Extraperitoneal laparoscopic iliac para-aortic lymph node dissection for gynecologic cancer

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摘要

The description of the extraperitoneal laparoscopic iliac para-aortic lymph node dissection for gynecologic cancer covers all aspects of the surgical procedure used for the management of gynecologic cancer.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: diagnostic laparoscopy, extraperitoneal approach, difficulties, lymphadenectomy, resection.
Consequently, this operating technique is well standardized for the management of this condition.

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2002-03

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WeBSurg.com, Mar 2002;2(03).
URL: http://www.websurg.com/doi-ot02en157.htm

Extraperitoneal laparoscopic iliac para-aortic lymph node dissection for gynecologic cancer

1. Introduction

In the presence of para-aortic lymph node involvement, the therapeutic strategy for pelvic gynecologic cancers is modified. The indications for chemotherapy for adnexal tumors, extended-field radiation or chemotherapy, or palliative treatment alone for uterine cancers are dependent on lymph node status. Imaging techniques are used to observe changes in the size of the lymph nodes.
Classically performed by xiphopubic or extraperitoneal laparotomy, para-aortic lymphadenectomy is associated with a high rate of both immediate and long-term morbidity, largely due to adhesions. Extraperitoneal laparoscopy has transformed the postoperative consequences of this procedure.

2. Anatomy

• Regional anatomy

Lymph node invasion in gynecologic cancers spreads progressively from the pelvis to the para-aortic region, the mediastinal lymph nodes and finally the supraclavicular lymph nodes. The metastases rarely skip a step by involving a superior group without an inferior group. At the para-aortic level, the periaortic and pericaval lymph nodes are interconnected. Lateralization in the involvement does not occur.
1. Inferior vena cava
2. Left renal vein
3. Ovarian pedicle
4. Inferior mesenteric artery
5. Ureter
6. Left common iliac vessels
7. Lymph nodes

• Lymph nodes

1. Precaval nodes
2. Superficial aortico-caval nodes
3. Preaortic nodes
4. Left latero-aortic nodes
5. Left sympathetic chain
6. Lumbar artery
7. Retro-aortic nodes
8. Deep aortico-caval nodes
9. Latero-caval nodes

3. Indications

Advanced cervical carcinomas
Extraperitoneal aortic lymphadenectomy is performed to evaluate cancer metastasis in order to determine the most appropriate modalities and the extensiveness of the treatment to be applied (concerning radiation therapy in particular).
This evaluation is proposed only if routine abdomino-pelvic MRI does not reveal major tumoral invasion. It includes:
- transumbilical diagnostic laparoscopy;
- laparoscopic extraperitoneal para-aortic lymphadenectomy (only if the results of the previous step are normal);
The indications are as follows: stage IB2, IIB, III, IVA (operable or operable centro-pelvic recurrence).
Lymphadenectomy precludes systematic extended-field radiation therapy and the associated risk of radiolesions if the lymph nodes have not been invaded. If they have been invaded, it rules out surgery that is probably ineffective. Lymphadenectomy also causes less adhesions than laparotomy.
In cases of macroscopic invasion at this level, the left supraclavicular lymph nodes are evaluated at the same time. If these lymph nodes have been invaded, a stage IVB cancer is diagnosed, requiring chemotherapy. Radiation therapy is becoming palliative in this instance.

Early invasive ovarian carcinomas (apparent stage I)
Staging of early invasive ovarian carcinomas systematically includes a thorough peritoneal exploration with staged biopsies, infracolic omentectomy, appendectomy, and bilateral pelvic, iliac and para-aortic lymph node dissection. If invasion has occurred, the classification changes from stage I to stage III, and chemotherapy is indicated (Leblanc et al., 2000).
The extraperitoneal approach in this indication is reserved for moderately obese patients for whom transperitoneal para-aortic dissection is generally the most difficult step.

Endometrial carcinoma
There is no routine indication for lymphadenectomy, other than in selected re-staging cases for seropapillary tumors that spread in a manner similar to ovarian carcinomas.

Contraindications
- morphology of the patient: obesity (body mass index >=25) is a contraindication only in cases of extreme obesity (BMI >30).
- previous history of retroperitoneal dissection: vascular surgery involving major vessels, kidney surgery or abdominal wall hernia repair with preperitoneal mesh considerably hindering extraperitoneal laparoscopic lymphadenectomy due to scar tissue formation. In these cases, open surgery is preferable.
- outcome of the preoperative workup or diagnostic laparoscopy: if the preoperative imaging or diagnostic laparoscopy reveals massive para-aortic lymph node invasion, visceral metastases or peritoneal carcinomatosis, the indication for laparoscopy should be reconsidered.

