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Laparoscopic pelvic lymph node dissection
Journal of Visceral Surgery (2011) 148, e111—e116
SURGICAL TECHNIQUE
Laparoscopic pelvic lymph node dissection M. Ballester a,b, E. Chéreau a,b, C. Coutant a,b, E. Daraï a,b, R. Rouzier a,∗,b a
Service de gynécologie-obstétrique et médecine de la reproduction, hôpital Tenon, AP—HP, 4, rue de la Chine, 75020 Paris, France b Inserm U149, Inserm-UMR S 938, UPMC université Paris 06, 75005 Paris, France Available online 8 April 2011
Introduction Bilateral pelvic lymphadenectomy can be performed by either open laparotomy or by a laparoscopic approach. It consists of en bloc dissection of the fibrocellular and lymphatic tissue medial to the external iliac vein, anterior to the obturator nerve, and lateral to the umbilical artery remnant. FIGO currently recommends bilateral pelvic lymphadenectomy to obtain accurate staging for cancers of the endometrium, uterine cervix, and ovary [1]. • Indications for pelvic lymphadenectomy for endometrial cancers [2]: in France, bilateral external iliac lymph node dissection is recommended for all stages of endometrial cancer except Stage IA grade 1/2 with endometrioid histology. Studies have shown that there is significant intra- and postoperative morbidity associated with lymphadenectomy in these patients who often present with important co-morbidities (obesity, diabetes, hypertension). • Indications for pelvic lymphadenectomy in uterine cervical cancer [3]: nodal status is an important prognostic factor as well as a critical criteria for decision with regard to adjuvant treatment. Dissection of the external iliac nodes with ilio-aorto-caval dissection is part of the surgical staging of cervical cancers. It may be performed at different points during the overall management depending on the initial stage of disease: ◦ stage IB1 (tumor < 4 cm): pelvic lymphadenectomy is performed at the time of an extended colpo-hysterectomy (Piver 2) either as the initial procedure or after preoperative radiation; ◦ stage IB2 (tumor > 4 cm and/or pelvic node +): lumbo-aortic nodal dissection can be added (or not) to iliac lymphadenectomy prior to adjuvant radiochemotherapy. • Indications for lymphadenectomy in ovarian cancer [4]: pelvic and lumbo-aortic nodal dissection is strongly recommended as an important part of surgical treatment of ovarian cancer. In stage I disease, it permits more precise staging and therefore a more specifically adapted surgery which can be performed laparoscopically.
∗
Corresponding author. E-mail address: [email protected] (R. Rouzier).
1878-7886/$ — see front matter © 2011 Published by Elsevier Masson SAS. doi:10.1016/j.jviscsurg.2011.02.004
e112
1
M. Ballester et al.
Patient positioning and set up
The patient is positioned to allow access to both the abdomen and perineum. The legs are spread with the calves and feet in boots, the knees partially flexed, taking care to avoid calf pressure with weight bearing on the heel. The operator should be able to modify leg position through the drapes. The table is inclined in 15◦ of Trendelenburg. The patient’s buttocks shoud overhang the end of the table slightly to prevent sliding. The operator stands to the patient’s left with the monitor at the feet. Four trocars are placed: a 10—12 mm trocar at the umbilicus, two 5 mm trocars in right and left lower quadrants (3 cm inside the anterior iliac spine), and a 10—12 mm midline suprapubic trocar The initial step is an exploration of the abdomen and pelvis to look for secondary peritoneal spread and to perform peritoneal washings for cytological examination in cancers of the endometrium.
Laparoscopic pelvic lymph node dissection
2
Opening of the retroperitoneum
3
Opening of the paravesical fossa
The lateral pelvic peritoneum is incised at the level of the external iliac vessels between the infundibulo-pelvic ligament and the round ligament. On the left side (as illustrated here) it is useful to free up lateral pelvic adhesions of the sigmoid colon in order to improve visualization the left iliac bifurcation. The round ligament is coagulated and divided, which increases the space open for dissection. However, preservation of the infundibulopelvic ligament and ovarian vessels allows a security margin between the dissection and other critical structures.
The peritoneal opening is extended inferiorly for several centimeters toward the umbilical artery. Opening of the paravesical space allows the lymphatic tissues to be freed anteriorly and medially. Identification and medial retraction of the umbilical artery with an atraumatic clamp facilitates opening of the paravesical fossa all the way to the pelvic wall and down to the levators. The obturator nerve can be identified anteriorly without difficulty or danger.
e113
e114
M. Ballester et al.
4
Opening of the pararectal fossa
5
Dissection of the lymphatic chain
Traction on the adnexal structures with an atraumatic clamp aids in delineating the ureter which adheres to the external surface of the peritoneum. At this stage, one should open into the pararectal fossa lateral to the ureter; this permits the ureter to be freed and retracted medially. The opening into the pararectal fossa should thus be made between the ureter and the internal iliac artery, taking care to avoid damage to the internal iliac vein which may be duplicated or plexiform. When performing a radical hysterectomy, it is useful to dissect the umbilical artery all the way to the internal iliac artery in order to resect the uterine artery at its origin.
