Chapter 10 Vaginal and Laparoscopic Trachelectomy. Operative Techniques

 Chapter 10 Vaginal and Laparoscopic Trachelectomy

GENERAL PRINCIPLES

Definition

■ A trachelectomy is performed to remove a cervical stump. The stump is the remnant of the uterus following a supracervical hysterectomy.

Differential Diagnosis

■ Pelvic mass

■ Cervical neoplasia

■ Prolapsed fallopian tube

■ Gartner duct cyst

■ Vaginal polyps

■ Vaginal adenosis

■ Vaginal endometriosis

IMAGING AND OTHER DIAGNOSTICS

■ Patients with abnormal vaginal bleeding require ultrasound imaging. Consider obtaining a CT scan if a pelvic mass is suspected.

■ Cervical cancer screening is required preoperatively.

PREOPERATIVE PLANNING

■ The route of surgery depends on the indication for trachelectomy, surgeon’s experience and comfort, the presence of comorbidities, and the need for concomitant procedures. The preoperative planning for a vaginal trachelectomy begins with a thorough history and physical examination.

The surgeon should pay particular attention to the degree of prolapse, the presence of a pelvic mass, adnexal tenderness, and whether the cervix is mobile. A laparoscopic approach should be considered if the patient has unexplained pelvic pain or suspected endometriosis, or if there is an adnexal/pelvic mass requiring removal. Counseling should include the risk of conversion to laparotomy, independent of a minimally invasive approach.

■ Confirm the patient’s cervical cancer screening is up-to-date.

■ Patients with significant medical comorbidities should also undergopreoperative clearance.

■ Perform thorough counseling and discuss the risks, benefits, alternative, and different routes of surgery. Obtain a signed, informed consent. Regardless of the surgical route, a trachelectomy is a clean-contaminated procedure and a prophylactic antibiotic should be administered prior to incision. We commonly use a first- or second-generation cephalosporin.

SURGICAL MANAGEMENT

■ The most common indications for trachelectomy are pelvic organ prolapse, pelvic mass, abnormal cytology, bleeding, and pain. Trachelectomy is a relatively safe and effective procedure. Patients should be counseled on the risk of bleeding and injury to the urinary tract or bowel.

Positioning

■ Positioning for a vaginal trachelectomy is similar to positioning for a vaginal hysterectomy (see Chapter 8.5, Vaginal Hysterectomy). The patient is placed in the dorsal lithotomy position using candy cane or Allen stirrups.

The use of Allen stirrups is preferred in cases where there is a high likelihood of converting to an abdominal procedure or if there is a need for concomitant laparoscopy.

■ Positioning for a laparoscopic/robotic trachelectomy is similar to the positioning for a laparoscopic/robotic hysterectomy. The patient is positioned in the dorsal lithotomy position using Allen stirrups with the patient’s arms secured to her sides (see chapter on Diagnostic Laparoscopy, Patient Positioning).

Approach

■ An abdominal (open, laparoscopic, or robotic) approach is preferred when the patient complains of pelvic pain or endometriosis is suspected. In addition, if a pelvic mass is appreciated on examination or imaging, an abdominal approach is mandatory.

■ A vaginal approach is preferred in patients with significant comorbidities, when abdominal exploration is not required or when the trachelectomy is performed due to prolapse.Procedures and Techniques: Vaginal Trachelectomy (Video 10.1)

Preparation

■ Prepare and drape the patient’s vagina, perineum, and lower abdomen.

■ Insert a Foley catheter and drain the bladder.

Tenaculum placement

■ Place a weighted speculum or retractor in the vagina to expose the cervix.

■ Grasp the cervix with a single-tooth or Jacob’s tenaculum and gently apply downward traction.

■ Circumferentially inject a vasoconstrictor (lidocaine with epinephrine or dilute vasopressin) at the cervicovaginal junction.

Incise the cervicovaginal junction and advance the bladder

■ Using a number 10 bladed scalpel or monopolar instrument, circumferentially

incise the cervicovaginal junction.

■ Using curved Mayo scissors, dissect the vagina and the bladder off the cervix anteriorly and posteriorly. Enter the posterior cul-de-sac

■ Carefully palpate the posterior cul-de-sac.

■ If no adhesions are noted and if entry into the peritoneal cavity is not required, place a Heaney clamp extraperitoneally above the cervical stump bilaterally.

Then excise the cervix with a scalpel or Mayo scissors.

■ If entry into the peritoneal cavity is required, deflect the cervix anteriorly, grasp and tent the tissue, and sharply enter the posterior cul-de-sac with Mayo scissors.

■ Then palpate the posterior cul-de-sac to assess for bowel adhesions. Transect the uterosacral ligaments and enter the anterior peritoneum

■ Use a Heaney clamp or a vessel sealing device to clamp and divide the uterosacral ligaments. If a Heaney clamp is used, suture ligate the pedicle with a No. 0 polyglactin 910 (Tech Fig. 10.1).

Tech Figure 10.1. The uterosacral ligament has been compressed, transected, and is being suture ligated.

■ To decrease bleeding from the posterior incision, we place a running, locked suture using No. 0 polyglactin 910.

■ Gently place a moistened and tagged thin, laparotomy sponge in the cavity to sweep the bowels cephalad, away from the field.

■ If the surgeon’s finger can reach the top of the cervix, and the bladder is not adhered to the cervix, use the surgeon’s finger to push anteriorly to delineate the vesicocervical space.

■ Use Mayo scissors to dissect the remaining tissue down to the peritoneal layer.

■ Then enter the peritoneum sharply and confirm the appropriate space has been accessed (Tech Fig. 10.2).

