INDICATIONS
Stages IB-IIA1 cervical cancer, any histologic type; stage II endometrial cancer
INTRA-OPERATIVE PREPARATIONS
Perioperative prophylactic antibiotics, indwelling urinary catheter, vaginal packing
POSITION
Supine position with15° Trendelenburg.
INCISION
Subumbilical vertical midline or low transverse (Maylard, Cherney, Pfannenstiel)
After entering the abdomen a thorough exploration of the entire peritoneal cavity and retro-peritoneum is done for evidence of metastasis. Any suspicious lesion is biopsied and evaluated on frozen section examination.
EXPOSING THE RETROPERITONEUM AND DEVELOPMENT OF LATERAL SPACES
The anterior leaf of broad ligament is incised lateral and parallel to the infundibulo-pelvic ligament (Fig. 1). This exposes the pelvic retro-peritoneal space. Psoas muscle, genitofemoral nerve and iliac vessels are easily indentified at this stage (Fig. 2).
DEVELOPMENT OF PARA-VESICAL AND PARA-RECTAL SPACES
Paravesical space is developed between external iliac vessels laterally and obliterated hypogastric artery medially using blunt or sharp dissection (Fig. 3).2
Fig. 2: Retro-peritoneal space (a) psoas muscle, (b) genitofemoral nerve, (c) external iliac vessel, (d) cut of the round ligament
BOUNDARIES
Medial: Bladder and obliterated umbilical artery
Anterior: Pubic bone
Lateral: obturator internus muscle
Posterior: Cardinal ligament
Fig. 3: Para-vesical space (right side) (a) bladder and obliterated hypogastric artery, (b) pubic ramus, (c) obturator internus muscle, (d) cardinal ligament, (e) levator muscle
Fig. 4: Para-rectal space (right side) (a) ureter, (b) posterior surface of the cardinal ligament, (c) hypogastric artery (internal iliac artery)
Pararectal space is developed by dissection between the ureter and hypogastric artery, posterior to uterine artery.
BOUNDARIES
Medially: Rectum and uterosacral ligament
Laterally: Hypogastric artery (internal iliac artery)
Anterior: Cardinal ligament
PARA-VESICAL AND PARA-RECTAL SPACES ARE SEPARATED BY THE CARDINAL LIGAMENT (FIG. 5).
Fig. 5: (a) Para-vesical space (b) para-rectal space, (c) cardinal ligament, (d) external iliac vessels, (e) ureter
PELVIC LYMPHADENECTOMY
Using sharp scissor dissection or electric cautery, all fatty tissue from lateral, anterior, medial and posterior sides of iliac vessels is stripped off from mid common iliac vessels proximally to circumflex iliac vein distally preserving the genitofemoral nerve. Obturator fossa is entered by retracting the external iliac vessels laterally or medially and stripping the fatty tissue off the pelvic side wall preserving the obturator nerve and vessels (Figs. 6–9). All suspicious nodes are sent for frozen examination. In case of positive node, complete lymphadenectomy is done including low para-aortic but hysterectomy is not done and the patient is treated with concurrent chemo-radiation.
UTERINE ARTERY LIGATION AND DISSECTION OF URETER AND BLADDER
Uterine artery is identified and ligated at its origin (Fig. 10). Next, the ureter is separated from its peritoneal attachment down towards the parametrial tissue taking care not to injure its adventitia (Fig. 11). The infundibulopelvic ligament is clapmed cut and ligated. Vescico-uterine fold of peritoneum is divided, the bladder is taken down till the level of vescicocervical ligament and the vesciocervical ligament is divided (Figs. 12 and 13). The ureteric tunnel deroofed exposing the ureter and separating it from the posterior parametrial tissues (Fig. 14).5
Fig. 6: Pelvic lymphadenectomy (right side) (a) external iliac vessels, (b) hypogastric artery (c) ureter, (d) bifurcation of common iliac artery
Fig. 8: Right obturator fossa approached from the medial side (a) external iliac vessels, (b) obturator nerve, artery and vein, (c) Internal iliac artery
Fig. 9: Left obturator fossa approached from the lateral side (a) psoas muscle with genitor-femoral nerve (b) external iliac vessels, (c) obturator nerve
Fig. 10: Ligation of uterine artery at its origin a) internal iliac artery, (b)ureter, (c) uterine artery arising from the internal iliac artery and crossing over the ureter
Fig. 11: The ureter is separated from its peritoneal attachment down towards the parametrial tissue (a) ureter
Fig. 13: The bladder is taken down till the level of vescicocervical ligament and the vesciocervical ligament is divided
Fig. 14: The ureteric tunnel deroofed exposing the ureter and separating it from the posterior parametrial tissues
POSTERIOR DISSECTION AND DIVISION OF CARDINAL AND UTEROSACRAL LIGAMENTS
The rectovaginal space is developed by incising the peritoneum between rectum and vagina (Fig. 15). Cardinal and uterosacral ligaments are clamped, cut and ligated closed to the lateal pelvic wall and the rectum, respectively (Fig. 16).
Fig. 16: Cardinal and uterosacral ligaments are clamped, cut and ligated closed to the lateal pelvic wall and the rectum, respectively.
DIVISION OF PARACOLPOS AND VAGINA
Vagina is entered 2–3cms below the tumor. Adequacy of margin inspected and vagina circumcised taking even margins at the entire circumference. The vagina is closed. The abdomen is closed after checking for hemostasis (Fig. 17).