Near Total Transection of the Obturator Nerve and Primary Repair during Laparoscopic Radical Hysterectomy for Cervical Cancer

Abstract

Background: Obturator nerve injury is a rare complication and it may occur during pelvic cancer surgery especially during pelvic lymphadenectomy. The injury may cause paraesthesia, sensory loss or pain in the medial thigh which may extend down to the knee. It can also cause weakness in adduction with gait disturbance, medial thigh wasting and possible medico-legal consequences. Case Report: The patient is a 57 year old lady who was found to have an early cervical cancer. MRI abdomen and pelvis was negative for regional lymphadenopathy or distant metastases hence clinically she had a Stage IB1 SCC of cervix. She underwent a Total Laparoscopic Wertheim's Radical Hysterectomy BSO Bilateral Pelvic Lymphadenectomy in February 2015. During the pelvic lymphadenectomy, the left obturator nerve was inadvertently damaged and partially transected by the Harmonic scalpel. The nerve was reconstituted by interrupted 5-O vicryl suture to the epineural layer of the nerve. Post operatively, the patient experienced weakness of the adductor muscles (3/5) but negligible sensory loss. Four months after intensive physiotherapy, the motor deficit was markedly reduced and her gait was normal. There was no sensory loss. Final histology revealed that the surgical margins was clear and 0/41 pelvic lymph nodes were negative. Hence she did not need any adjuvant therapy. Conclusion: Obturator nerve injury is a rare complication with a significant clinical impact if unrecognised. In uncomplicated cases, laparoscopic route of repair is feasible and safe and an immediate repair of the nerve is preferable.