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Schauta Radical Vaginal Hysterectomy and Total Laparoscopic Radical Hysterectomy — 457
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Figure 16.4.13. The cardinal ligaments are divided laterally.
of the para-isthmic windows are palpated. Their inferior brim
corresponds to the superior brim of the paracervical ligaments.
A right-angle dissector is pushed from back to front through
the parauterine ligament. Opening the dissector frees the upper
brim of the paracervical ligament. This is done while dividing
the paracolpos (i.e., the expansion that the paracervix sends to
the vagina). This division is done by deepening the dorsolateral
incision in the vagina and pushing it laterally while controlling
the bleeders encountered during this action.
Figure 16.4.11. The posterior cul-de-sac is opened sharply, paying
careful attention to the location of the rectum.
Figure 16.4.12. The rectal pillars are divided.
Figure 16.4.14. The pararectal space can be openedwithgentle spreading of the tissue in a downward and outward direction.
458 — Yukio Sonoda and Nadeem R. Abu-Rustum
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Once the dorsal and ventral aspects of the paracervical ligaments are both exposed with the superior and inferior brims,
they can be divided. Two clamps are placed on each ligament, the
most lateral being just at the contact of the tip of the knee of the
ureter.
With the two paracervical ligaments divided, the anterior
peritoneum is opened and the uterine fundus is delivered. Any
remaining peritoneal attachments are divided while assuring that
the ureters are pushed away. The closure of the cuff and vagina
are performed according to surgeon’s preference.
EVOLUTION OF TWO TECHNIQUES
The inability to perform a pelvic lymphadenectomy diminished
the popularity of the radical vaginal hysterectomy. The introduction of the laparoscopic lymphadenectomy provided the means to
overcome this shortcoming of radical vaginal surgery. As surgeons became more adept with the use of laparoscopy, the two
procedures of laparoscopic lymphadenectomy followed by vaginal radical hysterectomy eventually evolved into laparoscopically
assisted radical vaginal hysterectomy and total laparoscopic radical hysterectomy.
Laparoscopic Lymphadenectomy Followed by Radical
Vaginal Hysterectomy
Dargent’s initial experience was based on a two-step procedure
using laparoscopic surgery to perform a pelvic lymphadenectomy to be followed by radical vaginal hysterectomy. From 1986
to 1992 he performed 95 cases using such an approach (unpublished data). The mean duration of the laparoscopic staging was
60.4 ± 25.8 minutes. The Schauta–Stoeckel technique (less radical) was used in 28 cases, and the Schauta–Amreich technique
(more radical) was used in 67 cases. The mean duration of
the surgery was 74 ± 31 minutes and 89 ± 26 minutes, respectively. No perioperative complication was observed with
the Schauta–Stoeckel technique, whereas six complications were
observed with the Schauta–Amreich technique: one cystotomy,
four ureterotomies, and one proctotomy (all repaired immediately with no postoperative complication). Only one patient
required reoperation for postoperative bleeding after a Schauta–
Amreich procedure. Only 14 patients received transfusions.
Among the 28 patients who underwent the Schauta–Stoeckel
operation, eightsuffered from urinarybladder problems but only
one had persistent dysuria after 6 months. Among the67 patients
who underwent the Schauta–Amreich procedure, 27 suffered
the same bladder problems and 10 had persistent dysuria after
6 months.
Laparoscopically Assisted Vaginal Radical Hysterectomy
As surgeons became more familiar with laparoscopic surgery,new
techniques were developed. In addition to performing a laparoscopic lymphadenectomy, surgeons began using the laparoscope
to perform some of the dissection before performing the radical
vaginal hysterectomy. This allowed the resection to be comparable to that of a classic abdominal radical hysterectomy.
