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32 Pelvic andParaaortic Lymphadenectomy
353
obturator nerve. The nerve can then be mobilized
by freeing from the membranous attachments
posterior to the nerve. This will then expose the
obturator vessels, that can be traced toward the
obturator foramen distally. These vessels can be
isolated and secured with hemoclips or a vesselsealing energy device. This will then expose the
hypogastric nodal packet lateral to the internal
iliac artery and overlying the internal iliac vein.
Careful dissection of these lymph nodes will
allow for identication of the origin of the obturator vessels, particularly the vein which must be
re-secured at its origin. Careful dissection around
the internal iliac veins is required to avoid injury
to the posteriorly located hypogastric venous
channels. When extensive involvement of this
region is encountered, ligation and resection of
the internal iliac vein may be required as clinically indicated.
Branches or the main divisions of the internal
iliac artery may likewise be injured during the
dissection of the obturator fossa. The arteries are
less delicate and therefore less prone to injury,
which is best prevented by the development of
the paravesical and pararectal spaces and prophylactic ligation as clinically indicated.
The external iliac vein is a large bore with a
visible and predictable location and course. It
may be obscured by retroperitoneal fat or nodal
tissue. Prevention of injury to this vein during a
pelvic lymphadenectomy requires adequate
development of the retroperitoneal spaces,
cautious dissection parallel to the wall of the
vein, and prudence regarding the risk-benet of
attempted removal of densely adherent positive
nodes. Laterally located psoas branches will be
encountered during dissection of the external
iliac vessels. Multiple branches may be present
and are paired arterial and venous channels.
Securing these with clips or energy ligation may
be needed to completely free the external iliac
vessels from the surrounding lymphatic tissues.
Injury of the common or external iliac arteries
during lymphadenectomy may occur when resection of densely adherent positive nodes is
attempted. Weighing risk versus benet is particularly important given the potential loss of
blood supply to an extremity. Attempting resec-
tion in such cases begins with securing proximal
and distal access (vessel loops) followed by cautious, precise arteriolysis. An anterior split and
roll technique can facilitate the identication of
the vessel wall.
Lymph nodes along the right (versus left)
common iliac vein are much more likely to be
involved with metastatic disease from gynecologic malignancy. Injury of this vein or the inferior vena cava (IVC) during lymphadenectomy is
commonly the result of shearing of a venule
entering these veins, which may be avoided by
dissecting in a cephalad to caudal direction and
meticulous prophylactic control of the venules as
they are encountered. As with the external iliac
vein, resection of densely adherent lymph nodes
must be approached with great caution. The left
common iliac vein is at risk of injury when the
left side is approached from the midline and dissection is misdirected during the development of
the left retroperitoneal space. Initial identication of the right common iliac artery and laterally
the IVC formation can provide optimal visualization needed to clear the left common iliac vein.
Anatomic relationships are key to understanding
this region. The left common iliac vein will travel
posterior (dorsal) to the right common iliac
artery. The initial clearing of the aortic bifurcation and right common iliac artery will allow for
the dissection to proceed medially along the right
common iliac artery. At this location, the anterior
wall of the left common iliac vein can be identied. A careful split and roll of the lymphatics
along its anterior wall will facilitate the freeing of
the remaining vein. Care should be taken as small
venous branches of the left common iliac vein
may be present. They can variably arise anteriorly or along the cephalad groove just medial to
the left common iliac artery. Initial Identication
of the left common iliac artery helps identify the
correct plane of dissection.
Considering the risk/benet ratio based on the
biology of the patient’s tumor type, resection of
tumor densely adherent to the aorta must be carefully considered. During paraaortic lymphadenectomy, the IMA may be avulsed from the aorta.
This may occur during mobilization and retraction of the sigmoid colon.
354
ab
M. Homan et al.
Recognition
“There will be blood” [5].
Management
When hemorrhage from the internal iliac veins is
encountered, gentle tissue handling is important
in order to prevent further injury to the plexus
and exacerbation of the problem. Pressure (judiciously applied), hemostatic agents, sutures and
clips may all be useful. The obturator nerve and
the lumbosacral nerve plexus are in harm’s way.
Injury to internal iliac arterial branches is
more easily identied than those of the veins but
with the same issue of limited surgical accessibility. However, such injuries are more easily
controlled.
