Introduction
Radical hysterectomy plays an important role in the treatment of early-stage cervical cancer however minimally invasive methods of radical hysterectomy have been associated with poorer outcomes compared with laparotomy (1). Such outcomes have been suggested to be related to the use of transcervical uterine manipulators and lack of proper tumour containment, factors which are being addressed in ongoing studies.(2)
Study objective
To demonstrate a technique to prevent tumour spillage using the McCartney tube at the time of robotic-assisted radical hysterectomy for cervical cancer.
Design
A video demonstration of the technique with step-by-step description
Setting
A metropolitan teaching and research hospital
Patient selection
A 46 year old woman with stage 1B1 cervical adenocarcinoma; 1cm tumour confirmed on pelvic magnetic resonance imaging. PET/CT showed no evidence of metastatic disease.
Interventions
Robotic assisted radical hysterectomy, bilateral salpingectomy with sentinel node biopsy and ovarian transposition.
Measurements and Main Results
After inserting a urinary indwelling catheter, 2mL (1.5mg per ml) of ICG was injected at 3 and 9 o’clock positions of the cervix. The appropriate size McCartney tube was inserted.
Using a DaVinci Xi system (ISI Sunnyvale), four ports were placed in an M configuration into the anterior abdominal wall. After gaining entry using Veress needle, pneumo-peritoneum was established. A 10mm assistant port was placed at the left upper quadrant to allow for nodal retrieval, needle exchange and suction irrigation. A 3D high definition 30-degree endoscope was used to enhance the visualisation of the pelvic structures. The lateral pelvic spaces were then developed systematically. Sentinel node mapping utilising the FireflyÒ function of the DaVinci robot was used to enable harvesting of bilateral sentinel nodes. Care was taken not to rupture lymph nodes to avoid potential spillage of disease, and the nodes were retrieved within small bags. The uterovesical fold was opened and the bladder was dissected. The cervico-vesical ligaments were dissected, and the communicating vessels were ligated. The ureters were lateralised, and the uterine vessels were ligated. The 30-degree scope was then rotated upwards to facilitate the development of the rectovaginal space, and the pelvic nerves were lateralised. The paracolpos was then divided using a wristed vessel sealer to minimise bleeding.
A 15cm long 0 barbed suture was used to suture through the vaginal wall into the McCartney tube circumferentially. This allowed the containment of the cervix and the upper vagina within the vaginal tube. Colpotomy was then carried out below this suture line. The specimen attached to the upper end of the tube was then removed trans-vaginally. Finally, the vaginal cuff was closed with 0 barbed suture in a continuous non-locking fashion. The pelvis was irrigated, and haemostasis was achieved. The console time was 100 mins and there was less than 5mL of blood loss.
The patient was discharged in 12 hours with minimal pain. The indwelling catheter was removed at an ambulatory service with standardised trial of void protocol five days after surgery. Her recovery was uneventful, and she remains disease-free after two years.
Conclusion
Suturing of the vaginal cuff to the McCartney tube before colpotomy provides a safe and simple method to prevent tumour spillage at the time of a radical hysterectomy. This may improve outcomes related to minimally invasive surgery in patients with cervical cancer.
References