Between January 1, 2012 and March 25, 2012, 19 cervical cancer patients were referred to the Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Catholic University of the Sacred Heart in Rome, Italy. All of these patients were prospectively evaluated for M-LPS treatment. Inclusion criteria were FIGO stage IA2-IB1 cervical cancer with no evidence of lymph node and/or adnexal and/or corpus uteri involvement at computed tomography/magnetic resonance imaging; uterine size <12 weeks' gestation; no history of previous xifo-pubic abdominal major laparotomic surgery (laparotomy for peritonitis, bowel resection, etc); body mass index (BMI) <35; and American Society of Anesthesiologists score <II.
Our institutional review board approved the study, and patients were informed about the M-LPS technique and signed a written informed consent acknowledging the risk of standard laparoscopic and/or laparotomic conversion. The same surgical team (1 experienced surgeon, 1 fellow, and 1 resident) performed all of the interventions.
Patient demographic (age, race), surgical (type of hysterectomy, operative time, blood loss), and postoperative (complications, discharge, bladder voiding function, ileus) data were prospectively collected. Clinical (BMI, previous neoplasms) and diagnostic information regarding actual disease (stage, grade, histotype, lymph nodes, residual disease) were also noted from paper patient charts and electronic medical records. Operative time (OT) was defined as the interval between incision start and closure. Operative complications were defined as bowel, bladder, ureteral, or vascular injuries, and an estimated blood loss (EBL) ≥500 mL. Anemia was considered when hemoglobin level was <8 g/dL, and fever was considered when body temperature was at least 38 °C in 2 consecutive measurements at least 6 hours apart, excluding the first day after surgery.
Patients were discharged home when they were fully mobile, apyrexial, and could pass urine satisfactorily. Early postoperative complications were defined as any adverse event that occurred within 30 days after surgery, and they were considered severe if they resulted in unplanned readmission, blood transfusion, or a secondary surgical procedure.
Surgical Instruments and Technique
Surgical procedures were performed with one disposable optic-view transumbilical 10-mm port (Endopath Xcel 10-mm optic-view; Ethicon Endo-Surgery, Cincinnati, OH). A 10-mm 0 ° HD-videolaparoscope (Endoeye; Olympus Winter & Ibe GmbH, Hamburg, Germany) was inserted in the umbilical port. Patients under general anesthesia were positioned in the dorsal lithotomic position with both legs supported in Allen stirrups with a Trendelenburg tilt. A reusable intrauterine manipulator (Karl Storz, Tuttlingen, Germany) was used to move the uterus. Once pneumoperitoneum (12 mm Hg) was achieved, 3 additional 3.5-mm reusable ports with conical tip were inserted, and 3-mm operative instruments (Karl Storz) were used ()
from choices of dissecting and grasping forceps, monopolar scissors or spatula, suction and irrigation tube (Karl Storz), and 2 types of bipolar coagulator (Take-Apart bipolar coagulating forceps [Karl Storz] and PK Molly forceps [Gyrus ACMI, Hamburg, Germany]. Monopolar scissors/hook/spatula were inserted into the suprapubic port; bipolar forceps were inserted into the left port; and the right port was used for grasping or as a suction/irrigation device. The disposition of the instruments did not change during the intervention. After pelvic and abdominal exploration and washing, the operations started with opening of the pelvic retroperitoneal spaces. Paravesical and pararectal spaces were developed with blunt dissection. Systematic removal of external iliac and obturator nodes was performed by a combination of bipolar forceps and monopolar scissors/spatula ()
. A free endo-bag was inserted through the umbilical port after removing the camera; then after replacing the camera, lymph nodal specimens were put into the endo-bag, removed throughout the umbilical port after removing the camera again, and sent for frozen section analysis. The uterine artery was identified, coagulated, and sectioned at the origin from the umbilical artery with bipolar forceps. The uterosacral ligament was transected after separation of the hypogastric nerve after Okabayashi's pararectal space development with combination of mono- and bipolar instruments ()
. The paracervical tissue and the uterosacral ligaments were transected combining monopolar and bipolar devices with the “vessel by vessel” technique. Dissection of the ureteral tunnel and vesicovaginal spaces was accomplished with monopolar and blunt technique and with the aid of bipolar coagulation ()
. At that point, the vaginal wall was identified and transected with a monopolar hook using pure section energy to avoid postoperative ureteral and bladder complications. The specimens were removed vaginally. The vaginal cuff was then closed by laparoscopy with 0 polyglactin running sutures using a 3-mm needle holder (Karl Storz). A hydropneumatic test for bladder integrity was performed at the end of the procedure. The laparoscopic access point was not sutured but was closed only with steri-strips. Radical hysterectomy was classified according to Querleu and Morrow classification.16
External vision of the surgical field: one 10/12-mm umbilical port and three 3-mm ancillary ports.
Right pelvic lymphadenectomy. EIA = external iliac artery; EIV = external iliac vein; GN = genitofemoral nerve; ON = obturator nerve, OUA = obliterated umbilical artery, PM = psoas muscle.
Dissection of the posterior paracervix. HN = hypogastric nerve; R = rectum; U = ureter; US = uterosacral ligament; V = vagina.
Dissection of the right paracervix after uterine artery section and ureteral tunnel development. P = paracervix; U = ureter; UVL = uterovesical ligament.