A small injury to one of the major veins (less
than 1–2mm) is likely to require pressure only,
with or without hemostatic agents. Some advanced
hemostatic agents are now available that may at
least temporarily control signicant bleeding. It is
important to know which agents are available in
the operating room and have familiarity with their
use. Have patience and apply gentle pressure for
10–15minutes without trying to explore the area
for bleeding. Blind dissection or attempts to
suture the area without control will lead to excessive hemorrhage and the potential to make the
injury worse. With a larger defect, suture repair
will be necessary. At times this can be accomplished expeditiously during control by gentle
pressure and avoidance of further trauma to the
vein. Temporary closure of the hole with Allis
clamps or isolation of the hole from the venous
stream are useful techniques. Proximal and distal
control with vessel loops or even vascular clamps
may be necessary. Suture repair should be perpendicular to the lumen if possible, to avoid constriction (Fig. 32.2). Caution should be taken to
include an adequate bite of the vein and to avoid
excessive tension on the vein when tying the
suture to prevent tearing the vein and creating a
larger defect. It is important to generously hydrate
the monolament suture (5–0 or 6–0) and the surgeons’ hands when tying knots to prevent breaking the suture. Exposure and visualization of the
defect is critical when repairing venous injuries
and calling for experienced help should be considered before attempting repair. Skillful placement of the suction cannot be underestimated.
Our experience suggests that these patients are at
high risk for subsequent deep vein thrombosis [6,
7]. Ligation of the vein is a lifesaving measure
when conservative efforts fail [8]. Distal and
proximal control as well as repair are approached
Lateral venorrhaphy
Fig. 32.2 (a and b) Lateral venorrhaphy. (a) Venous laceration repaired parallel to the lumen, resulting in constriction
of the caliber. (b) Venous laceration repaired perpendicular to the lumen, with preservation of the caliber
Vein
narrowed
32 Pelvic andParaaortic Lymphadenectomy
355
with caution to avoid exacerbating a tear of the
rather delicate vein wall. f direct repair of the vein
is likely to cause stenosis then patch repair can be
considered with autogenous saphenous vein or if
necessary bovine pericardium. The patch should
be sewn in longitudinally. It is typical to extend
the venotomy to allow adequate caliber to the
vein. Patch repair should be started in the proximal and distal ends with 5–0 or 6–0 polypropylene sutures. Bring each suture to the middle of the
patch and tie to the opposite end.
Injury of the external or common iliac artery or
aorta during lymphadenectomy requires immediate focal or proximal and distal control, followed
by suture repair. Surgical repair of a focal arterial
injury can be easily achieved with simple transverse interrupted stitches. Care should be taken to
include the intima and adventitia to avoid delayed
pseudoaneurysm formation. If possible a double
needle 5–0 monolament suture placed from
Fig. 32.3 Some useful
vascular instruments.
Curved vascular clamp,
Statinsky clamp,
Castro-Viejo needle
holder, bulldog clamps,
Debakey forceps
intima to adventitia under direct vision provides
assurance of a durable repair. Placing multiple
individual sutures prior to tying the knots rather
than a running suture is recommended for larger
injuries. For larger defects (>50% of the lumen)
patch angioplasty should be considered to avoid
vessel stenosis and occlusion. With avulsion of
the IMA, it may be possible to secure the stump
with clips or suture. With complete avulsion there
will be a signicant (2mm) hole in the aorta with
rapid and life-threatening hemorrhage.
Immediate control and suture repair are critical. Partial aortic occlusion can be obtained with
a Satinsky or similar vascular clamp (Fig.32.3).
Direct pressure should control bleeding until adequate help can be called in. Loss of the IMA at
this level is rarely of consequence regarding
intestinal blood supply due to extensive collateral
circulation from the celiac, SMA and internal
iliac arteries. If the colon side of the transected
DeBakey forceps
Curved vascular
clamp
Bulldog clamps
Castro-Viejo
needle holder
Satinsky clamp
356
M. Homan et al.
artery demonstrates brisk back-bleeding then
good collateral circulation is likely. If the colon
exhibits evidence of ischemia after IMA ligation,
the IMA should be reconstructed either directly
or with a vascular bypass. Assessment of the
blood supply of the colon with intravenous injection of indocyanine green dye and intraoperative
uorescence angiography may be considered if
this is available.
Lymphedema
Background
Factors that increase the likelihood of lymphedema subsequent to PPLND include the extent
of lymph node dissection, removal of lymph
nodes lateral to the external iliac vessels, removal
of lymph nodes distal to the circumex iliac vein
(suprainguinal), and prior or planned postoperative external beam pelvic radiation therapy
[9–11].
Prevention
Limiting the extent of pelvic lymphadenectomy,
particularly by conning dissection to the sentinel lymph nodes, has the greatest impact on the
prevention of subsequent lower extremity lymphedema [12–14]. When a more complete pelvic
lymphadenectomy is indicated, dependent upon
the clinical ndings, the risk of lymphedema is
reduced by avoiding disruption of the lymphatics
lateral to the external iliac artery and distal to the
circumex iliac vein [14]. In addition, nonclosure of the pelvic peritoneum after pelvic
lymphadenectomy has been shown to reduce the
incidence of lower extremity lymphedema [15].
