Danielle Vicus and Allan Covens
CERVICAL CONIZATION
Procedure Overview
Box 26-1 Master Surgeon’s Corner
The size and histologic cell type of the lesion, together with the desire for future fertility, help guide the technique and extent of the procedure.
A cervical conization refers to the surgical excision of the squamous-columnar junction. The indications are both therapeutic and diagnostic. It is a therapeutic procedure in cases of cervical intraepithelial neoplasia grade 2 or 3 and microinvasive carcinoma of the cervix (negative margins). Diagnostic indications include unsatisfactory colposcopy, positive endocervical curettage, persistent positive cytology for dysplasia in the presence of a normal colposcopy, and a cervical biopsy positive for microinvasion. The full management paradigm has been discussed in previous chapters and will not be reviewed here (see Chapters 4 and 5). A knife cone biopsy is the gold standard and has the advantage of proper evaluation of the margins because no thermal energy is used; however, for the most part, a loop electrosurgical excision procedure (LEEP) is sufficient. The exception is in cases in which a precise margin is essential. LEEP is usually performed as an outpatient procedure under local anesthesia, whereas in cases of knife cone biopsy, general or regional anesthesia is used.
Knife Cone Biopsy
Preoperative Preparation
Preoperatively a colposcopic evaluation of the cervix is performed to evaluate the extent of disease. Biopsies from appropriate areas are sent, and if a conization is indicated, formal informed consent is obtained with emphasis on possible complications including cervical incompetence, bleeding, and infection. The patient is admitted to the hospital on the day of surgery.
Operative Procedure
Box 26-2 Caution Points
Optimal visualization is important in order to properly evaluate the extent of the lesion and thus minimize the need for repeat procedures.
The size of the excision should be sufficient to remove the entire lesion; however, it should be kept in mind that the deeper the conization, the greater is the likelihood of future cervical incompetence.
The use of relatively large loop electrodes can lead inadvertently to removal of large amounts of the cervix.
The procedure is performed under general or regional anesthesia. The patient is put in the semilithotomy position, and a bimanual examination is performed. The patient is then prepped and draped and the bladder emptied via a catheter. A speculum is inserted into the vagina for maximum visualization. Lugol’s stain may be used to help delineate the dysplasia. A single-tooth tenaculum is used to grasp the anterior aspect of the cervix. Bleeding from the cervix can be minimized by injecting a dilute solution of vasopressin in lidocaine into the 4 quadrants of the cervical stroma. Figure-of-eight “stay” stitches of 1-0 delayed-absorbable suture can be placed at the 3 o’clock and 9 o’clock positions on the cervix just below the cervicovaginal junction. These stitches will aid in hemostasis and can be used to manipulate the cervix during conization. A #11 or a #15 blade is used to make a circumferential incision incorporating the demarcated area and the entire transformation zone. A cone-shaped incision should be made to the depth of approximately 2 to 2.5 cm, depending on the depth of the cervix (Figure 26-1). The cone should preferably be excised in a single piece and a suture placed at 12 o’clock to facilitate orientation of the specimen by the pathologist. Once the cone has been removed, an endocervical curettage is performed.
FIGURE 26-1. Knife cone biopsy.
Hemostasis of the cone bed can be obtained using one of many techniques. Electrocautery, either with a ball electrode or a regular cautery tip, is commonly used. Monsel’s solution applied generously to the cone bed can also control the bleeding. An additional option is suturing the bed of the cone with either a running lock absorbable suture or interrupted figure-of-eights that also approximate the proximal and distal edges. A combination of techniques, together with direct pressure or hemostatic agents (eg, Surgicel), may be used in case of heavy bleeding.
Loop Electrosurgical Excision Procedure
Loop diathermy has been shown to be an effective and reliable alternative to cold knife conization with the advantages of it being performed in an outpatient setting without the need for general anesthesia. It has been found to be technically easier and less time consuming than cold knife conization.1,2
The LEEP probe consists of a wire loop (stainless steel or tungsten), which comes in multiple sizes, attached to an insulated T-bar. It is performed with a blend of coagulation and cutting. The size of the loop is chosen with respect to the volume of the lesion. Most commonly, loop sizes of 10 to 20 mm are used. Although there is an advantage in obtaining the entire specimen in 1 pass because it helps the pathologist identify the surgical margins, the depth required usually entails a minimum of 2 passes of the loop (Figure 26-2). The procedure is performed under colposcopic guidance, and therefore, the margins can be re-examined before completion of the procedure. Bleeding from the cone bed can be controlled with the same techniques mentioned earlier for knife cone biopsy.