One of the technical difficulties of the radical vaginal
approach is obtaining a large amount of parametrium. This is
in large part a result of the oblique angles that the vaginal surgeon is faced with, which can make the lateral placement of a
clamp at the pelvic side wall difficult. However, because laparoscopic instruments are introduced transabdominally, placement
can be adjusted to operate with an instrument in the plane of
the pelvic side wall. Endoscopic staplers, vessel sealers, and argon
beam coagulators are some examples of instruments that the surgeon can employ to divide the lateral parametrium at the pelvic
side wall. There have been several reports since 1992 [12–20]
of series describing the laparoscopically assisted vaginal radical
hysterectomy (LAVRH) during which the surgeon divided the
parametrium during the laparoscopic step. The common feature
of the techniques described therein was the use of the laparoscope to increase the resection of the parametrium. Once this
is performed, the remainder of the procedure can be performed
using either a Schauta–Amreich or Stoeckel approach. As a consequence, the operative specimen is very large (i.e., identical to
the type III abdominal radical hysterectomy).
The concept of the “paracervical cellulolymphadenectomy”
has been combined with a modified radical vaginal hysterectomy, thereby accomplishing the oncologic goals of the radical hysterectomy.[17] The paracervical cellulolymphadenectomy
consists of removing all the lymph node–bearing tissues located
in the lateral part of the paracervical ligament in a multistep procedure.
First, the obturator nodes below the obturator nerve are
removed to identify the origin of the obturatorvessels and expose
the ventral surface of the paracervical ligament. In the second
step, the dorsal aspect of the paracervix is exposed. The pararectal space opens when pushing the posterior sheet of the broad
ligament, to which the ureter is attached, medially. Following the
ureter ventrally, one arrives at the point where the ureter crosses
the uterine artery. Starting from this point, the pararectal space
is developed as far as the sacrospinous muscle. The node-bearing
tissues lying anterior to the sacrum, lateral to the rectum, and
medial to the pelvic side wall are removed. During this step, the
dissection must proceed with caution, particularly on the left
side, where the left common iliac vein is encountered. Once the
two aspects of the paracervical ligament are exposed, the fatty
tissue among the paracervical vascularnetwork mustbe carefully
removed.
Hertel et al. [12] have reported the largest series of LAVRH to
date. Over an 8-year period, 200 patients underwent the procedure. One patientrequiredconversiontolaparotomyand was not
included in the evaluation. The mean Quetelet index was 25 (14
to 38). The average duration of the surgery was 333 (151 to 556)
minutes. A mean of 22 (three to 57) pelvic nodes were removed.
Major intraoperative injuries included14 bladder, seven ureteral,
four blood vessel, and one bowel injury. With a median followup of 40 months, the estimated 5-year survival was 83%. The
larger series of LAVRH reported in the literature are listed in
Table 16.4.1.[12–20]
TECHNIQUE OF TOTAL LAPAROSCOPIC
RADICAL HYSTERECTOMY WITH PELVIC
LYMPHADENECTOMY
For many surgeons more familiar with abdominal surgery, the
laparoscope may be used to perform the radical hysterectomy
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Table 16.4.1: Summary of the Larger Series of Laparoscopically Assisted Vaginal Radical Hysterectomy
Study Patients, no. PLN ORT, min. EBL, mL LOS, days Complications Recurrences, no.
Hertel et al.
[12]
Hallum et al.
[13]
Jackson et al.
[14]
Nam et al. [15] 47 33 232 — 15 1 bladder, 1 hernia,
Steed et al. [16] 71 210 7 bladder, 1 ureter,
Querleu et al.
[17]
Park et al. [18] 52 27 380 — — 4 ureter,
Sardi et al. [19] 56 17 267 — 4 2 bladder, 3 ureter,
Renaud et al.
[20]
PLN, mean pelvic lymph nodes; ORT, mean operating room time; EBL, mean estimated blood loss; LOS, mean hospital stay.
