经腹腹腔镜盆腔淋巴结清扫术（图文演示）

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
• 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
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