Radical Hysterectomy with Pelvic Lymphadenectomy

Radical Hysterectomy with Pelvic Lymphadenectomy

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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.

Surgical Technique

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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)
  6. 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)
  7. 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)
  8. 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.
  9. Steps (5)–(8) are then repeated on the left side.
  10. 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.
  11. 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)
  12. 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.
  13. 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).
  14. 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).
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  16. Steps (10)–(14) are repeated on the left side.
  17. 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).
  18. 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.
  19. 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.
  20. 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).
  21. 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).
  22. 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.
  23. 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.
  24. The  abdomen  is  then  closed  in  layers,  using  continuous  0  looped  PDS  in  a  modified  Smead-Jones technique.
Radical Hysterectomy with Pelvic Lymphadenectomy
Radical Hysterectomy with Pelvic Lymphadenectomy2
Radical Hysterectomy with Pelvic Lymphadenectomy3
Radical Hysterectomy with Pelvic Lymphadenectomy4
Radical Hysterectomy with Pelvic Lymphadenectomy5
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