Radical hysterectomy

Radical hysterectomy

1. RADICAL
HYSTERECTOMY
PRESENTED BY
DR HEM NATH SUBEDI
REGISTRAR
GYNEONCOLOGY , BPKMCH

2. CONTENTS
INTRODUCTION
HISTORY
STAGING OF CERVICAL CANCER
INDICATION
CLASSIFICATION OF RADICAL HYSTERECTOMY
RADIOTHERAPY VS RADICAL HYSTERECTOMY
PROCEDURE
COMPLICATIONS
ADVANCES IN RADICAL HYSTERECTOMY

3. INTRODUCTION
Cervicalcanceristhefourthmostcommoncancerinwomen.
In2018,anestimated570000womenwerediagnosedwith
cervicalcancerworldwideandabout311000womendied
fromthedisease.
Thesurgicalelectivetreatmentofcervicalcanceris
representedbytheradicalabdominalhysterectomy.
Thisoperationcombinestwoconceptions:theconceptionof
theorganextendedsurgeryandtheconceptionofthe
lymphaticterritorysurgeryappliedaccordingtoprinciple.

4. INTRODUCTION

5. HISTORY
CervicalAmputationandSimpleTotalHysterectomy
Cervicalcancerthatwasvisiblefromthevaginaenabledthe
vaginalresectionofthelesionintheprolapseduterus.
Theamputationofthecervixoftheprolapseduterusforthe
surgicaltreatmentofcervicalcancerstartedintheearly
seventeenthcentury

6. HISTORY

7. INTRODUCTION OF EXTENDED
HYSTERECTOMY

8. MODIFICATION

9. Situation of Radical Hysterectomy in Mid-
Twentieth Century

10. HISTORY

11. CLASSIFICATION OF RADICAL HYSTERECTOMY
At present , There are three standard classification systems
PIVER AND RUTLEDGE -SMITH CLASSIFICATION 1974
CLASS I EXTRA FASCIAL HYSTERECTOMY
CLASS II MODIFIED RADICAL HYSTERECTOMY (WERTHEIM)
CLASS III CLASSICAL RADICAL HYSTERECTOMY (MEIGS)
CLASS IV
CLASS V ADDITION OF THE EXCISION OF A PORTION OF THE URETER OR
BLADDER WHICH IS INVOLVED BY THE TUMOR

12. HISTORY
1951 Meigs Reevaluation of Radical Hysterectomy (Wertheim, Latzko) in the USA
:Meigs’ radical hysterectomy is almost the same as that of Latzko’s radical
hysterectomy
1961 Kobay ashi
Pioneer of nerve-sparing radical hysterectomy (pelvic splanchnic nerve)
1994 Dargent Pioneer of fertility-preserving radical surgery: Radical vaginal
trachelectomy
2003 Palfalvi &
Ungar
Laterally extended parametrectomy (LEP) is almost the same as that of
Mibayashi’s surgery
2003 Hockel Mesometrial resection (MMR) radical hysterectomy. New concept of
radical hysterectomy within the area of the embryological mesometrial
compartment. Surgical margin is almost the same as that of Wertheim
2007 Fujii Clarification of the detailed anatomy of the vesicouterine ligament for ideal
radical hysterectomy
2007 Fujii Clarification of the detailed anatomy of the inferior hypogastric plexus for
nerve-sparing radical hysterectomy
Surgical Novel Concepts and Anatomical Findings on Radical Hysterectomy

