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Gynecologic Oncology
Laparoscopic Radical Hysterectomy for Early-stage Cervical Cancer
a report by
Erin R King, MD, MPH
1
and Pedro T Ramirez, MD
2
1. Resident, Department of Obstetrics and Gynecology, University of Virginia;
2. Associate Professor, Department of Gynecologic Oncology, MD Anderson Cancer Center
While gynecologists have used laparoscopy for nearly 50 years, it was not an abdominal radical hysterectomy and pelvic lymphadenectomy. First
until the 1990s that laparoscopy gained acceptance among gynecological described by Canis et al.
1
and Nezhat et al,
2
TLRH for early-stage cervical
oncologists for advanced procedures such as hysterectomy with lymph- cancer has been proved efficacious and safe by a number of other groups
3–9
adenectomy for endometrial cancer. More recently, total laparoscopic radical
hysterectomy (TLRH) for early-stage cervical cancer (International Federation
of Gynecology and Obstetrics [FIGO] stages IA2 and IB1) has proved both
Newer robotic technology alleviates
safe and feasible. First described in the early 1990s,
1,2
growing evidence
some of the shortcomings of laparoscopy,
supports its benefits and possibly even superiority over laparotomy in radical
hysterectomy. While technically challenging with a steep learning curve, clear
and robot-assisted radical hysterectomy
advantages include decreased operating time, lower patient morbidity,
may soon surpass total laparoscopic
shorter length of inpatient hospitalization, less blood loss, improved
cosmesis, and comparable outcomes to laparotomy, including recurrence
radical hysterectomy as a minimally
rates and lymph- node yield. Newer robotic technology alleviates some of the
invasive procedure.
shortcomings of laparoscopy, and robot-assisted radical hysterectomy (RRH)
may soon surpass TLRH as a minimally invasive procedure.
and is gaining popularity. The best candidates for TLRH include those with
Total Laparoscopic Radical Hysterectomy early-stage disease (IA2 or IB1), tumor size <4cm, and uterine size <12cm.
Both patients and physicians have driven the advancement of minimally Patients with a bulky uterus or bulky cervical tumors, severe hip or joint
invasive surgery. The pursuit of cutting-edge technology by physicians and disease, or intraperitoneal metastases are generally not suitable candidates
academic institutions has promoted the expansion of minimally invasive for the procedure.
techniques, and training opportunities abound. With increasing public
awareness, many patients are now requesting minimally invasive surgery. Total Laparoscopic Radical Hysterectomy Technique
Patients with early-stage, IA2, or IB1 cervical cancer are traditionally offered Informed consent is obtained. All patients undergo pre-operative bowel
preparation and receive prophylactic antibiotics. After placement in
lithotomy position with arms tucked at the sides, a Foley catheter is inserted.
Erin R King, MD, MPH, is a third-year Resident in the
Department of Obstetrics and Gynecology at the University of
A uterine manipulator is placed. The patient is placed in steep Trendelenburg
Virginia. She plans to pursue a fellowship in gynecological position. Based on surgeon preference of endoscope size, a 5, 10, or 12mm
oncology on completion of her training, and is conducting
bladeless trocar is situated at the umbilicus under direct visualization of the
ongoing research in the efficacy of advanced-line
chemotherapeutic agents in recurrent epithelial ovarian cancer.
abdominal cavity. If the patient has a prior mid-line incision, entry can be
Dr King is a junior member of the American College of made at Palmer’s point 2cm below the left costal margin in the mid-clavicular
Obstetrics and Gynecology (ACOG).
line. The abdomen is insufflated, and three additional bladeless trocars (5,
E: erk7e@virginia.edu 10, or 12mm) are placed in the right lower quadrant, left lower quadrant,
and the mid-line 2cm above the pubic symphysis. At least one of the three
Pedro T Ramirez, MD, is an Associate Professor in the
Department of Gynecologic Oncology at MD Anderson Cancer
trocars must measure 10 or 12mm in order to permit lymphadenectomy. An
Center. He is also Director of Minimally Invasive Surgical
abdominal survey is then performed to rule out intraperitoneal disease. The
Research and Education. He serves as Chair of the Gynecologic
bowel is mobilized out of the surgical field.
Oncology Committee for the American Association of
Gynecologic Laparoscopists (AAGL). He is also the principal
investigator in the first phase III trial evaluating laparotomy
The round ligaments are then transected bilaterally. The peritoneum is
versus minimally invasive surgery for radical hysterectomy in
incised over the psoas muscle immediately lateral to the infundibulopelvic
patients with early-stage cervical cancer. Dr Ramirez is one of
the country’s leading surgeons in robotic surgery for women with gynecologic malignancies. He is
ligament, and the ureters are identified. Any suspicious-appearing lymph
also interested in the development of novel approaches for the treatment of young women with
nodes are then removed and sent for frozen pathology, as the procedure is
gynecologic malignancies who wish to preserve their fertility.
aborted in the presence of metastatic disease. Next, the paravesical and
E: peramire@mdanderson.org pararectal spaces are identified and exposed. The uterine vessels are
identified and transected at the point of origin from the iliac vessels. The
64 © TOUCH BRIEFINGS 2008
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