Laparoscopic lombo-aortic and pelvic lymphadenectomy for endometrial cancer

External iliac lymph nodes are the most commonly involved lymph nodes in endometrial cancer, and para-aortic lymph node (PAN) metastases spread via a route shared by the common iliac lymph nodes. We show a video of a 52-year-old female patient diagnosed with endometrial cancer, undergoing a laparoscopic lymphadenectomy (according to the FIGO guidelines).

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Laparoscopic lombo-aortic and pelvic lymphadenectomy for endometrial cancer

Authors

G Pignata, M Rosati, M Barone, U Bracale

Abstract

External iliac lymph nodes are the most commonly involved lymph nodes in endometrial cancer, and para-aortic lymph node (PAN) metastases spread via a route shared by the common iliac lymph nodes.
We show a video of a 52-year-old female patient diagnosed with endometrial cancer, undergoing a laparoscopic lymphadenectomy (according to the FIGO guidelines).

Catégorie

basic techniques

Mots-clés

Laparoscopic lombo-aortic pelvic lymphadenectomy, endometrial cancer

Type de vidéo

Vidéo chirurgicale

Durée

23'29''

Publication

2009-02

Popularité

Favoris

Favorites Media

Audio

Sous-titres

E-publication

WeBSurg.com, Feb 2009;9(02).
URL: http://www.websurg.com/doi-vd01en2535.htm

Laparoscopic lombo-aortic and pelvic lymphadenectomy for endometrial cancer

1. Clinical case presentation 00'17''

A 52-year-old Italian woman (gravida 2), ASA I, underwent total Laparoscopic hysterectomy and bilateral salpingo-oophorectomy in May 2007. Pelvic lymphadenectomy was not performed. Pathology revealed a uterus weighing 120 g; on microscopy, a G2 stage endometrial adenocarcinoma (endometrioid cells type) was seen to have penetrated the serosa. Peritoneal washings were negative to neoplastic cells. The tumor was staged as pT3a, N0, M0, stage IIIA, according to the International Federation of Gynecology and Obstetrics.1 Two months later, we proposed to the patient a laparoscopic lumbo-aortic lymphadenectomy in according to the FIGO guideline.

2. Team set-up and trocar positioning 01'06''

The patient is placed supine in the Lloyd-Davis position, with her arms alongside the body. Positioning of the trocars and the operating team is according to the schematic.

3. Exposure 01'20''

The root of the mesocolon is exposed by means of traction on the ileocaecal valve with sectioning up to the Treitz’ muscle. The right parietal colic recess is completely opened; a Kocher’s maneuver is used, and the right colon is mobilized with the respected Gerota’s and Toldt’s fascias. The Gerota’s fascia is opened on the right and ipsilateral ovarian vein is exposed. The right ureter is exposed, and together with each cellular lasso, it is loaded with the white vessel loop.

4. Ligation of right ovarian vein 02'44''

The right ovarian vein is isolated, ligated with clips and divided using Ultracision where the vena cava emerges.

5. Removal of cellular lasso 03'09''

The next step is the removal of the cellular lasso adhering to the ovarian vein up to the iliac vessels with exposure of the psoas muscle.

6. Access to the inter-aortic space 03'40''

The following step is isolation, ligature and division at the origin of the inferior mesenteric vein with exposure of the aortic belly. The lumbar aorta is freed on the peri-adventitial plane with exposure of the lumbar branches, which are divided between clips with complete mobilization of the lumbar aorta to give access to the inter-aortic space.

7. Left colon mobilization 05'08''

The left colon is mobilized with respect to Gerota’s fascia. The left ovarian vein is freed from the descending mesocolon up to its outlet in the left renal vein.

8. Duodenopancreatic bloc dislocation 06'32''

The duodenopancreatic bloc is dislocated from the large vessels, vena cava and aorta. The right and left renal veins are exposed, and this represents the limit of our dissection.

9. Vena cava 06'50''

The next step is the division on clips of the small afferent vessels of the vena cava with the freeing of this from the cellular lasso with ultrasonic device. The inferior vena cava is isolated and loaded with the blue vessel loop immediately underneath the outlet of the renal veins. The inter-aortic space is dissected with ultrasonic scissors and the right renal artery, which passes under the vena cava, is isolated.

10. Exposure of the left renal vein 09'30''

Now to the exposure of the left renal vein, which crosses the aorta anteriorly so that the outlet of the left ovarian vein is completely highlighted.

11. Dissection of the peri-adventitial plane 10'42''

Then to the loading of lumbar aorta on vessel loop and consequent dissection of the peri-adventitial plane of the aorta as far as the iliac intersection.

12. Isolation of the ureter and iliac arteries 11'57''

Gerota’s fascia is opened on the left and isolation of the ipsilateral ureter is carried out with the white vessel loop. The right and left common iliac arteries are isolated. Complete dissection of the iliac arterial vessels allows for a perfect vision of the venous intersection completely adhering to the spine. The venous iliac intersection is exposed.

13. “En bloc” removal of the lumbar inter-aortic cellular lasso 15'20''

‘En bloc’ removal of the lumbar inter-aortic cellular lasso and the common iliac artery is performed. Sectioning with clips is undertaken where the left ovarian vessel emerges, and complete dissection of this follows after a small incision of the left parietal colic ligament. Here’s an overall view of the mobilized and dissected lumbar aorta, vena cava with the right renal artery. The left mesocolon is exposed followed by ligature of the inferior mesenteric artery at the origin and exposure of Rioland’s arcade. The psoas muscle and the left ureter are visualized. The right external iliac artery is loaded with a vessel loop. The right external iliac artery is freed from the peri-adventitial plane using the ultrasonic scalpel. The right external iliac artery is mobilized from the psoas muscle. The right external iliac vein is exposed. The right external iliac vein is mobilized from the psoas muscle. The right external iliac vein is freed. The right external iliac vein is isolated and loaded with a vessel loop. The right external inter-iliac space is dissected with the ultrasonic device. The right obturator hollow is dissected and the cellular lasso is removed. The right obturator nerve is isolated and loaded with a yellow vessel loop.

14. Overall view 22'52''

Here’s an overall view of the right obturator nerve, the right ureter, the right external iliac vein, the right external iliac artery, the iliac bifurcation, the aortic bifurcation, and the left common iliac vein.