Presented by:
Michelle Anderson
Affiliations:
North York General Hospital
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What Is Approach to Laparoscopic Trachelectomy?
Laparoscopic trachelectomy is a minimally invasive procedure to remove the cervix, including in patients who previously underwent a supracervical hysterectomy in which the uterus was removed but the cervix was retained. Careful preoperative planning and restoration of pelvic anatomy are particularly important when prior surgery or other pelvic disease has altered normal tissue planes. Here’s what it involves:
- Preoperative Planning: Imaging and previous surgical history are reviewed to anticipate adhesions, altered anatomy, and associated pelvic pathology.
- Bladder Assessment: Retro-filling of the bladder and cystoscopy may be used to clearly identify its borders and help protect the urinary tract during dissection.
- Bladder Flap Creation: The vesicocervical peritoneum is opened and the bladder is carefully dissected away from the cervix.
- Cervical Vessel Identification: The cervical branches of the uterine arteries are identified on both sides and carefully controlled.
- Cervical Manipulation: A uterine manipulator with a colpotomizer may be inserted to help define the cervicovaginal junction and guide dissection.
- Colpotomy: Anterior and posterior colpotomies are created, allowing the cervix to be separated from the surrounding vaginal tissue.
- Cervical Removal and Cuff Closure: The cervical vessels are sealed, the colpotomy is completed, and the cervix is removed before the vaginal cuff is securely closed.
- Additional Disease Removal: Associated pathology, such as disseminated leiomyomas, may also be systematically identified and removed when appropriate.
This systematic approach allows the retained cervix to be removed laparoscopically while providing careful visualization of the bladder, blood vessels, and surrounding pelvic structures.
What are the risks Approach to Laparoscopic Trachelectomy?
Laparoscopic trachelectomy can be more technically challenging in patients with previous pelvic surgery because scar tissue and altered anatomy may make important structures more difficult to identify.
- Bladder Injury: The bladder may be densely adherent to the cervix following previous surgery, increasing the risk of injury while creating the bladder flap.
- Ureteral Injury: The ureters run close to the operative field and can be injured during dissection or control of the cervical blood supply.
- Bleeding: Injury to the cervical branches of the uterine arteries or other pelvic vessels can result in significant bleeding.
- Vaginal Cuff Complications: Bleeding, infection, poor healing, or separation of the vaginal cuff can occur following closure.
- Bowel Injury: Adhesions from previous surgery may place the bowel close to the operative field and increase the risk of inadvertent injury.
- Infection: Pelvic or vaginal cuff infection can occur following surgery.
- Injury During Adhesiolysis: Restoring anatomy in a previously operated pelvis may require extensive adhesiolysis, which can increase the risk of injury to surrounding structures.
- General Laparoscopic Risks: Blood clots, anesthesia-related complications, postoperative adhesions, and rarely conversion to open surgery are possible.
Careful preoperative planning, systematic restoration of anatomy, bladder assessment, and clear identification of the cervical vessels and urinary tract can help reduce these risks.