13. HISTORY
Surgical Novel Concepts and Anatomical Findings on Radical Hysterectomy
1895 Clark Abdominal extended (radical) hysterectomy1898 Wertheim Abdominal extended (radical) hysterectomy
1908 Schauta Vaginal extended (radical) hysterectomy without
lymphadenectomy
1911 Wertheim Abdominal extended (radical) hysterectomy. This surgery became
a standard of radical hysterectomy in Western countries
1917 Takayama Modified Wertheim method in Japan and demonstrated his live surgery at
the 15
th Scientific Meeting of Japan Society of Gynecology in Kyoto
1919 Latzko
Radical hysterectomy: Lymphadenectomy at first, then developing paravesical
and pararectal spaces, divide the cardinal ligament wider than that of Wertheim
1921 Okabayashi Radical hysterectomy: Almost the same type of Latzko’s surgery, but
characterized by the separation of the vesicouterine ligament independently from
the paracolpium
1941 Mibayashi
Super-radical hysterectomy is the surgery of total extirpation of internal iliac blood vessel
system (TEIIBS) with the cardinal ligament. Laterally extended parametrectomy (LEP) by
Palfalvi & Ungar (2003) is almost the same surgery.

14. STAGING OF CERVICAL CANCER
Stage I (2018): Carcinoma strictly confined to the cervix (extension to the uterine corpus should be disregarded)
2009 FIGO stage: Description 2018 FIGO stage: Description Comment
IA: Invasive carcinoma diagnosed only by
microscopy, with maximum depth of invasion
</= 5mm and largest extension </= 7 mm
IA: Invasive carcinoma diagnosed only by
microscopy, with maximum depth of
invasion <5mm
-Lateral extent of the carcinoma is
no longer considered in
distinguishing between FIGO
Stage IA and IB carcinomas
-If margins of loop are involved
patient is allocated to Stage IB1.IA1: Measured stromal invasion <3 mm in
depth and extension </= 7 mm
IA1: Measured stromal invasion <3 mm in
depth
IA2: Measured stromal invasion >/=3 mm
and
<5 mm in depth and extension </= 7 mm
IA2: Measured stromal invasion >/=3 mm
and <5 mm in depth
IB: Clinically visible lesions limited to the
cervix
or pre-clinical cancers greater than stage IA
IB: Invasive carcinoma with measured
deepest invasion >/= 5 mm (greater than
Stage IA), lesion limited to the cervix uteri
See above
-LVSI must be commented upon,
although does not affect FIGO
stage.
IB1: Clinically visible lesion </= 4.0cm in
greatest dimension
IB1: Invasive carcinoma >/= 5 mm depth of
stromal invasion, and <2 cm in greatest
dimension
-New stage category
IB2: Invasive carcinoma >/= 2 cm and < 4
cm in greatest dimension
-New stage category
IB2: Invasive carcinoma > 4 cm in greatest
dimension
IB3: Invasive carcinoma >/= 4 cm in
greatest dimension
-New stage category

15. Stage II (2018): Carcinoma invades beyond the uterus, but has not extended onto the lower third of the
vagina or to the pelvic wall
2009 FIGO stage: Description 2018 FIGO stage: Description Comment
IIA: Without parametrial invasion IIA: Involvement limited to the upper two-
thirds of the
vagina without parametrial involvement
-No major
change
IIA1: Clinically visible lesion </= 4 cm in
greatest dimension
IIA1: Invasive carcinoma < 4cm in greatest
dimension
IIA2: Clinically visible lesion > 4 cm in
greatest dimension
IIA2: Invasive carcinoma >/= 4 cm in
greatest dimension
IIB: With obvious parametrial invasion IIIB: With parametrial involvement but not
up to the pelvic
wall
No change
STAGING OF CERVICAL CANCER

16. Stage III (2018): Carcinoma involves the lower third of the vagina and/or extends to the pelvic wall and/or
causes hydronephrosis or non-functioning kidney and/or involves pelvic and/or para-aortic lymph nodes
2009 FIGO stage: Description 2018 FIGO stage: Description Comment
IIIA: Tumour involves lower third of the
vagina, with no extension to the pelvic wall
IIIA: Carcinoma involves the lower third of
the vagina with
no extension to the pelvic wall
No change
IIIB: Extension to the pelvic wall and/or
hydronephrosis or non-functioning kidney
IIIB: Extension to the pelvic wall and and/or
causes
hydronephrosis or non-functioning kidney
-No change
IIIC: Involvement of pelvic and/or para-
aortic lymph nodes,
irrespective of tumour size and extent (with r
and p
notations)*
-New stage
category
IIIC1: Pelvic lymph node metastasis only
IIIC2: Para-aortic lymph node metastasis
STAGING OF CERVICAL CANCER