FIGURE 26-2. Loop electrosurgical excision procedure (LEEP).
Postoperative Care
Box 26-3 Complications and Morbidity
Significant bleeding may occur 10 to 21 days after the procedure (5%-10% of cases) and is more common when using a larger loop and when a vasoconstrictive agent is not injected prior to the procedure.
Cervicitis and ascending endometritis are rare but can occur.
Cervical incompetence and, as a result, premature delivery have been reported to be doubled (approximately 6%) after a cervical excisional procedure.3 However, no increase in neonatal morbidity or mortality has been shown.
Cervical stenosis is an uncommon result (3%) of a cervical excisional procedure.
Patients usually tolerate cervical excisional procedures well and are discharged home on a regular diet the same day.
RADICAL TRACHELECTOMY
Procedure Overview
Box 26-4 Master Surgeon’s Corner
The oncologic outcomes of the radical trachelectomy are comparable to those of radical hysterectomy; therefore, patients wishing to preserve fertility who meet the eligibility criteria should be offered this procedure.
The radical trachelectomy is a fertility-sparing procedure that consists of removing the majority, if not all, of the cervix jointly with the parametrium and the upper portion of the vagina. It can be performed by an abdominal or vaginal approach. The latter was initially described by Dargent and, when performed together with a laparoscopic pelvic lymph node dissection, has been shown to have low morbidity, comparable onco-logic outcomes to the radical hysterectomy, and good obstetric outcomes.3-5 The indications are desire to preserve fertility, tumor size less than 2 cm, International Federation of Gynecology and Obstetrics (FIGO) stage IA1 disease with lymph vascular space involvement, stage IA2 or IB1 tumors, squamous cell or adenocarcinoma, no involvement of the upper endocervical canal, and no metastasis to regional lymph nodes on computed tomography or magnetic resonance imaging.6
Radical Abdominal Trachelectomy
Preoperative Preparation
Once a patient is diagnosed with cervical cancer and expresses a desire to retain fertility, thorough evaluation is warranted to help decide whether a radical trachelectomy is appropriate. Because the FIGO staging of cervical cancer is clinical (as previously discussed in Chapter 5), the first step is a complete history, physical, and pelvic examination. When the pelvic examination is challenging, an examination under anesthesia should be performed. In patients with early-stage disease, a chest x-ray, complete blood count (CBC), and kidney function (creatinine) are frequently performed preoperatively. Additional imaging and blood work are left to the discretion of the treating oncologist while taking into consideration the patient’s symptoms, comorbidi-ties, and results of the clinical examination.
Once a decision is made to proceed with a radical trachelectomy and pelvic lymph node evaluation, informed consent is obtained. It is important to discuss the possibility of bladder dysfunction, urinary tract injury, and lymphedema and the option of a radical hysterectomy, in addition to bleeding, infection, and injury to other adjacent organs.
The patient is admitted to the hospital on the morning of the operation. Prophylactic antibiotic is administered prior to surgery.
Operative Procedure
Box 26-5 Caution Points
The height of the cervical amputation should be as far away from the internal os as possible, as long as a surgical margin of 5 mm is obtained.
In a radical abdominal trachelectomy, the uterine artery is identified; however, attempts to preserve it should be made, and only the descending branches of the uterine artery should be ligated.
The patient is put in semilithotomy position, and general anesthesia is induced. Care is taken to place the legs appropriately to avoid pressure on the peroneal nerves. A bimanual examination is performed to assess the extent of disease to further guide the procedure. The abdomen and perineum are prepped and draped, and an indwelling Foley catheter is inserted into the bladder.
The incision can be either transverse (Pfannenstiel, Maylard, or Cherney) or a low midline incision from the umbilicus to the pubic bone. This is decided both by the extent of disease and the patient’s habitus.
Once the peritoneal cavity is entered, a full abdominal and pelvic exploration is performed to look for metastatic disease. Special attention to the retroperitoneal nodes and to penetration of the tumor through the cervix toward the parametrium and pelvic side-walls is noted. The patient is then put in Trendelenburg position, a self-retaining retractor is inserted, and the bowel is packed off to facilitate maximum exposure of the pelvis. Care must be taken to avoid undue pressure on the psoas muscles by the blades of the retractor to avert a femoral nerve injury secondary to compression. Thin patients are particularly vulnerable.