Nodal dissection begins with the external iliac chain at the level of the psoas muscle. The dissected tissues are retracted medially as the artery is progressively liberated. Care should be taken to avoid damage to the genitofemoral nerve, which runs along the lateral border of the external iliac artery. The dissection is pursued taking all the intermediate lymphatic tissue up to the iliac bifurcation. The dissected tissue is retracted medially with an atraumatic grasper, which allows the nodes inferior to the vein to be freed up passing in close contact to the iliac vein within its vascular sheath and then beneath the vein laterally as far as the pelvic side wall.
Laparoscopic pelvic lymph node dissection
6
Identification of the obturator nerve
7
Final liberation of the nodal dissection
The obturator nerve is found at the anterior aspect of the dissection at the level of its passage beneath Cooper’s ligament. It is often identified when the paravesical space is first developed.
The dissected tissue is now retracted anteriorly and the dissection follows along the length of the obturator nerve up to the iliac bifurcation. Division of the last attachments of the specimen requires coagulation of small vascular branches.
e115
e116
8
M. Ballester et al.
Landmarks at the end of nodal dissection
The nodal specimen should be removed in a bag through the suprapubic trocar site. The anatomic boundaries of the dissection are now easily visible: the external iliac vein laterally, the obturator nerve posteriorly, the iliac bifurcation superiorly, and the umbilical artery medially.
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.
References [1] Pecorelli S. Revised FIGO staging for carcinoma of the vulva, cervix, and endometrium. Int J Gynaecol Obstet 2009;105(2):103—4 [Erratum in: Int J Gynaecol Obstet 2010;108:176].
[2] Recommandations professionnelles sur le cancer de l’endomètre : http://www.e-cancer.fr/toutes-lesactualites/360/4731-publication-de-recommandationsprofessionnelles-sur-le-cancer-de-lendometre. 2010. [3] Gouy S, Uzan C, Zafrani Y, et al. La chirurgie ganglionnaire dans les cancers de l’utérus. J Chir 2008;145:51—5. [4] Morice P, Planchamp F, Daraï E, et al. Recommandations pour la pratique clinique: standards, options : recommandations 2007 pour la prise en charge des patientes atteintes de tumeurs épithéliales malignes de l’ovaire. Traitement chirurgical (rapport abrégé). Oncologie 2008;10: 283—8.
SURGICAL TECHNIQUE
Laparoscopic pelvic lymph node dissection M. Ballester a,b, E. Chéreau a,b, C. Coutant a,b, E. Daraï a,b, R. Rouzier a,∗,b a
Service de gynécologie-obstétrique et médecine de la reproduction, hôpital Tenon, AP—HP, 4, rue de la Chine, 75020 Paris, France b Inserm U149, Inserm-UMR S 938, UPMC université Paris 06, 75005 Paris, France Available online 8 April 2011
Introduction Bilateral pelvic lymphadenectomy can be performed by either open laparotomy or by a laparoscopic approach. It consists of en bloc dissection of the fibrocellular and lymphatic tissue medial to the external iliac vein, anterior to the obturator nerve, and lateral to the umbilical artery remnant. FIGO currently recommends bilateral pelvic lymphadenectomy to obtain accurate staging for cancers of the endometrium, uterine cervix, and ovary [1]. • Indications for pelvic lymphadenectomy for endometrial cancers [2]: in France, bilateral external iliac lymph node dissection is recommended for all stages of endometrial cancer except Stage IA grade 1/2 with endometrioid histology. Studies have shown that there is significant intra- and postoperative morbidity associated with lymphadenectomy in these patients who often present with important co-morbidities (obesity, diabetes, hypertension). • Indications for pelvic lymphadenectomy in uterine cervical cancer [3]: nodal status is an important prognostic factor as well as a critical criteria for decision with regard to adjuvant treatment. Dissection of the external iliac nodes with ilio-aorto-caval dissection is part of the surgical staging of cervical cancers. It may be performed at different points during the overall management depending on the initial stage of disease: ◦ stage IB1 (tumor < 4 cm): pelvic lymphadenectomy is performed at the time of an extended colpo-hysterectomy (Piver 2) either as the initial procedure or after preoperative radiation; ◦ stage IB2 (tumor > 4 cm and/or pelvic node +): lumbo-aortic nodal dissection can be added (or not) to iliac lymphadenectomy prior to adjuvant radiochemotherapy. • Indications for lymphadenectomy in ovarian cancer [4]: pelvic and lumbo-aortic nodal dissection is strongly recommended as an important part of surgical treatment of ovarian cancer. In stage I disease, it permits more precise staging and therefore a more specifically adapted surgery which can be performed laparoscopically.
∗
Corresponding author. E-mail address: [email protected] (R. Rouzier).