200 22 333 — — 7 ureter,
4 vascular,
1bowel,14bladder
37 35 225 525 5 2 bladder,
1 fistula, 1 bowel
57 180 350 5 3 bladder, 1 bowel 2
1 fistula,
1 obstruction
1 bowel, 2 fistulas
47 25 228 391 — 2 ureter 3
1 hematoma,
2 conversions
2 technical,
1 abscess
57 27 270 300 5 3 cystotomies,
1 vascular
37
—
4
4
2
4
2
by mimicking the same steps used at abdominal radical
hysterectomy. The laparoscopic radical hysterectomy with pelvic
and aortic lymph node dissection was first reported in 1990.[8]
This technique can be appealing to the abdominal surgeon in
that one needs to master only the laparoscopic skills required to
perform this procedure, compared with LAVRH, which requires
expertise in bothlaparoscopicandvaginal surgery. Once the technique was standardized, this operation became popular in the
United States becauseit complies with oncologic principles while
maintaining a minimally invasive approach.
Before beginning the laparoscopic radical hysterectomy,
the surgeon can perform cystourethroscopy and place ureteral
catheters. This decision depends on the surgeon’s preference but
may be helpful during ureteral dissection.
A variety of endoscopic dissecting instruments, clip appliers,
staplers, and specimen-retrieval devices, as well as monopolar
current attached to a dissector or scissors, may be used. The gas
flow is set to manual at 3 to 4 L/minute, which contributes to
increased pneumoperitoneum, necessitating continuous monitoring of intra-abdominal pressure and active venting during the
procedure via one of the laparoscopic trocar valves to keep the
intra-abdominal pressure under 16 mm Hg.
A four-trocar transperitoneal approach is usually used for
these procedures (Figure 16.4.15), with the initial incision
made in the periumbilical area. A carbon dioxide pneumoperitoneum is then generated, keeping the intra-abdominal pressure under 16 mm Hg. A 0
◦
laparoscope is then introduced
via the umbilical port, and the peritoneal cavity is inspected.
Three accessory 5- to 12-mm trocars are then placed under
direct visualization medial tothe iliaccrest and in the suprapubic
area.
Figure 16.4.15. Trocar placement.
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Figure 16.4.17. Opening of the right pararectal space.
Figure 16.4.16. Opening of the right paravesical space.
Transperitoneal pelvic lymphadenectomy is performed with
the patient in a 30
◦
to 45◦Trendelenburg position to facilitate
retroperitoneal exposure by retaining the small intestine in the
mid- and upper abdomen using gravity and gentle instrumentation. The use of intraoperative epidural anesthesia is surgeon
dependent and may facilitate exposure by contracting the intestine, as the result of sympathetic blockade.
The pelvic lymphadenectomy is started by developing the
paravesical and pararectal space. We routinely use the laparoscopic 10-mm argon beam coagulator (ABC) foot-switching
probe (ConMed Electrosurgery System 7500, Utica, NY), set at
70 W, for these laparoscopic procedures. The 10-mm ABC probe
replaces multiple laparoscopic instruments by working as a dissector, cutter, and coagulator. It also functions as a rigid probe
to allow transfer of tactile sensation from tissues to the surgeon’s
hand. The round ligament is divided with the ABC. The umbilical ligament is isolated medially, and a retroperitoneal incision
between the round ligament and the umbilical ligament, parallel
to the umbilical ligament, is performed and extended just to the
reflection of the interior abdominal wall. The umbilical ligament
is then placed on traction medially, and using the ABC, the paravesical space is developed to expose the external iliac vessels, the
obturator area and the obturator internus muscle, and the pubic
bone (Figure 16.4.16).
After developing the paravesical space, the retroperitoneal
incision is extended over the psoas muscle parallel to the
infundibulopelvic ligament. The infundibulopelvic ligament is
pulled medially. The ureter is visualized medially, and the
hypogastric vessel is identified laterally. The pararectal space is
developed between these two structures using blunt dissection
on the posterior leaf of the broad ligament (Figure 16.4.17).
After complete development of the pararectal and paravesical spaces, the lymph node dissection is started. This dissection
can begin over the common iliac artery on the right side and
may be carried to the level of the deep circumflex iliac vessels
(Figure 16.4.18). Leaving the ureter attached to the peritoneum
allows it to be retracted away with medial traction on the peritoneal edge and infundibulopelvic ligament. The psoas muscle is
identified, the genitofemoral nerve is protected, and the lymph
nodes between the genitofemoral nerve and the surface of the
right external iliac artery and vein are removed.