A bilateral pelvic lymph node dissection is usually performed prior to the trachelectomy. The retroperitoneum is entered either by dividing the round ligament or by opening up the peritoneum overlying the psoas muscle. Clamps may be placed on the round ligament stumps to facilitate uterine manipulation; however, clamps should not be placed across the fallopian tube/utero-ovarian ligament complex. This window to the retroperitoneum is then extended caudally toward the bladder reflection and cephalic toward the infundibulopelvic ligament. The retroperitoneal structures, including the psoas muscle and the external iliac vessels, are exposed while the uterus is retracted to the opposite side. The ureter is then identified as it crosses over the iliac bifurcation. The anterior peritoneum overlying the bladder is then dissected off the anterior wall of the vagina.
The paravesical and pararectal spaces are then developed (Figure 26-3). Care must be taken not to damage the adnexa, the uterus, or the ovarian vessels when manipulating the uterus. The pararectal space is found by carefully developing the space between the ureter and the internal iliac artery posterior to the cardinal ligament (ie, the uterine artery). The dissection is parallel to the sacrum and slants medial. The borders of the pararectal space are composed of the rectum medially, the internal iliac artery laterally, the cardinal ligament anteriorly, and the sacrum posteriorly. Care must be taken when developing the space in order to avoid bleeding from the lateral sacral or hemorrhoidal vessels and internal iliac vein. The paravesical space is then developed by gently dissecting between the obliterated hypogastric artery medially and the external iliac vein laterally. The dissection is carried to the level of the pelvic floor. Although this is potentially an avascular space, an aberrant obturator vein (24% of patients) may occupy this space and cause bleeding; therefore, care must be taken. The paravesical space is bordered by the obliterated umbilical artery medially, the obturator internus muscle laterally, the cardinal ligament posteriorly, and the pubic symphysis anteriorly.
FIGURE 26-3. Radical abdominal dissection. The paravesical and pararectal spaces have been developed, and the ureter, parametrium, and retroperitoneal structures are under direct visualization.
Once the paravesical and pararectal spaces have been properly developed, the cardinal ligament and the uterine vessels are easily identified. The uterine artery is then identified; ideally, it should be preserved, and only the descending branches of the uterine artery should be ligated. This can be performed in a number of fashions (eg, using 2 hemoclips and cutting in between or alternatively passing 2 ties under the artery and dividing in the middle). It is useful to be able to identify the medial side of the uterine artery later while dissecting out the parametrium.
The ureter is then unroofed from the vesicouterine ligament. This is facilitated by gently dissecting superior and medial to the ureter, with either Metzenbaum scissors or a right angle clamp. This forms a tunnel under the cardinal ligament. It is important to take caution to stay superior to the ureter and confirm that the tip of the dissecting instrument protrudes cephalic to the bladder. The tunnel is then enlarged laterally by opening and closing the right angle clamp. A tie or hemoclip is inserted into the tunnel and is tied or clipped as laterally as possible. Medial to the tie (clip), the tunnel is divided.
Attention is then brought to the posterior aspect of the uterus by sharply drawing the uterus anteriorly exposing the cul-de-sac and putting the uterosacral ligaments on stretch. The uterosacral ligaments are identified, and a small window in the peritoneum is made approximately 1 cm beneath the inferior margin of the cervix in the midline. This opens the rectovaginal space that can further be deepened by either blunt or sharp dissection. The ureter is then separated from the medial peritoneum. Once the rectum is pushed down and the ureter is freed from the medial peritoneum, the uterosacral ligaments are clamped, divided, and sutured.
The paravaginal fascia is then dissected to further obtain the tissue between the cervix and the upper vagina. The vagina is then examined both anteriorly and posteriorly to verify that adequate vaginal margins will be obtained when the specimen is transected from the vagina. If the anterior margin is insufficient, further sharp dissection of the base of the bladder is to be freed from the anterior vagina.
When the specimen is ready, 2 clamps are placed across the vagina approximately 2 cm inferior to the level of the cervix. The cervix is then divided from the vagina above the clamps.
