While technically challenging with a steep learning curve, clear advantages include decreased operating time, lower patient morbidity, shorter length of inpatient hospitalization, less blood loss, improved cosmesis, and comparable outcomes to laparotomy, including recurrence rates and lymph- node yield. Newer robotic technology alleviates some of the shortcomings of laparoscopy, and robot-assisted radical hysterectomy (RRH) may soon surpass TLRH as a minimally invasive procedure.

Total Laparoscopic Radical Hysterectomy
Both patients and physicians have driven the advancement of minimally invasive surgery. The pursuit of cutting-edge technology by physicians and academic institutions has promoted the expansion of minimally invasive techniques, and training opportunities abound. With increasing public awareness, many patients are now requesting minimally invasive surgery. Patients with early-stage, IA2, or IB1 cervical cancer are traditionally offered an abdominal radical hysterectomy and pelvic lymphadenectomy. First described by Canis et al.¹ and Nezhat et al,² TLRH for early-stage cervical cancer has been proved efficacious and safe by a number of other groups^3–9 and is gaining popularity. The best candidates for TLRH include those with early-stage disease (IA2 or IB1), tumor size <4cm, and uterine size <12cm. Patients with a bulky uterus or bulky cervical tumors, severe hip or joint disease, or intraperitoneal metastases are generally not suitable candidates for the procedure.

Total Laparoscopic Radical Hysterectomy Technique
Informed consent is obtained. All patients undergo pre-operative bowel preparation and receive prophylactic antibiotics. After placement in lithotomy position with arms tucked at the sides, a Foley catheter is inserted. A uterine manipulator is placed. The patient is placed in steep Trendelenburg position. Based on surgeon preference of endoscope size, a 5, 10, or 12mm bladeless trocar is situated at the umbilicus under direct visualization of the abdominal cavity. If the patient has a prior mid-line incision, entry can be made at Palmer’s point 2cm below the left costal margin in the mid-clavicular line. The abdomen is insufflated, and three additional bladeless trocars (5, 10, or 12mm) are placed in the right lower quadrant, left lower quadrant, and the mid-line 2cm above the pubic symphysis. At least one of the three trocars must measure 10 or 12mm in order to permit lymphadenectomy. An abdominal survey is then performed to rule out intraperitoneal disease. The bowel is mobilized out of the surgical field.

Table 1: Outcomes for Laparoscopic Radical Hysterectomy

OR = operating room; LOS = length of stay; EBL = estimated blood loss; NR = not reported. § This study included patients with IIIa and IIIb disease as well.

The round ligaments are then transected bilaterally. The peritoneum is incised over the psoas muscle immediately lateral to the infundibulopelvic ligament, and the ureters are identified. Any suspicious-appearing lymph nodes are then removed and sent for frozen pathology, as the procedure is aborted in the presence of metastatic disease. Next, the paravesical and pararectal spaces are identified and exposed. The uterine vessels are identified and transected at the point of origin from the iliac vessels. The bladder is then mobilized inferiorly. The ureters are freed from their medial attachments to the peritoneum, and then dissected off the parametrium down to their insertion into the bladder. The vesicouterine ligament is divided at its lateral aspect, and the bladder further mobilized so as to provide ample vaginal margins.