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Section 16.3. Laparoscopic Sentinel Lymph Node Identification
https://t.me/med1917
in Cervical Cancer
Pedro T. Ramirez, Charles Levenback, and Robert L. Coleman
In the United States, approximately 11,150 women will be diagnosed with cervical cancer in 2007. In that same year,nearly 3670
women will die of the disease.[1] In cervical cancer, the most
important prognostic factor is the status of the lymph nodes. The
primary lymphatic spread of cervical cancer is the pathologic
and anatomic reason for therapeutic lymphadenectomy. Tumor
cells reach the regional nodes at the pelvic wall, where they can
metastasize via the lymphatics in the parametria. The frequency
of regional lymph node involvement increases with increasing
size of the primary tumor.
In patients with early-stage cervical cancer (stage IA2–IB1),
lymph node status can influence treatment decisions. In general,
early invasivecarcinomaof the cervix isusuallytreatedwith either
a modified or a radical hysterectomy. A thorough lymph node
dissection is imperative because approximately 7% to 15% of all
patients with early invasive disease have lymph node metastases.
Pelvic radiotherapy alone is a reasonable alternative to lymph
node dissection for patients who are not surgical candidates. For
patients withstage IB1 cervical cancer,surgery inthe form of radical hysterectomy or radiotherapy is equally effective. Typically,
patients who areyoungand healthy opt foraradical hysterectomy
and pelvic lymphadenectomyto prevent complete obliterationof
ovarian function.
This section provides a brief review of the evolution of sentinel lymph node biopsy, illustrates challenges specific to sentinel lymph node biopsy for cervical cancer, describes the M. D.
Anderson technique of laparoscopic sentinel node biopsy for cervical cancer, and reviews the results of the studies published to
date on this procedure.
EVALUATION OF LYMPHATIC MAPPING
AND SENTINEL NODE BIOPSY
Gould et al. [2] coined the term sentinel lymph node in 1960. The
term next appeared in the literature in 1977, when Cabanas [3]
pioneered the concept of sentinel lymph node in his work on
penile carcinoma. He proposed that the metastatic status of the
lymph nodes that first receive drainage from a tumor, the “sentinel” nodes, accurately reflects the cancer status of the remainder of the nodal basin, and he proposed that the sentinel nodes
could be removed separately by limited surgery and examined to
determine whether a more extensive lymphadenectomy should
be performed.These concepts have been validatedfor both breast
cancer [4] and melanoma.[5] In gynecologic malignancies, Levenback et al. [6] showed that intraoperative lymphatic mapping
is technically feasible in vulvar cancer. In addition, Burke et al.
[7] proposed thatintraoperative lymphatic mapping might iden-
tify targets for selective nodal biopsy in women with high-risk
endometrial cancer. More recently,the potential feasibility of this
technique in cervical cancer has also been explored.
Initially, the sentinel lymph node was identified using lymphangiography. However, this method is technically difficult and
poorly reproducible and mayresultin cellulitis and lymphangitis.
Two different approaches are currently used. The first method,
introduced by Morton et al. [5], is the use of isosulfan blue dye
to identify the lymphatic ducts that drain into the sentinel nodes.
The second method, described by Alex and Krag [8], is the use
of radioactive tracers and a handheld gamma probe to directly
visualize the sentinel nodes.
Blue-dye staining is the standard for determining whether a
lymph node is a sentinel node: If a node and at least one afferent
lymphatic channel entering thenode are stained blue on intraoperative examination after injection of blue dye around thetumor,
then this node is considered a sentinel node. The various dyes
assessed as potential lymphatic mapping agents have included
isosulfan blue, methylene blue, patent blue-V, phenyl oxalate
ester (Cyalume, Cyalume Technologies, Inc.), and fluorescein.[9]
Methyleneblue was shown notto be ideal becauseit has very poor
uptake and diffuses rapidly into the surrounding tissue, causing
significant staining of the tissue without staining of the sentinel
node. Cyalume, a fluorescent dye, allows ready identification of
the lymphatic channels but is associated with significant background fluorescence. Fluorescein diffuses into the surrounding
tissue, making it difficult to distinguish the sentinel node from
the surrounding lymph nodes. The most useful mapping agents
identified so farare isosulfan blueand patent blue-V. Of thesetwo
agents, isosulfan blue is the one most commonly used because it
is rapidly transported through the lymphatics after intradermal
injection and is not associated with diffusion into the surrounding tissue.
