Radical vaginal hysterectomy

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Daniel Dargent

Introduction

The vaginal approach was first used when surgeons considered treating cancers of the cervix in ways other than by cauterization or similar palliative tools (Recamier 1829). However, at the turn of the nineteenth century the abdominal approach became prevalent, as a consequence of two simultaneous changes. First, even if it was more risky than vaginal surgery, abdominal surgery was no longer a death sentence. Second, the concept of radical surgery, introduced by Halsted in the field of breast cancer, was also spreading to the management of all other malignancies. The first 'radical hysterectomy' performed by Clark in 1895 included, as a true Halstedian operation, an extirpation of the parauterine tissues and pelvic lymph nodes. Just before Clark devised the radical abdominal hysterectomy, Pavlik in Czechoslovakia (1889) and Schuchart in Germany (1893) had described a method enabling the removal of the parauterine tissues at the same time as the uterus, while maintaining a vaginal approach. The removal of the pelvic lymph nodes was obviously not included in this operation.

The abdominal and vaginal techniques were used concurrently in middle Europe at the end of the nineteenth century. Wertheim became the champion of the first technique and Schauta the defender of the second. The long and hard fight between the two surgeons stopped at the time of publication of Wertheim's book (1911). Despite higher rates of per-and postoperative complications, the survival rates obtained by Wertheim were far higher than those noted by Schauta in his book of 1908. With Marie Curie's subsequent discovery of radium, surgery disappeared as an option.

Surgery found a new place in the management of cervical cancer as a tool to solve the problem of positive lymph nodes that were not managed by radiotherapy. Leveuf in France (1931) andTaussig in the USA (1935) proposed a combination of radiation therapy and pelvic lymphadenectomy in order to improve outcomes. This idea was the first step towards the reintroduction of radical surgery, whose official beginning was 1945, the year in which JV Meigs delivered his first paper about the new Wertheim operation. Since the highlight of the new radical surgery was systematic pelvic lymphadenectomy, the vaginal approach clearly could not benefit from the revival of surgery. However, the Indian surgeon Suboth Mitra (1959), following an idea first expressed by Navratil, found a way to reintroduce radical vaginal surgery and proposed to combine it with a systematic pelvic lymphadenectomy performed through an abdominal extraperitoneal approach.

The Suboth Mitra operation suited the local circumstances because, even if combined with an extraperitoneal abdominal incision, the vaginal approach remained three times less dangerous than the abdominal approach, just as it had been at the beginning of the twentieth century. In countries where the post-operative mortality rate after abdominal radical surgery is almost negligible, the Suboth Mitra operation cannot be considered as the operation of choice. We used it, as does Massi today, as a solution for high-risk surgical patients, but imposing an operation which leaves three scars instead of one is not acceptable for low-risk patients. The technique of laparoscopy has changed everything.

The role of laparoscopy

In 1986 we devised the laparoscopic lymphadenectomy in an attempt to avoid the 'three scars operation'. Subsequently the combination of laparoscopic lymphadenectomy with radical vaginal hysterectomy (RVH, or the 'coelio-Schauta' operation) became our elective method to treat early cervical cancer.

The first role of laparoscopy in this new surgical strategy is the assessment of the pelvic lymph nodes. If these nodes are not involved there is no reason not to adopt RVH as the procedure of choice. Conversely, if the nodes are involved, the combination of laparoscopic lymphadenectomy and RVH generates a lot of criticism. If the metastatic glands are enlarged and adherent, performing a debulking lymphadenectomy with the laparoscope is not sensible because of the risk of tumoral cell seeding from manipulations of laparoscopic instruments in the atmosphere of carbon dioxide insufflation. On the other hand, whilst aortic lymphadenectomy is mandatory in cases of pelvic lymph node involvement, it is not necessary if the pelvic nodes are not involved. Performing the aortic lymphadenectomy with the laparoscope is technically feasible, but such an extension of the dissection increases the operation time for a patient whose treatment is basically chemotherapy rather than surgery.

