腹腔镜腹膜外髂腹主动脉旁淋巴结清扫妇科肿瘤（图文演示）

EXTRAPERITONEAL   LAPAROSCOPIC   ILIAC   PARA-AORTIC   LYMPH   NODE   DISSECTION   FOR   GYNECOLOGIC   CANCER
Authors
E Leblanc, D Querleu
Abstract
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.

中文版：腹腔镜腹膜外髂腹主动脉旁淋巴结清扫妇科肿瘤（中文图文演示）

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.

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.