The introduction of radioactive tracer injection and lymphoscintigraphy has enhanced the accuracy of detection of the
sentinel nodes. This technique consists of injecting a radioactive
colloid around the tumor site and then obtaining lymphoscintigrams to track the movement of the colloid through the afferent lymphatic channels and the uptake of the colloid in sentinel
nodes. The primary advantage of radiocolloid injection and lymphoscintigraphy is that this technique may permit detection of
lymph nodes outside the routine anatomic boundaries of dissection and thus reduce the proportion of cases in which sentinel
nodes cannot be identified. In addition, with intraoperative use
of a gamma probe after radiocolloid injection, the surgeon may
be able to identifysentinel nodesthat might otherwise be missed,
that is, sentinel nodes with poor uptake of blue dye or sentinel
nodes not detected on lymphoscintigraphy.
447
448 — Pedro T. Ramirez, Charles Levenback, and Robert L. Coleman
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The ideal radiocolloid for lymphatic mapping must enter the
lumen of the initial lymphatic channel in sufficient quantity for
the lymph vessels to be seen on lymphoscintigraphy, it must
rapidly and predictably move toward the sentinel node, and it
must be retained in the sentinel node. In the United States, the
radiopharmaceutical most commonly used for lymphatic mapping is filtered technetium Tc-99msulfurcolloid. This agent hasa
particle size of less than 100 nm, is uniformly dispersed, is highly
stable, and given that it is a gamma emitter, has a short half-life.
This technique is a safe, reproducible, and noninvasive means of
imaging the regional lymphatic drainage systems.
SAFETY OF LYMPHATIC MAPPING
A concern voiced about lymphatic mapping is the possibility that
injection of blue dye around and into the tumor might cause
iatrogenic tumor spread. Thus far, however, there have been no
reports of this event in the literature. An issue of greater concern
is the direct side effects caused by blue dyes. Evidence suggests
that approximately 50% of isosulfan blue, in aqueous solution, is
weakly bound to serum proteins, leading to its affinity for lymphatic channels. Theprimary excretion of isosulfanblue is biliary
(90%), and thus patients with hepatobiliary insufficiency may be
at increasedrisk for complications.[10] The overall complication
rate is predicted not to exceed 1.5%.[11]
Allergic reactions with localized swelling at the site of administration and mild pruritus of the hands, abdomen, and neck
have been described. Urticaria following administration of blue
dyes was first reported by Collard and Collete in 1967.[12]
Urticaria is an immediate type I hypersensitivity reaction that is
immunoglobulin E dependent. The antigen from isosulfan blue
reacts with preformed immunoglobulin E on the surface of dermal mast cells, causingdegranulation.Vasoactive mediators, such
as histamine, leukotrienes, and prostaglandins, are released and
act on cutaneous venules to cause endothelial cell retraction and
gap formation. This increased vascular permeability allows fluid
and protein to leak into the superficial dermis, causing urticarial
edema.[13] Anaphylaxis has alsobeen reported following administration of blue dye, although the incidence of this side effect is
low. In cases of anaphylactic reaction to blue dye, there may be a
delayof15to30minutesbetween dye administration and anaphylaxis, reflecting the fact that the dyeis administered intradermally
rather than intravenously.
Another systemic manifestation seen after intradermal injections of isosulfan blue is an acute transient or longer-lasting
decline in oxygen saturation as measured by pulse oximetry.
Coleman et al. [14] provided a detailed review of the etiology of
this phenomenon. Pulse oximetry is a noninvasive modality that
provides continuous estimates of peripheral tissue oxygen saturation. The authors documented that the peak spectral absorption of isosulfan blue is similar to one of the hemoglobin species
routinely measured by pulse oximetry algorithms. Competition
at this wavelength can alter pulse oximetry measurements. The
inaccuracy of the pulse oximeter after blue dye injection is transient and is confirmed when arterial blood sampling during the
acute fall in spot oxygen saturation (SpO
) documents adequate
2
oxygen saturation. Surgeons and anesthesiologists involved in
lymphatic mapping need to be aware of this effect.
There are two areas of concern regarding the use of radiocolloids: effects on the patient and effects on the surgical team.