An estimation of the level of the lower uterine segment is made, and clamps are placed on the uterus at the level of the internal os. A knife is then used to transect the cervix approximately 5 mm below the level of the internal os (Figure 26-4). The specimen is then released and sent for frozen section to verify a negative endocervical margin. For patients with a positive margin or a margin less than 5 mm, an additional resection is performed. A #5 French catheter is inserted and sutured into the os to maintain patency. This is removed at the patient’s postoperative clinic visit. A permanent cerclage (Shirodkar) suture (Mersilene) is subsequently placed around the inferior edge of the uterus at the level of the internal os and the knot tied posteriorly. The uterus is then reapproximated to the vaginal cuff with 6 to 8 1-0 delayed-absorbable interrupted sutures (Figure 26-5). Hemostasis is obtained, and the abdomen is closed in the normal fashion.
FIGURE 26-4. Radical abdominal trachelectomy. The cervix with parametria and upper vagina have been separated from the vagina and are detached from the uterine fundus.
FIGURE 26-5. Radical abdominal trachelectomy. Cerclage has been placed, and the lower uterine segment is approximated to the upper vagina.
Radical Vaginal Trachelectomy
The patient is put in semilithotomy position, and general anesthesia is induced. Care is taken to place the legs appropriately to avoid pressure on the peroneal nerves. A bimanual examination is performed to assess the extent of disease to further guide the procedure. The abdomen and perineum are prepped and draped, and an indwelling Foley catheter is inserted into the bladder. The operating room is prepared for laparos-copy and vaginal surgery.
The procedure is initiated with a laparoscopic bilateral lymph node evaluation by either a lymph node dissection or a sentinel lymph node biopsy. If a sentinel lymph node biopsy is performed, the vaginal procedure is performed while waiting for the result of the frozen section; however, the laparoscopic equipment remains sterile.
The patient is then put in high lithotomy position, and the cervix is visualized. The vaginal mucosa around the cervix is injected with a dilute solution of vasopressin in lidocaine. A scalpel is used to circumferentially incise the vaginal mucosa taking care to leave an adequate margin of 1 to 2 cm from the cervical portio. The posterior cul-de-sac is entered, while the vesicovaginal space anteriorly is developed, but the bladder peritoneum is not incised. The paravesical spaces are created by dissecting at the small indentation created by retracting the anterior vaginal cuff at the 12 o’clock position and the lateral vaginal cuff at the 3 (or 9) o’clock position. Using a long curved Kelly clamp or Metzenbaum scissors, the paravesical space is developed by gently spreading in a superior-anterior-lateral direction (Figure 26-6). Cooper’s ligament is then palpable anteriorly. Krobach clamps are then placed horizontally on the vagina, which is closed over the cervix, facilitating traction of the cervix. The distal portion of the uterosacral ligaments can be safely clamped in their mid portion without identifying the ureter at this point. A Breisky retractor is placed in the paravesical space, and with a finger in the vesicouterine space, the ureter can be palpated against the retractor. The tissue between the paravesical and vesicouterine space is the vesicouterine ligament. The distal aspect of the vesicouterine ligament can be transected up to the level of the ureter. This is preferably done with 1 hand palpating the ureter while the other hand dissects the vesicouterine ligament. Once the dissection reaches the ureter superiorly, the ureter can be mobilized anteriorly, and the knee of the ureter is identified (Figure 26-7).
FIGURE 26-6. Radical vaginal trachelectomy. The left paravesical space is created by dissecting at the small indentation created by retracting the anterior vaginal cuff at the 12 o’clock position and the lateral vaginal cuff at the 9 o’clock position. Using a long curved Kelly or Metzenbaum scissors, the paravesical space is then developed by gently spreading in a superior-anterior-lateral direction.
FIGURE 26-7. Radical vaginal trachelectomy. The distal aspect of the vesicouterine ligament is transected up to the level of the ureter. Once the dissection reaches the ureter superiorly, the ureter can be mobilized anteriorly, and the knee of the ureter is identified.
The parametrium is identified, clamped, divided, and ligated to obtain an adequate margin. The cervicovaginal branch of the uterine artery is clamped, divided, and ligated. Once the parametrium and the cervicovaginal branch of the uterine artery have been divided, the cervix can be transected. By palpating posteriorly, the cervicouterine junction can be identified, and an appropriate portion of the cervix is transected from the uterus.