The second role of laparoscopy is, in the cases where RVH is chosen as definitive treatment, to assist the vaginal operation. In fact, during the first years of our experience the 'coelio-Schauta' procedure was simply the addition of laparoscopic pelvic lymphadenectomy to a genuine Schauta operation. At the time the endostapler became available it became clear that laparoscopy could be used as to make RVH both more radical and simpler to perform. Hence was born the concept of Laparoscopically Assisted Radical Vaginal Hysterectomy (LARVH). The first LARVHs performed were more radical than the Schauta Amreich procedures, (i.e. the most radical variant of the classical Schauta operation). Due to its radical nature the 'LARVH prototype' was more dangerous than the initial coelio-Schauta, particularly in the field of urinary bladder dysfunction. This negative outcome led Denis Querleu and the author to set up a third variant which appears as radical as the Schauta Amreich procedure but avoids the complications of it. This is the operation described in the following pages.

Indications

LARVH should be reserved for early cervical cancers, as was the classical abdominal approach. One has to remember that a radical operation must include the removal of 2 cm of uninvolved tissues around the tumor. The width of the pelvis is no more than 10.5 cm between the two sciatic spines where the paracervical ligaments are attached laterally. This anatomic constraint makes radical surgery controversial in cancers more than 4 cm in diameter. This is the case in radical abdominal surgery, but even more so in radical vaginal surgery, where placing clamps on the ligaments alongside the pelvic wall is more difficult from below than from above because of the slope of the pelvic wall. Careful assessment of the tumoral dimensions is the first step in the decision-making; we systemically use MRI. We do not perform LARVH in cases where the tumor is more than 4 cm in diameter.

The second condition for accepting RVH is certainty that the lymph nodes are not involved. As already discussed, the preliminary laparoscopic dissection aims to make the selection; here again preoperative imaging has an important role to play. If the nodes appear enlarged, stereotactic puncture is performed. In the cases where the metastatic involvement is confirmed, chemoradiotherapy has to be selected. Prior surgical node debulking can be considered but this debulking has to be performed through an open abdomen; the same applies if massive lymph node involvement is unexpectedly discovered at the beginning of the laparoscopy.

The laparoscopically retrieved nodes can be assessed by frozen section. Such an extemporaneous assessment enables the two parts of LARVH to be performed at the same sitting, but the rate of a false-negative frozen section is between 10 and 30%. In spite of this, the negative predictive value remains high because the incidence of lymph node involvement is low (around 15%) in the accepted indications of LARVH. However, the consequences of undertreatment due to ignorance of lymph node involvement can be considered more detrimental in a patient affected by early cancer. For this reason I prefer to perform the two parts of LARVH in two sittings. The assessment of the lymph nodes can be made after paraffin embedding. This means not only that false negatives can be avoided, but also that the final decision is taken with full information and the consent of the patient. This in itself is a psychological advantage that compensates for the discomfort induced by the necessity of two anesthetics and two hospital stays (the first one very short).

Operative procedure

The aim of the radical hysterectomy operation, whichever approach is chosen, is to retrieve part of the vagina and the parauterine tissues, together with the uterus itself. The ventral and dorsal surfaces of the vagina and of the tissues adjoining the uterus are in close proximity to the bladder floor and, to a lesser degree, to the rectum. In the vaginal operation one detaches the bladder floor (and the ureters) from the ventral surface of the specimen when opening the vesico-vaginal space on the midline and the paravesical spaces on either side in order to locate the bladder pillars and divide them after identification of the ureters. The dorsal aspect of the specimen is freed when the rectal pillars are divided (a much simpler step of the operation).

The laparoscopic operation

The laparoscopic part of the LARVH can be done using either the classical transumbilical transperitoneal route, or a direct extraperitoneal approach: the latter is more appropriate because if the peritoneal cavity is not entered, there is less chance of inducing peritoneal adhesions, but it takes more time. The rate of adhesions after laparoscopic surgery, whatever the route, is low; the only situation where it is important to have no adhesions is the conservative variant of the LARVH where one intends to preserve fertility (see below).

