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Laparoscopic transperitoneal pelvic lymphadenectomy

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Abstract

The description of the laparoscopic transperitoneal pelvic lymphadenectomy covers all aspects of the surgical procedure used for the management of gynecological cancers.
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: exposure/group, lymphadenectomy, anatomical landmarks.
Consequently, this operating technique is well standardized for the management of this condition.

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Publication

2001-12

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E-publication

WeBSurg.com, Dec 2001;1(12).
URL: http://www.websurg.com/doi-ot02en254.htm

Laparoscopic transperitoneal pelvic lymphadenectomy

1. Introduction

Assessment of the invasion of the pelvic lymph nodes is part of the staging process for several gynecological cancers, including carcinoma of the cervix, endometrium and ovaries. In most cases, imaging techniques cannot reliably evaluate lymphatic spread. Endoscopy offers a satisfying means of determining the surgical stage of the disease. Pelvic lymphadenectomy can influence the therapeutic strategy, especially when a combination of treatments are proposed.
Two approaches are possible:
- the intraperitoneal approach (described in this chapter) permits a complete exploration of the peritoneal cavity. Other surgical procedures such as radical colpohysterectomy can be combined if necessary;
- the extraperitoneal approach, also called lymphadenectomy by panoramic retroperitoneal pelviscopy, was described by Dargent (1992).

2. Anatomy

• Exeresis

External iliac lymphadenectomy involves the removal of the following nodal groups:
1. lateral external iliac lymph nodes: situated between the psoas muscle and the external iliac artery, they are few in number. The most frequently found lymph node on this chain is in a distal position.
2. intermediate external iliac lymph nodes: situated between the external iliac vein and artery or anterior to the external iliac vein. The lymph nodes on this chain are inconsistently identified.
3. medial external iliac lymph nodes: situated between the external iliac vein and the obturator pedicle. This is the principal external iliac chain with a large number of regularly found nodes.
The external iliac lymphadenectomy can be completed by the removal of other nodal chains including the internal iliac, common and lateral aortic (lumbar) chains.

• Landmarks

The anatomical landmarks used in performing the procedure are as follows:
1. round ligament of the uterus;
2. umbilical artery;
3. pelvic ureter;
4. external iliac vein and artery;
5. obturator nerve.

3. Indications

Cancer of the cervix
Carcinoma of the cervix is lymphophilic. The lymphatic spreading begins with the lymph nodes of the parametria, then spreads to the external iliac, common and lateral aortic (lumbar) chains, often in this order. Pelvic lymphadenectomy is therefore a determining element of the prognosis. If cancerous invasion is revealed, verification of the superior nodal levels is mandatory.

Cancer of the endometrium
Lymph node invasion occurs later in cancer of the endometrium than in cervical cancer. Pelvic lymphadenectomy is performed systematically for stages IB, IC and II. It is controversial for stage IA, especially with a well-differentiated tumor.

Cancer of the ovary
Laparoscopic management of ovarian cancer remains debatable due to the risks of dissemination. Pelvic and lumbo-aortic lymphadenectomy should be systematic in the early stages (I and II). It is more controversial in advanced forms of the disease (stages III and IV).

Cancer of the vulva
Invasive tumors of the vulva require an ipsilateral inguinal lymphadenectomy (bilateral with a medial tumor). Verification of the external iliac lymph nodes is sometimes necessary when the inguinal lymph nodes are affected.

4. Preop period

The respiratory and cardiac conditions of the patient must permit general anesthesia. Coagulation tests must be normal and the urinalysis results negative before the procedure. The patient is informed of the operative risks and of the potential need for intraoperative conversion to an open procedure.
The patient must undergo bowel preparation (enema) on the evening before surgery.

5. Operating room set-up

• Patient

- general anesthesia;
- Trendelenburg position (10° to 15°);
- supine;
- legs spread and attached to the table with adhesive strips;
- both arms alongside the body or the right arm positioned at an 80° angle;
- Foley catheter.
Cannulation of the uterus is not mandatory for pelvic lymphadenectomy. It is indicated if the lymphadenectomy is followed by a radical colpohysterectomy.

• Team

1. The surgeon is positioned on the left side of the patient.
2. The assistant is on the right side of the patient.
3. The scrub nurse is on the patient’s left, next to the surgeon.

• Equipment

The laparoscopic unit and monitor are placed at the patient’s feet. For ergonomic reasons, a second monitor should be placed opposite the assistant.

6. Trocar placement

• Landmarks

Four trocars are usually necessary. They are placed at the level:
- of the umbilicus;
- of the pubis;
- of the right anterior superior iliac spine;
- of the left anterior superior iliac spine.

• Trocar placement

The sizes and positions of the trocars are as follows:
A: 11 mm, at the level of the umbilicus
B: 11 mm, above the pubis, at the pubic hairline
C: 5 mm, in the right iliac fossa, 3 cm medial to the right anterior superior iliac spine
D: 5 mm, in the left iliac fossa, 3 cm medial to the left anterior superior iliac spine

7. Instruments

1. 0° laparoscope
2. Atraumatic graspers
3. Graspers
4. Scissors
5. Bipolar coagulating device
6. Monopolar coagulating device
7. Suction-irrigation device

8. Overview

Right lymphadenectomy
The procedure described is a right external iliac lymphadenectomy.

Major steps
The surgeon begins by inspecting the entire peritoneal cavity.
The actual laparoscopic pelvic lymphadenectomy includes several steps:
- identification of the right umbilical artery in its latero-vesical portion;
- opening of the lateral peritoneum;
- identification of the course of the pelvic ureter;
- opening of the paravesical fossa;
- lymphadenectomy of the lateral and intermediate external iliac lymph nodes;
- lymphadenectomy of the medial external iliac lymph nodes.