Tech Figure 10.2. Anterior peritoneal entry. After the bladder is advanced anteriorly and superiorly, the vesicocervical peritoneum is entered sharply with Mayo scissors.

■ Examine the bladder carefully to confirm no cystotomy has been made.

■ Place a right-angle retractor or thin malleable retractor anteriorly to apply gentle pressure on the sponge and to retract the bowel out of the surgical field.

Transect the cardinal ligaments

■ Use a Heaney clamp or a vessel sealing device to clamp and divide the remaining cardinal ligaments.

■ Deliver the excised cervical stump and inspect for hemostasis. Re-approximate any bleeding or oozing pedicles with simple, interrupted sutures.

■ Consider performing a concomitant McCall’s suture plication to prevent future prolapse of the vaginal apex.

Closure

■ Finally, close the vaginal cuff with No. 0 polyglactin 910 in a continuous or interrupted fashion.

■ Perform cystoscopy to assess ureteral patency and bladder integrity.

Procedures and Techniques: Laparoscopic Trachelectomy (Video 10.2)

Preparation

■ Prep and drape the patient’s vagina, perineum, and lower abdomen in a sterile fashion.

■ Insert a Foley catheter and drain the bladder.

■ Place a vaginal manipulator with an attached cup (i.e., Koh cup) to outline the cervicovaginal junction. Alternatively, a simple vaginal sponge stick may be substituted in the anterior or posterior fornix (Tech Fig. 10.3).

Tech Figure 10.3. Cervical stump. Cephalad traction with a vaginal manipulator will demarcate the cervical stump and cervicovaginal junction. This will also help delineate the vesicocervical peritoneum and rectovaginal space.

Laparoscopic port placement

■ Enter the abdomen using the customary laparoscopic entry techniques.

■ Place two to three 5-mm trocars in the lower quadrants. Be sure their placement is conducive to triangulation and that the instruments sufficiently reach the cervical stump. Reflect the vesicocervical peritoneum and create a bladder flap

■ Using an active electrode, circumferentially incise the cervicovaginal junction, as delineated by the vaginal cup.

■ Apply cephalad traction with the vaginal manipulator and gentle caudal pressure to help develop the bladder flap (Tech Fig. 10.4).

Tech Figure 10.4. Bladder flap. The vesicocervical peritoneum is incised with a

monopolar instrument and the bladder is mobilized caudally using blunt and sharp

dissection.

Develop the posterior peritoneal space

■ Inspect the posterior cul-de-sac to ensure no adhesions exist between the sigmoid colon and the posterior peritoneum.

■ If no adhesions are noted, extend the circumferential incision used to create the bladder flap posteriorly. Then mobilize the rectum caudally with gentle pressure.

■ If adhesions are noted, perform adhesiolysis with sharp dissection to ensure the rectum is not injured during cervical stump excision.

Transect the uterosacral and cardinal ligaments

■ Using advanced radiofrequency (RF) energy, clamp and transect the uterosacral and cardinal ligament complex. Be sure to apply the energy device to remain parallel to the cervix yet medial to the uterine artery pedicles.

■ Enter the vaginal mucosa at the level of the cervicovaginal junction, as demarcated by the vaginal cup. Use the RF instrument to make a circumferential colpotomy (Tech Fig. 10.5).

■ Re-approximate the vaginal cuff with intracorporeal sutures of No. 0 polyglactin 910 or polydioxanone sutures.

■ Perform cystoscopy to assess ureteral patency and to confirm bladder integrity.

Tech Figure 10.5. Colpotomy. As delineated by the vaginal cup, a colpotomy is created at the cervicovaginal junction.

PEARLS AND PITFALLS—VAGINAL APPROACH

Insufficient descensus of the cervix

It is crucial to apply downward traction by pulling on the tenaculum. Once the initial circumferential incision if performed, the surgeon should clamp and cut the uterosacral ligaments to improve descensus of the cervical stump.

Difficulty entering the peritoneum

A vaginal trachelectomy can be performed entirely extraperitoneally. The key to success and to minimizing risk of bladder or rectal injury are to dissect and retract the bladder while traction is applied over the cervix.

Difficulty with anterior entry

Place a finger through the posterior colpotomy and push anteriorly on the vesicocervical space. This delineates the anterior peritoneum and facilitates entry.

Once entry is confirmed, examine the bladder carefully to confirm that no cystotomy has been made.

Bowel protruding from vaginal cuff

Place a tagged, radio-opaque, laparotomy sponge in the peritoneal cavity to push the bowel cephalad. Use a right-angle retractor to apply gentle pressure on the sponge and to retract the bowel out of the surgical field.

PEARLS AND PITFALLS—LAPAROSCOPIC APPROACH

Unable to visualize stump

It is essential to apply cephalad traction using a vaginal manipulator with a cervical cup (i.e., Koh cup) or with a vaginal sponge stick.

Difficulty identifying bladder

Backfill the bladder with saline or dye-containing fluid (i.e., methylene blue) to identify the bladder margins.

POSTOPERATIVE CARE

■ Following a vaginal or laparoscopic trachelectomy, the patient can be discharged to home the same day or be admitted overnight for observation.

■ Ensure the patient can adequately void prior to discharge home or perform a voiding trial if more complex vaginal reconstruction is concomitantly performed.

■ Advise pelvic rest for 4 to 6 weeks and caution the patient against heavy lifting greater than 15 pounds.

■ Evaluate the patient in the office during the postoperative period and perform a postoperative pelvic examination to confirm cuff healing and reapproximation.

COMPLICATIONS

■ Complications of trachelectomy are low and include:

■ Infection

■ Perioperative bleeding

■ Bowel injury

■ Bladder injury

■ Urinary retention

■ Injury to ureters

■ Cuff cellulitis