Clinical Comparison On The Treatments For Early-Stage Cervical Cancer By Laparoscopic Surgery And Laparotomy

Objective: Laparotomy has been the main treatment for uterine cervical cancer for many years. Since laparoscope was introduced to treat gynecologic malignant tumor in the nineties era of the twenty century, it was the favourite choose by many gynecologic tumor specialists because of its minor abdominal incision, quick postoperative recovery, less blood loss in operation, and mild disturbance to abdominal cavity. With the improvement of laparoscopic equipment, the accumulation of clinical experience, and the development of operation skills in recent years, laparoscopic surgery has achieved remarkable achievements in curing gynecologic malignant tumor. Our hospital has carried out the research on laparoscopic surgery since June, 2006. The objective of this research is to: 1. Summarize the key operating procedure and skills of laparoscopic radical hysterectomy and plevic lymphadenectomy. 2. Compare the clinical effects and prognosis of laparoscopic radical hysterectomy and plevic lymphadenectomy, with laparotomy on treating early-stage cervical cancer.Methods: Thirty patients were selected to join the research as research group, who suffered from uterine cervical cancer and received laparoscopic surgery in the 4th hospital of Hebei medical university from June 2006 to December 2008. All patients were diagnosed as uterine cervical cancer by cervix tissue biopsy before operation. Another 30 cervical cancer patients were selected randomly as control group, who received laparotomy, with similar histological type, pathological grade, clinical stage, age and weight as research group. Standard clinical staging procedures were applied to both groups according to the criteria of the International Federation of Gynecology and Obstetrics (1995). The average age of the patients in research group was 45.30±10.27, the average weight was 62.35±10.49 kg. For clinical staging, there were 20 cases at stage Ib1 and 10 cases at stage Ib2 or IIa. For histological type, there were 27 cases of squamous cancer and 3 cases of adenocarcinoma. For pathological grade, there were 5 cases of Grade I, 19 cases of Grade II, and 6 cases of Grade III. While the average age of the patients in control group was 45.43±10.42, the average weight was 59.76±8.01 kg. For clinical staging, there were 19 cases at stage Ib1 and 11 cases at stage Ib2 or IIa. For histological type, there were 28 cases of squamous cancer and 2 cases of adenocarcinoma. For pathological grade, there were 6 cases of Grade I, 18 cases of Grade II, and 6 cases of Grade III. There were no significant differences (P>0.05) on age, weight, clinical staging, histological type, and pathological grade of both groups. Thus the condition of two groups were comparable. Results: The operations were successful for both groups. No patient in research group was converted to laparotomy. The operating time of research group was 277.40±54.88min (range 205 min ~435min), and that of control group was 187.3±38.69min (range 130min~265min). The operating time of research group was obviously longer than that of control group (P<0.001). The blood loss in operation of research group was 244.90±155.34ml (range 50ml~700ml), and that of control group was 465.10±270.41ml (range 150ml~1373ml). The blood loss in operation of research group is much less than that of control group (P<0.001). The numbers of the pelvic lymph nodes resected in research group was 16.70±4.53 (range 10~28), and that for control group was 15.10±4.36 (range 9~26), and no significant difference (P>0.05) between two groups. The postoperative recovery of intestinal function for research group was much quicker than that for control group. The time of exhaust for research group and control group were 34.70±19.11h and 61.33±16.29h respectively (P<0.001). The length of postoperative hospitalization for research group and control group were 9.8±3.36 d and 13.23±4.24 d respectively, and the difference was significant between two groups (P<0.05). The stay time of postoperative catheter a demeure for research group and control group were 11.20±4.68d and 10.67±2.69d respectively, and no significant difference between them (P>0.05). There were 8 cases of postoperative retention of urine, 2 cases of lymphocyst, and 2 cases of postoperative ureteral injury in research group. There were 9 cases of postoperative retention of urine, 1 case of postoperative bowel obstruction, 1 case of postoperative ureteral injury, 2 cases of lymphocyst, and 1 case of pelvic infection complicated with pulmonary infection in control group. The postoperative complications were 12 case and 14 case for research groups and control group respectively, no significant difference between them (P>0.05).With the help of pneumoperitoneum, the use of the electrosurgical unit in fast hematischesis, the camera lens in a closer view and amplificatory details, the laparoscope gave us a new understanding to the anatomy during the radical hysterectomy. Then we summarized the laparoscopic operating procedure again and improved the skills of laparotomy for cervical cancer. We summed up a pithy formula to get a easier understanding and acceptance for the anatomy and operating procedure, as following:1. Basic anatomy characters during laparoscopic lymphadenectomy:①"Two Sections": the terminal branch of anterior trunk of internal iliac artery was served as the boundary for the inner and outer sections. the outer section——lymphadenectomy section. the inner section——radical hysterectomy section.②"Two Boundaries": the upper boundary——2-3cm above bifurcate of arteria iliaca communis. For patients of local advanced stage (Ib2 or IIa), the upper boundary moved to where arteria mesenterica inferior branched from the abdominal aorta. the lower boundary——the deep inguinal lymph nodes.③"Three Layers": the front layer——the ilia external lymph nodes group at the front and outer side of arteria iliaca communis and arteria iliaca externa, and deep inguinal lymph nodes. the middle layer——the ilia interna lymph nodes group between external iliac vein and arteria iliaca interna. the back layer——the foramen obturatorium lymph nodes group behind the external iliac vein.④"Six Structures": after pelvic lymphadenectomy, six structures should be seen clearly to ensure that pelvic lymphadenectomy was finished completely. they are genitofemoral nerve, external iliac artery, external iliac vein, nervus obturatorius, anterior trunk of internal iliac artery, and ureter, respectively from outside to inside.2. Three pairs of ligament and three pairs of interspace should be disconnected out precisely during laparoscopic radical hysterectomy. We should identify the interrelation between three pairs of ligament and three pairs of interspace.①"Three pairs of interspace": fore and hind interspaces——bladder cervix vagina interspace and rectouterine interspace, bilateral bladder secund interspaces, bilateral rectum secund interspaces.②"Three pairs of ligament": bilateral uterosacral ligaments, bilateral cardinal ligaments, bilateral bladder cervix vagina ligaments.③"the interrelation between three pairs of ligament and three pairs of interspace":from front to after, bilateral bladder cervix vagina ligament between anterior diastema and bladder secund interspace; bilateral cardinal ligament between bladder secund interspace and rectum secund interspace; bilateral uterosacral ligament between rectum secund interspace and after interspace.Conclusion: The clinical research on small sample indicates that laparoscopic surgery can be used for radical hysterectomy and pelvic lymphadenectomy, and can be one of the surgical treatments for early-stage cervical cancer, with minor incision and quick postoperative recovery. However, its long-term effect needs to be observed further.We have gained a better understanding on the pelvic topography during laparoscopic radical hysterectomy and pelvic lymphadenectomy. The operating procedure before are summarized again, which makes it much easier, that the relatively complicated and dangerous operations such as pelvic lymphadenectomy, even abdominal aorta side lymphadenectomy, and type III radical hysterectomy. The reproducibility of the operating procedure is increased as well.