Page 26 - World Journal of Laparoscopic Surgery

Laparoscopic Radical Hysterectomy versus Open Radical Hysterectomy for Carcinoma Cervix Stage 1

to the level of the renal vessels; in addition, the ovarian vessels Between August 1994 and September 2003, pelvic and/or
were removed with the surrounding tissue. Peri- and para-aortic transperitoneal laparoscopic lymphadenectomy was
postoperative data were collected prospectively to monitor performed in 650 patients at the Department of Gynecology of
progress of surgical performance. the Friedrich-Schiller University of Jena. Retrospective and
prospective data collection and evaluation of videotapes were
Results: Mean operative time was 36 minutes (15-105 minutes)
for right-sided para-aortic and 24 minutes (12-49 minutes) for possible in 606 patients. Laparoscopic lymphadenectomy was
left-sided para-aortic lymphadenectomy; bilateral pelvic part of the following surgical procedures: Staging laparoscopy
lymphadenectomy took 64 minutes (44-110 minutes). On average in patients with advanced cervical cancer (n = 133) or early
26.8 (10-56) pelvic lymph nodes and 7.3 (0-19) para-aortic lymph ovarian cancer (n = 44), trachelectomy in patients with early
nodes were sampled. Major vessels were injured in 7 patients cervical cancer (n = 42), laparoscopic-assisted radical vaginal
of which 4 patients required laparotomy. Patients undergoing hysterectomy in patients with cervical cancer (n = 221),
lymphadenectomy alone were admitted for 3.2 days on average. 8 laparoscopy before exenteration in patients with pelvic
recurrence (n = 20), laparoscopic-assisted vaginal hysterectomy
STUDY DESIGN–3 or laparoscopic-assisted radical vaginal hysterectomy in
patients with endometrial cancer (n = 112), and operative
The surgical-anatomic principles of radical vaginal surgery and procedures for other indications (n = 34).
the techniques of three increasingly extended vaginal
hysterectomies are illustrated. Possible indications are pointed Results: After a learning period of approximately 20 procedures,
out on the basis of our personal experience from previously a constant number of pelvic lymph nodes (16.9-21.9) was
published retrospective studies. removed over the years. Pelvic lymphadenectomy took 28
minutes, and parametric lymphadenectomy took 18 minutes for
Results: Class I extended vaginal hysterectomy allows the “en each side. The number of removed para-aortic lymph nodes
bloc” dissection of the uterus along with the upper third of increased continuously over the years from 5.5 to 18.5. Right-
vagina and both the adnexa. The parametria are not removed. sided para-aortic, left-sided inframesenteric and left-sided
This procedure has proved to be of value for treatment of stage infrarenal lymphadenectomy took an average of 36, 28, and 62
I endometrial cancer. In the class II extended vaginal minutes, respectively. The number of removed lymph nodes
hysterectomy the distal tract of the anterior and posterior was independent from the body mass index of the patient.
parametria are preserved, whereas the cardinal ligament is entirely Duration of pelvic lymphadenectomy was independent of body
removed. This operation has shown promising results for mass index, but right-sided para-aortic lymphadenectomy lasted
treatment of stage IB-IIA cervical cancer of small volume while significantly longer in obese women (35 vs 41 minutes, P =
reducing the incidence of bladder and rectal dysfunctions. The 0.011). The overall complication rate was 8.7% with 2.9%
class III procedure includes the complete removal of the intraoperative (vessel or bowel injury) and 5.8% postoperative
parametria (anterior, lateral, and posterior). This operation has complications. No major intraoperative complication was
been shown to provide a high rate of cure for stage IB-IIA encountered during the last 5 years of the study.
cervical cancer. 9
In 57 consecutive patients with stage Ia to IIb cervical cancer, Conclusion: By transperitoneal laparoscopic lymph-
laparoscopic radical hysterectomy and lymphadenectomy were adenectomy, an adequate number of lymph nodes can be
performed. Forty-eight patients had squamous cell carcinomas, removed in an adequate time and independent from body mass
7 patients had adenocarcinomas, and 2 patients had index. The complication rate is low and can be minimized by
adenosquamous carcinomas of the cervix. standardization of the procedure. 11
Between January 1991 and March 1994, 70 patients with
Results: All but 2 surgical procedures were completed cervical cancer were treated by radical abdominal hysterectomy,
laparoscopically. The average operative time was 186 minutes and between August 1994 and May 1999, 70 patients with
(150-320 minutes). The average blood loss was 168 ml (120-700 cervical cancer were treated by laparoscopically assisted radical
ml). Average numbers of pelvic and para-aortic lymph nodes vaginal hysterectomy. Data from both the abdominal group
removed were 18.6 (12-23) and 8.2 (6-12), respectively. Eight and the laparoscopic-vaginal group were obtained
patients (14.0%) had positive lymph nodes. All surgical margins retrospectively.
were macroscopically negative. Operative cystotomies occurred
in 2 patients and one patient with venous injuries were repaired Results: The mean duration of surgery was significantly longer
laparoscopically. Two other patients underwent laparotomy to for the laparoscopic-vaginal approach than for the abdominal
control bleeding or repair ascending colon. After surgery, approach (292.9 vs 209.9 minutes). Significantly more pelvic
patients passed gas in 2.3 days and self-voided in 10.2 days on lymph nodes were removed by laparoscopy (27 vs 10.7). Blood
average. Follow-up has been provided every 3 months. There loss and transfusion rates were significantly lower in the
have been 3 cases of recurrences, one patient uncontrolled, laparoscopic-vaginal group. Intraoperative complications were
and one patient ureteral constriction. Three patients have seen more often during laparoscopic-vaginal surgery (p < 0.05).
retention of urine. 10 Early postoperative complications occurred significantly more

World Journal of Laparoscopic Surgery, September-December 2009;2(3):23-28 25