Introduction/Background*Minimally invasive surgery in the management of cervical cancer was dealt a heavy blow in 2018, with the laparoscopic approach to cervical cancer trial (LACC) taking the gynaecology oncology world by storm; leading to a complete overhaul of surgical techniques involved.
Methodology We present a 34-year-old fit and well nulliparous female referred with grade two squamous cell carcinoma; 4.3mm invasion depth on loop histology, stage 1A2. There was no radiological evidence of residual tumour, lymphadenopathy or metastatic disease. Following counsel, the patient underwent midline laparotomy, bilateral pelvic lymph node dissection and radical trachelectomy with no residual and 37 lymph nodes negative and uncomplicated recovery.
Result(s)*We present a stepwise surgical approach:
1. Midline laparotomy and pelvic side wall opening to develop eight avascular retroperitoneal spaces of pelvis with slinging of round ligaments and ureters and preservation of fallopian tubes and ovaries
2. Bilateral pelvic lymph node dissection sent for frozen section examination
3. Full mobilisation of cervix with ureterolysis, dissection of parametrium, paracolpium and vaginal cuff. Skeletonisation to bifurcation, sacrifice and preservation of descending and ascending uterine artery branches respectively – ensuring artery pulsation and uterine body perfusion during procedure
4. Measurement of the vaginal cuff from the central tumour bed – identification of a 2cm clear margin
5. Anterior colpotomy and sling through retrograde posterior colpotomy to ensure clear margins and complete detachment of cervix, vaginal cuff, paracolpium and parametrium from distal vagina
6. Insertion of H8 Hagars dilator into uterine cavity through cervical os
7. En bloc retrograde resection of cervix, vaginal cuff, paracolpium and parametrium at level of isthmus
8. Insertion of cervical cerclage around distal uterus and dilator using #1 continuous prolene suture
9. Replacement of Hagars dilator with Foleys catheter – subsequently removed 48 hours post-operatively
10. Formation of neo-cervix using #1 vicryl interrupted suture between distal uterine body and proximal vaginal cuff
Conclusion*We highlight the importance of a systematic approach to this challenging technique, acknowledging specialist anatomical knowledge and surgical skills. We present a stepwise procedure, achieving en block radical excision with fertility sparing preservation of ascending uterine artery branch, round and infundibulopelvic ligaments.
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