Radical and Simple Trachelectomy Technique

Updated: Dec 23, 2015
  • Author: Christine Rojas, MD; Chief Editor: Warner K Huh, MD  more...
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Technique

Approach Considerations

Pelvic lymphadenectomy should be performed first to evaluate lymph node involvement. On frozen section, all surgical margins should be free of disease prior to proceeding further with a fertility-sparing procedure.

Pelvic lymphadenectomy consists of removing lymphatic tissue along the external and internal iliac vessels, up to the lower common iliac vessels, and around the obturator nerve. [13]

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Vaginal Radical Trachelectomy

Vaginal radical trachelectomy consists of 5 steps: (1) vaginal cuff preparation, (2) posterior phase, (3) anterior phase, (4) lateral phase, and (5) excision of the specimen and closure. [3]

The procedure is begun by defining approximately 2 cm of the vaginal mucosa and grasping the vaginal margin with 5-8 straight clamps. A local anesthetic containing a vasoconstrictor is then injected followed by a circumferential incision along the vaginal mucosa.

Figure 1 (Figure 5): Vaginal Cuff Preparation Figure 1 (Figure 5): Vaginal Cuff Preparation

The anterior and posterior vaginal mucosa edges are grasped with clamps.

Figure 2(Figure 6): Completion of the Preparation Figure 2(Figure 6): Completion of the Preparation phase; placing the clamps

Then, the posterior phase is developed by opening the posterior cul-de-sac. The paracolpos are excised, and the pararectal space is opened. The uterosacral ligaments are isolated and divided. By releasing the posterior attachments, there is greater uterine descent to help with the anterior phase. [1]

The anterior phase is developed by opening the vesicouterine space followed by the paravesical spaces.

Figure 3 (Figure 7): Entering the vesicouterine sp Figure 3 (Figure 7): Entering the vesicouterine space
Figure 4 (Figure 8): Defining the paravesical spac Figure 4 (Figure 8): Defining the paravesical space

The ureter is localized and mobilized by dissecting the bladder pillar off the cardinal ligament.

Figure 5 (Figure 9): Defining both the vesicouteri Figure 5 (Figure 9): Defining both the vesicouterine and paravesical space; ureter exposed
Figure 6 (Figure 11): Excision of bladder pillars Figure 6 (Figure 11): Excision of bladder pillars

After the ureter has been dissected and identified, the uterine vessels will be visible over the ureter. Subsequently, the lateral phase is performed by excising the parametrium.

Figure 7 (Figure 12): Excision of parametrium Figure 7 (Figure 12): Excision of parametrium

Unlike in vaginal hysterectomy, only the descending branch of the uterine artery is excised. It is important to leave optimal vascularization of the uterus, since the procedure is being performed to preserve fertility.

The cervicovaginal artery is clamped, ligated, and cut.

Figure 8 (Figure 13): Identification of the descen Figure 8 (Figure 13): Identification of the descending branch of the uterine artery

Lastly, the cervix is transected approximately 1 cm below the internal cervical os.

Figure 9 (Figure 14): Transection of the cervix Figure 9 (Figure 14): Transection of the cervix

The specimen should be 1-2 cm wide, with a 1-cm vaginal mucosa and 1-2 cm of parametrium. [3]

The final step is the reconstruction phase. A prophylactic cerclage is placed at the level of the isthmus using a nonresorbable suture such as Prolene.

Figure 10 (Figure 15): Placing the cervical cercla Figure 10 (Figure 15): Placing the cervical cerclage

In order to avoid cervical stenosis, a rubber catheter is inserted into the remaining cervical canal.

The final step involves approximating the edge of vaginal mucosa to the new exocervix.

Figure 11(Figure 16): Completed vaginal closure Figure 11(Figure 16): Completed vaginal closure
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Abdominal Radical Trachelectomy

Abdominal radical trachelectomy can be approached multiple ways. The surgery can be performed with a low transverse (with either a Cherney or Maylard) or a vertical incision.

Upon entry into the abdominal cavity, an intraabdominal survey is performed by paying close attention to the abdominal viscera and parietal peritoneum for possible evidence of metastasis. A self-retaining or Bookwalter retractor is used to provide better exposure into the abdominal cavity. The liver, diaphragm, spleen, small and large bowel and omentum are evaluated for evidence of metastasis.

A bilateral complete pelvic lymphadenectomy is performed. Any suspicious lymph nodes are sent for frozen-section evaluation. Upon evidence of metastasis, the radical trachelectomy procedure is abandoned. If there is no evidence of metastasis, the procedure is started by developing the paravesical and pararectal spaces.

The retroperitoneal space is opened through the round ligament.

Clamps are placed on the medial round ligaments to assist with uterine manipulation.

Care is taken to avoid injury to the infundibulopelvic and tuboovarian ligaments.

Once the ureter and bladder are dissected, the uterine arteries at transected at their origin bilaterally.

After mobilizing the ureter off the broad ligament, the parametria and paracolpos are dissected in a fashion similar to a radical hysterectomy.

At this point, the posterior cul-de-sac is incised and the uterosacral ligaments are divided.

Finally, clamps are placed on the lower uterine segment at the level of the internal os followed by transection of the specimen.

The vaginal mucosa is sutured to the remaining cervical stump, followed by a prophylactic cerclage. [4]

Figure 16 (Figures 47.34 page 1265 from TeLinde's Figure 16 (Figures 47.34 page 1265 from TeLinde's textbook) : Cerclage placement
Figure 17 (Figure 47.35 page 1265 from TeLinde's t Figure 17 (Figure 47.35 page 1265 from TeLinde's textbook): Reconstruction of uterine corpus to vaginal mucosa

Many centers perform the procedure by completing the entire dissection, including colpotomy, prior to amputation of the trachelectomy specimen.

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Simple Trachelectomy

A tenaculum is placed on the cervix, followed by cervical injection of lidocaine solution containing a vasoconstrictor.

The vaginal wall is incised circumferentially just above the cervix, paying close attention to carry the incision through the full thickness of the wall.

Similar to a radical trachelectomy, the peritoneum is entered posteriorly and anteriorly. The uterosacral ligaments are clamped, cut, and ligated. Unlike a radical trachelectomy, the parametrium is not excised. The cervix is amputated just distal to the internal os.

The specimen is removed, and the cervical stump is sutured to the vaginal mucosa.

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