Radical Hysterectomy with Pelvic Lymphadenectomy
Radical abdominal hysterectomy was developed in the late nineteenth century for the treatment of cancer of the cervix uteri and upper vagina. The procedure was originally described in 1895 by Clark and Reis, but Wertheim is credited for the development and improvement of the basic technique of radical hysterectomy. Wertheim reported extensively on his early results with this procedure and was a pioneer in describing approaches to reducing problems with hemorrhage, urinary tract injury, fistula formation, and sepsis.
Over the past century, the procedure underwent several refinements in indications, patient selection, and surgical technique. Moreover, the advancements in anesthesiology, antibiotics, and preoperative and postoperative medical care have resulted in a significant reduction in morbidity and mortality from this procedure.
- The patient is placed in supine position and the abdomen and vagina are prepped. A foley catheter is placed in the patient’s bladder, and SCD’s are placed on both lower extremities.
- A vertical midline incision is made 3 cm above the umbilicus and is extended inferiorly to the pubic symphysis. A Bookwalter retractor is placed, and right-angle or body wall retractors are used to retract the pelvic sidewalls.
- Prior to initiating the pelvic procedure, the entire abdominal cavity is evaluated for evidence of metastatic disease. This includes all surfaces of the liver and diaphragm, the celiac plexus, omentum, small, and large bowel surfaces as well as the mesentery. Pelvic and para-aortic lymph nodes are palpated, and any enlarged or suspicious nodes are excised and sent for histologic evaluation.
- The bowel is packed into the upper abdomen using warm, moist laparotomy sponges. Two 8-inch Kelly Clamps are placed on the uterine cornua for retraction.
- The right round ligament is clamped, cut, and ligated at the right lateral pelvic wall. The anterior leaf of the right broad ligament is incised inferiorly along the lateral pelvic wall for a distance of approximately 3 cm. (Figure 1)
- The posterior leaf of the right broad ligament is incised superiorly along the lateral pelvic wall to the level of the infundibulopelvic ligament. (Figure 2)
- If the right ovary is to be preserved, the posterior leaf of the right broad ligament is further incised parallel and inferior to the infundibulopelvic and utero-ovarian ligaments. The right utero-ovarian ligament is then clamped, cut, and ligated, and the ovary is placed in the right iliac fossa. (Figure 3)
- If the right ovary is to be excised, the right infundibulopelvic ligament is clamped, cut, and doubly ligated at the lateral pelvic wall. The right utero-ovarian ligament is then clamped, cut, and suture ligated, and the right tube and ovary are removed.
- Steps (5)–(8) are then repeated on the left side.
- The right retroperitoneal space is entered along the lateral pelvic wall, thereby exposing the common iliac, external iliac, and internal iliac arteries and associated lymph nodal tissue.
- The ureter is identified, and two silk sutures are placed in the adjacent medial peritoneum, thereby pulling the ureter medially away from the iliac vessels (Figure 4)
- The lymph node dissection is begun by sharply excising all lymph nodal tissue surrounding the right common iliac, external iliac, and internal iliac arteries. The lateral extent of the pelvic lymph node dissection is defined by the genitofemoral nerve (Figure 5). The external iliac and common iliac arteries are retracted laterally, and lymph nodal tissue surrounding the common iliac, external iliac, and internal iliac veins is removed by sharp dissection. Lymph nodal tissue from each of the major anatomic sites (i.e., common iliac, external iliac, internal iliac) is placed in separate containers and submitted for histologic analysis.
- The anterior division of the internal iliac artery is identified, and the uterine artery is isolated, ligated with 2-0 silk ties, and transected. The superior vesicle artery is preserved (Figure 6).
- A vein retractor is placed on the medial aspect of the external iliac artery and vein, and the obturator nerveis identified. All lymph nodal tissue is removed from the obturator fossa by sharp dissection,placed in a separate container and submitted for histologic analysis (Figure 7).
- Steps (10)–(14) are repeated on the left side.
- The right pararectal space and paravesical spaces are defined by blunt dissection, and the lateral aspect of the cardinal ligament containing the vascular web is clamped, cut, and ligated with 2-0 silk ties. Ligation of the left vascular web is completed in the same fashion (Figures 8 and 9).
- The right ureter is dissected from the medial peritoneum at the level of the uterosacral ligament, (Figure 10) and a 3/8 inch Penrose drain is placed around the ureter (Figure 11). The ureter is dissected laterally from the parametrial tunnel using right angle clamps (Figure 12). The parametrial vasculature is ligated, and the ureter is rolled laterally out of the tunnel. The right ureter is dissected free from surrounding tissue until its entrance into the bladder (Figure 13). The left ureter is then dissected free from the left parametrium in the same fashion.
- The bladder is sharply dissected from the anterior vagina, and the peritoneum between the uterus and the rectum is incised. The anterior rectal wall is reflected away from the posterior vagina.
- The uterus is elevated and the uterosacral ligaments are clamped, cut, and tied (Figure 14). The anterior, posterior, and lateral attachments of the uterus and parametria have now been ligated. The paravaginal tissue at the inferior margin of the dissection is clamped, cut, and tied using curved Lainz clamps (Figure 15).
- The vagina is transected approximately 3 cm below the cervix and isolated bleeding sites on the vaginalcuff are ligated using 2-0 vicryl suture. The vagina is closed using a continuous interlocking 0 vicryl suture (Figure 16).
- Closed suction drains may be placed in both retroperitoneal spaces at the discretion of the surgeon. These drains are brought out through the anterior abdominal wall in each lower quadrant and are sutured to the skin using 2-0 silk suture.
- If the ovaries are retained, they are suspended to the lateral pelvic wall with 2-0 prolene, and titanium clips are placed on the suture site for future identification.
- The abdomen is then closed in layers, using continuous 0 looped PDS in a modified Smead-Jones technique.