The cutaneous incision is made along the inferior brim of the umbilicus. The abdominal fascia is opened under direct endoscopic guidance using a trocar with a transparent cutting tip (Visiport: Merlin Medical, Rhymney, UK; Optiview: Ethicon Endosurgery, Edinburgh, UK). Once the preperitoneal space is entered the trocar is removed, the carbon dioxide insufflation is linked to the sheath and the laparoscope is introduced, pushing it vertically until contact is made with the symphysis pubis. This creates a vertical tunnel, at the lower extremity of which an ancillary trocar is introduced. This preparation is pushed laterally to the McBumey area, at which level two more ancillary trocars are introduced, one on each side. Then, using three instruments (two forceps and one pair of scissors), the peritoneal sac is mobilized dorsally after the round ligaments have been cut at their most ventral, extraperitoneal, parts.

Vagina After Radical Hysterectomy

Figure 1

Laparoscopic view of the medial aspect of the common iliac bifurcation: laparoscopy has been performed using the preperitoneal approach. The superior vesical artery runs in a dorsal direction; the obturator artery runs in a ventral direction

The lymphadenectomy is performed in the same way as it is in the transumbilical transperitoneal laparoscopy. The panoramic view is the same. The only differences are better 'baro' haemostasis and absence of trouble with the intestines.

The medial aspect of the iliac vessels is easily cleaned. The lateral aspect is a little more difficult; however, it can be treated laparoscopically as carefully as it is treated using laparotomy, if not better. The iliac vessels are detached from the psoas muscle and pushed medially (Figure 1). The opened space is cleaned out until the obturator nerve is identified (Figure 2).

The last step of the laparoscopic procedure is dividing the uterine arteries and preparing the cardinal ligament (Figure 3). Rather than cutting the ligament laparoscopically, its lateral part is emptied of the lymph node-bearing tissues which are imprisoned in the vascular network of the ligament. This emptying is done by gentle teasing of the adipose tissue between the vessels. Among the vessels handled are the uterine arteries which are accompanied by lymphatic channels. A superficial uterine vein can accompany the artery as well.

The Vaginal Operation

The Schauta operation starts with determination of the vaginal margin (Figure 4). The separation is made roughly at the junction between the middle third and the upper third of the vagina. Traction is exerted on the forceps, creating a form of internal prolapse of the vagina. The inferior brim of the head of the prolapse is infiltrated using diluted synthetic vasopressin, primarily for prophylactic haemostasis but also to separate the two parts of the fold.

Dividing the vagina is done in four stages. The anterior aspect is treated first (Figure 5). It is the most difficult step, because the bladder floor is drawn inside the vaginal fold one pulls on. All the layers of the vaginal wall must be cut, without injury to the bladder wall. Treating the posterior aspect is easier because of the tissue present between the rectum and vagina. On the lateral aspects only the mucosa is cut (Figure 6) in order to keep the relationship between the vaginal cuff and the underlying structures, i.e. the paracervical ligaments. Compare this with the anterior and posterior surfaces, where the goal was separating the cuff from the underlying organs, i.e. the bladder and rectum.

Laparoscopic view of the lateral aspect of the common iliac venous convergence: the obturator nerve crosses the gluteal vessels

Figure 2

Laparoscopic view of the lateral aspect of the common iliac venous convergence: the obturator nerve crosses the gluteal vessels

1 Common iliac vein

2 Obturator nerve

3 Internal iliac vein

4 External iliac vein

Ureter Injury Uterine Artery

Laparoscopic view after transection of uterine artery: a superficial uterine vein will be cut next

Figure 3

Laparoscopic view after transection of uterine artery: a superficial uterine vein will be cut next

1 Inferior iliac artery

2 Uterine artery

3 Superior vesical artery

4 Uterine vein

Once the vaginal cuff is separated it is grasped using Chrobak forceps (Figure 7) and pulled downwards. Traction reveals the supravaginal septum, a pseudomembrane made by condensation of the connective fibres joining the bladder floor to the vagina. This pseudoaponeurosis has to be opened on the midline close to the base of the trigone (Figure 8). Once the aponeurosis has been opened (use the scissors perpendicularly to the vagina), the areolar tissue of the vesicovaginal space is visible and a tunnel can be dug and enlarged up to the level of the vesico-vaginal peritoneal fold (using the scissors parallel to the vagina becomes possible).

