Tips and misconceptions of radical hysterectomy
Cervical cancer is the most common gynecologic malignancy in China and one of the leading causes of death among women in developing countries.
The first radical hysterectomy for cervical cancer was performed by Clark (Johns Hopkins University) in 1895, perfected by Wertheim in 1898, and first studied in bulk and reported in 1905, but the complications and mortality associated with the procedure were so high at that time that no one talked about it for quite some time, meanwhile, the negative At the same time, radical hysterectomy became popular because of its low surgical complications and mortality. It was not until later that Meigs and Okabayashi modified Wertheim’s approach, which led to a significant reduction in complications and mortality associated with the procedure, and gradually led to the modern surgical approach to cervical cancer.
Ò»¡¢ a few comments on the name of the procedure
The Chinese name of Radical Hysterectomy (RH) has been rather confusing for several reasons: 1) different translation and understanding of the English vocabulary; 2) different understanding of the concept of surgery; 3) no unified and authoritative regulation of medical terminology.
First of all, let’s talk about the translation and understanding of the English vocabulary of Radical Hysterectomy. The direct English translation of this surgery should be radical or radical hysterectomy, and of course there have been scholars who think that it is more reasonable and smooth to call it radical hysterectomy for cervical cancer, especially in the earlier years. As people become more aware, more and more of them realize that cervical cancer is a disease that is difficult to be cured by surgery alone. However, RH is meant to represent a surgical procedure and to indicate the scope and extent required for such a procedure, i.e. to indicate a radical resection rather than the cure of a disease.
Many scholars have tried to change the name of the procedure to Extensive Hysterectomy, which is the direct translation of extensive hysterectomy in Chinese, but I think it is a bit inappropriate and even a bit suspicious of putting the cart before the horse. In my opinion, the word corresponding to Radical in the surgical nomenclature is Simple, not Localized or Local, and from this point of view Radical should not be called Extensive, but Radical or Radical. This is why there is so much clinical distinction between radical or radical resection and simple resection, rather than extensive resection and limited resection, and this situation is similar in other disciplines as well.
It is also important to understand the meaning of Radical correctly. The so-called radical resection and simple resection mainly include two meanings, one is the requirement for the breadth of the surgical scope and the other is the requirement for the depth of the surgical scope. For example, in vulvar surgery, the definition of Radical and Simple is obvious. If the name of the surgery is Radical resection, it requires the surgical margin to be at least 2 cm from the edge of the tumor (breadth), and the depth needs to include the skin, subcutaneous, and straight to the fascia (depth); while if the name of the surgery is Simple resection, it only requires the surgical margin to be 1 cm from the edge of the tumor (depth). If the operation is called Simple resection, it only requires the surgical margin to be 1 cm from the edge of the tumor (breadth), or even close to the tumor, and the depth only includes the skin and a little subcutaneous tissue, and this is the difference between the two. Other surgeries also require the same for radical resection and simple resection. In the case of hysterectomy, the so-called simple resection is only the resection that includes the uterus, and all the surgical margins are adjacent to the uterus, while radical resection is different in that it requires not only the removal of the uterus, but also the tissue surrounding the uterus, specifically the 4 cm of tissue adjacent to the uterus and 1/3-1/2 of the vagina. In addition, in this sense, radical hysterectomy is in accordance with the basic principle of radical tumor surgery, which requires that the margin of resection is not less than 4 cm from the edge of the tumor.
I. Technique or experience of radical hysterectomy
Radical hysterectomy is the most representative gynecologic tumor surgery. It is a surgery with regularity, or even a fixed procedure; in addition, it is a surgery with great emphasis on anatomical structure; at the same time, the learning and proficiency process through surgery is also the learning and proficiency process for the basic skills of gynecologic tumor surgery. It is for these reasons that radical hysterectomy is an important part of training gynecologic oncologists and can be considered as the golden key to enter the gynecologic oncology profession.
