STEP-BY-STEP NERVE-SPARING RADICAL HYSTERECTOMY BY LAPAROSCOPY: TIPS AND TRICKS!
ESGO eAcademy. Benito V. 02/07/19; 257459 Topic: Laparoscopic
Dr. Virginia Benito
Dr. Virginia Benito

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Abstract
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• OBJECTIVE: To demonstrate how to perform, step-by-step, a nerve-sparing radical hysterectomy (NSRH) laparoscopically with the sentinel lymph node (SLN) technique.

• METHODS: Surgery begins with the evaluation of the abdomino-pelvic cavity. SLN technique is performed bilaterally and may be identified following the blue dye. Subsequently, lymphadenectomy is completed according to conventional technique. Opening the pararectal fossa, medial to hypogastric artery and laterally to the ureter starts RH. The splacnic autonomic nerves may be identified at the base of the pararectal fossa. Then the paravesical space is developed, medial to the umbilical artery and caudally to the uterine vessels. This surgical procedure identifies the vascular parametria, which comprise, in a downward direction, uterine artery, uterine veins, veins of vesicouterine drainage and middle rectal artery. Then, section of the uterine vessels at its origin and the radical resection of the parametrium until the splenic nerves, is performed. The ureter is separated from the broad ligament and the hypogastric nerve is identified. Separating the hypogastric nerve from the broad ligament develops the Okabayashi space. The ureter is released from the roof of the parametrium by pulling the vascular pedicle on the opposite side until its entry inside the bladder. The vesicouterine fold is opened and caudally rejected after the rounds ligaments are resected. The peritoneum from the pouch of Douglas is opened and the sacrouterine ligaments are sectioned, with special attention to the hypogastric nerve. The vagina is then opened approximately 2-3 cm caudally to the vaginal occluder. Finally, colpotomy is closed and hemostasis is guaranteed.

• CONCLUSION: Laparoscopic NSRH is a feasible technique with proper training. Adequate knowledge of the pelvic anatomy is essential.
• OBJECTIVE: To demonstrate how to perform, step-by-step, a nerve-sparing radical hysterectomy (NSRH) laparoscopically with the sentinel lymph node (SLN) technique.

• METHODS: Surgery begins with the evaluation of the abdomino-pelvic cavity. SLN technique is performed bilaterally and may be identified following the blue dye. Subsequently, lymphadenectomy is completed according to conventional technique. Opening the pararectal fossa, medial to hypogastric artery and laterally to the ureter starts RH. The splacnic autonomic nerves may be identified at the base of the pararectal fossa. Then the paravesical space is developed, medial to the umbilical artery and caudally to the uterine vessels. This surgical procedure identifies the vascular parametria, which comprise, in a downward direction, uterine artery, uterine veins, veins of vesicouterine drainage and middle rectal artery. Then, section of the uterine vessels at its origin and the radical resection of the parametrium until the splenic nerves, is performed. The ureter is separated from the broad ligament and the hypogastric nerve is identified. Separating the hypogastric nerve from the broad ligament develops the Okabayashi space. The ureter is released from the roof of the parametrium by pulling the vascular pedicle on the opposite side until its entry inside the bladder. The vesicouterine fold is opened and caudally rejected after the rounds ligaments are resected. The peritoneum from the pouch of Douglas is opened and the sacrouterine ligaments are sectioned, with special attention to the hypogastric nerve. The vagina is then opened approximately 2-3 cm caudally to the vaginal occluder. Finally, colpotomy is closed and hemostasis is guaranteed.

• CONCLUSION: Laparoscopic NSRH is a feasible technique with proper training. Adequate knowledge of the pelvic anatomy is essential.
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