4. Preoperative period

- shaving of pubic hair and upper thighs for xiphopubic laparotomy for hemostasis in the event vascular control is necessary;
- no digestive preparation;
- low molecular weight heparin at an isocoagulant dose, and injection of broad-spectrum antibiotics when anesthesia is induced.

5. Principles/procedure

Extraperitoneal laparoscopic para-aortic lymph node dissection is achieved via a left internal iliac approach (Dargent, 1999). Any contraindication to diagnostic laparoscopy must be ruled out prior to the procedure. The left side is chosen for this approach because most of the lymph nodes are found in the left para-aortic region (Michel, 1998) and because it is also possible to dissect on the right side via this approach (Dargent, 2000). If the preoperative workup reveals right-sided adenopathy, a similar approach on the right is entirely possible.

6. Operating room

• Patient

- general anesthesia;
- urinary catheter;
- gastric tube;
- supine position, with torso on the left edge of the table;
- arms spread at a right angle and legs together;
- flat on the table, but a slight right rotation should be possible.

• Team

1. The surgeon is on the patient’s left.
2. The assistant who handles the laparoscope is to the surgeon’s left.
3. The scrub nurse is to the assistant’s left.

• Equipment

1. Operating table
2. The laparoscopic unit and electrocautery device are opposite the surgeon, on the patient’s right.
3. The suction-irrigation system is behind the surgeon.

7. Trocar placement

• Transumbilical diagnosis

The trocars are placed as follows:
Trocar A, a 10 mm balloon-tipped trocar, is situated at umbilical level. The 0° laparoscope is inserted through this trocar.
Trocar B, 5 mm, through which atraumatic forceps are inserted, is situated in a median supra-pubic position.
Trocar C, 5 mm, through which atraumatic forceps are inserted, is situated medial to the antero-superior iliac spine.

• Extraperitoneal lap

The extraperitoneal installation requires a common surgical instrument kit. In obese patients, Farabeuf retractors of various lengths and widths may be needed.
The characteristics of the different trocars are as follows:
Trocar D, a 10 mm balloon-tipped trocar, is situated in the upper left iliac fossa, 2 to 3 cm above and medial to the iliac spine, on the midclavicular line. A 0° laparoscope is inserted through this trocar.
Trocar E, 10 or 12 mm (with 5 mm converter), is situated in the left flank on the midaxillary line. Grasping forceps, scissors and bipolar instruments are inserted through this trocar.
Trocar F, 5 mm is situated in the left subcostal region, on the external clavicular line. Grasping forceps, scissors, bipolar instruments and the suction-irrigation system are introduced through this trocar.
Trocar G (optional), 5 mm, is situated in the left subcostal region, lateral to trocar F. Grasping forceps are inserted through this trocar.

8. Instruments

Standard laparotomy instruments, along with specific instruments for vascular surgery, must be available.
Few instruments are required for this procedure.
Disposable instruments:
1. Monopolar scissors
2. Extraction bag
3. 10 mm clip applier (not systematic)
Reusable instruments:
4. 10 mm, 0° laparoscope
5. 2 bipolar instruments (2 mm forceps and 5 mm fenestrated grasping forceps)
6. 2 atraumatic, fenestrated grasping forceps
7. Suction-irrigation system

9. Diagnostic laparoscopy

During placement of the trocars, it is essential to avoid perforating the peritoneum in the areas of the future extraperitoneal mobilization.
Trocar placement is therefore done with an umbilical open laparoscopy technique: direct transumbilical cutaneous incision, followed by aponeurotic and peritoneal opening under direct vision.
The 10 mm balloon-tipped trocar is introduced into the peritoneal opening, which is insufflated up to 10 mm Hg.
Two 5 mm operating trocars are placed: one in a median suprapubic position and the other medial to the right anterior-superior iliac spine.
The entire peritoneal cavity is explored, with particular attention to the view of the liver and of the peritoneum of the cupulae. A thorough inspection of the pelvis is carried out, noting the condition of the rectouterine pouch and the reproductive organs. Biopsies are performed on all suspicious nodules, during the procedure if possible. The surgeon concludes by palpating the iliac lymph node area to check for an adenopathy. The abdomen is then exsufflated. The trocars are left in place.

10. Extraperitoneal approach

• Left iliac incision

An incision approximately 2 cm long is made 2 fingerbreadths above and medial to the anterior-superior iliac spine, on the midclavicular line, strictly outside of the contours of the rectus abdominus muscle.

