Discussion
Cancer, tumor, cancer, early-stage cervical cancer, tumors, bipolar coagulation
TUMOR, CANCER, UTERUS, MALIGNANCIES, CERVICAL CANCER, CAVITY, CERVICAL LESION, TUMORS, VAGINA, EXTRAVASATION, SPILLAGE, CANCER
The use of LRH for cervical cancer was first reported in 1992 [The main principles of tumor surgery include the prevention of possible tumor extravasation; however, cervical cancer itself possesses the characteristic of spreading outward and toward the vagina, which can complicate surgery. The findings of the 2018 LACC trial [Moreover, it is believed that cancer cells can detach from the tumor surface during surgery for cervical malignancies and contaminate the carbon dioxide-filled peritoneal cavity. In a study by Kong et al. [Furthermore, during intraabdominal vaginotomy, the last step during LRH, intra-abdominal exposure to the tumor while separating the vagina could easily cause abdominal and pelvic dissemination and increase the risk of tumor spillage. In order to avoid the direct exposure of tumor tissue to the abdominal cavity, open surgery often uses preoperative vaginal fornix clamping, but laparoscopic radical hysterectomy cannot routinely replicate this step. It can be achieved by creating vaginal cuffs or closing vaginal cuffs by suture or permanent tie. Yuan et al. [Therefore, we modified our laparoscopic surgery as follows: (1) instead of using a uterine manipulator, we used transuterine suspension sutures, which ensured that the angle and position of the uterus could be adjusted for complete exposure of the surgical field of view without squeezing or destroying the tumor. (2) In this trial, cutting and closing the vagina with the endocutter instead of the traditional way of closure allowed for a more straightforward procedure, with enough room for complete vaginal wall and cervical lesion resection. At the same time, it ensured the safety of the vaginal resection margin and reduced the spillage of intraperitoneal tumors. Compared with the previous vaginal suture methods, the endocutter closes the vaginal vault more evenly and tightly, and the closure is superior. (3) The complete resection (tumor-free) principle was strictly implemented in this trial. Previous studies have identified an association between positive vaginal excision margins and an increased risk of early-stage cervical cancer recurrence along residual vaginal tissue [The vaginal stump treatment time in the laparotomy group was significantly shorter than in the laparoscopic group. This may be related to the limitation of the laparoscopic technique itself; time is saved when using the right-angle sealing forceps compared with the endocutter device. It takes more time to follow the principle of complete resection when working under a limited field of view, and it also requires more time to extract the specimen from the vagina than direct extraction during laparotomy. However, this study found no significant difference in the total operation time between the two groups, suggesting that time spent before the treatment of the vaginal stump during the initial steps of the laparoscopic procedure can be optimized. Steps such as skin incision are relatively faster than in laparotomy; laparoscopic pelvic lymph node dissection time is shorter than open radical hysterectomy, mainly because laparoscopy has a high resolution and provides more accurate anatomy exposure, and more energy devices such as bipolar coagulation used for hemostasis are less time-consuming.From a subjective point of view, the study guaranteed the quality of the operations. The trial facility is a quality control pilot unit of the National Cancer Center and is one of China’s top 50 tertiary hospitals. The patients used in the trial were strictly screened, and the surgical staff involved have all passed strict certification procedures; they have rich experience, and all operations were completed independently. This study also has the benefit of using a prospective randomized controlled design to assess short-term clinical outcomes and the efficacy of a modified minimally invasive radical hysterectomy. These findings will help plan and design subsequent studies on the safety and efficacy of early-stage cervical cancer surgical treatment.