Cervical cancer is the most common malignant tumor of female reproductive system, which seriously endangers the life and health of women. At present, radical cervical cancer surgery has been widely carried out in various large and medium-sized cities in China.
I. Pre-operative preparation
In addition to accurate pathological diagnosis, staging and necessary imaging examination, patients with cervical cancer should have a comprehensive assessment of their overall quality before surgery in order to formulate appropriate surgical methods.
1.Improve anemia and hypoproteinemia, blood phantom, protein below 100g/L, albumin below 30g/L need to be improved by blood or albumin transfusion.
2, disease state: local co-infection patients, preoperative antibiotics can be used to control infection.
3.Control of diabetes, patients with combined diabetes who usually apply hypoglycemic drugs or long-acting insulin should switch to subcutaneous injection of insulin before surgery, and control blood glucose in normal or mildly elevated state.
4.Patients with hypertension, cardiac arrhythmia and poor cardiac function should be treated with oral medication.
5.Patients with chronic lung disease are prohibited from smoking before surgery, and lung function exercise is performed.
6. Necessary examination to determine the presence of thromboembolic disease or coagulation abnormalities and necessary treatment.
7, Within 24h before surgery.
(1) Perform a comprehensive preoperative evaluation again, and clarify the surgical plan.
(2) Prepare skin and blood at the surgical site and perform antibiotic allergy test.
(3) Pre-operative dinner with liquid food, 12h pre-operative fasting, 4h pre-operative water fasting.
(4) Oral mannitol bowel cleansing in the afternoon before surgery, and clean bowel cleansing in the morning of surgery if necessary.
(5) Sedation is given the night before surgery to ensure sleep.
(6) Remove the urinary catheter, flush the vagina and fill with iodine gauze in the morning of the operation.
(7) Apply antibiotics prophylactically 30 minutes before surgery.
II. Surgical principles and steps
1.Conical hysterectomy
(1) Preoperative cervical biopsy should be performed under the guidance of colposcopy after cervical iodine test, and cervical canal scraping should be performed at the same time to determine the extent of lesion and exclude infiltrating cancer.
(2) The extent of resection should include the abnormal lesion seen under colposcopy, the entire metastatic zone, the entire squamous-columnar junction and the lower part of the cervical canal. The extent of resection should be 0.3~0.5 cm outside the lesion, and the depth should be about 2 cm below the endocervical canal.
(3) The cone specimen should be examined in detail, and attention should be paid to the edge of the specimen and the tissue at the top of the cone for any residual lesions.
(4) Close follow-up should be performed after conization, including regular cytology and colposcopy. The uterine cavity should be explored 2~3 months after surgery to prevent cervical adhesions, and cervical scraping should be done if necessary.
(5) Sexual intercourse should be prohibited for 2~3 months after surgery.
2.Surgical procedure
(1) Surgical position: the patient is placed in bladder truncal position.
(2) Expose the cervix by dilating the vagina with a heavy hammer dilator to reveal the cervix, and clamp the outer wall of the anterior lip of the cervix with a cervical forceps.
(3) Prevention of bleeding.
(1) Ligation of the inferior branch of the uterine artery with absorbable sutures at 3 and 9 o’clock in the proximal vault of the cervix with 8-string sutures respectively.
(2) Submucosal injection of 1:300 epinephrine saline or 1:5 posterior pituitary hormone. Key note! Use with caution in cardiovascular patients.
(4) Determine the extent: Apply iodine solution to the surface of the uterine cervix and observe the site and extent of iodine staining.
(5) Conical excision.
(1) Make a circular incision 5~l0 mm outside the cervical orifice or 3 mm outside the edge of the iodine-stained uncolored area with a surgical tip blade or electric knife.
(2) Perform conical cervical resection at an angle of 30-50° obliquely toward the cervix, with a depth of 1.5-2 cm, with the tip of the cone obliquely toward the endocervix, and complete conical resection.
(6) Determine whether there are residual lesions above the cutting edge of the conical specimen.
For cervical conization wound treatment, two strands of 0-gauge absorbable thread were inserted at 3 o’clock in the cervix and exited from the bottom of the defect, and then from the opposite side of the bottom of the defect and exited at 9 o’clock.
3.Extrafascial total hysterectomy
(1) Incision: A median incision is made in the lower abdomen, and a median abdominal incision is made from the superior border of the pubic symphysis to the inferior umbilicus, and all layers of the abdominal wall are incised in turn;
(2) Comprehensive exploration: from top to bottom, including intra-abdominal organs, pelvic organs and retroperitoneal lymph nodes, mainly paying attention to the presence of metastatic nodes, the enlargement, texture and mobility of the lymph nodes in the para-aortic and pelvic groups, and checking the uterus, adnexa and adhesions with surrounding tissues and organs;
(3) Exposure of the operative field: drainage of the intestinal canal, placement of a double-lobe pelvic auto-pull hook, interrupted suturing of the anterior bladder peritoneum with the skin of the lower edge of the incision for 2~3 stitches to suspend the bladder and fully expose the operative field.
(4) Treat the bilateral round ligaments and clamp the round ligaments of the uterine horns, fallopian tubes and ovarian ligaments on both sides with kelly clamp, lift the uterus towards the head, cut the round ligaments at the inner 1/3 of the round ligaments, and tie them with silk sutures and then pull and temporarily fix them on the dressings on both sides of the incision with Wen’s clamp, and pull the stump round ligaments tightly for traction.
4.Open the bladder uterine peritoneal reflexion
(1) Cut the anterior lobe of the broad ligament from the round ligament cut, and cut the retroperitoneal fold of the uterine bladder in the anterior, medial and inferior directions, and finally cut the anterior lobe of the contralateral broad ligament posteriorly, externally and superiorly to the contralateral round ligament cut.
(2) Downward pushing of the bladder: the peritoneum at the reflex was lifted upward with several medium curved forceps to cut the peritoneum to fully reveal the loose connective tissue in the uterine bladder space, and the loose connective tissue was separated here with scissors or electric knife, and finally the remaining fibrous tissue of the bladder was bluntly separated with the thumb close to the uterus or cervix, and the bladder was pushed downward to the level of the external cervical opening.
5. Treatment of the ovarian vasculature.
The anterior lobe of the broad ligament is cut from the broken end of the round ligament to the level of the pelvic funnel ligament, and then the posterior lobe of the broad ligament is opened in the avascular area below the medial pelvic funnel ligament to reveal the ovarian arteries and veins, and the ureter is identified by finger touch, and then the ovarian vasculature is clamped, cut, and double ligated. The resected attachments are tied to the forceps that lift the uterus to better expose the operative field.
6.Cut the posterior lobe of the broad ligament along the lateral wall of the uterus, and cut the posterior lobe of the broad ligament to the uterosacral ligament.