- Email: [email protected]
Extra-peritoneal laparoscopic para-aortic lymphadenectomy for staging of uterine cervix carcinoma
+Model
ARTICLE IN PRESS
JVS-677; No. of Pages 8
Journal of Visceral Surgery (2017) xxx, xxx—xxx
Available online at
ScienceDirect www.sciencedirect.com
SURGICAL TECHNIQUE
Extra-peritoneal laparoscopic para-aortic lymphadenectomy for staging of uterine cervix carcinoma M.-E. Neveu ∗, E. Bentivegna , S. Gouy Service de chirurgie générale, Gustave-Roussy, 114, rue Édouard-Vaillant, 94800 Villejuif, France
Introduction Surgical staging for para-aortic lymph node involvement is a key step in the management of locally advanced carcinoma of the uterine cervix. Effectively, the standard treatment for FIGO stages IB2 (2009) or higher, is pelvic chemo-radiotherapy combined with concurrent brachytherapy [1]. The extent of irradiation should be adapted to lymph node status [2,3]. Because the false negative rate may be as high as 12 to 22% for PET scan, the reference imaging study, surgical staging of the lumbo-aortic lymph nodes is indispensable, in order to provide the best adapted treatment. This procedure was long considered to be at high risk for complications, however, the advent of laparoscopic, and in particular, extra-peritoneal laparoscopic assessment, introduced in 1995, has drastically decreased the associated morbidity [4]. This is currently the preferred route for lymph node assessment. Moreover, the extra-peritoneal route circumvents the difficulty of dealing with bothersome intestinal loops, facilitates the procedure in patients with elevated body-mass index (BMI) and decreases post-operative adhesions [5]. Conversely, because of not infrequent anatomic variations in this area (left-sided vena cava, retro-aortic renal vein or inferior renal polar artery), rigorous pre-operative analysis of abdomino-pelvic CT and MRI is necessary.
∗
Corresponding author. E-mail address: [email protected] (M.-E. Neveu).
http://dx.doi.org/10.1016/j.jviscsurg.2017.01.005 1878-7886/© 2017 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Neveu M-E, et al. Extra-peritoneal laparoscopic para-aortic lymphadenectomy for staging of uterine cervix carcinoma. Journal of Visceral Surgery (2017), http://dx.doi.org/10.1016/j.jviscsurg.2017.01.005
+Model JVS-677; No. of Pages 8
ARTICLE IN PRESS
2
M.-E. Neveu et al.
Patient position and exploration of 1 the peritoneal cavity
The patient is positioned recumbent, with the legs slightly parted, the right arm at the side, and the left arm abducted at 90◦ . The patient should be positioned close to the left edge of the operation table. The surgeon stands to the patient’s left, the first assistant either on the operator’s left, or between the patient’s legs. The instrument nurse is on the left of the operator. The video tower is placed on the right, opposite the surgeon. The first step is to perform routine diagnostic laparoscopy to see that there is no peritoneal carcinomatosis. A 10 mm trans-umbilical trocar is placed for the optical device after open access. A 5 mm trocar in the right iliac fossa for an atraumatic grasper allows complete exploration of the abdominal cavity, adnexae and uterus.
Incision for the extra-peritoneal 2 approach
The left iliac lymph nodes are explored through a left iliac incision because most of the lymph nodes are in the left para-aortic region and it is possible to dissect on the right through this same approach. A 2 cm iliac incision is made two fingerbreadths above and medial to the left antero-superior iliac crest at the mid-clavicular line, lateral to the bulge of the rectus muscles.
Please cite this article in press as: Neveu M-E, et al. Extra-peritoneal laparoscopic para-aortic lymphadenectomy for staging of uterine cervix carcinoma. Journal of Visceral Surgery (2017), http://dx.doi.org/10.1016/j.jviscsurg.2017.01.005
+Model JVS-677; No. of Pages 8
ARTICLE IN PRESS
Extra-peritoneal laparoscopic para-aortic lymphadenectomy in cervical cancer
3
3
Extra-peritoneal approach
With adequate retractors and Mayo scissors, the external and internal oblique and transverse muscles are successively divided in the direction of their fibers (a—c). The peritoneum may be seen deep in the incision; the lateral aspect of the peritoneum is freed from the transversus muscle with blunt finger dissection, but not extending medial to the lateral border of the rectus sheath. Posteriorly, the dissection is pursued down to the psoas muscle and the pulsations of the left common iliac artery.
Please cite this article in press as: Neveu M-E, et al. Extra-peritoneal laparoscopic para-aortic lymphadenectomy for staging of uterine cervix carcinoma. Journal of Visceral Surgery (2017), http://dx.doi.org/10.1016/j.jviscsurg.2017.01.005
+Model JVS-677; No. of Pages 8
ARTICLE IN PRESS
4
M.-E. Neveu et al.