The obturator nerve is then identified, the obturator vessels
are protected, and the lymph node package between the external
iliac vein and obturator nerve is dissected. Lymph nodes around
and below the obturator nerve are removed. Hypogastric nodes
can now be removed from the proximal part of the umbilical
ligament and near the uterine artery origin. The iliac vessels can
then be dissected from the psoas muscleand pulledmedially,and
the obturator space is exposed through the lateral approach to
Figure 16.4.18. The removal of the right external iliac lymph nodes.
Schauta Radical Vaginal Hysterectomy and Total Laparoscopic Radical Hysterectomy — 461
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Figure 16.4.19. Right iliac and obturator lymphadenectomy using the
lateral approach between the psoas muscle and right external iliac vessels.
Figure 16.4.21. The medial edge of thedivided uterine vesselsis pulled
medially, and the ureter is unroofed with the argon beam coagulator
and endoscopic right angle dissector, with clips placed as needed.
Figure 16.4.20. The uterine vessels are stapled with a vascular endoscopic stapler at the origin from the hypogastric vessels.
Figure 16.4.22. A posterior cul-de-sacperitoneal incision is madewith
the argon beam coagulator, and the rectovaginal septum is developed.
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Figure 16.4.23. The uterosacral ligaments are divided or stapled.
Figure 16.4.24. The remaining parametria and paracolpos are divided
by the endoscopic stapler.
Figure 16.4.25. Anterior colpotomy is performed using the argon
beam coagulator, guided by the nonconducting vaginal probe and the
incision extended circumferentially.
Figure 16.4.26. The vaginal cuff is closed anterior to posterior using
the Endo Stitch (United States Surgical Corporation, Norwalk, CT) in
a running manner.
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Table 16.4.2: Summary of Reports on Laparoscopic Radical Hysterectomy and Pelvic Lymphadenectomy with or without
Para-aortic Aortic Lymphadenectomy
Author Group Year Patients, no.
∗
PLN ORT, min. EBL, mL LOS, days Complications
Nezhat 1992 [10]
1993 [22]
Sedlacek 1994 [23]
1995 [24]
Ting 1994 [25] 4 8.0 330–480 150–500 — None
Ostrzenski 1996 [26] 6 — 280 — 2.0–6.0 1 hydronephrosis
Kim 1998 [27] 18 22.0 363 619 — None
Hsieh 1998 [28] 8 — — 6.5 None
Spirtos 2002 [21] 78 23.8 205 250 2.9 1.3% transfusion,
Lee 2002 [29] 12 19.2 235 428 6.8 2 transfusions
Lin 2003 [30] 10 16.8 159 250 4.1 None
Obermair 2003 [31] 55 — 210 200 5.0 3 vascular, 1 nerve
Pomel 2003 [32] 50 13.2 258 200 7.5 1 bladder, 1 ureter,
Abu-Rustum 2003 [33] 19 25.5 371 301 4.5 1 transfusion,
Gil-Moreno 2005 [34] 27 19.1 285 400 5.0 None
∗
Some patients may be reported more than once.
PLN, mean pelvic lymph nodes; ORT, mean operating room time; EBL, mean estimated blood loss; LOS, mean hospital stay; VVF,
vesicovaginal fistula; UVF, ureterovaginal fistula; DVT, deep venous thrombosis.
7 22.0 315 30–250 2.1 None
14 16.0 420 334 5.5 1 VVF,
1 ureteral injury
3 cystotomies, 1 UVF,
1 DVT, 5 conversions
1 hernia
2 conversions 1 fever
ensure removal of all nodal tissue, particularly in the proximal
part just lateral to the common iliac artery (Figure 16.4.19). The
same steps are performed on the contralateral side.