• Parietal passage

The anterior-lateral abdominal muscles are divided in the direction of their fibers, plane by plane, until the peritoneum is reached. The surgeon then introduces a finger into the incision.

• Peritoneal mobilization

The surgeon’s finger laterally mobilizes the parietal peritoneum from the parietal muscles. The transversalis fascia, which will collapse posteriorly, is pushed back until the fibers of the psoas major muscle are found and the beating of the left common iliac artery can be perceived.
1. Psoas major muscle
2. Left common iliac artery

• Trocars

• First trocar

The 10-12 mm trocar is inserted, under control of the finger in the iliac incision, into the left flank, facing the psoas major muscle, halfway between the iliac crest and the 11th rib, on the midaxillary line.

• Insufflation

Extraperitoneal insufflation up to a maximal pressure of 12 mm Hg is carried out through the 10-12 mm trocar introduced into the left flank.
The laparoscope is introduced through this trocar.
1. Psoas major muscle
2. Aorta
3. Ureter
4. Parietal peritoneum

• Other trocars

1. The 5 mm subcostal trocar is placed under extraperitoneal visual guidance and under the control of the finger left in the iliac incision. It is inserted through the muscular planes, remaining at a distance from the reflection of the mobilized peritoneum. It is pushed down into the space created.
2. The “iliac finger” is then replaced by the last 10 mm trocar whose balloon tip is inflated under visual guidance in the extraperitoneal space, either with air or with saline (20 mL).
3. The laparoscope is put back into the iliac trocar and the instruments are inserted through the 2 other trocars.

11. Difficulties

Extraperitoneal approach
- previous history of iliac surgery: a previous hernia repair or an appendectomy (in the case of an approach on the right side) can hinder the extraperitoneal approach and lead to tearing of the peritoneum. To prevent this from happening, the iliac incision should be made higher and more externally than the pre-existing scars.
- difficulty in perceiving the psoas major muscle: to avoid getting lost in the posterior-lateral muscle planes, it is necessary to first cause the transversalis fascia to collapse. Exposure of the psoas major muscle can be facilitated by the placement of the trocar in the flank, insufflation and insertion of the laparoscope. The index finger then exposes the anterior surface of the psoas major muscle under visual guidance.

Extraperitoneal dissection space is insufficient
- major obesity: the weight of the peritoneal cavity contents can prevent the extraperitoneal gaseous expansion required for a safe dissection.
In these cases it is advisable to:
- ensure that the muscle relaxation of the patient is sufficient;
- accentuate the tilt of the table to the right;
- increase the maximal insufflation pressure (to no higher than 14 mm Hg).
A fourth trocar may be placed in subcostal position, posterior to the 5 mm trocar, to lift up the kidney, the perirenal fat and the peritoneal contents that impair the view.
If these measures are insufficient or are not well tolerated, the surgeon must discontinue the laparoscopic procedure. A BMI>30 should alert the surgeon to potential difficulties in laparoscopy.
- pneumoperitoneum: whether it occurs by progressive diffusion of CO2 or by peritoneal tearing, the intraperitoneal pressure of the pneumperitoneum can cause the extraperitoneal space to cave in and hinder the dissection.
In this case, the laparoscopic umbilical trocar should be opened wide to evacuate the pneumoperitoneum. This can take care of the problem in the case of pneumoperitoneum by diffusion.
If visible peritoneal tearing occurs, the breach is sutured.

12. Lymphadenectomy

• Principles

After identification of vascular landmarks and development of the peritoneal space, iliac and para-aortic lymph node dissection involves several successive lymph node removal steps, the order of which is left up to the surgeon.
All suspicious lymph nodes are sent for examination during the procedure. Positive results should make the surgeon reconsider pursuing the procedure.

• Vascular landmarks

• Step 1

- wide mobilization of the parietal peritoneum bearing the uterer and the gonadal vessels, and then of the psoas major muscle posteriorly and the aorta medially.
Landmarks are identified in several steps, increasingly precise from left to right:
- initial identification of the left common iliac artery where it crosses the ureter, and then of the left flank of the aorta, still covered by the lymph nodes and crossed by the sympathetic postganglionic nerve fibers.
1. Gonadal vessels
2. Ureter
3. Aorta
4. Psoas major muscle

• Step 2

- identification of the left renal vein, following the course of the ovarian vein.
1. Gonadal vessels
2. Left renal vein

• Step 3

- exposure inferiorly of the aortic branching and of the origin of the right common iliac artery.
1. Aortic branching