17. Stage IV (2018): Carcinoma has extended beyond the true pelvis or has involved (biopsy-
proven) the mucosa of the bladder or rectum. (A bullous oedema, as such, does not permit a
case to be allotted to Stage IV.)
2009 FIGO stage: Description2018 FIGO stage: DescriptionComment
IVA: Spread of the growth to
adjacent organs
IVA: Spread to adjacent pelvic
organs
No change
IVB: Spread to distant organsIVB: Spread to distant organs
STAGING OF CERVICAL CANCER

18. INDICATIONS FOR RADICAL HYSTERECTOMY
Indications Extent of disease
Invasive cervical cancer Stage IA1 with LVSI
Stage IA2
Stage IB1
Stage IB2 (selected)
Stage IIA (selected )
Invasive vaginal cancer Stage I-II (limited to upper one third of vagina,
usually involving posterior vaginal fornix)
Endometrial carcinoma Clinical stage IIB (gross cervical invasion)
Persistent or recurrent cervical cancer after
radiotherapy
Clinically limited to cervix or proximal vaginal fornix

19. GCG-EORTC (Gynecologic Cancer Group, which was part
of the European Organization of Research and Treatment
of Cancer )
Type I Simple hysterectomy
Type IIModified Radical Hysterectomy
Type IIIRadical Hysterectomy
Type IVExtended Radical Hysterectomy
Type V Partical pelvectomy
CLASSIFICATION OF RH

20. Querleu and morrow Classification 2008
Type A: minimum resection of paracervix (Extrafascial
hysterectomy)
Type B: trensection of paracervix at the level of ureter
B1: without removal of lateral paracervical lymphnodes
B2: with removal of lateral pacervical lymphnodes
Type C: transection of paracervix at junction with internal
iliac vascular system
C1: with nerve preservation
C2: without preservation of autonomic nerves
Type D: laterally extended resection
CLASSIFICATION OF RH

21. Comparison three classification system
Piver-rutledge
EORGTC-GCG QUERLEU AND MORROW
CLASS I Extrafactial hysterectomy
Identification of ureters
through transparency and
avoiding the ureters injury by
running than outside the
operators field without
dissection.
The uterine artery is
laterouterine sectioned and
ligated.
The uterosacral ligament are
not removed.
No vaginal portion is excised.
Type ISimple
hysterectomy
Type AExtrafascial
hysterectomy
Identification and
palpation of ureter with
out the dissecton of
ureteral layer
Uterine arteries and
uterosacral ligament
and cardinal ligament
resected as close as
possible to the uterus
Removal of vaginal
portion as small as
possible <10mm

22. Piver-rutledge
EORGTC-GOG QUERLEU AND MORROW
CLASS
II
Modified radical
hysterectomy
Ureters are disected in
the paracervical region
but are not reseted
from the pubocervical
ligament
The uterine arteries
are sectioned beside
and medial to the
ureter
Uterosacral ligaments
are excised midway
from their sacral
insertion
Resection of the
cardinal ligaments
upto their medial half
Removal of the upper
third of the vagina
Pelvic
lymphadenectomy
Type
II
Modified
radical
hysterectomy
Ureters are
dissected upto the
point they enter
the bladder
Uterine arteries
are sectioned and
ligated at the
medical half of
parameter
Proximal
uterosacral
ligament resected
The medical half
of the cardinal
ligament is
excised
1 to 2 cm from
upper portion of
the vaginal is
removed
Type
B
B
1
The ureters are deperitonized and
rolled to the lateral side.
Partial resection of the uterosacral
and vesico uterine ligment.
Section of paracervical tissue at
ureteral tunnel level
At least 10mm of the vagina are
measured from the cervix or the
tumor
With out removal of lateral
paracervical lymphnodes
B
2
The ureters are deperitonized and
rolled to the lateral side.
Partial resection of the uterossacral
and vesicouterine ligamnets
Section of paracervical tissue at
ureteral tunnel level
At least 10 mm of vagina measured
from the cervix or the tomor
removal of lateral para cervical
lymphnodes