As far as the techniques of radical hysterectomy are concerned, I think the following points are more important.
1. Vaginal tamponade
It should be stated that not all colleagues use this method, and it is not that this is the gold standard and it is incorrect not to do so, this is just a personal experience for reference only.
This is a very important part of a radical hysterectomy. The point is that by filling the vagina, the vagina is kept in tension and hardness, making the following parts of the operation very easy. These include: 1) clear determination of the bladder limits: before opening the peritoneal fold of the bladder, the vagina is filled with sufficient gauze to move the bladder up and down very easily, allowing very clear determination of the bladder limits; 2) easier pushing down of the bladder: because the vagina remains tense and rigid, it is very easy to push the bladder away from the vagina and down to the required length for surgery. 3. Clearly determine the boundary between rectum and vagina: because the vagina maintains good tension, the rectum can slide easily on the surface of the vagina during surgery, which is conducive to determining the boundary between rectum and vagina and is less likely to enter the entrapment, thus significantly reducing intraoperative bleeding; 4. It is very easy and pleasant to push a very soft rectum away from the surface of the vagina which has a certain tension and hardness, because a good level is obtained and the vagina keeps a certain tension. At the same time, rectal injuries caused by pushing down the rectum can be greatly reduced.
Second, the blunt and sharp separation is reasonably applied
It is generally believed that different parts and different conditions should be separated in different ways.
1, the level: before there is no clear judgment of the level, more use of sharp separation method, and once the level is clear, blunt separation is more effective. For example, after opening the peritoneal fold of the bladder, it is usually not wise to push down the bladder directly because there are many tortuous blood vessels here and blunt separation often causes bleeding.
2. Tension: Different methods are needed when tension and resistance are encountered in the separation process. When the tension is small, blunt separation is the main method, while when the tension or resistance is large, it is wiser to use sharp separation. When pushing down the bladder and rectum, when the resistance is small, it often means that the level is better and can be bluntly pushed down, while when there is resistance, it often means that the level is not good, and if the blunt separation continues, it may cause bleeding or injury, and at this time it is better to carefully and carefully use scissors to sharply separate.
3, bleeding: when there is little bleeding, blunt separation is the main method, and when there is a lot of bleeding, more sharp separation should be used. Bleeding often means that the level of surgery is not correct, and continuing will cause unnecessary bleeding and injury, such as when pushing down the bladder and rectum, if there is a sudden increase in bleeding, it usually indicates that there is a problem with the level of surgery, and at this time, a sharp method should be used to re-define the level.
Exposure of lateral fossa of bladder and rectum
Surgery for cervical cancer is largely an operation performed in strict accordance with anatomical structures, which is why radical hysterectomy is often used as a way to develop the surgical skills of young gynecologic oncologists. The most important part of the procedure is the opening of the four lateral fossae for cervical cancer surgery, namely the two lateral bladder fossae and the two lateral rectal fossae.
It is very important to know the location of the lateral fossa of the bladder and the lateral fossa of the rectum, but more important than that is to know or understand their role and significance, which is one of the essentials of radical hysterectomy.
1. Revealing the lateral fossa of the bladder
The lateral bladder fossa is one of the most important anatomical structures in cervical cancer surgery, and many fellow surgeons encounter the problem of revealing the lateral bladder fossa, and even some complications such as bladder and vascular injuries have occurred.
The lateral fossa of the bladder is located, as the name implies, on the lateral side of the bladder, so it is lined by the lateral wall of the bladder, laterally by the terminal branch of the internal iliac artery, the superior cystic artery, anteriorly by the part of the pelvic pubic bone, and posteriorly by the uterine arteries and loose connective tissue. This fossa is only separated from the foramen ovale by a membrane at the deep end, and the two fossae are combined into one during surgery when the foramen ovale lymph nodes are removed.
