1. SURGICAL MANAGEMENT
OF CARCINOMA CERVIX
Ashish Tripathi

2. Investigation: Establishing the Dx
 General physical examination including
examination of supraclavicular,axillary and
inguinofemoral lymph nodes.
 Colposcopy
 Cervicography
 Cervical biopsy
 Conisation
 Endocervical canal curettage

3. CERVICAL BIOPSY
 Colposcopy available : biopsy from suspicious area
 If not: employing iodine solution Shiller’s 0.3%,
lugol’s iodine and Acetic acid.
 Types:
– Surface biopsy
– Punch biopsy
– Wedge biopsy
– Ring biopsy
– Cone bipsy

4. CONIZATION
 Both diagnostic and therapeutic purpose
 Removal of cone of the cervix which includes
Squamocolumnar junction, stroma with glands and
endocervical mucous membrane.
 Methods: Cold knife, CO₂ laser, Laser diathermy loop
 Indication:
– Unsatisfactory colposcopic findings
– Inconsistent findings
– Positive endocervical curettage for CIN II and III
– Biopsy shows microinvasion – to exclude gross invasive
carcinoma

5. Investigation Used during Cervical Cancer Staging
Testing To Identify:
Laboratory
CBC Anaemia prior to surgery, chemotherapy
or radiotherapy
Urinalysis Hematuria
Liver function Liver metastasis
Creatinine and BUN levels Hydronephrosis

6. Radiologic
Chest radiograph Lung metastasis
Intravenous pyelogram (IVP) Hydronephrosis
CT scan (abdomen and pelvis) Lymph node metastasis,
metastasis to other distant
organs, and hydronephrosis
MR imaging Local extracervical invasion +
those for CT scan
PET scan Lymph node metastasis
Procedural
Cystoscopy Tumor invasion into the bladder
Proctoscopy Tumor invasion into the rectum
Examination under anesthesia

7. Investigations for
management
CBC, Hb
Serum Urea, Creatinine
LFT, RFT
CXR – PA view
CT, MRI, Abdomino-pelvic USG
Lymphangiography
 Biopsy and histopathologic evidence of invasive
malignancy should precede any treatment
modality.

8. Surgery:General Considerations
 patients with FIGO stage I to IIA cervical cancer
 Operable growth: Smaller tumors, not fixed to
the pelvic wall and no distant metastasis
 Those who are physically able to tolerate an
aggressive surgical procedure
 Those who wish to avoid the long-term effects of
radiation therapy

9.  Radio-resistant growth.
 Typical candidates include young patients who
desire ovarian preservation.
 Retention of a functional, non-irradiated vagina.
 Women with pelvic masses, pelvic infections,
chronic salpingitis, extensive bowel adhesion
from previous peritonitis, endometriosis.

10. Classification of extent of
operation
1. (Type I ) extrafascial hysterectomy
3. (Type II) modified radical
hysterectomy/ Wertheim
hysterectomy
5. (Type III) radical hysterectomy/
Meigs-Wertheim
hysterectomy
7. (Type IV) extended radical
hysterectomy
9. Type V operation: exenteration

11. Simple Hysterectomy (Type I)
 Also known as an extrafascial hysterectomy or
simple hysterectomy, removes the uterus and
cervix, but does require excision of the
parametrium or paracolpium.
 It is appropriately selected for benign
gynaecologic pathology, preinvasive cervical
disease, and stage IA1 cervical cancer.

12. Modified Radical Hysterectomy
(Type II)
 Modified radical hysterectomy removes the cervix,
proximal vagina, and parametrial and paracervical tissue.
 This hysterectomy is well suited for tumors with 3- 5mm
depths of invasion and smaller stage IB tumors.

13. Radical Hysterectomy (Type III)
 Requires greater resection of the
parametria, and excision extends to the
pelvic sidewall .
 The ureters are completely dissected
from their beds, and the bladder and
rectum are mobilized to permit this more
extensive removal of tissue. In addition,
at least 2 to 3 cm of proximal vagina is
resected.
 This procedure is performed for larger IB
lesions, and for patients with relative
contraindications to radiation such as
diabetes, pelvic inflammatory disease,
hypertension, collagen disease or
adnexal masses.

14.  Type IV - Extended radical hysterectomy
– Removal of all periureteral tissue, superior vesicle artery
and ¾ of vagina.
– Indication: Anteriorly occurring central recurrences
where preservation of bladder still possible.
 Type V - Exenteration
– Portion of ureter and bladder are also dissected.
– Indication: Central recurrent cancer involving portion
of the distal ureter or bladder.

15. Patient Preparation
 T/t and control of systemic illness like DM,HTN.
 PAC and consultation with anesthesiologist.
 Blood grouping and cross matching with
adequate Mx of blood for transfusion if
required.
 Mini-heparisation: s/c heparin 5000IU tid 8-24
hrs prior to SX.
 Bowel preparation.
 Prophylactic antibiotics.
 Optimal RFT, Resp.FT and LFT.

16. Management of Invasive
Cancer of the Cervix
Stage Ia1
≤3 mm invasion, no LVSI Conization or type I
hysterectomy
≤3 mm invasion, w/LVSI Radical trachelectomy or type II
radical hysterectomy
with pelvic lymph node
dissection
la2 >3–5 mm invasion Radical trachelectomy or type II
radical hysterectomy
with pelvic lymphadenectomy
lb1 >5 mm invasion, <2 cm Radical trachelectomy or type III
radical hysterectomy
with pelvic lymphadenectomy
>5 mm invasion, >2 cm Type III radical hysterectomy
with pelvic
lymphadenectomy

17. lb2 >5 mm invasion Type III radical hysterectomy
with pelvic and paraaortic
lymphadenectomy or primary
chemoradiation
Stage IIa Type III radical hysterectomy
with pelvic and paraaortic
lymphadenectomy or primary
chemoradiation
IIb, IIIa, IIIb Primary chemoradiation
Stage IVa Primary chemoradiation or
primary exenteration
IVb Primary chemotherapy ±6
radiation
LVSI: lymphovascular space invasion

18. Complications of Radical
Hysterectomy
Acute Complications
1.Blood loss (average, 0.8 L) and shock
2.Ureterovaginal fistula (1% - 2%)
3.Vesicovaginal fistula (1%)
4.Pulmonary thrombo-embolism (1% - 2%)
5.Small bowel obstruction, ileus (1%)
6.Sepsis, pelvic cellulitis (7%) and urinary tract infection (6%).
Wound infection, pelvic abscess, and phlebitis in <5% of
patients.
7.Damage to adjacent organs

19. Subacute complications
 Postoperative bladder dysfunction,
ureteric fistula, urine retention.
 Lymphocyst formation.

20. Chronic complications
 Bladder hypotonia
 Bladder Atony
 Ureteric strictures :rare

21. Palliative care
 Radiotherapy and Chemotherapy
 Pain Management
– Intrathecal injection of phenol
– Analgesics
 Good nursing care
 Psychological and physical support
 Follow up

22. References:
 Howkins & Bourne Shaw’s Textbook of
Gynaecology,14th edition
 Novak’s Gynaecology,14th edition
 Williams’ Gynaecology,