1878-7886/$ — see front matter © 2011 Published by Elsevier Masson SAS. doi:10.1016/j.jviscsurg.2011.02.004
e112
1
M. Ballester et al.
Patient positioning and set up
The patient is positioned to allow access to both the abdomen and perineum. The legs are spread with the calves and feet in boots, the knees partially flexed, taking care to avoid calf pressure with weight bearing on the heel. The operator should be able to modify leg position through the drapes. The table is inclined in 15◦ of Trendelenburg. The patient’s buttocks shoud overhang the end of the table slightly to prevent sliding. The operator stands to the patient’s left with the monitor at the feet. Four trocars are placed: a 10—12 mm trocar at the umbilicus, two 5 mm trocars in right and left lower quadrants (3 cm inside the anterior iliac spine), and a 10—12 mm midline suprapubic trocar The initial step is an exploration of the abdomen and pelvis to look for secondary peritoneal spread and to perform peritoneal washings for cytological examination in cancers of the endometrium.
Laparoscopic pelvic lymph node dissection
2
Opening of the retroperitoneum
3
Opening of the paravesical fossa
The lateral pelvic peritoneum is incised at the level of the external iliac vessels between the infundibulo-pelvic ligament and the round ligament. On the left side (as illustrated here) it is useful to free up lateral pelvic adhesions of the sigmoid colon in order to improve visualization the left iliac bifurcation. The round ligament is coagulated and divided, which increases the space open for dissection. However, preservation of the infundibulopelvic ligament and ovarian vessels allows a security margin between the dissection and other critical structures.
The peritoneal opening is extended inferiorly for several centimeters toward the umbilical artery. Opening of the paravesical space allows the lymphatic tissues to be freed anteriorly and medially. Identification and medial retraction of the umbilical artery with an atraumatic clamp facilitates opening of the paravesical fossa all the way to the pelvic wall and down to the levators. The obturator nerve can be identified anteriorly without difficulty or danger.
e113
e114
M. Ballester et al.
4
Opening of the pararectal fossa
5
Dissection of the lymphatic chain
Traction on the adnexal structures with an atraumatic clamp aids in delineating the ureter which adheres to the external surface of the peritoneum. At this stage, one should open into the pararectal fossa lateral to the ureter; this permits the ureter to be freed and retracted medially. The opening into the pararectal fossa should thus be made between the ureter and the internal iliac artery, taking care to avoid damage to the internal iliac vein which may be duplicated or plexiform. When performing a radical hysterectomy, it is useful to dissect the umbilical artery all the way to the internal iliac artery in order to resect the uterine artery at its origin.
Nodal dissection begins with the external iliac chain at the level of the psoas muscle. The dissected tissues are retracted medially as the artery is progressively liberated. Care should be taken to avoid damage to the genitofemoral nerve, which runs along the lateral border of the external iliac artery. The dissection is pursued taking all the intermediate lymphatic tissue up to the iliac bifurcation. The dissected tissue is retracted medially with an atraumatic grasper, which allows the nodes inferior to the vein to be freed up passing in close contact to the iliac vein within its vascular sheath and then beneath the vein laterally as far as the pelvic side wall.
Laparoscopic pelvic lymph node dissection
6
Identification of the obturator nerve
7
Final liberation of the nodal dissection
The obturator nerve is found at the anterior aspect of the dissection at the level of its passage beneath Cooper’s ligament. It is often identified when the paravesical space is first developed.
The dissected tissue is now retracted anteriorly and the dissection follows along the length of the obturator nerve up to the iliac bifurcation. Division of the last attachments of the specimen requires coagulation of small vascular branches.
e115
e116
8
M. Ballester et al.
Landmarks at the end of nodal dissection
The nodal specimen should be removed in a bag through the suprapubic trocar site. The anatomic boundaries of the dissection are now easily visible: the external iliac vein laterally, the obturator nerve posteriorly, the iliac bifurcation superiorly, and the umbilical artery medially.
Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.
References [1] Pecorelli S. Revised FIGO staging for carcinoma of the vulva, cervix, and endometrium. Int J Gynaecol Obstet 2009;105(2):103—4 [Erratum in: Int J Gynaecol Obstet 2010;108:176].
[2] Recommandations professionnelles sur le cancer de l’endomètre : http://www.e-cancer.fr/toutes-lesactualites/360/4731-publication-de-recommandationsprofessionnelles-sur-le-cancer-de-lendometre. 2010. [3] Gouy S, Uzan C, Zafrani Y, et al. La chirurgie ganglionnaire dans les cancers de l’utérus. J Chir 2008;145:51—5. [4] Morice P, Planchamp F, Daraï E, et al. Recommandations pour la pratique clinique: standards, options : recommandations 2007 pour la prise en charge des patientes atteintes de tumeurs épithéliales malignes de l’ovaire. Traitement chirurgical (rapport abrégé). Oncologie 2008;10: 283—8.