The traditional method of staging is by clinical examination under anesthesia (staging EUA). Applying FIGO staging [11] (Table 32.1) enables a decision to be made as to the best form of treatment. Stages IAI and IAII may be adequately treated by cone biopsy ensuring that an adequate margin of clearance is obtained. Risk of lymph node involvement for a stage IAI tumour is 1 % increasing up to 7–8 % in stage IAII [12]. With lympho-vascular space invasion (LVSI), a pelvic node dissection is required and the incidence of this in stages IAI and IAII is between 3 and 4 %. The incidence of lymph node involvement, with metastases increases to 16–18 % with stage IB tumours. These lesions require a thorough pelvic node dissection with a Wertheim’s radical hysterectomy.

Pelvic node dissection may be carried out by laparoscopy with or without robotic assistance. This is part of the overall staging procedure but whether the removal of microscopically negative lymph nodes as an en bloc dissection is therapeutic, is debatable. Improving imaging perhaps with PET scanning or sentinel node assessment may change this.

This is carried out laparoscopically either at the time of the staging EUA or in conjunction with the vaginal trachelectomy. The advantage of the former is that patients with positive lymph node metastases are identified before definitive surgery to the cervix is undertaken. A four portal approach is employed using a Hasson direct entry technique. The abdominal and pelvic cavity is thoroughly inspected not only to look for possible metastatic disease especially involving the pelvic peritoneum and Pouch of Douglas but also to look for other pathology such as endometriosis or chronic pelvic inflammation.

The pelvic side walls are exposed with a T shaped incision into the peritoneum overlying the external iliac vessels, just proximal to the round ligaments. The infundibulo-pelvic ligament is identified and separated from the ureter. The nodes are removed from the lower common iliac, internal and external iliac and obturator regions. The obturator nerve is exposed and conserved. The paravesical space is identified and opened. Care is taken to avoid aberrant obturator vessels.

The procedure is repeated on the contralateral side resulting in a harvest of approximately 30–40 lymph nodes.

An extended lithotomy position is used to expose the cervix which is infiltrated with 0.25 % Bupivacaine and 1 in 200,000 adrenaline. The technique is well described by Shepherd [13] utilizing a circumcervical incision including a 2 cm cuff of vagina with cutting diathermy. Sharp dissection mobilizes the bladder anteriorly, identifying the bladder pillars by opening the paravesical space on either side. Posteriorly the uterosacral ligaments and rectovaginal septum are identified. The harmonic scalpel (ultracision Eithicon endoscopy LLC) is used for dissection and haemostasis. The bladder pillar is transected and the descending branch of the uterine artery supplying the cervix is isolated and divided after cauterization. The ureteric tunnel is identified and the ureter reflected cranially and laterally. The dissection continues laterally dividing the lateral (cardinal) ligaments the utero-sacral ligaments posterolaterally. As much paracervical and paravaginal tissue as necessary depending on the size of the tumour, should be resected (Fig. 32.3). To give an adequate 1–2 cm clearance of tumour-free tissue. The rectovaginal septum is incised and the tissue posteriorly pushed by blunt dissection cranially. It is not necessary to open the Pouch of Douglas and by keeping this closed possible sepsis spreading to the pelvis is avoided. If the peritoneal cavity is opened, this may be easily closed with absorbable sutures. The dissection is performed on both sides thus mobilizing the central cervix including a 2 cm cuff of vagina. A no. 6 Hegar dilator is placed into the endocervical canal which may then be transected using cutting diathermy (Fig. 32.4). The isthmus is easily identified by visualizing where the peritoneum is reflected anteriorly, above the uteroversical ligament and posteriorally at the reflection of the Pouch of Douglas. An individual decision is taken as to whether a complete trachelectomy removing all the cervix is required or whether it is possible to conserve a small cuff of proximal upper cervix depending on the exact location of the tumour.

An isthmic cerclage using monofilament, non-absorbable material, such as No 1 nylon or prolene, is inserted with four large bites around the isthmus, through the stroma of the cervix. Care is taken not to occlude the isthmic os by keeping the Hegar dilator in situ during this procedure. The knot is tied anteriorly around this dilator. This will allow normal menstruation to occur and passage of a cannula for any future necessary procedures.

Holding the cerclage suture for identification and traction, the vaginal margins are grasped and anastomosed to the isthmus using four interrupted mattress sutures with no 1 Vicryl (Polyglactin, Ethicon). Care is taken to avoid closing the isthmic and endocervical canal by leaving the Hegar 6 dilator in situ whilst inserting the sutures. Two or three further mattress sutures are placed on either side to close the angles of the lateral fornices (Fig. 32.5).