For the total laparoscopic radical hysterectomy, the bladder
flap is dissected sharply and pushed caudally using the ABC. A
vaginal probe (Apple Medical Corporation, Marlboro, MA) facilitates the dissection by stretching the vaginal fornix. The uterine vessels are either divided with a vascular endoscopic stapler
(Autosuture Multifire Endo GIA 30-2.0; United States Surgical
Corporation, Norwalk, CT) at their origin from the hypogastric
vessels (Figure 16.4.20), or sealed with the endoscopic vessel sealing system (LigaSure; Valleylab, Boulder, CO). The medial edge
of the divided uterine vessels is then pulled medially, and the
ureter is unroofed with the ABC and endoscopic right-angle dissector, with clips placed as needed (Figure 16.4.21). A posterior
cul-de-sac peritoneal incision is then made and the rectovaginal
septum developed (Figure 16.4.22).Theuterosacralligaments are
divided or stapled, andthe remaining parametria and paracolpos
are divided (Figures 16.4.23 and 16.4.24). Anterior colpotomy is
then performed using the ABC, guided by the vaginal probe, and
the incision is extended circumferentially (Figure 16.4.25). The
specimen is removed vaginally. The vaginal cuff is then closed
from anterior to posterior using the Endo Stitch (United States
Surgical Corporation, Norwalk, CT) with absorbable suture in
a running manner (Figure 16.4.26). The ureteral catheters are
usually removed at the completion of the operation or before
discharge.
The largest series reported so far, by Spirtos et al. [21],
describes 78 consecutive patients, all with early cervical cancer
and a Quetelet body mass index greater than 35, who underwent
this procedure. In all, 94% of the procedures were completed
laparoscopically, with an average operative time of 205 minutes
and an average blood loss of225mL, with onlyonepatient (1.3%)
requiring transfusion. There was one ureterovaginal fistula documented. The average lymph node count was 34, with 11.5%
of patients having positive lymph nodes. Three patients (3.8%)
had closeor positive surgical margins, and eight patients(10.3%)
had a recurrence with a minimum of 3-year follow-up. The estimated 5-year disease-free interval for those patients was 89.7%.
Table 16.4.2 summarizes published reports on laparoscopic radical hysterectomy and pelvic lymphadenectomy with or without
para-aortic lymphadenectomy.[10, 21–34]
CONCLUSIONS
Laparoscopy has revived interest in the minimally invasive surgical approach to the management of early cervical cancer. In
addition to allowing the vaginal radical hysterectomy to remain
a surgical option, it has provided a means of facilitating the
vaginal dissection while also increasing the extensiveness of the
dissection. Furthermore, total laparoscopic radical hysterectomy
has also opened the world of minimally access surgery to surgeons more accustomed to abdominal surgery. As more data are
464 — Yukio Sonoda and Nadeem R. Abu-Rustum
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accumulated, the exact role of these procedures in the surgical
management of cervical cancer will be determined.
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4. Amreich I. Zur anatomie und technik der erweiterten vaginalen
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5. Stoeckel W. Die vaginale radikaloperation des kollumcarzinom.
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6. Mitra S. Mitra Operation for Cancer of the Cervix. Springfield: Ch
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7. Dargent D. A new future for Schauta’s operation through
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8. Nezhat C, Nezhat F. Videolaseroscopy for the treatment of upper,
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AAGL, Nov. 1990.
9. Nezhat C, Nezhat F, Silfen S. Videolaseroscopy: the CO
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10. Nezhat CR, Burrell MO, Nezhat FR, Benigno BB, Welander CE.
Laparoscopicradical hysterectomy with paraaortic andpelvicnode
dissection. Am J Obstet Gynecol. 1992;166:864.
11. Possover M, Krause N, Schneider A. Identification of the ureter
and dissection of thebladder pillar in laparoscopic-assisted radical
vaginal hysterectomy. Obstet Gynecol. 1998;91:139–143.
12. Hertel H, Kohler C, Michels W, Possover M, Tozzi R, Schneider
A. Laparoscopic-assisted radical vaginal hysterectomy (LARVH):
prospectiveevaluationof200patientswith cervical cancer. Gynecol
Oncol. 2003;90:505–511.