23. Piver-rutledge
EORGTC-GOG QUERLEU AND MORROW
CLASS
III
Classical
radical
hysterectomy
Complete
dissection of
ureters
pubocervical
ligaments except
for a small part
where the
umblical bladder
artery is situated
to the level of their
penetration in to
the bladder
Uterine arteries
are cutoff at the
origin of a
hypogastric
region.
Uterosacral
ligament are
excised at their
insertion
Cardinal ligaments
are resected close
to the pelvic wall
Routine pelvic
lymphadenectomy
Type
III
Radical
hyesterect
omy
Removal as
far as
possible from
the
uterosacral
ligaments
Parameters
is resected
as near as
possible to
pelvic wall
Uterine
vessels are
ligated at the
origin
1/3rd of
upper vagina
is remove
Type
C
C
1
Ureters are fully mobilized
Sectioning of uterosacral ligement at the
level of the rectum
Sectioning of vesicouterine ligament at the
level of the bladder
Complete resection of paracervical tissue
15 to 20 mmfrom the vagina resected
towards the cervix or tumor and
correspondents paracolpus
With the preservation of the autonomic
nerves
C
2
Ureters are fully mobilized
Sectioning of uterosacral ligement at the
level of the rectum
Sectioning of vesicouterine ligament at
the level of the bladder
Complete resection of paracervical
tissue
15 to 20 mmfrom the vagina resected
towards the cervix or tumor and
correspondents paracolpus
With out preservation of the autonomic
nerves

24. Piver-rutledge
EORGTC-GOG QUERLEU AND MORROW
CLASS
IV
It differs from
previous class
according to the
following aspets
which gives a
higher radicality
Complete
dissection of the
ureter from
pubocervical
ligaments
Umblical-vesical
arteries are
sacrificed
Removal of
3/4th of upper
vagina
Type
IV
Extended
Radical
hyesterecto
my
Similar to
Type III but
removal of
3/4th of the
vagina and
paravaginal
tissue
counter part.
Type
D
D
1
Full resection of the paracervical tissue upto
the wall of the pelvic bone together with the
hypogastric vessels exposing the sciatic nerve
roots.
Ureter is fully ambulant
D
2
Full resection of the paracervical tissue
upto the wall of the pelvic bone together
with the hypogastric vessels exposing
the sciatic nerve roots.
Ureter is fully ambulant
Resection of muscles and adjacent
fascia

25. Piver-rutledge
EORGTC-GOG QUERLEU AND MONROW
CLASS V It is more radical than
previous class with the
addition of excision of a
portion of the ureter or
bladder which is invaded
and then the reimplantation
of the ureter into bladder
Type
V
Partial
pelvectomy
Terminal ureter
or a portion of the
bladder or rectum
is resected
together with the
uterus and
parameters (
supra levatorial)

26. CLASSIFICATION OF RH

27. Compariosn of surgery versus radiation for
stage IB/IIA cancer of cervix
Parameters surgery radiation
Survival 85% 85%
Serious complications Urologic fistulas 1%-2% Intestinal and urinary strictures
and fistulas 1.4%-5.3%
Vagina Initially shortened but may
lengthen with regular intercourse
Fibrosis and possible stenosis,
particularly in post menopausal
patients
ovaries Can be conserved Destroyed
Chronic effects Bladder atony in 3% Radiation fibrosis of bowel and
bladder in 6%-8%
Applicability Best candidates are younger
than 65 years of age, <200ib,
and in good health
All patients are potential
candidates
Srugical mortality 1% 1% (from pulmonary embolism
during intra cavitary therapy

28. Surgical anatomy

30. Surgical spaces during RH
Cross-sectional
viewofthepelvis
atthelevelof
cervixshowing
major three
supportivetissues
and their
corresponding
ligaments

