Keywords
cervical cancer - laparoscopic radical hysterectomy - nerve-sparing - no-look no-touch
technique - tumor spillage
Preoperative Evaluation
Patients with early-stage cancer (clinical stage IA2, IB1, IB2, and IIA1 based on
the revised 2018 International Federation of Gynecology and Obstetrics staging system)
are eligible for laparoscopic radical hysterectomy.[1] It is important to confirm the appropriate indication for laparoscopic surgery.
In this study, pelvic examination, magnetic resonance imaging, and computed tomography
were performed for all patients, and the results were assessed in a preoperative meeting,
where all gynecologists assembled to discuss the diagnosis and operative procedure.
Patients suspected to have parametrium invasion and/or lymph node metastases should
be excluded. Laparoscopic surgery is not indicated for uterus with a large fibroid
that is difficult to extract via the vaginal.
There are 12 surgical steps as follows:
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1. Creation of a vaginal cuff
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2. Placement of the trocar
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3. Insertion of the forceps via the vagina
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4. Development of the pararectal and paravesical spaces
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5. Suspension of the rectum
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6. Pelvic lymphadenectomy
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7. Mobilization of the bladder and transection of the upper ligaments
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8. Dissection around the ureter and transection of the uterine artery
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9. Transection of the cardinal ligament
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10. Transection of the posterior layer of the vesicouterine ligament
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11. Transection of the paracolpium and rectovaginal ligament
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12. Transection of the paravaginal tissue, extraction of the specimen via the vagina,
and closure of the vagina
Explanation of the Surgical Procedure
Explanation of the Surgical Procedure
Tumor spillage is a common concern in laparoscopic surgery for malignant tumor. Several
cases have been reported in various fields, including tumor spillage in patients with
rectal cancer.[2]
[3] Transanal total mesorectal excision, a surgical procedure for rectal cancer, has
been associated with higher rate of local recurrence due to the exposure of the tumor
caused by anastomotic leakage.[3] To the best our knowledge, tumor perforation, tumor exposure to circulating CO2 gas, and direct manipulation of the tumor are considered to cause cancer dissemination.[3]
[4]
[5]
[6] These issues are considered surgeon-related factors and are preventable.[7] Therefore, we believe it is important to prevent tumor spillage during laparoscopic
operation performed for a patient with cervical cancer.
The following four major aspects of our total laparoscopic radical hysterectomy approach
prevent tumor spillage: (1) creation of a vaginal cuff, (2) manipulation of the uterus
without a uterine manipulator, (3) minimal handling of the uterine cervix, and (4)
extraction of the specimen in a collection bag. We call this the “no-look no-touch
technique.” We reported that total laparoscopic radical hysterectomy using the no-look
no-touch technique might be a useful to reduce the risk of recurrence.[8] Here, we describe these surgical procedures in detail.
Creation of a Vaginal Cuff
Creation of a Vaginal Cuff
Prior to laparoscopic surgery, we create a vaginal cuff for both the prevention of
tumor spillage and to create an accurate vaginal incision.
First, approximately 12 to 15 cm sutures are placed around the circumference of the
vagina, approximately 1.5 cm away from the tumor ([Fig. 1A]). The sutures are pulled to obtain a good view of the incision line. Adrenaline,
at a dilution of 1:1,000,000, is administered in the incision line to reduce bleeding.
The vaginal mucosa is incised circumferentially, approximately 2 cm away from the
tumor ([Fig. 1B]), and the connective tissue is scrape down beneath the mucosa using unipolar electrocautery.
Subsequently, a vaginal cuff is created by closing the incision with continuous sutures
([Fig. 1C]).
Fig. 1 Creation of a vaginal cuff. (A) A total of 12 to 15 sutures are placed around the circumference of the vaginal,
approximately 1.5 cm away from the tumor. (B) The vaginal mucosa is incised circumferentially, approximately 2 cm away from the
tumor. (C) Vaginal cuff closure is completed.
Placement of the Trocar
The patient is positioned in the lithotomy position with a Trendelenburg tilt of 10 degrees.
