Problem: radical hysterectomy can be highly invasive

The use of minimally invasive techniques for treatment of cervical cancer is increasing. Most of the recent innovation associated with surgical treatment of this disease has involved robotic-assisted laparoscopy. Several reports document equivalent oncologic outcome and reduced perioperative morbidity when patients with early cervical cancer undergo laparoscopic radical hysterectomy, often performed with robotic support, rather than abdominal surgery.

Laparoendoscopic single-site (LESS) surgery is an evolving approach aimed at further diminishing invasiveness. Rather than using multiple incisions, as in traditional or robotic-assisted laparoscopy, procedures are performed through a single small incision. Experience using LESS procedures for both benign and malignant gynecologic conditions is rapidly expanding.

Our solution

A 56 year old woman presented with abnormal Papanicolaou smear results that were concerning for cancer. Cervical conization confirmed squamous cell carcinoma involving the margin of excision and measuring at least 10 mm wide and 7 mm deep. Preoperative imaging with positron emission tomography-computed tomography was negative for distant metastatic disease. Definitive surgical therapy with radical hysterectomy (type III) and bilateral pelvic lymphadenectomy was recommended for clinical stage IB1 cervical cancer.

The surgery was performed using a LESS approach. Following induction of general anesthesia, the patient was placed in the dorsal lithotomy position using Allen stirrups; her arms were tucked at her sides. A RUMI uterine manipulator and the Koh Colpotomizer System (both from Cooper Surgical Inc, Trumbull, CT) were employed as described by Frumovitz and Ramirez. After a vertical 2.5 cm incision was made through the base of the umbilicus, the peritoneal cavity was accessed via the Hasson technique. Next, a single multichannel port (Olympus QuadPort; Olympus America Inc, Center Valley, PA) was introduced, and pneumoperitoneum was established. The surgical methods for radical hysterectomy and pelvic lymphadenectomy were performed based on traditional principles.

A 5 mm laparoscope with a deflecting tip (EndoEYE; Olympus America Inc, Center Valley, PA) and an articulating grasper (Covidien, Mansfield, MA) were helpful in the re-creation of triangulation and minimization of hand collision. Ultrasonic shears (SonoSurg Ultrasonic Cutting and Coagulating System, Olympus America Inc) were used for tissue dissection and vessel sealing. The specimen was delivered vaginally, and the vaginal cuff was closed transvaginally. Lymph nodes were removed with an endoscopic bag.

Operative time was 270 minutes, and the estimated blood loss was less than 100 mL. The patient was discharged home on postoperative day 1. A Foley catheter bladder drainage was left in place until postoperative day 14. Pathology revealed residual squamous cell carcinoma invading to a width of 10 mm and a depth of 7 mm, with negative margins, negative parametria, and no lymphovascular space invasion. Twenty-five pelvic lymph nodes had been removed; all were negative for tumor. She had no complications. Close clinical surveillance was recommended.

Our initial experience with LESS involved simple procedures, including prophylactic bilateral salpingo-oophorectomy in women carrying BRCA gene mutations and simple hysterectomy for preinvasive uterine disease. As we became more proficient in instrumentation and technique, we used LESS to successfully complete increasingly complicated procedures, including endometrial cancer staging. To our knowledge, this case is the first reported LESS radical hysterectomy (type III). Safety and oncologic adequacy necessarily remain our top priorities during surgical management of gynecologic cancers. The potential advantages of limiting the number of laparoscopic incisions to one are unclear and require further study. Nonetheless, we value the quest to further minimize surgical morbidity and hope this report will encourage like-minded colleagues.