• Step 4

- exposure of the origin of the inferior mesenteric artery: this can be identified by the convergence at its origin of sympathetic postganglionic nerve fibers;
- progressive freeing of the anterior surface of the aorta, caudad to cephalad, up to the duodenum.
1. Inferior mesenteric artery

• Step 5

- exposure, followed by coagulation-division, of the origin of the left ovarian artery that can be easily avulsed. This is potentially dangerous, as the left renal artery can arise beneath the vein. Special care must be taken when this level is reached;
- complete exposure of the left renal vein, previously identified, and finally of the vena cava.
1. Left renal vein
2. Coagulated ovarian artery
3. Aorta
4. Azygos-lumbar venous network
5. Left ovarian vein

13. Resection

• Resection 1

Resection of the iliac and aortic nodes is done en bloc, caudad to cephalad, along the vascular adventitia.
- the node-bearing tissue is divided at the level of the left common iliac artery;
- the lymph nodes along the aorta are mobilized en bloc, until the left renal vein is reached, simultaneously separating them from the preaortic lymph node group and from the posterior plane made up of the psoas major muscle, the left sympathetic chain and the vertebral plane;
- the post-ganglionic nerve fibers are progressively divided;
- the lumbar vessels that course behind the sympathetic chain are easily identified and preserved if the progression remains strictly above the plane of the sympathetic chain;
- the lymph node chain is divided at the base of the left renal vein or its artery; note the renal-azygos-lumbar venous network that is almost always present. Dissection of the renal vein must be meticulous, in order to first identify the posterior junction of the azygos vein with the renal vein and to free the azygos vein cephalad to caudad along its entire course.
1. Inferior mesenteric artery
2. Aorta
3. Lumbar artery
4. Left renal vein

• Resection 2

The superficial precaval and aortico-caval lymph nodes are resected.
The vena cava is identified by following the left renal vein (with bipolar coagulation and division of the large lymphatic trunks that cross over it). Its anterior surface is then freed. When the right ovarian artery is exposed, it is coagulated with the bipolar grasper and divided.
a) The lymph nodes situated above the origin of the inferior mesenteric artery are dissected and removed as follows:
- mobilization of the preaortic and precaval node-bearing tissue of the large vessels posteriorly and the pancreaticoduodenal block posteriorly;
- superior limit at the level of the left renal vein. The origin of the right ovarian artery must be coagulated and divided as soon as it is exposed;
- inferior limit of the lymph node chain facing the origin of the inferior mesenteric artery.
b) The precaval and interaortico-caval lymph nodes situated below the inferior mesenteric artery origin and those of the aortic bifurcation are dissected and removed as follows:
- mobilization of the anterior aortic node-bearing tissue of the large vessels posteriorly and the posterior parietal peritoneum anteriorly; the superior limit is the inferior mesenteric artery origin, and the inferior limit is situated below the aortic and caval bifurcation;
- dissection of the aortic bifurcation (with exposure of the 2 common iliac arteries down to their bifurcation), the left common iliac vein and the inferior caval confluent;
- resection of the lymph nodes of the aortic bifurcation and the common iliac bifurcations until the promontory is reached.
a b
1. Left ureter
2. Left common iliac bifurcation
3. Inferior caval bifurcation
4. Right common iliac bifurcation

• Resection 3

Resection of the ilio-caval lymph nodes involves the following steps:
- mobilization of the peritoneum on the right, beyond the common iliac artery and vena cava;
- identification of the right psoas major muscle, the ureter and the right gonadal vessels;
- freeing of the right latero-iliac and latero-caval lymph nodes, up to the right ovarian vein.
1. Psoas major muscle
2. Ureter
3. Right ovarian vein
4. Inferior vena cava
5. Aorta
6. Inferior mesenteric artery

• Resection 4

The aorta is lifted, and the resection of the retro-aortic and deep aortico-caval lymph nodes is carried out between the lumbar pedicles. The lumbar pedicles are preserved.
The coagulation or stapling and division of the lumbar arteries makes it possible to lift the aorta, in order to scoop out the remaining, more deeply situated retro-aortic and interaortic lymph nodes. This is indicated only if there is a suspicious lymph node at this level.
1. Inferior mesenteric artery
2. Aorta
3. Inferior vena cava
4. Left renal vein

14. Difficulties

Vascular anomalies
If possible, vascular anomalies (of the vena cava, retro-aortic renal vein or inferior polar renal artery) should be identified during the preoperative workup (CT scan or MRI). Dissection of the vascular axes must be meticulous.

