Para-aortic Lymph Node Evaluation The bowel is packed to expose the peritoneum overlying the bifurcation of the aorta. The peritoneum is incised medial to the ureter and over the right common iliac artery. A retractor is placed retroperitoneally to expose the aorta and the vena cava. Any enlarged para-aortic lymph nodes are removed, hemoclips are applied for hemostasis, and specimens are sent for analysis by frozen section. If the lymph nodes are positive for metastatic cancer, an option is to discontinue the operation and treat the patient with radiation therapy (71). If the lymph nodes are negative for disease, the left side of the aorta is palpated through the peritoneal incision with a finger passed under the inferior mesenteric artery. The lymph nodes on this side of the aorta are more lateral and nearly behind the aorta and the common iliac artery. If the left para-aortic lymph nodes appear healthy and the cervical tumor is small with no suspicious pelvic lymph nodes, these additional lymph nodes are not submitted for frozen-section analysis. If they are removed, they may be dissected through the incision made for the right para-aortic nodes, or they may be dissected after reﬂection of the sigmoid colon medially.
Development of Pelvic Spaces The pelvic spaces are developed by sharp and blunt dissection (Fig. 36.8).
The paravesical space is bordered by the following structures: 1.
The obliterated umbilical artery running along the bladder medially.
2.
The obturator internus muscle along the pelvic sidewall laterally.
3.
The cardinal ligament posteriorly.
4.
The pubic symphysis anteriorly.
The attachments of the vagina to the tendinous arch form the ﬂoor of the paravesical space.
Figure 36.8 The pelvic ligaments and spaces. (From Berek JS, Hacker NF. Berek & Hacker’s Gynecologic Oncology. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2010:360, with permission.)
The pararectal space is bordered by the following structures: 1.
2.
3.
4.
The coccygeus (levator ani) muscle forms the ﬂoor of the pararectal space.
The development of these spaces before pelvic lymphadenectomy will aid in identification and dissection of the pelvic lymph nodes and dissection of the ureter as it passes into the vesicouterine ligament tunnel.
Dissection of the Bladder The dissection of the bladder from the anterior part of the cervix and vagina is a critical step. Occasionally, tumor extension into the base of the bladder (which cannot be detected with cystoscopy) precludes adequate mobilization of the bladder ﬂap, leading to the abandonment of the operation. Therefore, this portion of the operation should be undertaken early in the procedure. The bladder should be mobilized off of the upper third of the vagina to remove the tumor safely and with adequate margins.
Dissection of the Uterine Artery The superior vesicle artery is dissected away from the cardinal ligament at a point near the uterine artery. The uterine artery, which usually arises from the superior vesicle artery, is thus isolated and divided, preserving the superior vesicle arteries. The uterine vessels are brought over the ureter by application of gentle traction. Occasionally, the uterine vein passes under the ureter.