Radical abdominal hysterectomy

J Richard Smith Deborah CM Boyle Giuseppe Del Priore

Radical abdominal hysterectomy is designed to remove the uterus, cervix, upper third of the vagina, either part or the whole of the parametrium, and the uterosacral and vesicouterine ligaments. In addition, the common iliac, internal iliac, external iliac, obturator, hypogastric and presacral lymph nodes are also removed, as may be the paraaortic nodes.

This operation is used for management of Stage IA2 and IB 1 and 2 tumors of the uterine cervix. It may be used by some surgeons for management of Stage IIA cervical tumours and occasionally in management of vaginal cancer. It has been classified by Rutledge as radical abdominal hysterectomy types II and III (Piver et al, 1974). Staging of cervical cancer, carried out preoperatively, is not further discussed in this chapter. The choice of whether to perform this procedure or one of those described in Chapters 8, 9 and 10 depends upon the surgeon's preference, with each operation tailored to the needs of the specific patient. The radicality of the procedure planned depends upon the characteristics of the tumor.

Prior to surgery, the patient's bowel should be prepared using the standard protocol. Consent for the specific procedure, including oopherectomy if planned, should have been obtained.

Operative procedure

A general anesthetic is administered with or without an epidural anesthetic. The addition of a regional anesthetic allow better pain control post-operatively and facilitates surgery by reducing intraoperative blood loss.

The patient is then placed supine on the operating table. The bladder is catheterized with an indwelling Foley catheter and the vagina packed with a roll of gauze. Some surgeons insert the Foley catheter postoperatively, whilst others prefer to insert a suprapubic catheter at the end of the procedure. The authors' practice depends on the radicality of the procedure. In cases of Stage IIA cervical cancer the vagina may be marked with cutting diathermy 2-3 cm away from the vaginal lesion to assist in later ensuring good resection margins.

The abdomen is opened using either a subumbilical, vertical midline incision or a large lower transverse, rectus muscle-cutting incision, dependent on the patient's desire for cosmesis (Figure 1). It may be helpful to insert stay sutures to hold the peritoneum to the edges of the transverse skin incision.

After adequate exposure of the pelvis, the lymph nodes of the pelvis, the common iliac nodes and those above the bifurcation of the aorta are palpated, as is the liver.

The round ligament is then grasped, divided and ligated close to the pelvic side-wall and the broad ligament opened to expose the retroperitoneal structures including the ureter attached to the medial aspect (Figure 2).

Suprapubic Cruciate Incision

Figure 1

Opening the abdomen. (A) Low transverse rectus muscle-cutting incision. (B) Vertical subumbilical incision

The paravesical space is the first of the potential spaces to be developed during the operation (Figure 3). This is achieved with the use of blunt dissection with a combination of dissecting scissors and fingers or mounted pledgets. The dissection is commenced medial and slightly inferior to the external iliac vein. The paravesical space is bounded medially by the bladder and obliterated hypogastric artery and caudally by the ventral aspect of the cardinal ligament. The obturator muscle and fossa form the lateral border; this is dissected out later.

The pararectal space is then opened using a similar technique (Figure 4). This space is bounded by the rectum medially, the sacrum ventrally, the pelvic sidewall and internal iliac vessels laterally and the cardinal ligament anteriorly. This allows the cardinal ligament and parametrium to be directly assessed by placing one's fingers in the newly opened paravesical and rectal spaces (Figure 5).

The lymphadenectomy is commenced at the bifurcation of the common iliac vessels, excising the loose lymphatic tissue overlying the internal and external iliac arteries and veins (Figures 6, 7). This is performed in a caudal direction, having first identified psoas muscle and the genitofemoral and lateral cutaneous nerve of the thigh. The dissection of the external iliac vessels continues caudally until the circumflex iliac vessels are encountered. Dissection in a cephalad direction allows clearance of common iliac and paraaortic nodes. Presacral nodes are also removed (Figure 8).

Once the external iliac artery and vein are exposed they can be separated from the underlying tissue laterally. With gentle lateral (Figure 9) and/or medial (Figure 10) traction on the external iliac vessels the obturator fossa is now exposed. It is often helpful to sweep the external iliac vessels off the pelvic side-wall and approach the obturator fossa from the lateral side (Figure 11). Great care must be taken to preserve the obturator nerve, and the dissection always becomes much easier once this structure has been identified

Ligating Round Ligament Hysterectomy

Figure 2

The round ligament is divided and the broad ligament opened

Figure 3

Developing the paravesical space

(Figures 12 and 13). Occasionally, the obturator artery and vein may require to be sacrificed to allow adequate dissection of the tissues posterior and lateral to the nerve.

The ureter is further dissected from the peritoneum. Sharp dissection is employed to create the vesicouterine and vesicocervical space (Figure 14). It is important to find the correct tissue plane since this facilitates easier and bloodless dissection. The uterine arteries are clamped, divided and ligated close to their origins at the internal iliac arteries using either ligatures or haemoclips (Figure 15).

Paravesical Space Border

Figure 4

Developing the paravesical space

Posterior Parametrium

Figure 5

Boundaries of the paravesical space

The ureteric tunnels are then deroofed, allowing exposure of the ureters and their separation from parametrial tissue (Figure 16). This can be performed cephalad to caudal or vice versa. Roberts clamps or large haemoclips are helpful in minimizing haemorrhage. Whatever technique is used, bleeding tends to be brisk at this stage.

The pararectal space is further developed from above from between the ureter medially and the internal iliac vessels laterally (Figure 17). The boundaries have been described above but the dissection now takes place to the level of the pelvic floor. The rectum is dissected away from the uterus, thus freeing it of its posterior visceral attachments (Figure 18). This is best achieved by grasping the rectum between the fingers and lifting it in a cephalad direction and then entering the rectovaginal space by sharp dissection. The rectum is often much higher on the uterus than is often at first suspected and this technique minimizes the prospects for inadvertent rectal injury.

Figure 6

Pelvic lymphadenectomy

Figure 7

Pelvic lymphadenectomy: side-wall dissection

Clamping, division and ligation of the uterosacral ligament then takes place (Figures 19, 20). This can either be performed midway along the ligaments or at the sacrum, depending upon the size and nature of the tumor. The cardinal ligaments are then clamped, divided and ligated again either halfway between the cervix and the pelvic side-wall or at the pelvic sidewall, using the same criteria as with the uterosacral ligaments (Figure 21). These differing levels of radicality have been classified by Rutledge and the procedures just described are Rutledge II and III procedures (Piver et al 1974) (Figure 22).

The division of these ligaments causes the paravesical and pararectal spaces to be united (Figures 23 and 24).

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