Design: A single case of a patient undergoing laparoscopic trachelectomy for cyclic pelvic pain after supracervical hysterectomy.

Setting: The patient underwent her planned surgery at a large-volume county hospital. Video footage was obtained during this procedure.

Patients or Participants: A 49-year-old woman who had undergone a prior abdominal supracervical hysterectomy, presented with cyclic pelvic pain for several years. Pelvic ultrasound and MRI demonstrated a 5cm mass at the vaginal cuff, concerning for a cervical remnant. The patient elected to undergo a laparoscopic trachelectomy.

Interventions:

Safe laparoscopic trachelectomy can be achieved by following these steps:

1. Lyse any adhesions to the cervical stump and surrounding anatomy
2. Backfill the bladder to delineate the bladder borders
3. Begin making the bladder flap to allow for safe cervical dilation
4. Dilate the cervix under direct visualization
5. Place a manipulator with colpotomy cup if able; alternatively, Breisky Navratil retractors can be placed in the anterior and posterior vaginal fornices to assist with manipulation and colpotomy
6. Complete the bladder flap and safely dissect the bladder below the colpotomy cup
7. Continue this peritoneal excision circumferentially around the cervical stump
8. Identify critical adjacent structures, such as the ureter; ureterolysis is often necessary due to ureteral proximity to the cervical stump
9. Ligate and lateralize the uterine vessel “pedicle” remnants bilaterally
10. Complete the circumferential colpotomy

Measurements and Main Results: The presented case demonstrates successful execution of the above steps and ultimately safe completion of laparoscopic trachelectomy.

Conclusion: Though the reported incidence of trachelectomy following a supracervical hysterectomy is low (2%), it is important for the gynecologic surgeon to be prepared to perform this procedure for this subset of patients. Here we demonstrate a clear, stepwise approach for completing a laparoscopic trachelectomy, providing gynecologic surgeons with a strategy to safely manage the unique challenges presented by the cervical stump and maintain a minimally invasive approach.