Hysterectomy From Ovarian Cancer

Figure 4

Infiltration of the vaginal margin

Figure 4

Infiltration of the vaginal margin

Mitra Schauta

Figure 5

The Schauta operation: separatipn of the vaginal cuff on the ventral (anterior) aspect; the incision is full thickness

Next the vesicovaginal space is opened, with the paravesical space.

To open the paravesical spaces, two forceps are applied to the brim of the vagina (at positions 1 o'clock and 3 o'clock for the left side, 11 o'clock and 9 o'clock for the right side). Pulling on the forceps reveals a depression located close to the most lateral instrument (Figure 9). Deepening this depression by blunt use of Metzenbaum's scissors oriented laterally and ventrally (Figure 10) opens the paravesical space, into which is introduced a micro-Breiski retractor. The structure interposed between this retractor and the previously opened vesicovaginal space is the bladder pillar, inside which the contour of the ureter can be identified while palpating, the pillar against the retractor. The characteristic 'snap' of the ureter is evinced (Figure 11).

While appropriate exposure is maintained with the retractors, the inferior brim of the pillar, which appears vertical, is opened with the tip of the scissors and its lateral fibres are separated using the same scissors (Figure 12). After a new palpatory assessment (make sure the ureter is located, laterally to the isolated part of the pillar) the fibres of the pillar are cut (Figure 13). The paravesical space becomes wider, and a broader retractor is introduced. The lateral aspect of the 'knee' of the ureter becomes visible (Figure 14). The medial fibres of the pillar can then be cut to release the ventral aspect of the paracervical ligament (Figure 15): this enables location of the arch of the uterine artery in the para-isthmic window (a

Vaginal Cuff Separation

Figure 6

Separation of the vaginal cuff on the lateral aspect; the incision is only through the skin

Figure 6

Separation of the vaginal cuff on the lateral aspect; the incision is only through the skin

Vaginal Woman Africa

Grasping the vaginal cuff with the forceps

Figure 7

Grasping the vaginal cuff with the forceps space whose inferior brim is the superior edge of the paracervical ligament). The descending branch of the arch is tugged and the already divided artery arrives in the operative field with a staple at the cut end (Figure 16).

After freeing the ventral aspect of the specimen, the surgeon moves to the dorsal aspect. The first step is opening the pouch of Douglas (Figure 17). The rectouterine ligaments are then divided, at a point equidistant between the uterus and the intestine. Cutting at this level is easy (no preventive clamping is needed) and leads directly to the dorsal aspect of the paraisthmic window, the ventral aspect of which has been identified previously. The tip of a right angle forceps is pushed into the window from back to front.

Two clamps can be put onto the cardinal ligament. The first one is placed medially, and traction is exerted. The second clamp (which has a slightly greater curvature) is placed laterally; the convexity of its curvature lies in contact with the 'knee' of the ureter (Figure 18).

Following transection of the ligaments the uterine body can be turned in a dorsal direction, and the adnexa can be left in place or removed, depending on the age of the patient (Figure 19). The subsequent steps are straightforward. The author's preference is for peritonization with two lateral angled stitches and a middle continuous suture, placing the stumps in an extraperitoneal position and joining the rectal peritoneum

Rectal Vaginal Ligaments

Figure 8

Opening the vesicovaginal space on the midline 1 Bladder

Figure 8

Opening the vesicovaginal space on the midline 1 Bladder

Rectal Vaginal Ligaments

Figure 9

Opening the paravesical space 1 Bladder pillar

Figure 9

Opening the paravesical space 1 Bladder pillar and the vesical peritoneum. Haemostasis is performed as necessary. The vagina is closed without a drain or gauze. A Foley catheter is left in place for 4 days.