32. Surgical step of radical hysterectomy
Open of the abdominal cavity
Exposure of the pelvic cavity
Visual and Manual Examination of the Spread of the Disease
and Operability
Traction of the Uterus
Ligation and Division of the Round Ligament

33. Traction of uterus and clamp cut ligation of the
round ligament

34. Ligation and Division of the Suspensory
Ligament of the Ovary (Ovarian Vessels)

35. Confirmation of the Ureter
Manually,firmlypress
thetubularstructure
betweenthethumb
andmiddlefinger,
whichshouldleadto
thetubularstructure
slippingfromyour
fingerswith a
“snappingsensation.”
The snapping
sensation is
characteristicsofthe
ureter

36. Isolation of the Ureter
Theureterrunningalong
theposteriorperitoneal
layerofthebroad
ligamentisseparated
fromtheconnectivetissue
oftheretroperitonealside
oftheperitoneum.
Theureteriseasierto
isolate from the
surroundingconnective
tissue,whenapproached
ascraniallyatthelevelof
thecommoniliacartery

37. Development of the Pararectal Space
Betweentheposteriorperitoneallayerandinternaliliacvein/
artery,theretroperitonealconnectivetissueisdissected.
Whenperformingnerve-sparingradicalhyster-ectomy,the
developmentofLatzko’spararectalspaceisenoughand
developmentoftheOkabayashi’spararectalspaceisnot
required.

38. Division of the Peritoneum at Pouch of
Douglas
The peritoneum between the
uterus and the rectum is
lifted from the base of the
Pouch of Douglas.
The incision is made on the
elevated peritoneum and
extended with scissors
across the dorsal side
(back) of the cervix.

39. Separation of the Peritoneum of the
Vesicouterine Pouch
The peritoneumis
dividedacrossthe
ventralsideofthe
cervix,just1–2cm
below the
vesicouterine fold
wherescissorscan
insinuateanddivide
theperitoneumeasily
withoutanydamageto
theurinarybladder.

40. Pelvic Lymphadenectomy
Start the dissection of lymph nodes from the supra-inguinal
area and finish cranially by the common iliac area.

41. Exposure of the adipose tissues in the supra-
inguinal area
(a) Exposed retroperitoneal adipose tissues of the broad ligament. (b)
A cross-sectional view of the retroperitoneal structures in the pelvis
at the level of a two-directional arrow (cross-sectional line) drawn in
Figure. A dotted arrow line indicates the separation point of the
connective tissue from the iliopsoas muscle

42. Exposure of the Iliopsoas Muscle
The connective tissue with adipose tissue is dis-sected from
the surface of the iliopsoas muscle toward the ventral surface
of the external iliac artery

43. Separation of the External Supra-Inguinal Nodes from the Ventral
Surface of the External Iliac Artery
In the supra-inguinal region, usually the deep circumflex iliac vein runs across the
external iliac artery. Avoiding a deep circumflex iliac vein, the adipose tis-sue with
lymph nodes is dissected up from the ventral sur-face of the external iliac artery.

44. Development of the Paravesical Space
Bytheseparationofthe
connectivetissuebetween
theobliteratedumbilical
arteryandtheexternaliliac
veinatapoint2–3cmcranial
tothepubicbone,the
cobweb-likelooseconnective
tissuebecomesvisible.
Thisistheentranceofthe
paravesicalspace.

