Laparoscopic-Vaginal Radical Hysterectomy

Eleven patients with stage IA2-IIA carcinoma of the cervix have been treated by combined laparoscopic-vaginal radical hysterectomy and bilateral pelvic lymphadenectomy (3-Stage IA2, 5-stage IB, 3-Stage IIA). The patients were unselected. Three patients had bulky (>e; 5 cms) tumors, one of whom weighed 239 lbs; one had prior anterior-posterior repair, was apareunic and had significant vaginal narrowing; two patients had extensive pelvic adhesions, one of whom also had a 480 gram uterus. Pelvic lymph node metastases were present in one patient and paracervical lymph node metastases in one. The technique used has undergone significant modification. The laparoscopic phase of the procedure contributes much more to the operation than the lymphadenectomy for it allows a symbiotic partitioning of the operation into the laparoscopic and vaginal components. Only those steps of the operation are carried out vaginally that are easier to perform from below (division of the uterosacral and cardinal ligaments, unroofing of the ureter), and they are made much easier by the preceding laparoscopic phase of the operation. Laparoscopic development of the para-vesical and para-rectal spaces makes vaginal entry into these spaces very straightforward, and laparoscopic division of the uterine artery facilitates vaginal unroofing of the ureter. By allowing the proximal ureter to be freed from the medial leaf of the broad ligament, and the proximal attachments and blood supply of the uterus to be divided, the laparoscopic phase of the operation also permits the cervical ligaments to be divided before the ureters are freed from the vesico-cervical ligament, which helps to avoid a Schuchardt incision in most patients.