Surgical Technique Variation for the Laparocopic Radical Trachelectomy Through the Initial Development of the Pararectal Spaces and Isolation of the Hypogastric Nerves

Abstract

Video Objective Demonstrate a surgical technique variation for the laparoscopic radical trachelectomy by initiating the procedure through the development of the pararectal space and the identification of the hypogastric nerve. Setting A 26 years-old patient was diagnosed with a papillary squamous cell carcinoma of the uterine cervix – (FIGO - stage IB1) Interventions With the advancement of surgical techniques in frozen pelvis for the treatment of deep endometriosis - we, from the School of Minimally Invasive Surgery from the Crispi Institute (Brazil), adopted a systematic approach, as to always initiate with the dissection of the pararectal space at the level of the promontory, medializing the mesorectal fascia and lateralizing the hypogastric nerve, along with the endopelvic fascia. We follow this dissection caudally towards the pelvic floor – establishing the “base” for the known spaces – Okabayashi, Latsko and paravescial. With the lateralization of the ureter, the isolation of the hypogastric nerve is facilitated and resection of the uterosacral ligaments is performed. Next, the development of the rectovaginal septum and the dissection of the loose areolar tissue can be accomplished – maintaining the adipose tissue attached to the intestinal wall. After medializing and tunelizing the ureter, we develop the Latsko space, communicating this region to the “base” of the pararectal space, previously established. Next, we can easily dissect the paravesical space, opening the anterior leaflet of the broad ligament, medializing the vesical wall until we reach the floor of the pararectal space. By medially dissecting the obliterated umbilical artery, we develop the lateral paravesical spaces. Connecting the right and left spaces, through the anterior compartment, we resect the vesical pillars and develop the Yabuki and vesicovaginal spaces. After developing all the spaces and isolating the hypogastric nerves, we follow the trachelectomy as usual. Conclusion This is a viable and secure approach to initiate a trachelectomy.