This is a surgical video demonstrating minimally invasive, fertility-sparing radical trachelectomy. This video highlights the case of a 24-year-old G0 who was found to have high-grade dysplasia on a pap smear. She was found to have a 1B1 lesion and underwent ELITE procedure demonstrating invasive, poorly differentiated carcinoma. Imaging demonstrated no evidence of parametrial, lower uterine segment, or nodal spread of disease. Appropriate patients for fertility-sparing radical trachelectomy include those who have FIGO stage 1A1 to 1B1 lesions that are less than 2 cm, without extensive LVSI, and with limited endocervical involvement. After counseling of her treatment options, the patient elected for fertility-sparing radical trachelectomy. This was performed by the minimally invasive robotic-assisted approach. After the patient was prepped and draped, robotic trocars were inserted to allow access to the pelvis. These were placed approximately 6-8 cm apart, as shown here, with an assistant port inserted in the left upper quadrant. In this case, sentinel lymph node sampling was performed using injection of endocyanine green dye in the cervix. The right sentinel lymph node is identified transperitoneally in the right common iliac chain. The lymphatic chains are seen here traveling from the cervix, condensing in the parametrium, and then traveling cephalad, condensing in the lymph nodes in the right common iliac chain. The sentinel lymph node is removed. The sentinel lymph node mapping and dissection procedure is repeated on the left. However, here, the dye condenses in the parametrium, and a left parametrial sentinel lymph node is identified. Additionally, lymph channels cross over the obliterated umbilical ligament, and an external iliac sentinel lymph node is identified. These are removed. The radical trachelectomy is now begun. The ureter is identified on the right. The uterine artery is subsequently identified, and it is skeletonized. The round ligament is divided and the paravesical space is developed. This is repeated on the left side. The bladder is dissected such that sufficient space for the upper vagina to be removed is given. Attention is now turned posteriorly and the location of the cervical lower uterine segment junction where the cervix will be divided from the uterine fundus is marked. The rectovaginal space is identified and developed. The right uterine artery is now ligated and divided. The ventral parametrium is completely dissected from the cervix. The ureter is completely freed of its attachments. The medial leaf of the broad ligament is divided, and the uterus-acral ligament is identified and divided. This is repeated on the left side. The cervical lower uterine segment junction is identified and the uterine vessels are again ligated. This marks the location where the cervix will be separated from the uterus. This is repeated on the right side. Posteriorly, the serosa of the lower uterine segment is divided. The cervix and upper vagina are now dissected and the specimen including the bilateral parametria, upper vagina, and cervix is delivered vaginally. The specimen is sent for frozen section to ensure no tumor is present at the uterine margin. A cerclage is placed in the lower uterine segment using a permanent suture. The vaginal apices are re-approximated using a delayed absorbable suture. Using a barbed suture, the lower uterine segment is reattached to the vaginal cuff posteriorly. and it is attached anteriorly. The round ligaments are re-approximated bilaterally. At the completion of the procedure it is noted that the uterus is pink and healthy and that the infundibulopelvic ligaments have been kept intact. General pathology demonstrated residual tumor measuring four millimeters in horizontal dimension and three millimeters of depth and 17 millimeter clearance from the endocervical margin. Lymph nodes were negative.

fertility-sparing radical trachelectomy

minimally invasive surgery

cervical cancer treatment

sentinel lymph node mapping

tailored surgical approaches