Minilaparoscopic nerve sparing radical hysterectomy in locally advanced cervical cancer after neoadjuvant radiochemotherapy

Objective We report the technique to performminilaparoscopic nerve sparing radical hysterectomy (NSRH) in locally advanced cervical cancer. Methods Three patients aged 32, 53, and 51 respectively (median 46), with a median body mass index of 23 (18-26), one nulliparous and two pluriparous, were diagnosed with cervical squamous carcinoma on cervical biopsy, FIGO stage II B, and underwent a minilaparoscopic NSRH, bilateral salpingo-oophorectomy and systematic pelvic lymphadenectomy after neoadjuvant radiochemotherapy (pelvic irradiation in 22 fractions 1.8 Gy/day, totaling 39.6 Gy in combination with cisplatin 20 mg/m 2, 2-h intravenous infusion and 5-fluorouracil 1000 mg/m 2, 24-h continuous intravenous infusion, both on days 1-4 and 27-30) according to a protocol in our Institution [1,2]. Operative technique The procedures required a 5 mm 0 endoscope (Endoeye, Olympus Winter& Ibe GmbH, Hamburg-Germany) inserted in a trans-umbilical optical viewing port (Endopath Xcel, Ethicon Endo-surgery, Cincinnati, OH) and three additional sovrapubic 3-mm diameter ports placed. Three millimeter instruments were employed including atraumatic graspers, monopolar scissors, a suction-washing system (Karl Storz Endoskope-3 mm Instrument set, Tuttlingen Germany) and bipolar coagulator (Robi, Karl Storz). As already described, after pelvic and abdominal exploration, the operation starts with the coagulation and transection of the round ligament next to the pelvic wall and the opening of the anterior and posterior peritoneal layers of the broad ligament in order to enter the pelvic retroperitoneum. Once developed the paravesical and pararectal spaces the ureter can be easily identified. The uterine artery is then isolated and coagulated at its origin from umbilical artery. Before starting the pelvic lymphadenectomy, the dissection of the paravesical space laterally to the obliterated umbilical artery needs to be completed until the obturator nerve is identified. External and common iliac lymph nodes are removed from vessel surfaces by blunt or sharp dissection. Moreover, the obturator fossa is entered laterally and the obturator nerve and vessels are skeletonized before removing superficial and deep obturator lymph nodes. The anatomical margins for the pelvic lymph node dissection are medially the ureter, laterally the psoas muscle and the genitofemoral nerve, posteriorly the obturator nerve and cranially the mid portion of the common iliac artery. The same procedure was performed on the controlateral side. Once the ureter is identified, the infundibulopelvic ligament can be coagulated and transected. The pararectal space is then developed in a medial portion (Okabayashi space) and in a lateral portion (Latzko space), having the ureter in the middle. This maneuver allows the surgeon to identify the inferior hypogastric nerve, that appears approximately 2-3 cm dorsally of the ureter in the lateral part of the uterosacral ligament when entering the lateral parametrium. After its identification, this nerve is followed until it runs dorsally to the deep uterine vein. At this point the pelvic splanchnic nerves running from the S2-S4 roots of the sacral plexus join in the inferior hypogastric plexus with the inferior hypogastric nerves. After the identification of the above mentioned nerve structures, we performed a radical resection of the uterosacral and paracervical tissues according to the nerve sparing technique [3,4]. 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 clos