The radiation dose to which the patient is exposed is determined
by the degree and speed of clearance from the site of injection
and the lymph node. The clearance of radiocolloids from the
interstitial space is very slow; therefore, the site that receives the
highest radiation dose is the site of injection. Accordingto the inversesquarelaw, exposure to radiation diminishes withthesquare
of the distancefrom the source. Hiller andRoyal [15]showedthat
the doses per sentinel node mapping procedure to the surgeon’s
body and finger using 500 μm Tc-99m were 0.29 mrem and 6.60
mrem, respectively. The radiation dose to the pathologist is low
compared with the dose to the surgeon because the pathologist
has only a briefcontactwith the specimen. Thedosetothepathologist’s body in the study by Hiller and Royal was 0.052 mrem.
TECHNICAL CHALLENGES IN LYMPHATIC
MAPPING FOR CERVICAL CANCER
Lymphatic drainage patterns of cervical cancer may pose technical challenges in lymphatic mapping for this disease. Plentl
and Friedman [16] described a predictable pattern of lymphatic
drainage from the cervix. This pattern includes a stepwise progression from the cervical stroma andserosal lymphatics tonodal
groups in the parametrial, pelvic,pararectal,and para-aortic lymphatics. According to Leveuf and Godard [17], the main route of
lymphatic drainage from the cervix follows the uterine artery,
crosses the inferior vesical artery ventral to the point where the
uterine artery arises from the internal iliac artery, crosses the
obturator nerve, and stops in a lymph node located alongside
the caudal, medial, or cephalic surface of the external iliac vein.
There is overwhelming evidence that most sentinel nodes will be
found in the pelvis. It would be rare to detect a sentinel node
in the para-aortic area exclusively without evidence of a sentinel
node in the pelvis. A detailed review of lymphatic anatomy can
be found in other sources published from our institution.[18]
Pelvic lymph node metastases are found in 0% to 16% of
patients with stage I cervical cancer and 24% to 31% of patients
with stage II cervical cancer. Para-aortic lymph node metastases
are found in 0% to 22% of patients with stage I disease and 11%
to 19% of patients with stage II disease.[19]
M. D. ANDERSON TECHNIQUE FOR
LAPAROSCOPIC LYMPHATIC MAPPING
AND SENTINEL LYMPH NODE BIOPSY
Because hypothesis testing is critical to making an inference into
the applicability of the technique in prospective trials and treatment algorithms, accurate false-negative rates must be established. At the University of Texas M. D. Anderson Cancer Center,
cervical cancerpatients who areconsideredcandidates for radical
hysterectomy and lymphadenectomyhavethe option ofenrolling
in a Gynecologic Oncology Group (GOG)-sponsored investigational protocol of lymphatic mapping and sentinel lymph node
biopsy (GOG 206).The goal of thistrial is to estimate thesensitivity of the sentinel lymph node in determination of the lymph node
metastases inpatients with invasive carcinoma of the cervix using
combined preoperative and intraoperative lymphatic mapping.
Laparoscopic Sentinel Lymph Node Identification in Cervical Cancer — 449
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A
Figure 16.3.1. (A) Initial laparoscopic assessment is made with modified gamma probe. (B) Each of the lymphatic beds is evaluated for in vivo
radioactivity. Blue dye can be seen infiltrating the cervical stroma. (Images provided by Michel Roy, MD.)
In addition, it also aims to evaluate the false negative predictive
value of the sentinel lymph node. The trial allows for either a
laparotomy or laparoscopy to perform the sentinel lymph node
identification. The procedure for patients who undergo laparoscopic sentinel node identification is described in the following
paragraphs.
The day before surgery, the patient reports to the nuclear
medicine suite. Under direct visualization, while the patient is in
the lithotomy position, Tc-99m–labeled sulfur colloid is injected
in four quadrants of the cervix. Immediately after the injection,
dynamic lymphoscintigraphy is performed using a gamma cam-
B
hematoxylin–eosin (H&E) staining. Nodes that are negative on
routine H&E staining may also be sent forimmunohistochemical
staining for cytokeratinantigen. The protocol in our institutionis
to includestep sectioning at five levels with an interval of 250 μm
with H&E and immunohistochemistry when the first-level H&E
section is negative. The findings on frozen section evaluation are
used to determine how to proceed. If pelvic nodes are found
to contain metastatic disease, a para-aortic lymph node sampling is performed to determine what type of radiation field will
be required and the radical hysterectomy is abandoned (Figures
16.3.1–16.3.3).
era. The next morning, before surgery, Tc-99m–labeled sulfur
colloid is once again injected in four quadrants of the cervix.
