After the publication of the LACC trial, most surgeons have refrained from laparoscopic radical hysterectomy. Numerous clinics have switched back to open surgery. So far, there is no data on the extent to which this has negative consequences for complications and side effects(1, 2). The renunciation of morcellation has also led to the resumption of the laparotomy and resulted in significantly higher complication rates. Ultimately, this must also be expected for radical hysterectomy. One of the great advantages of the laparoscopic procedure is undoubtedly the possibility of being able to protect the pelvic nerves much better. There were significantly fewer urinary and defecation disorders than via laparotomy. No comparable randomized study is currently available. However, there are large studies that do not confirm the data of the LACC trial. These have existed before and new ones are being added (3, 4). Since the LACC trial has many weaknesses and the results obviously have to be interpreted as learning curves, we did not switch completely to laparotomy. The German S3 guideline also recommends laparotomy for the treatment of cervical carcinoma, ultimately only on the basis of the LACC trial(5).
It would be important to create comparable, very well-designed studies to really classify the LACC trial. As long as this is not available, from our point of view it is very difficult to suddenly negate the good results to date. Assuming that the data reflect reality, the poorer result cannot be caused by the laparoscopic preparation. If one continues to assume that all surgeons have achieved real radicality, then the only remaining cause is the opening of the vagina in the CO2 milieu. The latter is said to lead to the spread of tumor cells.
In order to take this assumption into account, we have combined our procedure laparoscopic and open. Ultimately, to obtain the benefits of the laparoscopic nerve-sparing approach. So far, we have performed the radical hysterectomy laparoscopically and the separation of the uterus from the vagina via a classical cross-sectional laparotomy. The latter to avoid potential contamination of the abdomen by tumor cells. In order not to have to perform a laparotomy unnecessarily, we have developed a stapler procedure for the last step. After complete dissection, a 60mm stapler is inserted from the side and the vagina is stapled analogously to the bowel resection. After the preparation has been separated, it is temporarily stored in a recovery bag. Then the row of staples remaining on the vagina is separated and recovered trans-vaginally together with the other preparation bags. The procedure guarantees an adequate vaginal cuff and avoids potential contamination. The video shows the procedure.
1: Obermair A, Asher R, Pareja R, Frumovitz M, Lopez A, Moretti-Marques R, et al. Incidence ofadverse events in minimally invasive vs open radical hysterectomy in early cervical cancer: results of arandomized controlled trial. American journal of obstetrics and gynecology. 2020;222(3):249. e1-. e10.
2: Ramirez PT, Frumovitz M, Pareja R, Lopez A, Vieira M, Ribeiro R, et al. Minimally Invasive versusAbdominal Radical Hysterectomy for Cervical Cancer. N Engl J Med. 2018;379(20):1895-904.
3: Li Z, Chen C, Liu P, Lu A, Zhao H, Zhan X, et al. Comparison between laparoscopic and abdominalradical hysterectomy for low-risk cervical cancer: a multicentre retrospective study. Archives ofGynecology and Obstetrics. 2022;305(2):449-58.
4: Malzoni M, Tinelli R, Cosentino F, Fusco A, Malzoni C. Total Laparoscopic Radical HysterectomyVersus Abdominal Radical Hysterectomy with Lymphadenectomy in Patients with Early Cervical Cancer:Our Experience. Annals of Surgical Oncology. 2009;16(5):1316-23.
5: Fehm T, Stübs FA, Koch MC, Mallmann P, Dannecker C, Dietl A, et al. Diagnosis, Therapy andFollow-up of Cervical Cancer. Guideline of the DGGG, DKG and DKH (S3-Level, AWMF RegistryNo. 032/033OL, May 2021) – Part 2 with Recommendations onPsycho-oncology, Rehabilitation, Follow-up, Recurrence, Palliative Therapy and Healthcare Facilities.GebFra – DGGG-Gesellschaftsausgaben. 2022(01):181-205.