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Radical Vaginal Trachelectomy

Recently, radical vaginal hysterectomy (RVH) has developed into laparoscopically assisted radical vaginal hysterectomy (LARVH), which is associated with the laparoscopical procedure, and it is applied as radical vaginal trachelectomy and semi-radical vaginal hysterectomy. LARVH is indicated for patients with stage IB1 and IIA1 cervical carcinoma, especially those with a tumor size of less than 2 cm, because the cardinal ligaments cannot be resected widely. Although RVH that is associated with laparoscopic pelvic lymphadenectomy is the most used surgical procedure, radical trachelectomy may be performed either abdominally or vaginally (laparoscopic or robotic). One report found that the pregnancy rate was higher in patients who underwent minimally invasive or radical vaginal trachelectomy than in those who underwent radical abdominal trachelectomy.


Principle and Indication
Trachelectomy is the removal of the cervix, upper vagina, and parametrium (tissue surrounding the cervix). Pelvic lymph nodes may also be removed. Some cases of early-stage cervical cancer in women who wish to keep their fertility and ability to be pregnant can be treated with RVT. In particular, it is indicated for patients with stage IB1 and IIA1 cervical carcinoma, especially those with a tumor size < 2 cm, because the cardinal ligaments can be resected widely.

Preoperative Evaluation
Cervical carcinoma is diagnosed according to the histologic examination of tissues obtained after conization or from a biopsy under colposcopy. For cervical carcinomas, tumor Keywords ► cervical cancer ► trachelectomy ► laparoscopically assisted radical vaginal hysterectomy ► fertility ► laparoscopy ► minimal invasiveness Abstract Recently, radical vaginal hysterectomy (RVH) has developed into laparoscopically assisted radical vaginal hysterectomy (LARVH), which is associated with the laparoscopical procedure, and it is applied as radical vaginal trachelectomy and semi-radical vaginal hysterectomy. LARVH is indicated for patients with stage IB1 and IIA1 cervical carcinoma, especially those with a tumor size of less than 2 cm, because the cardinal ligaments cannot be resected widely. Although RVH that is associated with laparoscopic pelvic lymphadenectomy is the most used surgical procedure, radical trachelectomy may be performed either abdominally or vaginally (laparoscopic or robotic). One report found that the pregnancy rate was higher in patients who underwent minimally invasive or radical vaginal trachelectomy than in those who underwent radical abdominal trachelectomy. progression is routinely evaluated by digital rectal examination, computed tomography (CT), and magnetic resonance imaging (MRI). Abdominal hysterectomy is recommended for patients with parametrium-invading tumor, tumor size > 2 cm, and/or narrow vagina. The surgeon must perform colposcopy precisely to determine the correct incision areas. In colposcopy, the vaginal orifice is stretched, and Schuchardt episiotomy is performed for an especially narrow vagina.

Technique Pelvic Lymphadenectomy
Originally done extraperitoneally, pelvic lymphadenectomy has been recently performed laparoscopically using the classical peritoneal route. The round ligaments and ovaryspecific ligaments are sealed and incised using energy modalities. After expanding the retroperitoneum, the surgeon dissects the pelvic lymph nodes. Unlike the medial aspect of the iliac vessels, the lateral aspect is difficult to clean; however, it can be achieved laparoscopically as effectively as during laparotomy.

Incision of the Vaginal Wall
After the resection site is determined, the vaginal wall is clamped and lifted using short Kocher hemostatic forceps at 6 to 8 points, conforming to a line circumscribing the cervix. The incision site and the planes between the bladder and vagina are injected with epinephrine (0.1% diluted in 100 mL of saline solution). The forceps are brought forward simultaneously, and a circular incision is made to a depth of approximately 5 mm (►Fig. 1).

Opening the Paravesical Space
The traction sutures are retracted laterally to the lower right to expose the left side. Furthermore, the vaginal wall is clamped with Kocher forceps at 2 o'clock position and For penetrating the paravesical and retrovaginal spaces, the paracolpos is hooked with the forefinger or curved forceps. Then, a midsized vaginal retractor (2.5 Â 8.5 cm) is inserted into the paravesical space. The paracolpos is subsequently clamped, divided, and transfixion-sutured with a 2-0 polyglycolic acid suture.

Division of the Inner Vesicouterine Ligament
The uterus is firmly extended to the lower right by retracting the bladder and stretching the vesicouterine ligament longitudinally. To confirm its position, the ureter must be felt and touched    between the forefinger and middle finger. The outer top of the external vesicouterine ligament is clamped in two places and then divided using a pair of curved scissors (►Fig. 5). Thereafter, the clamps are replaced with a 2-0 polyglycolic acid transfixion suture. From the divided area, the curved scissors are passed into the ureteric tunnel through gentle dissection. Using the same maneuver, the surgeon divides the inner vesicouterine ligament into two or three separate stages. After the inner vesicouterine ligament is separated and ligated, the site where the uterine artery crosses the ureter is seen clearly. The uterine artery, which has already been divided laparoscopically, is pulled out. The outer vesicouterine ligaments, which contain the bladder branch of the pelvic splanchnic nerve, are preserved to exclude them at the dorsal side, and they are partially divided using the curved operating scissors (►Fig. 6). Thus, the procedure corresponds to levels II and III of the Piver classification. 10

Division of the Cardinal Ligament
The surgeon placed a curved clamp (or finely serrated multipurpose forceps) approximately 2 cm from the cervical edge, and the cardinal ligament is divided and resected near where the uterine artery and ureter cross. The same procedure is used for the right side. However, the surgeon can only resect the cardinal ligament after the anterior part of the peritoneum is opened.

Excision of the Cervix and Reconstruction of a Neocervix
The procedure ends by dividing the uterus that is transected 5 to 10 mm underneath the isthmus (►Fig. 7). For the Fig. 6 Division of the outer vesicouterine ligaments. Comment: The surgeon preserves the outer vesicouterine ligaments, which contain the bladder branch of the pelvic splanchnic nerve, to exclude them at the dorsal side and partially divide them using curved operating scissors.