45. Separation of the Connective Tissue Between
the External Iliac Artery and Iliopsoas Muscle
The connective tissue
surrounding the
external iliac artery is
separated by
insertion of a small
retractor and medial
traction of the
external iliac artery
as shown in Figure

46. Separation of the Uterine Side Connective
Tissue of the External Iliac Artery and Vein
The dissection
proceeds toward the
medial side of the
external iliac artery
and continues to the
sheath of the medial
side of the external
iliac vein

47. Lymphadenectomy of the External Iliac Nodes
of the Uterine Side
Picking up the adipose tissue on the medial side, the external iliac lymph nodes are
dissected from the external iliac artery and vein. The direction of the separation is
illustrated using a dotted arrow line in Figure

48. Lymphadenectomy of the External Iliac Nodes
of the Uterine Side
Picking up the adipose tissue on the medial side, the external iliac lymph nodes are
dissected from the external iliac artery and vein. The direction of the separation is
illustrated using a dotted arrow line in Figure

49. Separation Between the Iliopsoas and the External
Iliac Vessels Toward the Pelvic Floor
The connective tissue of the external iliac artery side is picked up and scissors
are advanced into the connective tissue along the medial side of the
iliopsoas muscle

50. Dissection of the External Iliac Nodes
Drawing the external iliac artery medially by a small retractor, the loose connective
tissue sheath on the external iliac vein is separated toward the dorsal surface of the
external iliac vein

51. Separation of the Connective Tissue on the
Internal Iliac Artery
Separation of the connective tissue on the internal iliac artery. Once the internal iliac
artery is found medially, the adipose and connective tissues are separated from the
ventral side of the internal iliac artery as illustrated using a dotted arrow line

52. Confirmation of the Obturator Nerve in the
Obturator Fossa
Confirmation of the obturator nerve in the obturator fossa. In the dorsal level of the external iliac vein, usually appre-
ciate a yellow-white solid string running in the obturator fossa. This is the obturator nerve. The obturator nerve
becomes a landmark of the obturator fossa. As illustrated using a dotted arrow line, the connective tissue with
lymph nodes is separated toward the obturator nerve

53. Lymphadenectomy of the Obturator Fossa
Picking up the adipose tissues of the dorsal side of external iliac vein, the connec-
tive/adipose tissues surrounding the obturator nerve are separated. The
obturator nerve is easily stripped from the adipose tissues

54. The Lymphadenectomy of the Common Iliac
Nodes
The connective tissues
with lymph nodes at the
bifurcation of the
external and internal
iliac vessels are already
sepa-rated.
The cranial side of the
bifurcation is the
common iliac artery and
vein.

55. Lymphadenectomy of the Sacral Nodes
The dividedadipo-
connectivetissuesare
separatedfromthesacral
bonealongwiththe
internaliliacveintoward
thefoot/distalside

56. Treatment of cardinal ligement
Separation of the Loose Connective
Tissue Between the Uterine Artery
and the Superior Vesical Artery
Development of the Paravesical
Space and Confirmation of the
Uterine Artery

57. Isolation and Division of the Uterine Artery
The uterine artery originating from the
internal iliac artery is appreciated on the
most ventral side of the cardinal
ligament.
The uterine artery is easily isolated, doubly
clamped, ligated, and divided between
the two ligatures.
The suture on the uterine side of the uterine
artery is usually left longer to act as an
anatomical landmark.

58. Separation of superficial uterine and
deep uterine vein
Calmp cut and ligated both superficial and deep uterine
vein

59. Confirmation and Division of the Pelvic
Splanchnic Nerve
Alooseconnective
tissuelayerinthe
dorsalpartiseasily
separatedandthetwo
spaces (the
paravesicalspaceand
thepararectalspace)
areconnectedwith
thebaseofthepelvic
floor.
Bythedivisionofthe
cardinalligament,the

60. Development of the Rectovaginal Space and
Division of the Uterosacral Ligament
SeparationandDivisionof
thePeritoneumofthe
Douglas’Pouch
Uterusheldovertothe
pubicarchandtherectum
stretchedtowardthe
cranialsidebyhand,a
looseconnectivetissue
layerbetweentherectum
andthecervix/vaginais
appreciated.Thisisthe
landmarkoftherecto-
vaginalspace

61. Development of the Rectovaginal Space
Pressing the tips of scissors
against the cervical fas-cia,
the rectum is bluntly
detached from the
cervix/upper part of the
vagina. The separation
should be carried in the
correct plane.
There is risk of injury to the
rectum, if the plane is
developed too close to the
surface of the rectum.

