Laparoscopic radical hysterectomy (LRH) is a cornerstone procedure in the surgical management of early-stage cervical cancer and selected cases of uterine malignancies. It involves the complete removal of the uterus, cervix, parametrial tissue, and upper portion of the vagina, along with pelvic lymphadenectomy, aiming to achieve oncologically sound margins while preserving the function of adjacent organs. In his lectures, Dr. R. K. Mishra, a pioneer in laparoscopic surgery, emphasizes the meticulous surgical steps, anatomical knowledge, and technical nuances required for this complex procedure.

Introduction

Cervical cancer remains a significant health issue worldwide, and surgical intervention is often required for early-stage disease (FIGO stages IA2–IB2). Open radical hysterectomy has historically been the standard, but laparoscopy has introduced significant advantages: minimally invasive access, reduced blood loss, faster recovery, shorter hospital stay, and improved visualization of pelvic anatomy. Dr. Mishra highlights that LRH provides outcomes comparable to open surgery while minimizing morbidity.

Indications

Laparoscopic radical hysterectomy is indicated for:

Early-stage cervical carcinoma (IA2, IB1, selected IB2 cases).

Early-stage endometrial carcinoma in select patients with high-risk features.

Patients with adequate performance status and no contraindications to laparoscopy.

Contraindications include locally advanced tumors, extensive adhesions, poor pulmonary or cardiac reserve, and uncorrected coagulopathy.

Preoperative Evaluation

A thorough preoperative assessment ensures optimal outcomes:

Imaging studies: MRI or CT scan to determine tumor extent and assess parametrial involvement.

Cystoscopy and sigmoidoscopy if bladder or rectum involvement is suspected.

Blood investigations and anesthesia evaluation.

Informed consent, emphasizing the extent of resection, potential complications, and fertility implications if applicable.

Dr. Mishra stresses the importance of patient counseling regarding urinary and sexual function post-surgery.

Surgical Technique

Dr. Mishra’s approach to laparoscopic radical hysterectomy is systematic, emphasizing anatomical landmarks and safe dissection:

Anesthesia and Positioning

The patient is under general anesthesia, placed in a modified lithotomy position, with steep Trendelenburg to allow bowel displacement.

Port Placement

Pneumoperitoneum is established using a Veress needle or open technique.

A 10 mm umbilical camera port is placed, with additional 5 mm or 10 mm working ports triangulated for instrument maneuverability.

Pelvic Exposure

The peritoneum is incised over the broad ligament.

Ureters are carefully identified and dissected away from the parametrial tissue to prevent injury.

Pelvic Lymphadenectomy

Systematic removal of lymph nodes along the external iliac, internal iliac, obturator, and common iliac vessels.

Dr. Mishra emphasizes meticulous hemostasis to reduce lymphatic complications.

Parametrium and Uterine Vessel Division

The parametrial tissue is carefully dissected, preserving autonomic nerves if possible.

Uterine arteries are skeletonized and divided close to their origin to ensure oncologic clearance.

Vaginal Cuff Resection

A portion of the upper vagina is excised en bloc with the uterus and parametrial tissue.

Intracorporeal suturing is used to close the vaginal cuff, ensuring watertight closure.

Specimen Retrieval

The specimen is retrieved via a laparoscopic bag to prevent tumor spillage.

Morcellation is avoided in malignancy cases.

Completion

Hemostasis is confirmed, ports are removed, and incisions closed.

A pelvic drain may be placed selectively.

Technical Pearls by Dr. Mishra

Maintain constant awareness of ureter and bladder location to prevent injury.

Use sharp dissection along avascular planes for optimal exposure.

Ensure tension-free closure of the vaginal cuff to prevent postoperative fistula.

Meticulous hemostasis and lymphatic control minimize postoperative complications.

Postoperative Care

Early ambulation and deep-breathing exercises are encouraged.

Oral intake resumes once bowel sounds are present.

Pain is controlled with oral or intravenous analgesics.

Discharge is usually within 3–5 days, with follow-up for drain removal and suture check.

Long-term follow-up includes imaging and cytology to monitor recurrence.

Advantages of Laparoscopic Approach

Reduced blood loss compared to open surgery.

Enhanced visualization of pelvic structures for precise dissection.

Shorter hospitalization and quicker return to routine activities.

Lower postoperative pain and improved cosmetic results.

Complications

While safe in trained hands, complications may include:

Urinary tract injury (bladder or ureter)

Vascular injury leading to hemorrhage

Lymphocele formation

Infection or wound complications

Rare recurrence of malignancy if oncologic principles are not followed

Dr. Mishra emphasizes that adherence to meticulous surgical technique minimizes these risks.

Conclusion

Laparoscopic radical hysterectomy, as taught by Dr. R. K. Mishra, represents the convergence of oncologic safety and minimally invasive surgery. With proper patient selection, structured training, and adherence to surgical principles, LRH provides excellent oncological outcomes, reduced morbidity, and improved patient satisfaction. This technique exemplifies the modern approach to gynecologic oncology, offering women effective cancer treatment while optimizing recovery and quality of life.