4
Trocar placement
After dissection of the extra-peritoneal space, a 10 mm trocar (Trocar # 4) is inserted in the left flank, in the mid-axillary line, half-way between the iliac crest and the costal margin, making sure that the peritoneum is not breached, thanks to the finger placed in the left iliac incision. The laparoscope is introduced into the 10 mm trocar; insufflation pressure is set at 12 mmHg. The anterior aspect of the psoas is identified with the index finger, which is then pushed medially until the left ureter, the ovarian vessels and the common iliac artery can be identified. A 5 mm left subcostal trocar is placed through the transversus muscle (Trocar #5). The index finger is replaced by a 10 mm balloonarmed trocar and then the laparoscope is reinserted through this trocar (Trocar #3).
Please cite this article in press as: Neveu M-E, et al. Extra-peritoneal laparoscopic para-aortic lymphadenectomy for staging of uterine cervix carcinoma. Journal of Visceral Surgery (2017), http://dx.doi.org/10.1016/j.jviscsurg.2017.01.005
+Model JVS-677; No. of Pages 8
ARTICLE IN PRESS
Extra-peritoneal laparoscopic para-aortic lymphadenectomy in cervical cancer
5
5
Identification of the anatomical landmarks
The dissection of the left parietal peritoneum is continued posteriorly with atraumatic graspers, in contact with the psoas, visualizing the left ureter, ovarian vessels, the aorta and the psoas (a). The common iliac bifurcation, crossed by the left ureter, is identified. The left ureter is allowed to remain adherent to the peritoneum anteriorly. The antero-lateral aspect of the left common iliac artery and then the aorta are identified. By gentle dissection, the peritoneum with the ureter and left ovarian pedicle are retracted allowing visualization of the first few centimeters of the inferior mesenteric artery, then cephalad (b), following the anterior aspect of the aorta and the left ovarian vein upward until the left renal vein is identified (c).
Please cite this article in press as: Neveu M-E, et al. Extra-peritoneal laparoscopic para-aortic lymphadenectomy for staging of uterine cervix carcinoma. Journal of Visceral Surgery (2017), http://dx.doi.org/10.1016/j.jviscsurg.2017.01.005
+Model JVS-677; No. of Pages 8
6
ARTICLE IN PRESS M.-E. Neveu et al.
6
Lymphadenectomy
The order of the following steps is for arbitrary; the order can be modified according to surgeon preferences or anatomical difficulties. Lymphadenectomy starts at the level of the left iliac bifurcation using the ultrasonic dissector, respecting the left ureter. Dissection continues along the anterior surface of the left common iliac artery and aorta. Lymphadenectomy is pursued along the aorta, respecting the inferior mesenteric artery. Continuing behind and to the left of the aorta, the surgeon identifies the left sympathetic chain, as well as the vertebral column and the lumbar pedicles that are either preserved or coagulated. The dissection of the pre- and latero-aortic lymph node laminae is pursued up to the left renal vein. Caution is warranted during dissection because of the many possible anatomic variations in this area. The upper limit of the lymphadenectomy is the left renal vein. The lymph node lamina is divided flush with the left renal vein or artery with clips in order to limit leakage of lymphatic fluid. The dissection of the renal vein should identify the termination of the ascending lumbar vein, nearly always present, on the inferior aspect of the left renal vein. This vein must be dissected free from top to bottom along its entire length. The left lateral aspect of the aorta and the inferior aspect of the left renal vein are thus entirely dissected free of all lymphatic tissues. The specimen is extracted in an endoscopic bag. Hemostasis and lymphostasis are completed as needed.
Please cite this article in press as: Neveu M-E, et al. Extra-peritoneal laparoscopic para-aortic lymphadenectomy for staging of uterine cervix carcinoma. Journal of Visceral Surgery (2017), http://dx.doi.org/10.1016/j.jviscsurg.2017.01.005
+Model JVS-677; No. of Pages 8
ARTICLE IN PRESS
Extra-peritoneal laparoscopic para-aortic lymphadenectomy in cervical cancer
7
Fenestration
8
Post-operative follow-up
The peritoneum is fenestrated transperitoneally. This requires that the laparoscope and insufflator be repositioned in the initial trans-umbilical trocar. The left latero-sigmoid and laterocolic peritoneum have already been dissected free of the deeper planes (a). Next, the peritoneum is opened widely, with the intent of decreasing the incidence of lymphocele by creating a communication between the retroperitoneal space and the peritoneum (b). Abdominal drainage is not necessary.