A 12-mm trocar is placed at the umbilicus as a camera port, and three trocars are
placed in the lower abdomen ([Fig. 2]). The middle port is placed midway between the umbilicus and pubis to perform the
laparoscopic procedure easily in the upper area around the common iliac artery; in
this position, the middle port is placed relatively higher than its placement in the
typical diamond position. A 12-mm trocar, instead of a 5-mm trocar, is used as the
right lateral port. We can easily pass gauze in and out through the right 12-mm trocar,
especially in case of sudden bleeding.
Fig. 2 Placement of the trocars. A 12-mm trocar is placed at the umbilicus as a camera port,
and three trocars are placed in the lower abdomen.
The primary operator stands on the right side of the patient and uses the middle and
left trocars. The first-assistant stands on the right side with a camera and uses
forceps inserted through the right trocar to maintain appropriate traction. The second-assistant
sits between the patient's legs and manipulates the uterus, as described below.
Insertion of the Forceps via the Vagina
Insertion of the Forceps via the Vagina
A 1–0 absorbable synthetic braided suture is placed around the uterine body. A 5-mm
extra-long (150 mm) trocar (Covidien, Mansfield, MA) is placed in the posterior vaginal
fornix ([Fig. 3A]). We insert the forceps through this trocar, and the thread around the uterine body
is griped by the forceps ([Fig. 3B]). By pulling or pushing the uterine thread, the second assistant manipulates the
uterus.
Fig. 3 Insertion of forceps via the vagina. (A) A 5-mm extra-long trocar is placed in the posterior vaginal fornix. (B) Forceps are inserted through this trocar, and the thread around the uterine body
is gripped by the forceps.
In this procedure, a vaginal cuff is created prior to the laparoscopic surgery, thus
overcoming the issue of using a uterine manipulator, which results in direct excessive
tumor manipulation. When placing an extra-long trocar, the second assistant should
be careful to not break the vaginal cuff. The finger should be placed on the side
of the trocar to insert an extra-long trocar safely.
Development of the Pararectal and Paravesical Spaces
Development of the Pararectal and Paravesical Spaces
First, we develop Latzko pararectal space. We begin to open the area circumscribed
by the round ligament, the infundibulopelvic ligament, and the iliac vessels. We create
a wide and deep pararectal space, with preservation of the mesoureter.
Next, we develop the paravesical space. We begin to develop this space from outside
the umbilical ligament. We create a wide and deep paravesical space, with preservation
of the vesico-hypogastric fascia. After this procedure, the cardinal ligament is exposed
([Fig. 4]).
Fig. 4 Development of the pararectal and paravesical spaces (on the right side). We create
a wide and deep space. The cardinal ligament is exposed.
Subsequently, we scrape the ureter down beneath the posterior leaf of the broad ligament.
This results in the development of the Okabayashi pararectal space. After developing
the Okabayashi pararectal space, the hypogastric nerve can be identified.
We incised either the infundibulopelvic ligament or ovarian ligament depending on
whether we preserve the ovary.
This step is an important procedure as a sufficient and safe operative view, and an
appropriate incision line for radical hysterectomy is obtained with this procedure.
The pararectal and paravesical spaces consist of avascular connective tissue in principle.
Therefore, in step 4, we should fully develop these spaces to expose the important
pelvic structures, including the vesico-hypogastric fascia, hypogastric nerve, and
cardinal ligament.
Suspension of the Rectum
The rectum is mobilized and lifted upwards by using cotton tape. When we perform the
operation from the right side, the rectum is lifted toward the left side. The suture
is placed on the tape and the thread is fixed in the upper part of the abdominal wall
([Fig. 5]).
Fig. 5 Suspension of the rectum. The rectum is lifted upwards toward the left using a cotton
tape. Behind the rectum, the hypogastric nerve can be seen.
“Suspension of the rectum” is an unfamiliar concept to a gynecologist; however, it
is a very important technique in pelvic surgery. With this technique, the parametrium
is exposed and the pararectal and paravesical spaces are developed; thus, sufficient
radical hysterectomy can be safely performed, without direct handling of the uterine
cervix. Moreover, this technique is effective, even in cases of bulky tumors and obese
patients.