After induction of general anesthesia, while the patient is in the
lithotomy position, asterile speculum is used to exposethe cervix
for full visualization. A short 25-gauge needle attached to a needle extender is used to inject a total of 5 mL of Lymphazurin 1%
RATIONALE FOR LAPAROSCOPIC SENTINEL
LYMPH NODE IDENTIFICATION IN
CERVICAL CANCER AND RESULTS
OF STUDIES TO DATE
(isosulfan blue, United States Surgical Corp.) into the mucosa
and cervical stroma midway between the cervical os and the rim
of the exocervix, in four quadrants.
The laparoscopic exploration is then started by placing four
bladeless trocars: one trocar in the umbilicus, two trocars in the
right and left lower quadrants, and one trocar in the suprapubic
area. The retroperitoneum is opened and explored very carefully to avoid bleeding, which may prevent adequate visualization of the lymphatic channels. Nodes with increased radioactivity (“hot” nodes) are identified using a laparoscopic gamma
probe (Navigator, Autosuture, Norwalk, CT). The laparoscopic
gamma probe is inserted through either of the lower-quadrant
trocars. Sentinel nodes are also identified by searching the lymph
node basins for nodes stained bright blue. Once a sentinel node
is identified, its anatomic location is noted. The node is subsequently excised separately andsentto a pathologist forimmediate
frozen section evaluation. The laparoscopic gamma probeis then
reinserted to ensure that there are no other hot nodes, and once
this is confirmed, the lymphadenectomy is completed. The same
laparoscopic sentinel node biopsy procedure is then performed
on the opposite side.
At our institution, serial sectioning is performed on sentinel nodes that are negative for metastatic disease on routine
Gynecologistsfirst used laparoscopic surgery inthe1960s as a tool
for the evaluation of the abdominal and pelvic cavity. Approximately 10 years later,laparoscopicsurgerywasused in performing
bilateral tubal ligation. Itwasnotuntilthe 1980s that laparoscopic
surgery was first used in the treatment ofcancer – specifically, testicular cancer.
A large number of publications in the literature describe the
potential benefits of laparoscopic surgery. Among the most common are improved quality of life, faster return to daily activities,
decreased requirements for pain medication in the immediate
postoperative period, fasterreturn of bowel function, and shorter
length of hospitalization.
According to Plante et al. [20], a number of factors support
a laparoscopic approach to lymphatic mapping in cervical cancer. First, the laparoscopic approach allows for a more delicate
and bloodless dissection of the retroperitoneum. Second, the
laparoscope allows magnification, which facilitates visualization of the blue lymphatic vessels. Third, if positive nodes are
identified, the surgeon has the opportunity to end the procedure and offer patients chemotherapy and radiotherapy with
only minor delays, thus reducing morbidity in comparison to
laparotomy.
450 — Pedro T. Ramirez, Charles Levenback, and Robert L. Coleman
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A
Figure 16.3.2. (A) Once the retroperitoneal spaces are carefully opened, a reassessment of radioactivity and blue dye is made. (B) The path of a
blue dye lymphatic channel is easily seen traversing the parametrial tissue to the external iliac chain. (Images generously provided by Michel Roy,
MD.)
A number of studieshave been published ontheuseof laparoscopic surgery in the detection of sentinel nodes. In the following paragraphs, we summarize the findings of the largest studies
to date (see Table 16.3.1). Daniel Dargent was one of the pioneers in exploring laparoscopic sentinel lymph node identification in cervical cancer. In 2000, Dargent et al. [21] reported on
a series of 35 patients with early cervical cancer who underwent
laparoscopic sentinel node identification using patent blue violet. In that study, the authors made a series of very important
observations. First, the rate of failure to identify a sentinel node
depended on the amount of blue dye injected: The failure rate
was 50% when 1.5 mL or less of blue dye was used and only 10%
when 4 mL of blue dye was used. Second, the detection rate was
improved by injecting the blue dye directly into the cervix rather
than into the cervicovaginal junction, as these authors had previously done. Third, the rate of false-negative sentinel nodes was
zero. Fourth, prior conization, tumor volume, and stage did not
affect the failure rate. Dargent et al. found that the overall fail-
B
ure rate was 14.5%. However, one should note that these authors
used only blue dye and not the combination of blue dye and a
radiocolloid.