I believe that the earlier the lateral bladder fossa is exposed during surgery, the better, because the earlier it is, the more helpful it is and the earlier it is. And the more fully the lateral bladder fossa is opened, the better the procedure will be. Therefore, I usually advocate opening the lateral bladder fossa immediately after severing the round ligament and opening the retroperitoneum in a smooth fashion. The opening of the lateral bladder fossa is achieved by pulling the uterus upward posteriorly with a pulling hook in the direction of the iliac vessels, maintaining tension on the iliac vessels, at which point the external and internal iliac arteries are easily located, and the lateral bladder fossa is accessed by bluntly separating medially along the terminal branch of the internal iliac artery, the superior cystic artery. To obtain better space and exposure, gauze can be filled into the lateral fossa of the bladder, which will help to fully expose the lateral fossa while avoiding damage to the vessels of the pelvic floor.
2. Reveal of the lateral rectal fossa
The lateral rectal fossa is another important anatomical structure in radical hysterectomy, and it should be said that it is even more important than the lateral cystic fossa in the surgery of cervical cancer. The main reason is that the structures around the lateral rectal fossa are more complex and are prone to injury, especially vascular injury, during surgery.
The medial side of the lateral rectal fossa is the ureter, the lateral rectal wall and the uterosacral ligament, the lateral side is the internal iliac artery, sometimes the internal iliac vein can be seen below, the posterior side is part of the sacrum, and the anterior side is the uterine artery with some tortuous veins at the bottom.
I advocate that the earlier the lateral rectal fossa is opened the more meaningful and helpful it will be. After opening the retroperitoneum, the lateral rectal fossa is usually opened immediately after opening the lateral fossa of the bladder. The lateral rectal fossa is opened by pulling the uterus to the opposite side, pushing the ureter medially and dividing it bluntly downward along the ureter between the ureter and the internal iliac artery into the lateral rectal fossa, which should not be entered too deeply because of the more tortuous vessels at the bottom of the lateral rectal fossa.
3. The significance of the lateral fossa of the bladder and the lateral fossa of the rectum
One of the main reasons why radical hysterectomy has become a classic procedure is that this procedure is performed in strict accordance with the anatomical structures. And among some anatomical structures, the most important ones are the lateral fossa of the bladder and the lateral fossa of the rectum.
The significance of the lateral fossa of the bladder and the lateral fossa of the rectum is not its own, but the anatomical structures surrounding it. This means that the complex anatomy of the pelvic floor will become clear when these four fossae are clarified. The blood vessels in the pelvic cavity will be clear at a glance, and the ligaments of the pelvic cavity will be visible when these four fossae are opened. The significance of the four fossae should never be misunderstood, and the deeper meaning of opening the four fossae should be ignored for the sake of playing the lateral fossae.
IV. Treatment of ureteral tunnel
The treatment of the ureteral tunnel is another important aspect of radical hysterectomy, and whether it is handled smoothly or not will be directly related to whether the operation can be completed successfully and its visualization, and many predecessors have a lot of experience in dealing with the ureteral tunnel.
The so-called ureteral tunnel is actually the section of the ureter that travels through the cervical ligament of the bladder before it enters the bladder, and because many surgeons do not understand this very well, they often have difficulty handling this part of the procedure, resulting in bleeding, ureteral injury, and bladder injury. In fact, most of the most likely surgical complications in radical hysterectomy are related to the management of the ureteral tunnel.
I have the following experience in dealing with the ureteral tunnel: 1. The ureteral tunnel is real; during surgery, in order to better free the ureter from the tunnel, you can often put this part of the tissue in your hand and twist it a few times before tunneling, which facilitates the exposure of the ureteral tunnel. In addition, if you put the ureter in your hand and gently pull the ureter downward, you can usually very clearly See the top of the ureteral tunnel, here is the starting part of opening the ureteral tunnel; 2, the ureteral tunnel is not long; do not think that the ureteral tunnel is very long and fight down righteously, which results in ureteral or bladder damage at the entry of the ureter into the bladder, even if it is lucky that the bladder is not damaged, that still causes damage to the bladder section of the ureter, and here is the important link of ureteral anti-reflux, which is easy to cause postoperative Ureteral dilatation, which can even have an impact on renal function; 3. Preparation before tunneling is very important; before dealing with the ureteral tunnel, the bladder should be pushed down as far as possible, especially in the two corners, and the best preparation is to be able to push the bladder below the ureteral tunnel, that is, below the cervical ligament of the bladder, so that the ureteral tunnel is very easy to deal with, and at the same time, damage to the bladder segment of the ureter can be avoided.