62. Division of the Uterosacral Ligament
The uterosacral ligament on
either side is stretched
forward and dissected at
its base at the rectal
sidewall. Hypogastric
nerve is often divided by
this procedure
Further Division of the
Uterosacral Ligament and
Development of the
Okabayashi’s Pararectal
Space
.

63. Separation of the Urinary Bladder and the
Vesicouterine Ligament
Separation of the Urinary Bladder from
the Cervical Fascia
Picking up the bladder itself with the
peritoneum, the bladder is separated
from the center of the cervical fascia to
the level of the trigone of the urinary
bladder
Connective tissue bundles become defined
on both sides of the cervix. The connective
tissue bundle contains the ureter, the
uterine artery, and several blood vessels.
This is the vesicouterine ligament, also
known as ureteric tunnel.

64. Lateral(Right) Side View of the Treatment of the
Anterior (Ventral) Leaf of the Vesicouterine
Ligament with Each Surgical Step
Separation of the Uterine Artery and
Superficial Uterine Vein from the
Ventral Surface of the Ureter
Isolation and division of the Ureteral
Branch of the Uterine Artery
Separation of the Superficial Uterine
Vein from the Surface of the Ureter
and Confirmation of the Superior
Vesical Vein then Isolation and
Division of the Superior Vesical Vein
Separation of the Cut-Ends of the
Uterine Artery and the Superficial
Uterine Vein from the Ventral
Surface of the Ureter

65. Separation of the Connective Tissues
in the Anterior (Ventral) Leaf of the
Vesicouterine Ligament
Division of the Cervicovesical
Vessels
Mobilization of the Ureter to the
Symphysis Side and Confirmation
of the Posterior (Dorsal) Leaf of the
Vesicouterine Ligament

66. Posterior (Dorsal) Leaf of the Vesicouterine
Ligament
Confirmation of the Posterior (Dorsal)
Leaf of the Vesicouterine Ligament
by the Mobilization of the Ureter with
the Urinary Bladder Toward the
Symphysis Side.
Separation of the Cut-End of the
Cardinal Ligament from the Pelvic
Sidewall and the Sidewall of the
Rectum
Isolation and division of middle and
inferior vesicle vein

67. Three different method of cutting dorsal
vesicouterine ligament

68. Separation of the Cut-End of the Cardinal Ligament (the
Deep Uterine Vein and the Pelvic Splanchnic Nerve) from
the Lateral Surface of the Rectum
The cut-end of the cardinal ligament
(the deep uterine vein with the
pelvic splanchnic nerve) is lifted and
separated from the connective
tissues of the lateral surface of the
rectum at the level where the pelvic
splanchnic nerve merges with the
hypogastric nerve.
This merging point is the inferior hypo-
gastric plexus.
A purple two-directional arrow is
indicating the blood vessels of the
paracolpium

69. Division of the Rectovaginal Ligament
Division of the rectovaginal ligament frees the dorsal side of the vaginal wall.
Therefore, the length of the vaginal cuff can be tailored to the desired length,
depending on extent of disease.

70. Further Division of the Rectovaginal Ligament
Tractionoftheuterustoward
thecranialsidestretches
thebladderbranchofthe
inferiorhypogastricplexusin
theuterineside.
Duringthedivisionofthe
rectovaginalligamentthe
bladderbranchfromthe
inferiorhypogastricplexusis
likelytobesacrificed.

71. Division of the Paracolpium (Vaginal Blood
Vessels)
The division of the
rectovaginal ligament can
separate the vaginal blood
vessels (the paracolpium)
from the connective tissue
of the rectal sidewall.
At the designated level, the
blood vessels of the
paracolpium are clamped,
cut, and ligated.

72. Incision to the Vaginal Wall
The division of the paracolpium
leads to the detachment of the
uterus from all structures
except the vagina.
Once the paracolpium is divided
bilaterally, the length of the
vaginal cuff is confirmed. The
incision is then made in the
ventral wall of the vagina.

