Page 25 - World Journal of Laparoscopic Surgery

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undergo this surgical procedure with argon beam coagulation In laparoscopy-assisted radical vaginal hysterectomy,
and endoscopic staplers. Sixty-eight patients had squamous laparoscopy is used to develop the paravesical and pararectal
cell carcinomas; 8 patients had adenocarcinomas, and 2 patients spaces. The cardinal ligament is isolated and cut after bipolar
had adenosquamous carcinomas of the cervix. coagulation to the level of the deep uterine vein. By the vaginal
approach, the ureters are identified before their entry into the
Results: All but 5 surgical procedures were completed
laparoscopically. The average operative time was 205 minutes bladder pillar. The uterine vessels are pulled down until their
(range, 150-430 minutes). The average blood loss was 225 mL laparoscopically coagulated ends become visible. After incision
(range, 50-700 mL). One patient (1.3%) had transfusion. of the vesicocervical reflection, the uterine fundus is grasped
Operative cystotomies occurred for 3 patients: 2 cystotomies and developed (Döderlein maneuver). The lower cardinal and
were repaired laparoscopically, and 1 cystotomy required uterosacral ligaments are exposed by pulling the cervix and
laparotomy. One patient underwent laparotomy because of fundus uteri to the contralateral side. The cardinal and
equipment failure, and another patient underwent laparotomy uterosacral ligaments are dissected and ligated, and the
to pass a ureteral stent. Two other patients underwent specimen is removed. We combined laparoscopic
laparotomy to control bleeding sites. All surgical margins were lymphadenectomy with radical vaginal hysterectomy in 33
macroscopically negative, but 3 patients had microscopically women with cervical cancer. The mean operating time was 80
positive and/or close surgical margins. One patient had a minutes for the vaginal phase and 215 minutes for the
ureterovaginal fistula. There have been 4 documented laparoscopic phase, including para-aortic and pelvic
recurrences (5.1%), with a minimum of 3 years of follow-up. 3 lymphadenectomy and preparation of the cardinal ligaments.
Blood transfusions were necessary in four women. Three
STUDY DESIGN–2 patients sustained injury to the bladder, one patient to the left
ureter, and another patient to the left internal iliac vein. Repair
A type III radical hysterectomy with bilateral aortic and pelvic was achieved at primary surgery for all intraoperative
lymph node dissection was separated into eight component complications. No fistula was observed. The patients had fully
parts: (1) right and left aortic lymphadenectomy, (2) right and
left pelvic lymphadenectomy, (3) development of the paravesical recuperated after a mean of 28 days. The laparoscopy-assisted
and pararectal spaces, (4) ureteral dissection, (5) ligation and Schauta-Stoeckel approach may prove to be a safe alternative
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dissection of the uterine artery, (6) development of the to conventional radical abdominal hysterectomy.
vesicouterine and rectovaginal spaces, (7) resection of the A vaginal or a laparoscopic approach in radical surgery for
parametria, and (8) resection of the upper vagina. The adequacy cervical carcinoma has been proposed. A pilot study of eight
of the component parts was determined and documented on cases shows that an oncologic surgeon familiarized with these
video. techniques is able to take advantage of the benefits of both
routes in the same patient: Laparoscopic surgery is adapted to
Results: Complete aortic and pelvic lymphadenectomy and a lymph node dissection, section of the origin of the uterine artery,
type III radical hysterectomy were performed by operative and dissection of the ureter under direct vision; vaginal surgery
laparoscopy. allows a precise incision of the vaginal cuff. Both routes may be
Conclusion: A complete pelvic and aortic lymphadenectomy used for the section of parameters, but we propose the use of
and type III radical hysterectomy were performed the vaginal route. The combination of vaginal and laparoscopic
laparoscopically. This approach could potentially decrease surgery spares the pain and discomfort of both laparotomy and
morbidity historically associated with radical hysterectomy and perineotomy. 7
lymphadenectomy performed either abdominally or vaginally. The clinical usefulness of laparoscopic pelvic and para-
Only prospective randomized trails will allow for the evaluation aortic lymphadenectomy for staging and therapy of
of potential benefits associated with this surgical technique. 4 gynecological cancer was analyzed prospectively.
Fourteen cases of radical hysterectomy with bilateral pelvic
and common iliac lymphadenectomy for a stage IB squamous Method: Laparoscopic para-aortic and pelvic lymphadenectomy
carcinoma of the cervix. To date fourteen of these procedures was performed in 150 patients with cervical (n = 96), endometrial
have been performed with few complications. The complications (n = 41), or ovarian cancer (n = 13). Lymphadenectomy was
encountered thus far include narrowing of a right ureter combined with laparoscopically assisted vaginal radical
detected by an intravenous pyelogram obtained on hysterectomy in 70 patients, with laparoscopically assisted
postoperative day 10 and a small vesicovaginal fistula. The vaginal hysterectomy and/or bilateral salpingo-oophorectomy
narrowed right ureter had a retrograde stent placed as a and/or appendectomy and/or omentectomy in 24 patients, with
precaution. It would appear that laparoscopic radical trachelectomy in 2 patients, and with laparoscopic radical
hysterectomy in selected patients offers significant advantages hysterectomy in 2 patients; lymphadenectomy alone was
in terms of hospitalization, incision size, and wound, pulmonary, performed in 52 patients. Right-sided para-aortic
and intestinal complications. In addition to the clinical lymphadenectomy extended to the level of the right ovarian
advantages, laparoscopic radical hysterectomy appears to be vein; left-sided dissection reached the level of the inferior
more cost effective than traditional laparotomy. 5 mesenteric artery. In ovarian tumors, dissection was extended
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