Summary

In 2018 the results of an early termination of the LACC trial were published,1 followed by several retrospective trials, all showing inferior outcomes of patients with cervical cancer who underwent minimally invasive surgery. After years of training in laparoscopic radical hysterectomy we had go backwards and start learning the open way of surgery again.2

This is an educational video showing a combination of strategies and surgical approaches in patients with cervical cancer after the LACC trial

Since we already have the laparoscopic platform for sentinel lymph node mapping with indocyanine green, we decided to start surgeries with minimally invasive surgery. After cervical injection of indocyanine green, we search for the bilateral sentinel lymph nodes. If we see macroscopically suspicious lymph nodes, they are sent to frozen section. The radical hysterectomy is prepared through laparoscopy by dissecting the retroperitoneal space, identifying vascular structures and the ureter. In 2019 to 2020, Dr Kohler and Dr Chiva suggested that closing the vagina over the tumor is a feasible technique that could avoid tumor spillage and might improve outcomes in minimally invasive surgery.3 4 So, we began our learning curve in vaginal cuff in open surgery. Here we show how we infiltrate the vagina, dissect bladder and rectum, and perform a continuous suture.

The procedure is continued by the open way. We coagulate and section the uterine artery and ventral, lateral, and posterior parametrium.

Prospective randomized trials are needed to prove that minimally invasive surgery is safe for our patients with the addition of surgical changes, such as creation of the vaginal cuff and no uterine manipulator. Meanwhile, we continue our radical hysterectomies by the open approach, starting with laparoscopy for the sentinel lymph node dissection and identification of retroperitoneal spaces, with additional time to create the vaginal cuff.