In a 2001 report, Malur et al. [22] described their experience
with laparoscopic sentinel node identification using a radioactive isotope, blue dye (patent blue), or both. This group was
the first to report on the use of a laparoscopic gamma probe
in sentinel node identification. In their series of 50 patients, 46 of
whom underwent sentinel nodeidentificationbylaparoscopy,the
authors reported a sentinel node detection rate of 78%. In addition, the investigators found that the combination of isotope and
blue dye led to the highest detection rate: The detection rate was
55% with blue dye alone, 76% with radiolabeled albumin alone,
and 90% when both techniques were used. The false-negative
rate in that study was 16.6%. The high false-negative rate may
reflect the use of blue dye alone in some patients; the amount of
blue dye injected (2 mL) also may not have been ideal. Finally,
Malur et al. found that the majority of para-aortic sentinel nodes
A
Figure 16.3.3. (A) Once the candidate sentinel node is identified, great care is used to isolate the node and (B) resect it. Ex vivo radioactivity along with the blue characteristic and location are recorded for pathologic assessment. (Images generously provided by Michel Roy,
MD.)
B
Laparoscopic Sentinel Lymph Node Identification in Cervical Cancer — 451
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Table 16.3.1: Laparoscopic Sentinel Lymph Node Identification
Study Patients, no. Stage Tc-99m
Dargent et al.
[21]
Maluretal.
[22]
Lambaudie
et al. [26]
Buist et al.
[23]
Barrenger
et al. [24]
Plante et al.
[20]
Gil-Moreno
et al. [27]
35 IA2–IB2 No Yes 86 0
46 I–IV Yes Yes 90 17%
12 IA–IB1 Yes No 92 0
25 IB1–IIA Yes Yes 100 11%
13 IA2–IIA Yes Yes 92 0
70 IA–IIA Yes Yes 93 0
12 IA2–IB1 Yes Yes 100 0
identified (66%) were located in the precaval region. Interestingly, no patient had evidence of isolated para-aortic sentinel
nodes.
In another study, Buist et al. [23] evaluated the utility of
laparoscopic sentinel node identification in patients with early
cervical cancer. In that study, the investigators reported on 25
patients who underwent lymphatic mapping before radical hysterectomyusingintracervicalradiocolloidinjection as well as blue
dye. The authors noted that one or more sentinel nodes could be
detected via laparoscopy in 100% of patients. The investigators
also evaluated the accuracy of frozen section of sentinel nodes
at the time of surgery. They noted that frozen section sensitivity
per sentinel node was 97% and per patient, 96%. Another interesting observation noted by the investigators was that sentinel
node identification might be a time-consuming procedure. The
median time from first incision to detection of the first sentinel
node was 55 ± 17 minutes (range, 15 to 80 minutes). This was
not significantly different between the first and second half of
their learning curve.
In the largest series published to date on laparoscopic sentinel node identification, Plante et al. [20], in 2003, reported
on 70 patients undergoing radical surgery for early-stage (stage
IA–IIA) cervical cancer. The combination of preoperative lymphoscintigraphy and intracervical blue dye injection was used in
42% of those patients. In the remaining patients, sentinel node
identification was performed using intracervical blue dye injection only. Sentinel node detection rates were 87% overall, 79%
with blue dye alone, and 93% with blue dye plus lymphoscintigraphy. Among patients with macroscopically involved nodes at
laparoscopy, the sentinel node identification rate was only 56%.
This finding may reflect blockage of the lymphatic channels by
tumor cells, prohibiting the blue dye or radiocolloid from reaching the sentinel node. The authors reported that the majority of
the sentinel nodes (88%) werelocatedintheexternaliliacarea,the
obturator area, or the bifurcation of the iliac vessels. Seventy-five
percent of the patients had two or more sentinelnodes identified.
The false-negative rate was zero. Only two patients (3%) suffered
Blue
Detection
Detection
Rate
False Negative
Rate,%
an allergic reaction. One patient had the characteristic skin reaction withdevelopment of bluehives. Another patientdeveloped a
more severe reaction with profound vasomotor shock afterinjection of the blue dye. Although that patient recovered without any
major sequelae, shedidrequireuseof vasopressors and admission
to the intensive care unit.
Also in 2003, Barranger et al. [24] published their experience
with laparoscopic sentinel node identification using a combined
approach with radioisotopes and patent blue dye. Although their
series was small, including only 13 patients, their study is important becauseitwasthefirsttoshowthat laparoscopicsentinelnode
detection was possible in patients who had undergone neoadjuvant chemotherapy and radiotherapy.