Pelvic Lymphadenectomy
We perform en bloc pelvic lymphadenectomy. First, we develop the space between the
psoas muscle and the external iliac vessels widely to expose the obturator nerve and
vessels. We dissect the fatty tissue, including the lymph nodes, from the boundary
of the endopelvic fascia covering the psoas, internal obturator, and levator ani muscles.
We seal the upper end of the lymphatic tracts (around the bifurcation of the common
iliac arteries) using an advanced bipolar device to prevent lymphocele formation.
Following the sealing of the upper end of the lymphatic tracts, the lymphofatty tissue
is easily scraped down beneath the external and internal iliac vessels.
Next, we separate the lymphofatty tissue from the obturator nerve and vessels. In
case of possible lymph node metastases, both the obturator vessels and the lymph nodes
are removed to prevent spillage of the remaining cancer cells. We also seal the lower
end of the lymphatic tracts using an advanced bipolar device.
Finally, we harvest the internal iliac lymph nodes, and dissect the lymphofatty tissue
between the internal iliac vessels and hypogastric nerve, toward the cardinal ligament.
After removing the lymphofatty tissue completely, we place the lymph nodes in a plastic
bag to prevent tumor spillage ([Fig. 6A–D]).
Fig. 6 Pelvic lymphadenectomy (on the right side). (A) Development of the space between the psoas muscle and the external iliac vessels
until the obturator nerve are exposed. (B) Harvesting the internal iliac lymph nodes. (C, D) Final view of the pelvic lymphadenectomy.
We must perform pelvic lymphadenectomy with en bloc removal of the lymphatic tissue
to prevent scattering cancer cells, lymphatic loss, and blood loss.
For nerve-sparing radical hysterectomy, complete removal of the lymph nodes in the
internal iliac region is essential. We perform lymphadenectomy meticulously to expose
the cardinal ligament and pelvic nerve networks, including the hypogastric nerve,
pelvic splanchnic nerves, pelvic nerve plexus, and their vesical branches.
Mobilization of the Bladder and Transection of the Upper Ligaments
Mobilization of the Bladder and Transection of the Upper Ligaments
We incise the bladder peritoneum and mobilize the bladder down to the level where
the vaginal cuff is placed. We should be careful not to incise the vaginal wall itself,
which is weakened by the creation of the vaginal cuff. Finally, we incise the round
ligament laterally using an advanced bipolar device.
Dissection around the Ureter and Transection of the Uterine Artery
Dissection around the Ureter and Transection of the Uterine Artery
We dissect the connective tissue around the ureter. The ureter is wrapped by the mesoureter,
which is connected to the uterine artery, deep uterine vein, and hypogastric nerve.
It is essential to incise each connection to develop a ureteral tunnel.
First, we open the fascia circumscribed by the uterine artery, umbilical ligament,
and superior vesical artery, thereby isolating the umbilical ligament. We hang the
vessel tape around the umbilical ligament to clear the operative field and to facilitate
dissection around the ureter ([Fig. 7A]). Next, we incise the connection around the ureter. Some branches from the uterine
artery can be seen in the connection between the mesoureter and uterine artery, and
they are incised by using an advanced bipolar device ([Fig. 7B]). After the dissection, a branch from the uterine artery to the bladder is separated
(middle vesical artery). We transect the uterine artery and middle vesical artery,
and then the uterine artery can be completely isolated from the ureter.
Fig. 7 Dissection around the ureter (on the left side). (A) Hanging the vessel tape around the umbilical ligament to facilitate dissection around
the ureter. (B) Incision of the connection around the ureter.
Subsequently, the bladder pillar is dissected meticulously, leading to the isolation
of the small vessels between the uterus and bladder (cervico-vesical vessels). We
transect the cervico-vesical vessels, and unroofing of the ureter is accomplished.
The ureter is a metanephrogenic organ; therefore, it can be easily dissected from
the uterus, which is a mesonephros organ. Embryologically, these positions are reversed,
leading to the formation of the fusion fascia around the ureter. Separating this fusion
fascia is essential for dissecting the ureter from the uterine-related structures.
This concept enables us to perform this procedure safely. Incising the connection
around the ureter is similar to mobilizing the fusion fascia around the ureter, such
as the Toldt fascia around the colon.