The cervical specimen is sent for frozen section to confirm a tumor-free margin of at least 5 mm. For patients with a positive margin or a margin less than 5 mm, an additional resection is performed. A #5 French catheter is inserted and sutured into the os to maintain patency. This is removed at the patient’s postoperative clinic visit. To prevent cervical incompetence, a Mersilene (Shirodkar cerclage) suture is placed around the lower uterine segment and tied posteriorly. The vaginal cuff is then sutured to the most lateral portions of the “neocervix” while burying the Mersilene suture.
Laparoscopic Radical Trachelectomy
The laparoscopic radical trachelectomy may be performed using a variety of laparoscopic instruments. This specific procedure will be described using the argon beam coagulator and the LigaSure.
The patient is put in semilithotomy position, and general anesthesia is induced. The patient is prepped and draped in the usual fashion with the patient’s arms tucked by her sides. Entry into the abdomen can be obtained by inserting a Veress needle either 1 cm above or below the umbilicus or through the Hasson open technique, as per the surgeon’s preference. A pneumoperitoneum is obtained, and the camera is inserted through a 5-mm (high-definition laparoscope) or 10-mm trocar at the umbilicus. Patients with a previous midline incision can be managed using either an alternate entry site or a needle laparoscope at the umbilicus. The patient is then put in steep Trendelenburg position. A 10-mm trocar is placed suprapubically in the midline, and two 5-mm trocars are placed laterally approximately 2 cm medial to the anterior superior ischial spine and at the level of the umbilicus.
The pelvis and abdomen are then fully explored to rule out any macroscopic disease. The argon beam coagulator is inserted, along with a grasper and the LigaSure. A decision is made to start with the pelvic lymph node dissection or with the radical trachelectomy. Lymph node dissection is described in Chapter 28.
The peritoneum overlying the psoas muscle is grasped and put on tension. A continuous suction or venting of gases is advisable. This can be as simple as wall suction attached to the gas valve of one of the trocars. The peritoneum is then cauterized with the argon beam coagulator and then further opened parallel to the infundibulopelvic ligament exposing the iliac vessels and the psoas muscle. The argon beam is then used to further open the anterior peritoneum caudally up to the level of the bladder reflection. The infundibulopelvic ligament is retracted medially to facilitate exposure of the ureter, adjacent to the medial peritoneum, as it crosses over the iliac bifurcation.
The bladder peritoneum is then dissected off the anterior vagina and incised with the LigaSure or with the argon beam coagulator. The bladder is reflected inferiorly with sharp and blunt dissection until the bladder is adequately reflected off the anterior vaginal wall.
The paravesical and pararectal spaces are now developed bilaterally as described for radical abdominal trachelectomy. Care is taken to cauterize any small vessels encountered because bleeding highly impairs visualization.
Once the paravesical and pararectal spaces have been properly developed, the uterine vessels are easily identified (Figure 26-8). Ideally, an attempt should be made to preserve the uterine artery and ligate only the descending branches using the LigaSure. However, the significance of ligating the uterine artery at its origin, during a trachelectomy, is unclear.
The ureter is then unroofed from the vesicouterine ligament. This is facilitated by gently dissecting superior and medial to the ureter, with the tip of the LigaSure or a Maryland grasper. This forms a tunnel under the cardinal ligament. It is important to take caution to stay superior to the ureter and confirm that the tip of the dissecting instrument is directed cephalic to the bladder. Each step consists of gentle dissection, cauterization (or hemoclip), and then division. Inserting the Colpotomizer at this stage helps to identify the level of the cervix and to verify that the bladder is adequately dissected inferiorly off the vaginal wall.
FIGURE 26-8. Laparoscopic radical trachelectomy. Visualization of the right uterine artery.
Once the tunnel is complete and the ureter is unroofed up to the bladder, attention is brought to the posterior aspect of the uterus. The uterus is anteverted, and the cul-de-sac and uterosacral ligaments are exposed. A grasper is used to hold up the posterior peritoneum inferior to the cervix in the cul-de-sac. A window is made with the argon beam coagulator, and the rectovaginal space is entered. The space is then developed with blunt dissection, thus pushing the rectum posteriorly. The ureter is then separated from the medial peritoneum, and the uterosacral ligaments are cauterized and divided (Figure 26-9). The specimen is then examined to confirm that there are ample margins both anteriorly and posteriorly and the position of the ureters. Once this has been confirmed, the vagina is incised with the argon beam coagulator on the Colpotimizer. The cervix is then transected from the vagina. The next step is identifying the cervicouterine junction to define an appropriate level of the cervix to be transected from the uterus. This step can be performed with monopolar cautery or, alternatively, can be facilitated using a vaginal approach.
