Vasilescu C, Stănciulea Oana, Popa Monica, Anghel Rodica, Herlea V, Florescu Arleziana
Department of General Surgery and Liver Transplantation, Fundeni Clinical Institute, Bucharest, Romania.
Chirurgia (Bucur). 2008 Jan-Feb;103(1):99-102.
The surgical treatment of endometrial cancer is still a matter of debate. Two of the most controversial issues are the beneficial effect of lymphadenectomy and the feasibility of laparoscopy. The aim of the case report was to describe the feasibility of total laparoscopic radical hysterectomy with pelvic lymphadenectomy in a 56-years-old Caucasian woman diagnosed with endometrial cancer. After a CO2 pneumoperitoneum was created the peritoneum was incised cranially to the para-colic fossa just above the external iliac vessels until the psoas muscle is visualized. The external iliac vessels were identified and lymph nodes from the anterior and the medial surface were removed until the iliac bifurcation and placed in an Endo-bag. The procedure continued with the identification of the hypo-gastric and the umbilical artery which were pulled medially in order to open the obturator fossa and remove the lymphatic tissue superior to the obturator nerve. The next step was the opening of the para-vesical and pararectal spaces by using blunt dissection; this maneuver was facilitated by pulling the uterine fundus towards the opposite direction with the uterine manipulator. The parametrium being isolated between the two spaces can be safely divided. At the superior limit of the parametrium the uterine artery is identified and divided at its origin. Thereafter, by placing the uterine fundus in median and posterior position, the vesicouterine peritoneal fold was opened by scissors and a bladder dissection from the low uterine segment down to the vagina was performed. Then the ureter is dissected, freed from its attachments to the parametria and de-crossed from the uterine artery down to its entry into the bladder. Next the rectovaginal space is opened and the utero-sacral ligaments divided; this allows the division of para-vaginal attachments. The vagina is sectioned and the specimen is extracted transvaginally. Then the vaginal stump was sutured by laparoscopy. Total laparoscopic radical hysterectomy with pelvic lymphadenectomy was not associated with an increased operative time or blood loss and appears to be a feasible alternative to conventional surgical approach in patients with endometrial carcinoma.
子宫内膜癌的外科治疗仍是一个有争议的问题。两个最具争议的问题是淋巴结切除术的有益效果和腹腔镜手术的可行性。该病例报告的目的是描述在一名56岁被诊断为子宫内膜癌的白种女性中进行全腹腔镜根治性子宫切除术加盆腔淋巴结切除术的可行性。建立二氧化碳气腹后，在髂外血管上方的结肠旁沟上方颅骨切开腹膜，直到可见腰大肌。识别髂外血管，切除其前表面和内侧表面的淋巴结，直至髂总动脉分叉处，并放入Endo袋中。手术继续进行，识别并向内侧牵拉下腹动脉和脐动脉，以打开闭孔窝并切除闭孔神经上方的淋巴组织。下一步是通过钝性分离打开膀胱旁间隙和直肠旁间隙；用子宫操纵器将子宫底向相反方向牵拉有助于这一操作。在两个间隙之间分离的子宫旁组织可以安全地切断。在子宫旁组织的上界识别子宫动脉并在其起始处切断。此后，将子宫底置于中位和后位，用剪刀打开膀胱子宫腹膜反折，并从子宫下段向下至阴道进行膀胱分离。然后解剖输尿管，使其与子宫旁组织的附着分离，并从子宫动脉下方至其进入膀胱处进行交叉分离。接下来打开直肠阴道间隙并切断子宫骶韧带；这允许切断阴道旁附着。切断阴道，经阴道取出标本。然后通过腹腔镜缝合阴道残端。全腹腔镜根治性子宫切除术加盆腔淋巴结切除术与手术时间增加或失血增加无关，似乎是子宫内膜癌患者传统手术方法的一种可行替代方案。