9. Exposure/group

• Identification of the umbilical artery

The umbilical artery is identified using palpation. The artery is retracted caudally and medially through the peritoneum with an atraumatic grasper.

• Incision of the lateral peritoneum

The incision of the lateral peritoneum is performed between the lumbo-ovarian pedicle (suspensory ligament of the ovary) and the external iliac vessels, from the right paracolic fossa to the round ligament of the uterus, which is divided. The peritoneal incision is extended a few centimeters caudad towards the umbilical artery.
1. Round ligament
2. Umbilical artery

• Identification of the pelvic ureter

The right adnexa are retracted medially with an atraumatic grasper. The surgeon looks for the ureter on the external surface of the peritoneum. The ureter is not necessarily dissected at this point in the procedure. Nevertheless, it must be visible and easily identifiable at all times to avoid injury.

• Opening the paravesical fossa

The umbilical artery is dissected, and then retracted medially with an atraumatic grasper.
The paravesical space is opened using simple diverging traction with the graspers. This plane is generally easy to find. Because the dissection is bloodless, it requires no cauterization. It is extended to the latero-vesical pelvic wall (plane of the levator ani muscles over which the pectineal ligament is suspended).
Posteriorly, dissection of the umbilical artery is pursued to the branching of the internal iliac artery. Dissection of the common trunk leading to the umbilical and uterine arteries to its origin is very useful if the procedure is to be followed by a radical colpohysterectomy.
1. Umbilical artery

10. Lymphadenectomy

• Step 1

Intermediate and lateral external iliac lymph nodes are addressed.
This step begins with the dissection of the external iliac vessels.
The external stump of the round ligament is retracted laterally with a grasper to expose the external iliac artery, which must be dissected along the adventitia of the vessel. The external nodal chain above the external iliac artery is dissected using simple traction. This dissection is continued to the iliac junction.
The surgeon then dissects the internal surface, followed by the superior surface of the external iliac vein. This makes it possible to obtain the nodes situated between the external iliac vein and artery.
1. External iliac artery
2. Lateral external iliac nodes
3. Psoas muscle
4. Intermediate external iliac nodes
5. External iliac vein

• Step 2

1. Medial external iliac nodes
2. External iliac vein
3. External iliac artery

• Dissection

Medial external iliac lymph nodes are addressed.
The internal and inferior surfaces of the external iliac vein are dissected. This dissection is pursued to the pelvic wall, freeing the superior surface of the nodal chain. By dissecting free the lymph nodes, the surgeon can identify the obturator nerve, which represents the deep limit of the lymphadenectomy. Once identified, the nerve is dissected along the portion corresponding to the lymphadenectomy.
1. External iliac vein
2. Pelvic wall
3. Medial external iliac nodes
4. Obturator nerve

• Exeresis

The nodal chain is now freed from its lateral and deep attachments.
The lymph nodes are retracted posteriorly. Their anterior attachments are divided after the use of hemoclips for lymphostasis.
The entire nodal chain is then mobilized medially to expose and dissect the posterior attachments to the iliac vessel bifurcation.
1. Medial external iliac nodes
2. Obturator nerve

• Extraction of the lymph nodes

The lymph nodes are extracted in a laparoscopic bag to avoid contaminating the wall.

11. Anatomical landmarks

The anatomical landmarks at the end of the procedure are:
- medially: the umbilical artery, skeletonized from its paravesical portion to its bifurcation with the internal iliac artery, through the common trunk leading to the umbilical and uterine arteries;
- superiorly and laterally: the external iliac artery and vein skeletonized from the anterior wall to the iliac bifurcation posteriorly;
- inferiorly: the obturator nerve, which is white;
- the ureter.
1. Umbilical artery
2. External iliac artery
3. External iliac vein
4. Obturator nerve
5. Ureter
6. Umbilico-uterine trunk

12. Complications

Intraoperative complications
Complications are rare if the dissection is carried out meticulously. By finding good dissection planes, bleeding can be avoided.
Two difficult situations exist:
- when the procedure is preceded by radio-chemotherapy treatment;
- when the lymph nodes are invaded.
Meticulous hemostasis is mandatory in these cases to correctly identify each element and to avoid division of the obturator nerve.
A small anastomotic vein is sometimes found between the external iliac vein and the obturator pedicle. Care must be taken not to injure it.
External iliac vein injuries are rare, but difficult to identify. Applying strong pressure can sometimes resolve the problem.

Late complications
Late complications rarely occur.
Severe lymphedema of the lower limbs is exceptionally rare. Lymphoceles are more frequent, but are often asymptomatic. To decrease lymphatic weeping, it is advisable to place clips before dividing the anterior and posterior attachments.

13. Reference

Bruhat MA, Glowaczower E, Canis M, Pomel C, Wattiez A, Mage G. Future endoscopic trends in
gynecological oncology. Zentralbl Gynakol 1996;118:49-52.
Lecuru F, Taurelle R. Transperitoneal laparoscopic pelvic lymphadenectomy for gynecologic
malignancies (II). Indications. Surg Endosc 1998;12:97-100.
Magrina JF, Mutone NF, Weaver AL, Magtibay PM, Fowler RS, Cornella JL. Laparoscopic
lymphadenectomy and vaginal or laparoscopic hysterectomy with bilateral salpingo-oophorectomy for
endometrial cancer: morbidity and survival. Am J Obstet Gynecol 1999;181:376-81.
Querleu D, Dargent D, Ansquer Y, Leblanc E, Narducci F. Extraperitoneal endosurgical aortic and
common iliac dissection in the staging of bulky or advanced cervical carcinomas. Cancer
2000;88:1883-91.

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