FIGURE 26-9. Laparoscopic radical trachelectomy. The ureter is seen separated from the medial peritoneum, and the uterosacral ligaments are ready to be cauterized and divided.
The cervical specimen is removed through the vagina and sent for frozen section to confirm a tumor-free margin of at least 5 mm. For patients with a positive margin or a margin less than 5 mm, an additional resection is performed.
The patient is then put in high lithotomy position. A #5 French catheter is inserted and sutured into the os to maintain patency. This is removed at the patient’s postoperative clinic visit. To prevent cervical incompetence, a Mersilene (Shirodkar cerclage) suture is placed around the lower uterine segment and tied posteriorly. The vaginal cuff is then sutured to the most lateral portions of the “neocervix” while burying the Mersilene suture.
Hemostasis is obtained, the gas is let out of the abdomen, and the port sites are sutured closed.
Robotic-Assisted Radical Trachelectomy
The robotic-assisted radical trachelectomy is performed in a similar fashion to the laparoscopic radical trachelectomy; however, the port placement and the instruments may differ. The instruments commonly used in the robotic procedure are the monopolar scissors, bipolar cautery, and a grasper. Once the patient is under general anesthesia, prepped, and draped and a Foley catheter is inserted into the bladder, maximum Trendelenburg position is obtained. The procedure is then initiated by insufflation of the abdomen and placement of the trocars. A subumbilical stab can facilitate insertion of the Veress needle, and a pneumoperitoneum is obtained. A supraumbilical trocar, approximately 25 cm superior to the symphysis pubis, is then placed to accommodate the robotic camera. Two right lateral 8-mm ports are then placed; it is important to verify that there is a minimum of 10 cm between each port in order for the robotic arms to be able to maneuver optimally during the procedure. An additional 2 left lateral ports are inserted: one 8 mm and one 12 mm. The 12-mm port will act as the accessory port and be used by the assistant. The robot is then docked, and the procedure is begun. The steps of the procedure are identical to those previously noted for the laparoscopic radical trachelectomy.
Postoperative Care
Box 26-6 Complications and Morbidity
Neurogenic bladder dysfunction: Radical trachelectomy can cause denervation of the bladder and a portion of the urethra; the degree is in direct correlation to the extent of the dissection.
Vesicovaginal fistula is a rare complication but can heal spontaneously (if small).
Ureteric or bladder injury can occur intraoperatively.
Patients who undergo a full lymph node dissection are at risk of developing leg lymphedema.
Patients commonly do well postoperatively, and the mode of surgical entry correlates with the postoperative management. Patients who undergo radical vaginal trachelectomy or minimally invasive surgery can be discharged the same evening or the following day on a regular diet, and mobilization is initiated once they recover from the anesthesia. After all radical procedures, there is some degree of denervation of the bladder and urethra; therefore, an indwelling Foley catheter is left in and then discontinued on postoperative day 3 to 6 after a postvoid residual (PVR) of less than 100 mL is demonstrated confirming normal bladder function. Patients who undergo a laparotomy usually tolerate a full diet and normal activity in approximately 3 days and can therefore be discharged home at that time. The Foley catheter can be left draining the bladder until the discharge day in which it is removed and a PVR is performed. Alternatively, a trial with a PVR can be performed on postoperative day 1 and the catheter reinserted if the PVR is greater than 100 mL. This can also be determined on an individual basis as per the extent of dissection.
The rubber catheter that was placed in the cervical os is removed after 3 weeks.
SIMPLE TRACHELECTOMY
Procedure Overview
Box 26-7 Master Surgeon’s Corner
The size of the cervical stump together with the habitus, parity, and previous surgeries of the patient assist in deciding on the preferred surgical approach.
A simple trachelectomy is surgical removal of the cervix. It can be performed vaginally or abdominally in cases of early cervical cancer, rare cases of persistent endocervical dysplasia after multiple excisions, or in patients who underwent a subtotal hysterectomy and subsequently require surgical excision of the cervix. In the majority of cases, the initial indication for the hysterectomy was benign; however, the final pathology identified a malignancy (eg, endometrial cancer or uterine sarcoma). Because radical trachelectomy has been discussed previously in this chapter, we will focus here on removal of the cervix in patients who had a prior subtotal hysterectomy.