The bladder catheter is removed in the operating room at the end of the operation. Alimentation is allowed the same day and the patient can leave the hospital on post-operative day 1. Level 1 or 2 analgesics are prescribed upon discharge. Class 2 compression stockings are recommended for one month. Preventive anticoagulation is also recommended for one month. The patient is seen on day 15; chemo-radiation can start at that date.
Please cite this article in press as: Neveu M-E, et al. Extra-peritoneal laparoscopic para-aortic lymphadenectomy for staging of uterine cervix carcinoma. Journal of Visceral Surgery (2017), http://dx.doi.org/10.1016/j.jviscsurg.2017.01.005
7
+Model JVS-677; No. of Pages 8
ARTICLE IN PRESS
8
M.-E. Neveu et al.
Disclosure of interest The authors declare that they have no competing interest.
References [1] Nath R, Rivard MJ, DeWerd LA, et al. Guidelines by the AAPM and GEC-ESTRO on the use of innovative brachytherapy devices and applications: Report of Task Group 167. Med Phys 2016;43(6):3178. [2] Chemoradiotherapy for Cervical Cancer Meta-analysis Collaboration (CCCMAC). Reducing uncertainties about the effects of
chemoradiotherapy for cervical cancer: individual patient data meta-analysis. Cochrane Database Syst Rev 2010;(1):CD008285. [3] Gouy S, Morice P, Narducci F, et al. Nodal-staging surgery for locally advanced cervical cancer in the era of PET. Lancet Oncol 2012;13(5):e212—20. [4] Cartron G, Leblanc E, Ferron G, Martel P, Narducci F, Querleu D. Complications of laparoscopic lymphadenectomy in gynaecologic oncology. A series of 1102 procedures in 915 patients. Gynecol Obstet Fertil 2005;33(5):304—14. [5] Sonoda Y, Leblanc E, Querleu D, et al. Prospective evaluation of surgical staging of advanced cervical cancer via a laparoscopic extraperitoneal approach. Gynecol Oncol 2003;91(2): 326—31.
Please cite this article in press as: Neveu M-E, et al. Extra-peritoneal laparoscopic para-aortic lymphadenectomy for staging of uterine cervix carcinoma. Journal of Visceral Surgery (2017), http://dx.doi.org/10.1016/j.jviscsurg.2017.01.005
ARTICLE IN PRESS
JVS-677; No. of Pages 8
Journal of Visceral Surgery (2017) xxx, xxx—xxx
Available online at
ScienceDirect www.sciencedirect.com
SURGICAL TECHNIQUE
Extra-peritoneal laparoscopic para-aortic lymphadenectomy for staging of uterine cervix carcinoma M.-E. Neveu ∗, E. Bentivegna , S. Gouy Service de chirurgie générale, Gustave-Roussy, 114, rue Édouard-Vaillant, 94800 Villejuif, France
Introduction Surgical staging for para-aortic lymph node involvement is a key step in the management of locally advanced carcinoma of the uterine cervix. Effectively, the standard treatment for FIGO stages IB2 (2009) or higher, is pelvic chemo-radiotherapy combined with concurrent brachytherapy [1]. The extent of irradiation should be adapted to lymph node status [2,3]. Because the false negative rate may be as high as 12 to 22% for PET scan, the reference imaging study, surgical staging of the lumbo-aortic lymph nodes is indispensable, in order to provide the best adapted treatment. This procedure was long considered to be at high risk for complications, however, the advent of laparoscopic, and in particular, extra-peritoneal laparoscopic assessment, introduced in 1995, has drastically decreased the associated morbidity [4]. This is currently the preferred route for lymph node assessment. Moreover, the extra-peritoneal route circumvents the difficulty of dealing with bothersome intestinal loops, facilitates the procedure in patients with elevated body-mass index (BMI) and decreases post-operative adhesions [5]. Conversely, because of not infrequent anatomic variations in this area (left-sided vena cava, retro-aortic renal vein or inferior renal polar artery), rigorous pre-operative analysis of abdomino-pelvic CT and MRI is necessary.
∗
Corresponding author. E-mail address: [email protected] (M.-E. Neveu).
http://dx.doi.org/10.1016/j.jviscsurg.2017.01.005 1878-7886/© 2017 Elsevier Masson SAS. All rights reserved.
Please cite this article in press as: Neveu M-E, et al. Extra-peritoneal laparoscopic para-aortic lymphadenectomy for staging of uterine cervix carcinoma. Journal of Visceral Surgery (2017), http://dx.doi.org/10.1016/j.jviscsurg.2017.01.005
+Model JVS-677; No. of Pages 8
ARTICLE IN PRESS
2
M.-E. Neveu et al.
