the laparoscopic removal of a cervical stump following a supra cervical ( subtotal ) hysterectomy was first described by nezhat et al , and they concluded that the cervical stump could be removed laparoscopically by an experienced surgeon .
the advantages of the laparoscopic approach included possible stump adhesiolysis , providing adequate postoperative vault support , and assessment of the pelvic lymph nodes .
the 43-year - old , presented with a history of persistent p v discharge and occasional post - coital bleeding .
she had undergone subtotal hysterectomy in 1994 , due to postpartum hemorrhage following a normal delivery .
a colposcopic biopsy done in january 2009 , reported severe dysplasia of the cervix , with a human papillomavirus ( hpv ) effect and crypt extension .
there was a strong family history of cancer of the cervix , as her mother had succumbed to the disease .
on general examination she was in fair general condition , well - built and well - nourished , with adequate hydration .
the hemoglobin was 13.3 g / dl , blood sugar was 5.3 mmols / l , urea and electrolytes were normal .
an initial diagnosis of abnormal pap smear was entertained and the patient opted for a laparoscopic trachelectomy , with the option of a laparotomy , after discussing all her options .
there were dense adhesions in the pouch of douglas involving the bowel and the cervical stump .
the pelvic lymph nodes were clearly visualized ( after intracervical methylene blue injection ) and did not appear to be enlarged .
gentle adhesiolysis was undertaken using sharp dissection , bipolar cautery , and a harmonic scalpel .
the vaginal vault was subsequently opened over the ceramic cup of a clermont ferrand elevator .
a cystoscopy with retrograde ureteral catheterization , to confirm the integrity of the bladder and ureters , was undertaken .
the cervical stump after laparoscopic trachelectomy at one week of follow - up the patient was well .
a postoperative intravenous urogram ( ivu ) confirmed that both the ureters and bladder were intact .
subtotal hysterectomy was developed as a procedure in the 1990s , and is regarded as a safe option to total abdominal hysterectomy in the management of benign uterine conditions and in obstetrics , due to severe postpartum hemorrhage .
okaro et al , in an assessment of the long - term outcomes of laparoscopic supracervical hysterectomy analyzed the case records of 70 consecutive women undergoing the procedure .
of these , 24.3% ( 17 cases ) reported symptoms related to the cervical stump , within 14 months of the original surgery .
in his series 14 of these patients underwent laparoscopic trachelectomy , one had only laparoscopic adhesiolysis and two underwent a laparotomy with trachelectomy due to dense bowel adhesions on the cervical stump .
histologically the stumps showed endometriosis ( 23.5% ) and mild dysplasia in 7.6% of the patients . in this case our patient presented with persistent p v discharge and occasional post - coital bleeding .
the subsequent pap smears were abnormal . in a retrospective of 41 patients undergoing laparoscopic subtotal hysterectomy , van der stege et al , noted that 98% of the patients were satisfied with their procedure , with 10% of them having monthly spotting .
they concluded that although laparoscopic hysterectomy for benign diseases was a satisfactory procedure , special attention should be paid to careful management of the cervical stump .
hilger et al , reviewed the indications of 310 trachelectomies performed at the mayo clinic from 1974 to 2003 .
they included stump prolapse ( 4% ) , fibroid mass ( 1% ) , cervical dysplasia ( 6% ) , carcinoma in situ ( 5% ) , irregular bleeding ( 2% ) , and cervicitis ( 53% ) .
the complications following vaginal trachelectomies were encountered in 80% of the procedures against 37% in the abdominal procedure . in our report the cervical stump confirmed carcinoma in situ .
 a 43-year - old , who underwent a subtotal hysterectomy for postpartum hemorrhage following a normal delivery , 10 years ago , presented with a history of persistent vaginal discharge and post - coital bleeding . 
 a pap smear reported moderate dysplasia , and a subsequent colposcopic biopsy reported severe dysplasia with crypt extension . 
 the patient underwent a laparoscopic trachelectomy , and histology of the stump reported cervical squamous carcinoma in situ , with no microinvasion . 
INTRODUCTION
CASE REPORT
THE OPERATION
DISCUSSION