Efficiencies in Robotic Radical Trachelectomy

Abstract

<h3>Study Objective</h3> To demonstrate an efficient and stepwise approach to performing a robotic radical trachelectomy. <h3>Design</h3> Video description of dissection of the retroperitoneal space and identification of key structures, the nerve sparing technique, creation of a deep and lateral bladder flap, cerclage placement and specimen removal, and reapproximation of the vagina to the uterus. Patient provided consent for the video and publication. This video with no identifying patient data was exempt from Institutional Review Boards Approval. <h3>Setting</h3> Robotic-assisted laparoscopy was performed. <h3>Patients or Participants</h3> We present a patient with early-stage cervical adenocarcinoma who was an appropriate candidate for fertility-sparing surgery. <h3>Interventions</h3> After the right retroperitoneum space is entered, key landmarks are noted. After finding the ureter, the paravesical and obturator spaces were created. The superior vesical artery, obturator nerve, and uterine artery are identified and dissected. The ureter is dissected off the flap to the level of the right uterine artery and uterosacral ligament. The rectovaginal septum is then dissected as the next natural field. The same steps are repeated on the left side. The bladder flap is created, making sure that it is both deep and lateral for easier dissection of the vesicovainal ligament and visualization during robotic surgery. The uterocervical junction is incised circumferentially. The round ligaments and uterine manipulator are left in place to aid in the placement of the cerclage, removal of the specimen, and suturing of the vagina to the uterus. <h3>Measurements and Main Results</h3> Utilizing these efficiencies resulted in a shorter operative time of 2 hours and 38 minutes (versus 5 hours and 8 minutes) in this robotic radical trachelectomy. <h3>Conclusion</h3> The efficiencies were the following: an orderly fashion in going from field to field which resulted in less movements, dissecting the bladder flap deep and lateral which aided in taking down the vesicovaginal ligament and visualization, and utilizing the uterine manipulator throughout the case.