CONCLUSIONS
Several conclusions can be drawn from these studies of laparoscopic sentinel node identification for cervical cancer. First, the
overall sentinel node detection rate ranges between 60% and
100%. Second, the majority of studies publishedtodateshowthat
the sentinel node identification rate is higher when both preoperative lymphoscintigraphy and blue dye injection are used than
when just one technique is used. Third, there is strong evidence
in the literature that in patients with macroscopically suspicious
nodes, the sentinel node detection rate is decreased. The explanation that has been proposed is that blockage of the lymphatic
channels by tumor cells prohibits the blue dye or radiocolloid
from reaching the sentinel node. In the prospective trial being
conducted by the GOG (GOG 206), any patient with evidence of
suspicious lymph nodes on preoperative evaluation is excluded
from entry. Fourth, the overall false-negative rate is relatively
low. This is important because for sentinel node identification to
be accepted in the routine management of patients with cervical
cancer,thereneedsto be definitive evidence thatthe sentinel node
status accurately represents the status of all lymph nodes in the
pelvis and para-aortic region. Fifth, the procedure is safe, with
452 — Pedro T. Ramirez, Charles Levenback, and Robert L. Coleman
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only rare cases of allergic reactions, which are transient and easily manageable. Most of these reactions are caused by the blue
dye and not the radioactive colloid. Some investigators have suggested that allergic reactions are generally more common when
larger amounts of blue dye (≥4 mL) are used.
UNRESOLVED QUESTIONS
Among the questions that remain unresolved regarding laparoscopic sentinel lymph node identification is the number of cases
required to master the technique. Some authors have suggested
that about 30 cases will be required because the intracervical
injection is technically difficult and the lymphatic drainage of the
cervix is much more complex, involving three main trunks per
side.[20] In the current GOG trial, an attempt at standardizing
surgical acumen forlymphatic mapping is incorporated–investigators contributing patients tothetrial must successfully perform
the procedure in three cases. The outcome in these patients will
not be used in the statistical design.
In addition, it remains to be determined whether immunohistochemical staining should routinelybeperformed on sentinel
nodes. There is increasing information intheliteraturesuggesting
that immunohistochemical staining in addition to serial sectioning may improve the rate of detection of metastatic disease in
the lymph nodes. Finally, we do not know the clinical implications of detecting occult micrometastases in patientswith cervical
cancer.
The combination of laparoscopicsentinel node identification
and fertility-preserving options in patientswith cervical cancer is
already being explored.[25] In addition, future studies will need
to explore the correlation of sentinel node findings with novel
imaging technologies, such as positron emission tomography–
computed tomography (PET-CT) scanning and high-resolution
magnetic resonance imaging. We also look forward to the results
of the prospective trial currently being conducted by the GOG
to determine the ultimate role of sentinel node identification in
patients with cervical cancer.
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Section 16.4. Schauta Radical Vaginal Hysterectomy and Total
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Laparoscopic Radical Hysterectomy
Yukio Sonoda and Nadeem R. Abu-Rustum
HISTORICAL BACKGROUND
The vaginal radical hysterectomy was initially described by the
surgeon Anton Pawlik [1], but it was popularized by the Austrian Frederik Schauta [2], who described this surgical treatment option for patients with cervical cancer. The procedure
was associated with a decreased postoperative mortality when
compared with the abdominal route that was championed by
Wertheim.[3] Schauta’s technique was eventually modified by
Peham and Amreich [4]and Stoeckel.[5] As pelviclymphadenectomy became incorporated intothe surgical treatment of thisdisease, however, the vaginal approach gave way to the abdominal
radical hysterectomy, which allowed for both procedures to be
performed through one incision. To counter this return to the
abdominal approach, the extraperitoneal pelvic lymphadenectomy was introduced into the management scheme [6], but this
still required multiple incisions. The laparoscopic lymphadenectomy was introduced by Dargent in 1987.[7] This allowed the
vaginal approach to be used without sacrificing the benefits of
a minimally invasive approach. Over time, the extent of the
laparoscopic dissection expanded. The first laparoscopic radical hysterectomy, para-aortic and pelvic lymphadenectomy was
performed by theNezhatsin 1989 andwas reported in1990, 1991
and 1992.[8–10] Now, many peform, such procedures routinely.