Transection of the Cardinal Ligament
Transection of the Cardinal Ligament
After pelvic lymphadenectomy, the vessels and nerves around the cardinal ligament
are already isolated. We clamp and incise only the deep uterine vein, not the vesical
vessels. Subsequently, we scrape the incised deep uterine vein upward to the level
of the hypogastric nerve, which lies in the upper end of the pelvic nerve network.
Thereafter, the pelvic nerve network can be seen ([Fig. 8]).
Fig. 8 Pelvic nerve network (on the right side). This network consists of the hypogastric
nerve and pelvic splanchnic nerves.
Transection of the Posterior Layer of the Vesicouterine Ligament
Transection of the Posterior Layer of the Vesicouterine Ligament
The posterior layer of the vesicouterine ligament consists of the vesical vessels,
nerves, and adipose tissue; therefore, dissection should be performed meticulously
to isolate the vesical veins, which are connected to the deep uterine vein ([Fig. 9]). We transect the vesical vein, with preservation of the nerves.
Fig. 9 Transection of the posterior layer of the vesicouterine ligament (on the right side).
The posterior layer of the vesicouterine ligament consists of the vesical vessels,
nerves, and adipose tissue.
Transection of the Paracolpium and Rectovaginal Ligament
Transection of the Paracolpium and Rectovaginal Ligament
First, we incise the uterine branch from the hypogastric nerve. The paracolpium tissue
is sutured above the hypogastric nerve; hence, nerve-sparing radical hysterectomy
can be performed ([Fig. 10]). The suture is also placed in the uterine body to reduce back bleeding from the
uterine body. The paracolpium tissue between the two sutures is incised using scissors.
Fig. 10 Transection of the paracolpium (on the right side). The paracolpium tissue is sutured
above the hypogastric nerve.
Next, we incise the Douglas peritoneum and dissect the rectum at the level of the
vaginal cuff. Both sides of the rectum are sufficiently dissected, providing a good
view of the sacrouterine ligament and rectovaginal ligament. We incise these ligaments
using unipolar electrocautery.
Höckel et al demonstrated the concept of total mesometrial resection (TMMR) based
on the theory of embryologically defined compartments, in which the Müllerian compartments,
except for the distal part, are completely removed.[9] This concept is theoretical and effective with respect to the radicality and safety
of radical hysterectomy.
In TMMR, the resection of the sacrouterine ligament is critical for the radicality
of surgery for cervical cancer. Höckel et al demonstrated that incomplete resection
of the Müllerian compartments, such as the sacrouterine ligament, leads to poor prognosis
of patients who undergo cervical cancer surgery. Although the TMMR theory is controversial,
it is important to explore an appropriate surgical margin for radicality and safety.
Transection of the Paravaginal Tissue, Extraction of the Specimen via the Vagina,
and Closure of the Vagina
Transection of the Paravaginal Tissue, Extraction of the Specimen via the Vagina,
and Closure of the Vagina
The forceps are removed via the vagina, and a vaginal pipe (VagiPipe; Hakko Co. Ltd,
Nagano, Japan) is inserted into the vagina to confirm the incision line. As the vaginal
cuff has been created, the vaginal wall can be easily transected.
A plastic bag is used to extract the specimen to prevent the scattering of cancer
cells ([Fig. 11A] and [B]). The vaginal mucosa is closed by using single sutures. The abdominal cavity is
flushed with a large amount of saline. A pelvic drainage tube is placed in the Douglas
space, and the abdominal incision is closed. [Fig. 12] shows the final operative view after laparoscopic nerve-sparing radical hysterectomy
using the no-look no-touch technique.
Fig. 11 Extraction and bagging of the specimen. (A) The specimen in the bag is extracted via the vagina. (B) The specimen.
Fig. 12 (A, B) Final operative view during the laparoscopic nerve-sparing radical hysterectomy
using the no-look no-touch technique.
A collection bag is used to extract the specimen via the vagina. The technique which
involves both the creation of a vaginal cuff and use of a collection bag, directly
prevents cancer exposure and abdominal contamination.
