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）

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


&#9654;
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.