CHAPTER 50

Cervical Stump Excision (Trachelectomy)

A cervical stump is the remnant of the uterus that remains following a subtotal hysterectomy (Fig. 50–1). Historically, supracervical hysterectomy was performed under adverse circumstances whereby rapid termination of the operation was essential for the well-being of the patient (e.g., in the complicated pregnancy). However, more recently surgeons are electively performing laparoscopic or robotic subtotal hysterectomy. Subsequent removal of the stump, or trachelectomy, may be required for various reasons, including persistent bleeding, prolapse, pain, and abnormal cervical pathology.

The cervical stump is removed in an identical fashion to the initial steps of a vaginal hysterectomy. Although entering the peritoneal cavity is not mandatory, it is preferred to ensure complete removal of the cervix and to allow for obliteration of the cul-de-sac and suspension of the vagina in cases of prolapse. The stump is grasped with a single-toothed tenaculum and is pulled inferiorly. A 1 : 100 diluted vasopressin solution is injected beneath the cervical and vaginal mucosa with a 25-gauge needle and a triple-ring 10-mL syringe. The solution will help to develop a plane of dissection. The injections are performed circumferentially around the cervix (Fig. 50–2A). With a scalpel, an incision is made into the cervix and is circumscribed below the cervicovaginal junction (Fig. 50–2B). The bladder is dissected from the cervix anteriorly; the vagina, together with the ureters, is pushed upward (craniad) from the lateral aspect of the cervix (Figs. 50–2C and 50–3A). The cul-de-sac and the rectum are dissected free posteriorly (Fig. 50–3B). The lower portion of the cardinal ligaments is clamped with curved Zeppelin clamps (Figs. 50–2D and 50–4). The uterosacral ligaments are identified and clamped (Figs. 50–2E and 50–5

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