margins.

• Vaginal suture

A running suture with absorbable, No. 0 braided suture is used to close the vaginal incision. An iodine-soaked gauze is introduced and left in place for 24 hours.

14. Reference

Canis M, Mage G, Pouly JL, Pomel C, Wattiez A, Glowaczover E et al. Laparoscopic radical hysterectomy
for cervical cancer. Baillieres Clin Obstet Gynaecol 1995;9:675-89.
Canis M, Mage G, Wattiez A, Pouly JL, Manhes H, Bruhat MA. La chirurgie endoscopique a-t-elle une
place dans la chirurgie radicale du cancer du col utérin ? J Gynecol Obstet Biol Reprod 1990;19:921.
Childers JM, Hatch K, Surwit EA. The role of laparoscopic lymphadenectomy in the management of
cervical carcinoma. Gynecol Oncol 1992;47:38-43.
Dargent D, Mathevet P. Hystérectomie élargie laparoscopico-vaginale. J Gynecol Obstet Biol Reprod
1992;21:709-10.
Dargent D, Mathevet P. Schauta's vaginal hysterectomy combined with laparoscopic lymphadenectomy.
Baillieres Clin Obstet Gynaecol 1995;9:691-705.
Dargent DF. Laparoscopic surgery in gynecologic oncology. Surg Clin North Am 2001;81:949-64.
Landoni F, Maneo A, Cormio G, Perego P, Milani R, Caruso O et al. Class II versus class III radical
hysterectomy in stage IB-IIA cervical cancer: a prospective randomized study. Gynecol Oncol 2001;80:3-
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Nezhat CR, Burrell MO, Nezhat FR, Benigno BB, Welander CE. Laparoscopic radical hysterectomy with
paraaortic and pelvic node dissection. Am J Obstet Gynecol 1992;166:864-5.
Nezhat CR, Nezhat FR, Burrell MO, Ramirez CE, Welander C, Carrodeguas J et al. Laparoscopic radical
hysterectomy and laparoscopically assisted vaginal radical hysterectomy with pelvic and paraaortic node
dissection. J Gynecol Surg 1993;9:105-20.
Pettersson F, editor. 22nd Volume of the FIGO Annual Report on the Results of Treatment in
Gynecological Cancer: Stockholm: Radiumhemmet; 1994.
Piver MS, Rutledge F, Smith JP. Five classes of extended hysterectomy for women with cervical cancer.
Obstet Gynecol 1974;44:265-72.
Pomel C, Canis M, Mage G, Dauplat J, Le Bouedec G, Raiga J et al. Hystérectomie élargie par
laparoscopie pour cancer du col: technique, indications et résultats. A propos d'une série clermontoise de
41 cas. Chirurgie 1997;122:133-6.
Querleu D. Laparoscopically assisted radical vaginal hysterectomy. Gynecol Oncol 1993;51:248-54.
Spirtos NM, Eisenkop SM, Schlaerth JB, Ballon SC. Laparoscopic radical hysterectomy (type III) with
aortic and pelvic lymphadenectomy in patients with stage I cervical cancer: surgical morbidity and
intermediate follow-up. Am J Obstet Gynecol 2002;187:340-8.
Spirtos NM, Schlaerth JB, Kimball RE, Leiphart VM, Ballon SC. Laparoscopic radical hysterectomy (type
III) with aortic and pelvic lymphadenectomy. Am J Obstet Gynecol 1996;174:1763-7; discussion 1767-8.

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