V. Misconceptions of radical hysterectomy
There are several situations that tend to occur during radical hysterectomy, which can perhaps be called “misconceptions”.
1. Prematurely opening the bladder peritoneum and pushing down on the bladder
Many people prefer to open the cystoperitoneum and push down on the bladder after cutting the round ligament, usually with a gauze pad to prevent local bleeding.
This may seem reasonable and the procedure feels quite smooth, but a very important point that is overlooked is that this step should be performed when it is needed, not too early, because the vascular network here is often dominated by tortuous veins and bleeding often occurs if not done carefully and will continue for almost the entire procedure. So, when is the best time to open the vesicoureteral reflex and push down on the bladder? It should be before preparing the ureteral tunnel for treatment.
2. Playing the lateral fossa for the sake of playing the lateral fossa, ignoring its true meaning
Many surgeons are very skilled, and the lateral fossa of the bladder and rectum are handled very quickly and smoothly, but do not clearly understand the true meaning of opening the lateral fossa.
As already mentioned, it is not the opening of the lateral fossa itself that is important, but rather the fact that once the fossa is opened, the anatomy of the pelvic floor will be clear and the rest of the procedure will be a very easy basic exercise. In order to do this, the lateral fossa of the bladder and the lateral fossa of the rectum should be opened as early as possible, the earlier it is done the more significant it will be and the more helpful it will be for the surgery. Also, the more fully the lateral fossa of the bladder and the lateral fossa of the rectum are revealed, the greater the significance will be and the more helpful it will be for the surgery and the fewer the surgical complications will be.
3.Overprocessing of ureteral tunnel
Most colleagues believe that the treatment of the ureteral tunnel is a difficult point in radical hysterectomy, and many predecessors have accumulated very rich experience in the treatment of the ureteral tunnel.
However, there seems to be a widespread over-treatment of the ureteral tunnel, leading to the misconception that the ureteral tunnel is long and difficult to handle. And what is the actual situation? The so-called ureteral tunnel is actually a special structure of the ureter that travels within the cervical ligament of the bladder, and its length is very limited, usually its length should not exceed 2 cm, and most of them are even less than 1 cm. then why is it sometimes felt that the ureteral tunnel is very long when handled? The main reason for this is due to treating part of the bladder segment of the ureter as part of the tunnel, in addition to the fact that there is more tissue at the beginning of the tunnel. In order to prevent this phenomenon, when preparing the ureteral tunnel, the tissue at the beginning of the tunnel should be cleared and the ureter should be gently pulled downward to find the top of the tunnel, which is the beginning of the tunneling process; in addition, blunt and sharp separation should be combined with pushing the bladder down as far as possible, especially under the cervical ligament of the bladder, which can be easily felt when dealing with the bladder, and pushing the bladder to both sides Separation, a sudden loss of tension will be felt below the cervical ligament of the bladder, this area is below the cervical ligament of the bladder and is also the end of the ureteral tunnel treatment. By clarifying the above rule, it seems that it will not be very difficult to deal with the ureteral tunnel, and at the same time, over-treatment of the ureteral tunnel will be avoided, the postoperative ureteral dilatation will be significantly reduced, and the chance of ureteral and bladder injury will be greatly reduced.
The above is my little experience and some opinions in the practice of radical hysterectomy, which is only for the reference of my colleagues and I hope it will be beneficial.