Laparoscopic complete parametrectomy associated with upper vaginectomy and bilateral pelvic lymphadenectomy

  • Abstract
    This video shows a reproducible approach to complete parametrectomy in a patient who had had a hysterectomy. The procedure begins with adhesiolysis and dissection of the lateral pelvic spaces in order to identify and isolate the parametrium. The paravesical fossa is then dissected medially and laterally using the umbilical artery as a landmark. The surgeon identifies the uterine artery and parametrium by following the umbilical artery. Using the uterine artery as a landmark of the parametrium, dissection is continued posteriorly developing the pararectal spaces in order to isolate the posterior part of the parametrium. The ureter is dissected towards the ureteral channel and unroofed. The procedure is carried on with the complete isolation of the ureter in its anterior aspect between the parametrium and the bladder. The bladder pillar is then transected at the level of the bladder. The rectal pillar is transected at the level of the rectum, paying attention to isolate the inferior hypogastric nerve. The parametrium is then cut at the level of the hypogastric vessel. The vagina is cut with ultrasonic scissors using a cap of RUMI II as a guide, and the specimen is extracted vaginally. The surgeon performs a bilateral lymphadenectomy. In this step, the obturator nerve is dissected to prevent injuries at the medial aspect of the obturator artery. The vagina is closed with continued stitches vaginally using an extracorporeal knotting technique.
  • 00'19" Clinical case
    This is the case of a 42-year-old woman with a squamous cell carcinoma of the uterine cervix staged 1a2 with lymphovascular space invasion and with no pelvic or para-aortic lymphadenopathy on MRI or PET-scan. On the patient’s first admission, the smear test result was a high-grade squamous intraepithelial lesion (HSIL). We then performed an endocervical curettage and cervical biopsy, which confirmed the presence of an HSIL. We then decided to perform a loop electrosurgical excision procedure (LEEP), which corroborated the existence of an HSIL. Since the micro-invasion could not be ruled out, the surgical team decided to perform a laparoscopic hysterectomy and bilateral salpingo-oophorectomy (which was added at the patient’s desire). In the pathology results, lymphovascular space invasion was positive. Six weeks after the operation, we performed a laparoscopic complete parametrectomy associated with an upper vaginectomy and a bilateral pelvic lymphadenectomy. The patient is now in her first postoperative year and she is disease-free.
  • 01'33" Exploration
    Exploration is begun and the vaginal cuff and lateral pelvic walls are identified.
  • 01'39" Adhesiolysis
    Adhesiolysis is performed at the left lateral wall and the left ureter is found. Retroperitoneal dissection is carried out towards the vaginal cuff.
  • 02'06" Dissection of left ureter
    Dissection of the left ureter is performed towards the ureteral roof.
  • 02'37" Dissection towards medial aspect of the external iliac vein
    Dissection is performed towards the medial aspect of the external iliac vein and the obturator fossa is developed.
  • 03'12" Development of left obturator artery
    The left obturator artery is developed.
  • 03'21" Obturator nerve dissection
    The obturator nerve is dissected at the medial aspect of the obturator artery.
  • 03'27" Dissection of left ureter
    The left ureter is dissected towards the ureteral channel.
  • 03'47" Development of medial paravesical fossa
    The medial paravesical fossa is developed.
  • 04'04" Dissection of medial paravesical fossa
    The medial paravesical fossa is dissected.
  • 04'19" Uterine artery dissection
    The uterine artery is dissected at the level of the internal iliac artery and of the umbilical artery.
  • 04'25" Entrance to retroperitoneal space
    The retroperitoneal space is entered at the right lateral pelvis and dissection is performed towards the right lateral parametrium.
  • 04'42" Identification of right ureter
    The right ureter is identified along with its peristaltic movement. The right umbilical artery is identified.
  • 06'01" Dissection of left lateral parametrium
    The left lateral parametrium is dissected.
  • 06'24" Full dissection of medial paravesical fossa
    The medial paravesical fossa is fully dissected after coagulation and cutting of the left lateral parametrium using the LigaSure™ vessel-sealing device.
  • 06'38" Dissection of left ureter
    The left ureter is dissected towards the ureteral channel.
  • 07'01" Dissection of 4th space of Yabuki
    The fourth space of Yabuki is dissected.
  • 07'05" Opening of ureteral roof
    The ureteral roof is sharply dissected and opened.
  • 07'35" Dissection of 4th space of Yabuki and dissection of ureter
    The fourth space of Yabuki is finally dissected as well as the ureter towards the entrance of bladder. The ureter is freed.
  • 08'11" Dissection of bladder
    The bladder is dissected starting from the left vaginal cuff through the entire cuff with bipolar forceps.
  • 08'32" Dissection of right ureteral roof
    The right ureteral roof is dissected.
  • 08'37" Dissection of right 4th space of Yabuki
    The right fourth space of Yabuki is dissected.
  • 08'50" Dissection and unroofing of right ureter at the level of bladder
    The right ureter is dissected and unroofed at the level of the bladder.
  • 09'07" Dissection of right posterior parametrium
    The right posterior parametrium is dissected.
  • 09'22" Dissection of right inferior hypogastric nerve
    The right inferior hypogastric nerve is dissected.
  • 09'32" Dissection of left posterior parametrium
    The left posterior parametrium is dissected.
  • 09'57" Dissection of left paravaginal tissues
    Left paravaginal tissues are dissected and the left ureter is lateralized.
  • 10'22" Dissection of right paravaginal tissues
    Right paravaginal tissues are dissected and the right ureter is lateralized.
  • 10'43" Dissection of bladder
    The bladder is dissected from the anterior vagina.
  • 10'57" Operative views
    This view shows the bilateral ureters which enter the bladder. This is the view of the bilateral parametrium and vaginal tissue over a length of 3cm prior to excision.
  • 11'12" Vaginal incision
    The vagina is incised with ultrasonic scissors.
  • 11'26" Bilateral lymphadenectomy, closure of vaginal cuff, and end of procedure
    Bilateral lymphadenectomy is performed. The vaginal cuff is closed, and the procedure ends with a final overview and hemostatic control.
  • Related medias
    This video shows a reproducible approach to complete parametrectomy in a patient who had had a hysterectomy. The procedure begins with adhesiolysis and dissection of the lateral pelvic spaces in order to identify and isolate the parametrium. The paravesical fossa is then dissected medially and laterally using the umbilical artery as a landmark. The surgeon identifies the uterine artery and parametrium by following the umbilical artery. Using the uterine artery as a landmark of the parametrium, dissection is continued posteriorly developing the pararectal spaces in order to isolate the posterior part of the parametrium. The ureter is dissected towards the ureteral channel and unroofed. The procedure is carried on with the complete isolation of the ureter in its anterior aspect between the parametrium and the bladder. The bladder pillar is then transected at the level of the bladder. The rectal pillar is transected at the level of the rectum, paying attention to isolate the inferior hypogastric nerve. The parametrium is then cut at the level of the hypogastric vessel. The vagina is cut with ultrasonic scissors using a cap of RUMI II as a guide, and the specimen is extracted vaginally. The surgeon performs a bilateral lymphadenectomy. In this step, the obturator nerve is dissected to prevent injuries at the medial aspect of the obturator artery. The vagina is closed with continued stitches vaginally using an extracorporeal knotting technique.