THE SCHAUTA–AMREICH RADICAL
VAGINAL HYSTERECTOMY
The Schauta–Amreich is the more radical form of radical vaginal
hysterectomy. Once the patient is positioned properly for radical
vaginal surgery, a diluted solution of epinephrine is injected into
the left mediolateral perineum in preparation for a Schuchardt
incision. This is a type of enlarged mediolateral episiotomy that
is madeat thejunction of the posterior and left lateral walls of the
vagina. It enlarges the operative field and provides access to the
left pararectal space. The incision extends from the most cranial
point, which isat the level of theexpected vaginal cuff incision, to
the distal point, which is on the perineum (Figure 16.4.1). At the
apex of this incision is the left pararectal space, which provides
access for the surgeon to bluntly displace the rectum medially.
The levator ani muscle can now be divided, except for the most
proximal portion, to fully expose the left pararectal space.
The vaginal margin is now delineated. A series of Kocher forceps are put circumferentially onto the vaginal mucosa at the
level of the junction between the upper and the middle thirds.
Traction is exerted on the forceps, which results in an internal
prolapse of the vaginal wall. The two walls of the vaginal fold
raised by the traction are separated from each other by injecting the epinephrine solution along the edge of the fold midway between each traction forceps (Figure 16.4.2). The outer
wall of the vagina is then incised circumferentially just beyond
the tips of the Kocher forceps (Figure 16.4.3). The pressure on
the scalpel blade must be released as soon as the outer wall of the
vagina is incised so as not to incise the inner vaginal wall. This
full-thickness incision (incision of the three layers of the vaginal
wall) is made only on the anterior and posterior aspects of the
developed vaginal cuff. Only the mucosa layer is incised on the
dorsolateral aspects (between 3 and 4 o’clock and between 8 and
9 o’clock), so that the relationship between the vaginal cuff and
the paracervical ligaments is maintained.
Once separatedfrom the remainder of the vagina, the vaginal
cuff is folded over the cervix to cover it by using strong grasping
forceps that are aligned in a frontal plane (Figure 16.4.4). It is
retracted dorsally in order to free the ventral aspect of the vaginal
cuff at the same time the ventral aspect of the uterus and surrounding tissues (i.e., paracervical and parametrial ligaments) is
freed. The bladder floor and terminal ureter are attached to these
structures and must be separated from them. The vesicovaginal
space is carefully developed in the midline so as not to injure the
bladder, which is very close to the tips of the grasping forceps.
Caution must be taken because of the condensation of the cellular tissue joining the bladder floor to the vagina. This condensation raises a pseudo-aponeurotic coronal structure named the
supravaginal septum, which must be perforated (Figure 16.4.5)
to reach the appropriate space. Once the vesicovaginal space has
been opened, dissection ofthe bladderpillars canbe approached.
This is where the knee of the ureter lies (Figure 16.4.6).
The left paravesical space can be opened by using curved
Metzenbaum scissors with closed tips pointed upward and outward (Figure 16.4.7). The scissors are introduced at the apex of
the Schuchardt incision just medial to the apex of the remaining
intact levator ani and lateral to the bladder pillar. The scissors are
opened to spread the loose connective tissue of the paravesical
space. The surgeon’s fingers are successively introduced into the
space and the bladder is mobilized medially.
Once the vesicovaginal and left paravesical spaces are developed, the left bladder pillar is divided and the ureter can be isolated. The bladder pillars are divided in two steps. Initially, the
pillar isseparated into the lateral and medial parts by openingthe
caudal brim of thepillaratanequaldistancefromitstwosides and
two extremities. After opening, the scissors are pushed laterally.
One ensures that the instrument is placed lateral to the ureter by
palpating and feeling the “click” (Figure 16.4.8).[11] Once these
fibers are divided by clamping and tying or bipolar cauterization,
the paravesical space becomes wider. A bigger retractor is put
453
454 — Yukio Sonoda and Nadeem R. Abu-Rustum
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Figure 16.4.1. A Schuchardt incision is used to improve exposure and
provide access to the pararectal space.
in place and the knee of the ureter appears in the deepest part.
Once the knee of the ureter has been identified, the medial fibers
(Figure 16.4.9) of the pillar can be divided. This division exposes
the ventral aspect of the juxta-uterine part of the paracervical
ligament. The para-isthmic window (the inferior brim of which
is the superior brim of the paracervical ligament) is identified by
palpation. The arch of the uterine artery is located inside it. The
afferent branch of the arch is isolated and dissected upward as far
as thelevel of theknee of the ureter. Thenthe dissection is pushed
further laterally inside the knee of the ureter, and the artery is cut
close to its origin (Figure 16.4.10).