Preoperative Preparation
Patients with an indication for a simple trachelectomy undergo a physical and pelvic examination, a chest x-ray, CBC, and kidney function (creatinine) preoperatively. Additional imaging and blood work are left to the discretion of the surgeon while taking into consideration the patient’s symptoms, comorbidities, and results of the clinical examination.
Once a decision is made to proceed with a simple trachelectomy, informed consent is obtained. It is important to discuss the possibility of complications including bleeding, infection, and injury to adjacent organs.
The patient is admitted to the hospital on the morning of the operation. Prophylactic antibiotic is administered prior to surgery.
Operative Procedure
Simple Abdominal Trachelectomy
Box 26-8 Caution Points
The proximity of the ureters to the cervix should be kept in mind when performing a vaginal or abdominal trachelectomy.
The patient is put in semilithotomy position, and general anesthesia is induced. Care is taken to place the legs appropriately to avoid pressure on the peroneal nerves. A bimanual examination is performed to assess the cervix and to further guide the procedure. The abdomen and perineum are prepped and draped, and an indwelling Foley catheter is inserted into the bladder.
The incision can be either transverse (Pfannenstiel, Maylard, or Cherney) or a low midline incision from the umbilicus to the pubic bone.
Once the peritoneal cavity is entered, a full abdominal and pelvic exploration is performed. The patient is then put in Trendelenburg position, a self-retaining retractor is inserted, and the bowel is packed off to facilitate maximum exposure of the pelvis.
The cervical stump is then identified; however, commonly the bladder and/or bowel are adherent superiorly to the cervical stump, and these must be taken down carefully before the cervix can be visualized. Once the cervix is exposed, it can be grasped with a single-tooth tenaculum to allow manipulation. The retroperitoneum is opened by incising the peritoneum overlying the psoas muscle. The retroperitoneal structures, including the psoas muscle and the external iliac vessels, are exposed, and the ureter is identified. A right angle clamp can be used to gently dissect the ureter off the peritoneum, and a vessel loop is placed under the ureter to assist in orientation of its position throughout the procedure. The cervix is then elevated and the bladder dissected off anteriorly. A heavy clamp (eg, Kelly or curved Rogers) is used to clamp the cardinal ligament on either side. The ligament is then cut and tied. The uterosacral ligaments are then clamped, divided, and sutured. The paravaginal fascia is then dissected to further obtain the tissue between the cervix and the upper vagina. When the specimen is ready, 2 heavy clamps (eg, curved Rogers, Heaney) are placed across the vagina. The uterus and cervix are then divided from the vagina above the clamps. The specimen is sent to pathology.
A delayed-absorbable suture is then placed under each clamp to assure hemostasis of the vaginal angles. The opening of the vaginal cuff is then closed with either a running locking suture or, alternatively, with multiple interrupted figure-of-eights with special attention to include the vaginal mucosa of both the anterior and posterior wall. If the mucosa is not obvious at the time of closure, a long straight Kocher can be placed on each wall to verify that they are both incorporated in the suture.
Simple Vaginal Trachelectomy
In general, the vaginal approach is easier and less morbid than the abdominal approach. The patient is put in lithotomy position, and general anesthesia is induced. Care is taken to place the legs properly as to avoid pressure on the peroneal nerves. A bimanual examination is performed to assess the remaining cervix as to further guide the procedure. The perineum is prepped and draped, and an indwelling Foley catheter is inserted into the bladder.
The vaginal mucosa around the cervix is injected with a dilute solution of vasopressin in lidocaine. A scalpel is used to circumferentially incise the vaginal mucosa. The posterior cul-de-sac is entered, and the vesicovaginal space is developed. The bladder peritoneum is not incised. The cervix is grasped with a single-tooth tenaculum, facilitating traction of the cervix. The uterosacral ligaments are then clamped, cut, and sutured bilaterally. The cardinal ligaments are then clamped, divided, and ligated bilaterally. The cervix is now free of its attachments, and gentle traction on the cervical stump facilitates removal of the cervix. If additional tissue is adherent to the superior aspect of the cervix, care is taken while dissecting off the adhesions because the bladder and bowel are commonly adjacent.