Patient position and exploration of 1 the peritoneal cavity
The patient is positioned recumbent, with the legs slightly parted, the right arm at the side, and the left arm abducted at 90◦ . The patient should be positioned close to the left edge of the operation table. The surgeon stands to the patient’s left, the first assistant either on the operator’s left, or between the patient’s legs. The instrument nurse is on the left of the operator. The video tower is placed on the right, opposite the surgeon. The first step is to perform routine diagnostic laparoscopy to see that there is no peritoneal carcinomatosis. A 10 mm trans-umbilical trocar is placed for the optical device after open access. A 5 mm trocar in the right iliac fossa for an atraumatic grasper allows complete exploration of the abdominal cavity, adnexae and uterus.
Incision for the extra-peritoneal 2 approach
The left iliac lymph nodes are explored through a left iliac incision because most of the lymph nodes are in the left para-aortic region and it is possible to dissect on the right through this same approach. A 2 cm iliac incision is made two fingerbreadths above and medial to the left antero-superior iliac crest at the mid-clavicular line, lateral to the bulge of the rectus muscles.
Please cite this article in press as: Neveu M-E, et al. Extra-peritoneal laparoscopic para-aortic lymphadenectomy for staging of uterine cervix carcinoma. Journal of Visceral Surgery (2017), http://dx.doi.org/10.1016/j.jviscsurg.2017.01.005
+Model JVS-677; No. of Pages 8
ARTICLE IN PRESS
Extra-peritoneal laparoscopic para-aortic lymphadenectomy in cervical cancer
3
3
Extra-peritoneal approach
With adequate retractors and Mayo scissors, the external and internal oblique and transverse muscles are successively divided in the direction of their fibers (a—c). The peritoneum may be seen deep in the incision; the lateral aspect of the peritoneum is freed from the transversus muscle with blunt finger dissection, but not extending medial to the lateral border of the rectus sheath. Posteriorly, the dissection is pursued down to the psoas muscle and the pulsations of the left common iliac artery.
Please cite this article in press as: Neveu M-E, et al. Extra-peritoneal laparoscopic para-aortic lymphadenectomy for staging of uterine cervix carcinoma. Journal of Visceral Surgery (2017), http://dx.doi.org/10.1016/j.jviscsurg.2017.01.005
+Model JVS-677; No. of Pages 8
ARTICLE IN PRESS
4
M.-E. Neveu et al.
4
Trocar placement
After dissection of the extra-peritoneal space, a 10 mm trocar (Trocar # 4) is inserted in the left flank, in the mid-axillary line, half-way between the iliac crest and the costal margin, making sure that the peritoneum is not breached, thanks to the finger placed in the left iliac incision. The laparoscope is introduced into the 10 mm trocar; insufflation pressure is set at 12 mmHg. The anterior aspect of the psoas is identified with the index finger, which is then pushed medially until the left ureter, the ovarian vessels and the common iliac artery can be identified. A 5 mm left subcostal trocar is placed through the transversus muscle (Trocar #5). The index finger is replaced by a 10 mm balloonarmed trocar and then the laparoscope is reinserted through this trocar (Trocar #3).
Please cite this article in press as: Neveu M-E, et al. Extra-peritoneal laparoscopic para-aortic lymphadenectomy for staging of uterine cervix carcinoma. Journal of Visceral Surgery (2017), http://dx.doi.org/10.1016/j.jviscsurg.2017.01.005
+Model JVS-677; No. of Pages 8
ARTICLE IN PRESS
Extra-peritoneal laparoscopic para-aortic lymphadenectomy in cervical cancer
5
5
Identification of the anatomical landmarks
The dissection of the left parietal peritoneum is continued posteriorly with atraumatic graspers, in contact with the psoas, visualizing the left ureter, ovarian vessels, the aorta and the psoas (a). The common iliac bifurcation, crossed by the left ureter, is identified. The left ureter is allowed to remain adherent to the peritoneum anteriorly. The antero-lateral aspect of the left common iliac artery and then the aorta are identified. By gentle dissection, the peritoneum with the ureter and left ovarian pedicle are retracted allowing visualization of the first few centimeters of the inferior mesenteric artery, then cephalad (b), following the anterior aspect of the aorta and the left ovarian vein upward until the left renal vein is identified (c).
Please cite this article in press as: Neveu M-E, et al. Extra-peritoneal laparoscopic para-aortic lymphadenectomy for staging of uterine cervix carcinoma. Journal of Visceral Surgery (2017), http://dx.doi.org/10.1016/j.jviscsurg.2017.01.005
+Model JVS-677; No. of Pages 8
6
ARTICLE IN PRESS M.-E. Neveu et al.