Hemorrhage
Course of action in case of minor bleeding:
- suctioning should not be excessive.
- tamponade is performed with the neighboring tissues or a sponge. It is held for a few minutes and then released.
- the site of the dissection is changed until the bleeding stops (this occurs frequently). Suction-irrigation is then done.
- if the bleeding persists, bipolar cauterization should be used.
Course of action in case of major bleeding:
- do not clip or clamp, as this can aggravate the lesions.
- tamponade is performed for a few minutes until hemostasis (at least partial) is achieved. Bipolar cauterization or clips may then be used with gentle irrigation-suction to achieve complete hemostasis.
- if hemostasis cannot be achieved, maintain the endoscopic tamponade and convert to a laparotomy.

Fixed adenopathy
In case of an adenopathy <= 3 cm, laparoscopic dissection can be attempted in the perinodal planes, but the surgeon should not persist if it is tightly adherent to the vessel.
In case of neoplastic dissemination, the surgeon should carefully perform a cytologic paracentesis and abandon the lymph node dissection.
In case of a voluminous adenopathy >3 cm or major adherence with the vessel, conversion to extraperitoneal laparotomy centered on the adenopathy is recommended.

Others
- ureteral injury: rare in this approach, it can occur in the case of adherence to nodes. Depending on its severity, the surgeon can perform an endoscopic suture over a stent or convert to an open approach to carry out the repair.
- nerve injury: if accidental injury (division, burn) to the sympathetic chain results in a unilateral sympathectomy with vasomotor disturbances in the leg, systematic division of the postnodal fibers has no reported consequences in women.
- hypercapnia: seen in elevated end-tidal CO2 (ETCO2), this is very moderate and can be controlled by adjusting the ventilation rate. With the pressures used, it has never led to operative complications.
- subcutaneous emphysema: rare and always limited, it has rarely, if ever, led to specific complications.

15. End of procedure

The lymph nodes are extracted in an endoscopic bag through the iliac incision, under guidance of the laparoscope introduced into the left flank.
Hemostasis and lymphostasis are carried out with a bipolar grasper.
In uterine cancer, the inferior limit of the lymphadenectomy (promontory) is clipped to determine the superior limit for subsequent radiation therapy in the absence of lymph node invasion.
Lavage of the operative area is performed.
Prevention of lymphoceles is done at the end of the procedure by internal drainage, after opening the peritoneum of the left paracolic gutter laparoscopically.
Following extraperitoneal exsufflation, the surgeon reinsufflates the abdomen and returns to classic laparoscopy.
The parietal peritoneum of the left paracolic gutter is opened facing the balloon tip of the iliac trocar. The incision is widened from this opening along the left colon.
Following exsufflation of the abdomen, the trocars are removed and trocar wounds are cleansed with betadine solution. Simple skin closure is done for the 5 mm openings. For openings 10 mm and larger, the aponeurotic plane is closed in addition to the cutaneous plane.
The gastric tube and urinary catheter are removed at the end of the operation.
Normal diet is resumed on the evening of the operation or on the next day.
The patient may return home on POD1 or POD2.
To prevent deep venous thrombosis, low molecular weight heparin is administered for about 10 days postoperatively.
a. Preventative marsupialization of the left paracolic gutter
1. 5 mm subcostal trocar
2. 10 mm trocar in the flank
3. Left colon
4. Extraperitoneal space
5. Opened peritoneum

16. Reference

Benedetti-Panici P, Greggi S, Maneschi F, Scambia G, Amoroso M, Rabitti C et al. Anatomical and
pathological study of retroperitoneal nodes in epithelial ovarian cancer. Gynecol Oncol 1993;51:150-4.
Dargent D. Retroperitoneal approach for Lymph Node Sampling and Dissection. In: Querleu D,
Childers J, Dargent D, editors. Laparoscopic Surgery in Gynaecological Oncology. London Edinburgh:
Blackwell Science Oxford; 1999. p. 34-46.
Dargent D, Ansquer Y, Mathevet P. Technical development and results of left extraperitoneal
laparoscopic paraaortic lymphadenectomy for cervical cancer. Gynecol Oncol 2000;77:87-92.
Leblanc E, Querleu D, Narducci F, Chauvet MP, Chevalier A, Lesoin A et al. Surgical staging of early
invasive epithelial ovarian tumors. Semin Surg Oncol 2000;19:36-41.
Michel G, Morice P, Castaigne D, Leblanc M, Rey A, Duvillard P. Lymphatic spread in stage Ib and II
cervical carcinoma: anatomy and surgical implications. Obstet Gynecol 1998;91:360-3.

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