73. Amputation of the Vaginal Wall and Closure of
the Vaginal Cuff
Long L-shaped forceps can be
used to secure the length of
the vaginal cuff and for the
confinement of cancer cells
and fluid from the upper
vagina.
Division of vagina is done.
Vaginal vault is closed with
interrupted or continuous
interlock suture.

74. Partial Suture to the Pelvic Peritoneum and
Insertion of Drains into the Retroperitoneal Space
Partial closure of the visceral peritoneum is
undertaken between the peritoneum of
the cranial side of the urinary bladder
and the peritoneum of the Pouch of
Douglas.
The peritoneum of the ventral side of the
pararectal space is not closed in order to
facilitate absorption of lymph fluid by the
surface of the peritoneum secondary to
lymphadenectomy.
Transabdominally retroperitoneal drain is
placed

75. Closure of the Abdominal Cavity
Abdominal wall closed
and skin is closed .
Drape removed and
dressing placed.

76. COMPLICATIONS (ACUTE)
Blood loss (average of 0.8 ltr)
Ureterovaginal fistula (1% to 2 )
Vesicovaginal fistula (1%)
Pulmonary Embolus (1% to 2%)
Small bowel obstruction (1%)
Febrile morbidity (25% to 50%)

77. COMPLICATIONS (SUBE ACUTE AND
CHRONIC)
Post operative bladder dysfunction
Hypotonia and dystonia of bladder (3%)
Lymphocyst formation (fewer than 5%)
Ureteric stricture formation
Recurrent of cancer

78. Recent advances in radical
hysterectomy
In 2003, Hockel et al. introduced a
new concept on radical
hysterectomy, namely:
mesometrial resection (MMR)
radical hysterectomy.
1. Description of embryologically
defined pelvic anatomy.

79. Radical trachelectomy
In 1994, Daniel Dargent reported a new transvaginal fertility-preserving radical
surgery that amputates the cervix with parametrium for women with early
invasive cervical cancer.
For the early invasive cervical cancer patients who wish to retain their fertility,
radical trachelectomy is a very important surgical technique.
An application of this surgery to the deeply invaded cervical cancer is still
controversial.

80. Nerve sparing RH
Atonicity and hypotonicity is common complication associated with
radical hysterectomy to minimizing those complication different
surgeon attempted different procedure which was not successful unitl
2007.
By isolating and dividing the uterine branch of hypogastric plexus alone,
well-defined anatomy for the nerve-sparing radical hysterectomy was
introduced by Fujii et al. In 2007

82. Laparoscopic and robotic
assisted Radical Hysterectomy
it was not until the 1990s that laparoscopy gained acceptance
among gynecological oncologists for advanced procedures
such as hysterectomy with lymphadenectomy for endometrial
cancer.
More recently, total laparoscopic radical hysterectomy (TLRH)
for earlystage cervical cancer (International Federation of
Gynecology and Obstetrics [FIGO] stages IA2 and IB1) has
proved both safe and feasible. First described in the early
1990s,growing evidence supports its benefits and possibly
even superiority over laparotomy in radical hysterectomy.
While technically challenging with a steep learning curve,
clear advantages include decreased operating time, lower

83. Conclusions
Role of radical hysterectomy is very crucial in complete
cure of early stage cervical cancer
Development is not abrupt it has take many hours of
human resources
Thorough anatomical education is theme of surgery each
step of surgery is associated with different complications.

84. References
Marin F, Plesca M, Bordea CI, Moga MA, Blidaru A. Types
of radical hysterectomies : From Thoma Ionescu and
Wertheim to present day. J Med Life. 2014;7(2):172-176.
Bhatla N, Aoki D, Sharma DN, Sankaranarayanan R.
Cancer of the cervix uteri. Int J Gynaecol Obstet. 2018
Oct;143 Suppl 2:22-36
Novaks gynecology 16
th
edition page 1304-1344
Telinde’s operative gynecology 11
th
edition page
Precise Neurovascular Anatomy for Radical Hysterectomy by
shigno fuji