6
Lymphadenectomy
The order of the following steps is for arbitrary; the order can be modified according to surgeon preferences or anatomical difficulties. Lymphadenectomy starts at the level of the left iliac bifurcation using the ultrasonic dissector, respecting the left ureter. Dissection continues along the anterior surface of the left common iliac artery and aorta. Lymphadenectomy is pursued along the aorta, respecting the inferior mesenteric artery. Continuing behind and to the left of the aorta, the surgeon identifies the left sympathetic chain, as well as the vertebral column and the lumbar pedicles that are either preserved or coagulated. The dissection of the pre- and latero-aortic lymph node laminae is pursued up to the left renal vein. Caution is warranted during dissection because of the many possible anatomic variations in this area. The upper limit of the lymphadenectomy is the left renal vein. The lymph node lamina is divided flush with the left renal vein or artery with clips in order to limit leakage of lymphatic fluid. The dissection of the renal vein should identify the termination of the ascending lumbar vein, nearly always present, on the inferior aspect of the left renal vein. This vein must be dissected free from top to bottom along its entire length. The left lateral aspect of the aorta and the inferior aspect of the left renal vein are thus entirely dissected free of all lymphatic tissues. The specimen is extracted in an endoscopic bag. Hemostasis and lymphostasis are completed as needed.
Please cite this article in press as: Neveu M-E, et al. Extra-peritoneal laparoscopic para-aortic lymphadenectomy for staging of uterine cervix carcinoma. Journal of Visceral Surgery (2017), http://dx.doi.org/10.1016/j.jviscsurg.2017.01.005
+Model JVS-677; No. of Pages 8
ARTICLE IN PRESS
Extra-peritoneal laparoscopic para-aortic lymphadenectomy in cervical cancer
7
Fenestration
8
Post-operative follow-up
The peritoneum is fenestrated transperitoneally. This requires that the laparoscope and insufflator be repositioned in the initial trans-umbilical trocar. The left latero-sigmoid and laterocolic peritoneum have already been dissected free of the deeper planes (a). Next, the peritoneum is opened widely, with the intent of decreasing the incidence of lymphocele by creating a communication between the retroperitoneal space and the peritoneum (b). Abdominal drainage is not necessary.
The bladder catheter is removed in the operating room at the end of the operation. Alimentation is allowed the same day and the patient can leave the hospital on post-operative day 1. Level 1 or 2 analgesics are prescribed upon discharge. Class 2 compression stockings are recommended for one month. Preventive anticoagulation is also recommended for one month. The patient is seen on day 15; chemo-radiation can start at that date.
Please cite this article in press as: Neveu M-E, et al. Extra-peritoneal laparoscopic para-aortic lymphadenectomy for staging of uterine cervix carcinoma. Journal of Visceral Surgery (2017), http://dx.doi.org/10.1016/j.jviscsurg.2017.01.005
7
+Model JVS-677; No. of Pages 8
ARTICLE IN PRESS
8
M.-E. Neveu et al.
Disclosure of interest The authors declare that they have no competing interest.
References [1] Nath R, Rivard MJ, DeWerd LA, et al. Guidelines by the AAPM and GEC-ESTRO on the use of innovative brachytherapy devices and applications: Report of Task Group 167. Med Phys 2016;43(6):3178. [2] Chemoradiotherapy for Cervical Cancer Meta-analysis Collaboration (CCCMAC). Reducing uncertainties about the effects of
chemoradiotherapy for cervical cancer: individual patient data meta-analysis. Cochrane Database Syst Rev 2010;(1):CD008285. [3] Gouy S, Morice P, Narducci F, et al. Nodal-staging surgery for locally advanced cervical cancer in the era of PET. Lancet Oncol 2012;13(5):e212—20. [4] Cartron G, Leblanc E, Ferron G, Martel P, Narducci F, Querleu D. Complications of laparoscopic lymphadenectomy in gynaecologic oncology. A series of 1102 procedures in 915 patients. Gynecol Obstet Fertil 2005;33(5):304—14. [5] Sonoda Y, Leblanc E, Querleu D, et al. Prospective evaluation of surgical staging of advanced cervical cancer via a laparoscopic extraperitoneal approach. Gynecol Oncol 2003;91(2): 326—31.
Please cite this article in press as: Neveu M-E, et al. Extra-peritoneal laparoscopic para-aortic lymphadenectomy for staging of uterine cervix carcinoma. Journal of Visceral Surgery (2017), http://dx.doi.org/10.1016/j.jviscsurg.2017.01.005