13. Hallum AV,HatchKD, NourM, SaucedoM. Comparisonofradical
abdominal hysterectomy with laparoscopic-assistedradicalvaginal
hysterectomyfor treatment of early cervical cancer. J Gynecol Tech.
2000;6:2–6.
14. Jackson KS, Das N, Naik R, et al. Laparoscopically assisted radical
vaginal hysterectomyvs.radicalabdominalhysterectomy for cervical cancer: a match controlled study. Gynecol Oncol. 2004;95:655–
661.
15. Nam JH, Kim JH, Kim DY, et al. Comparative study of
laparoscopico-vaginal radical hysterectomy and abdominal radical hysterectomy in patients with early cervical cancer. Gynecol
Oncol. 2004;92:277–283.
16. Steed H, Rosen B, Murphy J, Laframboise S, De Petrillo D, Covens
A. A comparison of laparoscopic-assisted radical vaginal hysterectomy and radical abdominal hysterectomy in the treatment of cervical cancer. Gynecol Oncol. 2004;93:588–593.
17. Querleu D, Narducci F, Poulard V, et al. Modified radical vaginal hysterectomy with or without laparoscopic nerve-sparing
dissection: a comparative study. Gynecol Oncol. 2002;85:154–158.
laser for
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18. Park CT, Lim KT, Chung HW, et al. Clinical evaluation of
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20. Renaud MC, Plante M, Roy M. Combined laparoscopic and vaginal radical surgery in cervical cancer. Gynecol Oncol. 2000;79:59–
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21. Spirtos NM, Eisenkop SM, Schlaerth JB, Ballon SC. Laparoscopic radical hysterectomy (type III) with aortic and pelvic lymphadenectomy in patients with stage I cervical cancer: surgical morbidity and intermediate follow-up. Am J Obstet Gynecol.
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22. Nezhat CR,NezhatFR,BurrellMO,et al. Laparoscopic radical hysterectomy and laparoscopically assisted vaginal radical hysterectomy with pelvic and paraaortic node dissection. J Gynecol Surg.
1993;9:105–120.
23. Sedlacek TV, Campion MJ, Hutchins RA, Reich H. Laparoscopic
radical hysterectomy: a preliminary report. J Am Assoc Gynecol
Laparosc. 1994;1(4 pt 2):S32.
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25. Ting HC. Laparoscopic radical hysterectomy: a preliminary experience. J Am Assoc Gynecol Laparosc. 1994;1(4 pt 2):S36.
26. Ostrzenski A. A new laparoscopic abdominal radical hysterectomy:
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27. Kim DH, Moon JS. Laparoscopic radical hysterectomy with pelvic
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28. Hsieh YY, Lin WC, Chang CC, Yeh LS, Hsu TY, Tsai HD.
Laparoscopic radical hysterectomy with low paraaortic, subaortic and pelvic lymphadenectomy. Results of short-term follow-up.
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31. ObermairA,GinbeyP,McCartneyAJ. Feasibilityandsafetyoftotal
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hysterectomy for invasive cervical cancer: 8-year experience of a
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33. Abu-Rustum NR, Gemignani ML, Moore K, et al. Total laparoscopic radical hysterectomy with pelvic lymphadenectomy using
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. 2003;10:80–84.
Section 16.5. Laparoscopy for Endometrial Cancer
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Javier F. Magrina, Andrea Mariani, and Paul M. Magtibay
Reports on the outcomes of laparoscopy or laparotomy for
benign gynecologic conditions have shown superior benefits for
patients treated laparoscopically. Laparoscopy offers three main
advantages: (1) reduced operative blood loss, (2) shorter hospitalization, and (3) a faster resumption to normal activities and
return to work.
Some gynecologic oncologists, encouraged by these findings,
have applied thesetechniquesto patients with gynecologic malignancies. Not surprisingly, similar benefits were noted for laparoscopically treated patients compared with laparotomy-treated
patients.