Conclusion

RVH is an acceptable alternative to radical abdominal hysterectomy as long as it is combined with control of the regional lymph nodes. Before the era of laparoscopy such control could not be obtained other than by performing two lateral extraperitoneal abdominal incisions, leaving RVH suitable in only exceptional circumstances. With the advent of laparoscopy the assessment of the regional nodes is possible and the combination of 'regional nodes control-RVH' has become realistic. There is no increase in the rates of per-and post-operative complications, disease-free long-term survival rates are no less, and the patient does not bear visible scars: this latter advantage is not open to dispute. The other advantages of faster recovery— better self-image, minimized sequelae and so on—are not, at the moment, proven, just as the cost-benefit balance remains to be assessed. Whatever the results of the studies currently in progress, one certain

Nursing Assessment Ovarian Cancer

Figure 10

Evincing the entry into the paravesical space on the left side 1 Bladder pillar

Evincing the entry into the paravesical space on the left side 1 Bladder pillar

Figure 11

Palpation of the bladder pillar on the left side to elicit the 'snap' of the ureter advantage favors the laparoscopically assisted vaginal technique. There is now the possibility of obtaining pregnancies and births for patients undergoing the conservative variant of the operation—a result that could never have been obtained by the surgeons performing the radical operation through laparotomy.

Bibliography

Amreich AI (1924) Zur Anatomic und Technik der erweiterten vaginalem Carzinom Operation. Arch Gynäkol 122:497. Clark JG (1895) A more radical method for performing hysterectomy for cancer of the uterus. Bull Johns Hopkins Hosp 6:120.

Leveuf J (1931) L'envahissement des ganglions lymphatiques dans le cancer du col de l'utérus. Bull & Mem Soc Nat De Chir 57:662.

Meigs JV (1945) Wertheim operation for carcinoma of the cervix. Am J Obstet Gynecol 49:542.

Mitra S (1959) Extraperitoneal lymphadenectomy and radical vaginal hysterectomy for cancer of the cervix (Mitra technique). Am J Obstet Gynecol 78:191-6. Pavlik K (1889) O extirpaci cele dèlohy a casti vaziva panvicniho. Casopis Lekaru Ceskych XVIII:28.

Trigone Pavlik

Figure 12

Separation of the lateral part of the bladder pillar on the left side

Structure Uterus

Figure 13

Cutting the lateral part of the bladder pillar

Recamier JCA (1829) Ablation de l'utérus cancéreux. In: Recherche sur le traitement du cancer. Paris: Gabon, 519-29.

Schauta F (1908) Die erweiterte vaginale Totalextirpation des Uterus beim Kollumkarzinome. Vienna: J. Safar.

Schuchart K (1893) Eineneue Methode der Gebärmutterexstirpation. Zbl Chir 1131.

Stoeckel W (1928) Die vaginale Radikaloperation des Collumkarzinomes. Zbl Gynäkol 52:39.

Taussig FJ (1935) The removal of lymph nodes in cancer of the cervix. Am J Roentgenol 34:354.

Wertheim (1911) Die erweiterte abdominale Operation bei Carcinoma Colli Uteri. Berlin: Urban & Schwarzenberg.

Rectal Vaginal Ligaments

Figure 14

Further division of the lateral fibers of bladder pillar on left side: the knee of the ureter is visible

Rectal Vaginal Ligaments

Figure 15

Division of medial part of bladder pillar on left side

Healing Time For Vaginal Hysterectomy
Figure 17

Opening the pouch of Douglas and the rectal pillar

Rectal Pillar

Figure 18

Paracervical ligament, is clamped, the lateral clamp being put underneath the tip of the 'knee' of the ureter

Bladder Pillars

Figure 19

Lateral portions of paracervical ligaments are lacking here, having been cleared out during the laparoscopic procedure

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  • goytiom
    Is the cervix always removed during a vaginal hysterectomy?
    8 years ago

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