The cervical specimen is sent for pathology. The vaginal cuff is then sutured closed with a running delayed-absorbable suture.
Laparoscopic Simple Trachelectomy
The laparoscopic simple trachelectomy may be performed using a variety of laparoscopic instruments. This specific procedure will be described using the argon beam coagulator and the LigaSure.
The patient is put in semilithotomy position, and general anesthesia is induced. The patient is prepped and draped in the usual fashion with the patient’s arms tucked by her sides. Entry into the abdomen and trocar placement are the same as described for laparoscopic radical trachelectomy.
The argon beam coagulator is inserted, along with a grasper and the LigaSure. The peritoneum lying over the psoas muscle is grasped and put on tension. A continuous suction or venting of gases is advisable. This can be as simple as wall suction attached to the gas valve of one of the trocars. The peritoneum is then cauterized with the argon beam coagulator and then further opened parallel to the infundibulopelvic ligament exposing the retroperitoneal structures (ie, the iliac vessels and the psoas muscle). The argon beam is then used to further open the anterior peritoneum caudally up to the level of the bladder reflection. The infundibulopelvic ligament is retracted medially to facilitate exposure of the ureter, adjacent to the medial peritoneum, as it crosses over the iliac bifurcation.
The bladder peritoneum is then dissected off the anterior vagina and incised with the LigaSure or with the argon beam coagulator. The bladder is reflected inferiorly with sharp and blunt dissection until the bladder is adequately reflected off the anterior vaginal wall.
The cervical stump is then grasped and pulled cephalic using a single-tooth tenaculum and a Colpotimizer in the vagina to further delineate the correct planes. The LigaSure is used to cauterize and cut the cardinal ligaments bilaterally. The uterosacral ligaments are then cauterized and divided.
The vagina is incised with the argon beam coagulator on the Colpotimizer. The cervix is then transected from the vagina, and the specimen is removed through the vagina and sent to pathology. The vaginal cuff is sutured laparoscopically, taking care to incorporate both sides of the vaginal cuff mucosa.
Hemostasis is obtained, the gas is let out of the abdomen, and the port sites are sutured closed.
Postoperative Care
Box 26-9 Complications and Morbidity
The retroperitoneum should be opened and the ureters identified in order to prevent an inadvertent ureteric injury.
The bladder and/or bowel are frequently adhesed to the superior aspect of the cervical stump; these should be dissected off carefully before clamping the cervix.
Patients commonly do well postoperatively, and the mode of surgical entry correlates with the postoperative management. Patients who undergo simple vaginal trachelectomy can be discharged the same evening or the following day as the catheter is removed on completion of the surgery; a regular diet and mobilization are initiated once they recover from the anesthesia. Patients who undergo a laparotomy usually tolerate a full diet and normal activity in approximately 3 days and can therefore be discharged home at that time.
REFERENCES
1. Mathevet P, Chemali E, Roy M, Dargent D. Long-term outcome of a randomized study comparing three techniques of conization: cold knife, laser, and LEEP. Eur J Obstet Gynecol Reprod Biol. 2003;106(2):214-218.
2. Mathevet P, Dargent D, Roy M, Beau G. A randomized prospective study comparing three techniques of conization: cold knife, laser, and LEEP. Gynecol Oncol. 1994;54(2):175-179.
3. Beiner ME, Covens A. Surgery insight: radical vaginal trachelectomy as a method of fertility preservation for cervical cancer. Nat Clin Pract Oncol. 2007;4(6):353-361.
4. Marchiole P, Benchaib M, Buenerd A, Lazlo E, Dargent D, Mathevet P. Oncological safety of laparoscopic-assisted vaginal radical trachelectomy (LARVT or Dargent’s operation): a comparative study with laparoscopic-assisted vaginal radical hysterectomy (LARVH). Gynecol Oncol. 2007;106(1):132-141.
5. Dargent D, Martin X, Sacchetoni A, Mathevet P. Laparoscopic vaginal radical trachelectomy: a treatment to preserve the fertility of cervical carcinoma patients. Cancer. 2000;88(8):1877-1882.
6. Piver MS, Rutledge F, Smith JP. Five classes of extended hysterectomy for women with cervical cancer. Obstet Gynecol. 1974;44(2):265-272.