Numerous literature reports have addressed the feasibility,
perioperative morbidity, conversion rates, quality-of-life measures, cost, recurrence, and survival results of laparoscopic techniques in patients with endometrial, cervical, ovarian, vaginal, or
vulvar cancers. For patients with endometrial cancer,laparoscopy
has been shown to provide additional benefits to laparotomy.
These findings are reviewed in this section.
LAPAROSCOPY APPLICATIONS
FOR ENDOMETRIAL CANCER
Laparoscopic techniques are applicable to patients with primary
endometrial cancer clinically localized to the uterus, for the staging of posthysterectomy patients with previously undiagnosed
endometrial cancer, and for patients with pelvic recurrences
amenable to surgical resection or irradiation.
Primary Endometrial Cancer
Gynecologic oncologists who complete a comprehensive review
of the multiple studies addressing the application of laparoscopy
for thesurgical treatment of primary endometrial carcinoma will
easily conclude thata total abdominal hysterectomywith bilateral
salpingo-oophorectomy is a viable alternative to treatment for
patients with endometrial cancer and that laparoscopy should be
the primary surgical approach.
Surgical Technique
Trocar placement for laparoscopic pelvic surgery is shown in
Figure16.5.1.Explorationoftheperitonealsurfaceoftheabdominal and pelvic cavities from the diaphragm to the pelvic cul-de-sac
is carried out, and pelvic peritoneal cytology is obtained. A total
laparoscopichysterectomy with bilateralsalpingo-oophorectomy
is performed. We routinely remove the appendix when it is
present. The uterus, tubes, ovaries, and appendix are extirpated
through the open vaginal cuff before closure. The uterus is
submitted for frozen histologic section. When indications for
lymphadenectomy are present (see below), we conduct a bilateral pelvic lymphadenectomy and, if indicated, an aortic lymphadenectomy to the renal vessels. A pelvic lymphadenectomy
includes the obturator, external, internal, and common iliac
nodes. The aortic nodes include right- and left-sided nodes and
lower(to inferior mesenteric artery)and higher (to left renalvein)
groups. For the right aortic lymphadenectomy, a bowel retractor is inserted through the left lower pelvic trocar to retract the
small-bowel mesentery and duodenum ventrally. For the left aortic nodes, an additional trocar is then inserted 7 to 10 cm craniad
to the left lower quadrant trocar (Figure 16.5.2). It is used to
retract sigmoid mesentery, the left ureter, and the left gonadal
vein laterally. The inferior mesenteric artery is routinely divided
to provide ample access to the higher group of the left aortic
nodes. The peritoneum of the pelvis and the aortic area are left
open, and drains are not routinely used.
Since March 2003, we have used a robotic surgical interface
system (da Vinci Surgical System; Intuitive Surgical, Inc., Sunnyvale, CA) in the treatment of patients with endometrial cancer. The robotic column is situated between the patient’s lower
extremities for the hysterectomy and pelvic node dissection. For
the aortic lymphadenectomy, itis positioned at thepatient’s head.
To expeditethe change of positions,we prefer to rotate the patient
on the operating room table 180
column cephalad.
The articulated instruments facilitate tissue dissection by
allowing the dissecting instrument to be directed in the correct
tissue plane and in the appropriate direction, instead of forcing the tissues to accommodate the direction of rigid conventional laparoscopic instruments. Because the articulated robotic
instruments can be directed in the correct tissue plane following the path of large vessels, nerves, ureters, and any other pelvic
structures, the robotic surgical system is most helpful for the
performance of pelvic surgery and, in particular, for treatment
of gynecologic malignancies. The system’s ability to downsize
the surgeon’s movements (3:1 or 5:1), its lack of tremor, and its
three-dimensional visualization screen provide increased accuracy of tissue dissection and suturing. Thesurgeon, thephysician’s
assistant, and the scrub nurse are also able to sit down comfortably duringsurgery,which reduces theirphysical fatigue. Because
robotic systems are limited to a few institutions at the present,
most gynecologic oncologists routinely perform the hysterectomy
and lymphadenectomy through a laparoscopic approach, a technique commonly used in Europe, Asia, Australia, and the United
States.