The right paravesicalspacecan be opened inasimilar fashion,
and the same procedure performed to isolate the right ureter.
Figure 16.4.3. The vaginal incision is made circumferentially. The lateral portions of theincision are madethrough the vaginalmucosaonly.
Next, the posterior peritoneal fold can be opened (Figure
16.4.11). The intestines are packed away with a packing tape, and
the rectum is displaced posteriorly with a retractor. The rectal
pillars can now be viewed. The peritoneum overlying the rectal pillars and rectum is first incised carefully as the ureters are
adherent to this peritoneum. The rectal pillars are now isolated
and divided close to the rectum (Figure 16.4.12).
Once the rectal pillars are divided, the cardinal ligaments can
be divided. An anterior retractor pushes the bladder away, and
Figure 16.4.2. An epinephrine solution is injected circumferentially to
separate the layers of the vagina.
Figure 16.4.4. Chrobak forceps are used to fold the vagina over the
cervix.
Schauta Radical Vaginal Hysterectomy and Total Laparoscopic Radical Hysterectomy — 455
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Figure 16.4.5. The vesicovaginal space is developed sharply. Note the relationship of the bladder to the plane of dissection.
two large clamps areplaced across the left cardinal ligament close
to the pelvic side wall (Figure 16.4.13). This is then divided and
the pedicle secured. The identical maneuver is repeated on the
right cardinal ligament.
The anteriorperitoneum isnow opened, and the uterine fundus can be delivered through it. At this point, the round ligaments and infundibulopelvic ligaments can be divided if the
ovaries are to be removed. The peritoneum and vaginal cuff
can be closed according to surgeon’s preference. The Schuchardt
Figure 16.4.6. The knee of the ureter lies in the bladder pillar.
Figure 16.4.7. The paravesical space is developed by careful spreading
of the tissue.
456 — Yukio Sonoda and Nadeem R. Abu-Rustum
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Figure 16.4.8. The knee of the ureter is palpated in the bladder pillar
using the surgeon’s opposite index finger.
incision is closed byfirst reapproximating the levator ani muscles
and then closing the subcutaneous tissues and skin.
THE SCHAUTA–STOECKEL RADICAL
VAGINAL HYSTERECTOMY
The Schauta–Stoeckel is less radical than the abovementioned
Schauta–Amreichtechnique.Many of the steps aresimilar,but the
major differences are that the Schuata–Stoeckel operation does
Figure 16.4.9. Once the knee of the ureter is located, the fibers of the
bladder pillar can be divided.
Figure 16.4.10. After the bladder pillar has been divided, the knee of
the ureter canbepushed laterally andthe uterine artery can be clamped
and ligated.
not employ a Schuchardt incision and the cardinal ligaments are
divided at an intermediate level.
The Schauta–Stoeckel begins with the formation of the vaginal cuff. This is performed in similar fashion to the Schauta–
Amreich procedure, with a series of Kocher forceps placed circumferentially onto the vaginal mucosa at thelevelofthejunction
between the upper and the middle thirds. The vagina is incised
and closedover the cervix as mentioned above. The vesicovaginal
space is opened in similar fashion as previously mentioned. The
paravesical space is then opened by placing two Kocher forceps
on the free edge of the vaginal cuff at 1 o’clock and 3 o’clock. As
outward traction is applied to these forceps, a small depression
becomes visible between them. This marks the entrance to the
left paravesical space, which is further developed by introducing
curved Metzenbaum scissors in an outward and lateral direction.
The left pararectal space is opened in a similar fashion by placing
two Kocher forceps on the free vaginal edge at the 3 o’clock and
5 o’clock positions. As outward traction isplaced ontheseforceps,
a small depression becomes evident. This is the opening to the
left pararectal space. This opening is further expanded by introducing curved Metzenbaum scissors in a downward and outward
direction (Figure 16.4.14). The right paravesical and pararectal
spaces can be opened by mirroring the technique on the opposite
side. The bladder pillars are divided in two steps as previously
described for the Schauta–Amreich procedure.
The pouch ofDouglas is opened in themidline, and therectal
pillars are divided, that is, the uterosacral ligaments or more precisely, the medial part of them (i.e., the rectouterine peritoneal
folds). Once theseligaments have been divided, the dorsal aspects
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