May 4, 2015
Written by Marty Susskind (class of 2014-2015)
Ill begin with the immortal words of the ninja turtles, “Radical Dude!”
Radical Abdominal Trachelectomy to be exact… with a hint of bilateral pelvic lymph node dissection, and a sprinkling of cerclage hysterectomy to boot!
In layman’s terms, I saw a forty year-old female patient with cervical cancer get her cervix removed and it was as intense an operation as it sounds. The bottom of the uterus was to be sewn to the vagina in hopes that the patient could still have a child. Basically, the cervix is nothing more than a passageway for sperm before fertilization, a conduit uniting vagina and uterus, and that purpose will now be carried out by the stretched bottom tissue of the uterus itself! Yes I realize I am finishing every paragraph with an exclamation point! (!)
After the 7AM discussion with the residents and a massive omelet off the HCP grill I walked into this already underway surgery and it was probably the crudest operation I have seen yet from an aesthetic perspective. The entire abdominal cavity was cut wide open; just a big gut-hole around 2.5 feet in diameter. The hole was kept open wide using a radial metal frame with 5 metal clamps pulling the skin and guts outward and away from the deep-set reproductive organs. I could make out the thick edges of the rectus abdominus, and internal oblique which had been separated to access the abdominal cavity. The stomach and intestines where pushed upward and held in place by the clamps and a wall of gauze towels. !
Once I had successfully geared up mentally for this surgery I actually began to take notes on the procedural steps being carried out. One doctor was holding onto the uterus at all times via four surgical clamps in order to give the other doctors access to the surrounding areas. They first worked to dissect the bladder from the uterine wall using the usual technique of cut+cauterize. Next, they took out the entire left and right pelvic lymph nodes in case they were infected with cancerous cells as well. The nodes were positioned right on top of the iliac artery and psoas muscles. Seeing all of this anatomy was so cool for me as I am a personal fitness trainer and I think about this “core musculature” all of the time. The other lymph nodes in the body can apparently compensate for the loss of the pelvic ones but there is a reported increase in swelling in 10% of the patients that undergo this surgery. The lymph node samples were sent down to the pathology lab to be screened for cancer.
The doctors put blue loops around both the L and R ureter because these vessels bring urine from the kidney to the bladder. It is REALLY important not to cut those bad boys on accident! They similarly ID’ed the obterate nerve… again, Watch Out! The doctors were finally able to fully separate the bladder from the uterus and there was a bit o’ vein severing along the way. I had a very informative discussion about blood vessels with all three surgeons and I was surprised to learn that while BP is higher in arteries than veins, veins will bleed more if cut. In this case, blood was actually spurting out of a uterine vein and it had to be clipped with a surgical tool that sounded sort of like a staple gun when the trigger was pulled. The patient had to be given two units of blood to make up for the massive loss!
Next came a lot of cut+cauterize… the cervix was cut along the superior proximal line where it turns into uterus (radical trachelectomy) and the inferior line where it meets the vagina and the entire organ was excised and sent down to pathology. The doctors then stitched around the newly opened “mouth” of the uterus and they stuck a long tube (basically a catheter) into the hole. A syringe full of saline was then pumped into the tube in order to expand a little balloon implanted into the uterus at the other end. This was to make sure the uterine tract remained open for the rest of the surgery. The abdominal cavity was so bloody at this point that the surgeons had to pour an entire jug of water into it to irrigate/ clean it before working on the uterine/ vaginal junction. The surgery was 5 hours in at this point and it was time for me to check out as there was still and estimated 2 hours left in the operation. These surgeons really do have amazing posture/strength/bladders!