The abdomen is opened through either a midline incision or a low transverse incision after the methods of Maylard or Cherney. The low transverse incision requires division of the rectus muscles and provides excellent exposure of the lateral pelvis. It allows adequate pelvic lymphadenectomy and wide resection of the primary tumor. After the abdomen is entered, the peritoneal cavity is explored to exclude metastatic disease. The stomach is palpated to ensure that it has been decompressed to facilitate packing of the intestines. The liver is palpated, and the omentum is inspected for metastases. Both kidneys are palpated to ensure their proper placement and lack of congenital and other abnormalities. The para-aortic nodes are palpated transperitoneally.
During exploration of the pelvis, the fallopian tubes and ovaries are inspected for any abnormalities. In premenopausal patients, the ovaries can be conserved. The peritoneum of the vesicouterine fold and the rectouterine pouch should be inspected for signs of tumor extension or implantation. The cervix is palpated between the thumb anteriorly and the fingers posteriorly to determine its extent, and the cardinal ligaments are palpated for evidence of lateral tumor extension or nodularity.
Lymphadenectomy After inspection of the abdomen and pelvis, the pelvic and paraaortic lymph nodes should be inspected and palpated. Lymph nodes suspicious for gross disease should be excised and evaluated by frozen section. If metastatic disease is identified, consideration should be given to abandoning radical surgery in favor of primary chemoradiation therapy. If the patient has no gross evidence of metastatic disease, the pelvic lymphadenectomy is begun.
Pelvic Lymphadenectomy The pelvic lymphadenectomy is begun by opening the round ligaments at the pelvic sidewall and developing the paravesical and pararectal spaces. The ureter is elevated on the medial ﬂap by a Deaver retractor to expose the common iliac artery. The common iliac and external iliac nodes are dissected, with care taken to avoid injuring the genitofemoral nerve, which lies laterally on the psoas muscle. At the bifurcation of the common iliac artery, the external iliac node chain is divided into lateral and medial portions.
The lateral chain is stripped free from the artery to the circumﬂex iliac vein distally. A hemoclip is placed across the distal portion of the lymph node chain to reduce the incidence of lymphocyst formation. The medial chain is dissected. The obturator lymph nodes are dissected; for this procedure, the lymph nodes are grasped just under the external iliac vein, and traction is applied medially. In most patients the obturator artery and vein are dorsal to the obturator nerve; however, 10% have an aberrant vein arising from the external iliac vein. The node chain is separated from the nerve and vessels and clipped caudally. Dissection continues cephalad to the hypogastric artery. The cephalad portion of the obturator space should be entered lateral to the external iliac artery and medial to the psoas muscle, where the remainder of the obturator node tissue can be dissected as far cephalad as the common iliac artery. Drainage of the pelvic and para-aortic lymph node beds is not performed because of the increase in complications in patients in whom drains were used (73).
Patients who have bulky cervical tumors or grossly positive pelvic nodes, or for whom frozen section evaluation will be performed, should undergo para-aortic lymph node evaluation to determine the full extent of disease and to guide adjuvant therapy.