◦
instead of moving the robotic
465
466 — Javier F. Magrina, Andrea Mariani, and Paul M. Magtibay
https://t.me/med1917
Figure 16.5.1. Trocar placement for pelvic lymphadenectomy and
hysterectomy.
Surgical Staging
Lymph node dissection is an integral part of the management of patients with endometrial cancer. The value of a lymphadenectomy (pelvic or aortic or both) is multiple: (1) staging –
to define theextentof the spread ofdisease,to provide an estimate
of prognosis, and to facilitate comparative evaluations among
institutions; (2) therapeutic – our retrospective data and that of
others indicate a therapeutic role for both pelvic [1–3] and aortic [4] lymphadenectomy; and (3) diagnostic – to determine the
need and extent of adjuvant therapy. In fact, patients with negative lymph nodes as determined by systematic surgical staging do
not benefitfrom adjuvant pelvic or aortic external irradiation.[5]
SELECTION OF PATIENTS TO AVOID PELVIC
AND AORTIC LYMPHADENECTOMY
Microinvasive Endometrial Cancer
At Mayo Clinic, pelvic lymphadenectomy is routinely performed
in all patients with the exception of a select group of patients
considered to be at extremely low risk for lymphatic spread.
These low-risk patients have endometrioid tumors localized to
the uterus (no spread to peritoneal surfaces, cervix, or adnexa)
with (1) no myometrial invasion (regardless of grade or tumor
diameter) or (2) grade 1orgrade 2 tumors 2cmorlessindiameter
with less than 50% of myometrial invasion.
One review of 123 patients with such histologic findings
found a 0%incidenceof nodal metastases ornodalrecurrence.[6]
At 5-year follow-up, all 123 patients(100%) were alive with no
evidence of disease. The absence of lymph nodal metastases in
such patients, reported also in other studies [7], confirms the
superiority of primary tumor diameter over grade in predicting
lymph node invasion in the above-defined low-risk group, which
could beaddressed as microinvasive endometrial cancer. Patients
with such histologic findings (approximately one fourth of all
endometrial cancer patients operated on at our institution) do
not benefit from surgical staging.
PELVIC DISSEMINATION: WHICH PELVIC
NODAL SITES ARE MOST LIKELY TO
CONTAIN METASTATIC DISEASE?
A review of our experience with endometrial cancer revealed
the external iliac region as the most frequently observed site of
nodal metastases,either isolated or in association with other positive nodal groups.[8] The second most common sites of nodal
metastases were the obturator nodes in patients without cervical involvement and the common iliac nodes for patients with
cervical involvement.[8]
INDICATIONS FOR PELVIC
LYMPHADENECTOMY
Pelvic lymphadenectomy is routinely performed in all patients
who do not fit the criteria for microinvasive endometrial cancer.
Such patients include all those with histologic types other than
endometrioid, regardless of the degree of myometrial invasion or
tumor size.
Figure 16.5.2. For aortic lymphadenectomy, a fifth trocar is inserted 7
to 10 cm above the left lateral trocar to retract the sigmoid mesentery.
AORTIC NODAL DISSEMINATION
Tumor invasion of the pelvic lymph nodestogether with lymphovascular invasion is the strongest predictor of cancer dissemination in theaortic area.[9] In previous reports from our institution
[8] and others [10], positive aortic nodes were observed in 55%
to 75% of patients with pelvic node metastases. In a more recent
analysis from Mayo Clinic, positive aortic nodes were detected
in 47% of patients with positive pelvic nodes, found either by
staging or as a subsequent relapse in the aortic area.[9]
AORTIC LYMPHADENECTOMY
Indications
Two of us (A.M. and P.M.) prefer to perform an aortic lymphadenectomy to renal vessels in all patients who do not fit the
criteria for microinvasive endometrial cancer. The rationale for
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