Lymphedema is one of the risks when weighing
the risk versus benet of adjuvant external beam
pelvic radiation therapy [15]. Prior to and subsequent to surgery, well-tted support stockings
may provide some additional level of prevention.
It is also worth mentioning that there have been
reports of early successes of microsurgery and
immediate lymphatic reconstruction in lymphedema prevention for breast cancer patients [16].
Recognition
Unilateral or bilateral lower extremity edema
will generally present early in the postoperative
course and progress over time. Deep vein thrombosis must be ruled out and other causes of lower
extremity edema (bilateral) should be considered, such as chronic venous insufciency, uid
overload, and congestive heart failure.
Management
Mild lymphedema should be managed proactively
with leg elevation while resting and well- tted
support stockings while ambulatory [17].
Avoidance of even minor trauma to the extremity
is important due to the susceptibility to lymphangitis. Prompt recognition and management of
lymphangitis reduces the likelihood of sepsis and
exacerbation of the lymphedema. For more severe
cases, referral to a lymphedema specialty clinic
should be considered. Additional measures that
are of potential benet include lymphatic massage, wrapping of the extremity, and an intermittent compression device. Microsurgical lymphatic
bypass has been shown to result in modest
improvement in selected patients although this
approach is not widely available [16, 17].
Nerve Injury
Background
Nerves that are most commonly injured during a
PPLND are the obturator nerve and the genitofemoral nerve [18–20]. Infrequently the sciatic nerve roots
may be injured, most commonly from sutures used
for controlling deep bleeding from the hypogastric
venous plexus. With an open procedure, injury of the
femoral nerve may occur from compression by the
lateral blade of a self- retaining retractor.
Prevention
Identication and dissection of the lymphatic
bundle away from the obturator nerve should be
Repair of transected obturator nerve
32 Pelvic andParaaortic Lymphadenectomy
357
the initial step during resection of the obturator
fossa lymph nodes. A systematic dissection from
anterior to posterior will facilitate optimal visualization of the obturator nerve while clearing all
lymphatic tissues from the fossa. Initial control
of the small lateral perforating vessels from the
obturator vessels laterally to the obturator internus muscle will allow for minimizing early
bleeding that would otherwise obscure visualization of the nerve. Avoid excessive traction on the
nerve during this dissection.
The genitofemoral nerve or a branch of it may
be difcult to identify even with normal anatomy,
particularly when obscured by retroperitoneal fat
or positive lymph nodes. Early identication,
avoidance of dissection lateral to the external
iliac artery, and dissection with minimal manipulation away from the nerve when necessary are
all measures that may prevent injury to this nerve.
When utilizing a self-retaining retractor, the
lateral blade should be placed above the psoas
muscle—particularly at the caudal location
where the femoral nerve becomes supercial as
it exits under the inguinal ligament. Overly tightening these retractor blades should also be
avoided, and period loosening during a long case
is a good practice.
Recognition
Obturator neuropathy is readily recognized by
the development postoperatively of unilateral
adductor muscle weakness. Numbness or
paresthesia of the medial thigh may also be
present. Injury of the genitofemoral nerve presents postoperatively as numbness or paresthesia
of the skin overlying the upper anterior thigh.
Femoral nerve injury may, unfortunately, be
recognized after the patient falls with her rst
attempt at postoperative ambulation. Flexion of
the thigh and extension of the knee will be
compromised.
Management
Following intraoperative recognition of partial or
complete transection of the obturator nerve, reapproximation of the epineurium with ne suture is
considered (Fig.32.4). Wrapping the repair with a
local neural regenerative agent may be of some
value as well, but the cornerstone of management is
physical therapy. There is no specic management
for genitofemoral nerve injury except reassurance
that the majority of these will resolve over time.
Fig. 32.4 (a and b)
Repair of transected
obturator nerve by
approximation of the
epineurium utilizing ne
suture
a
b
358
M. Homan et al.
Femoral nerve injury is managed by physical
therapy, and complete recovery occurs in the
majority of cases within 3 to 6months.
Ureteral Injury
Background
The pelvic ureter crosses and lies against the
bifurcation of the common iliac artery and
remains in close proximity to the major pelvic
vasculature up to the ureteric tunnel (Fig.32.1).
During pelvic lymphadenectomy, it is at risk of
injury during this entire course [21]. Likewise,
the abdominal ureter travels just lateral to the
inferior vena cava on the right side and just lateral to the aorta on the left side. During a left
paraaortic lymphadenectomy approached from
the midline, the left ureter may be difcult to
identify and keep out of harm’s way due to its
somewhat hidden position dorsal to the sigmoid
colon mesentery. The ureteral blood supply is
segmental, coming from multiple vessels from
the aorta, renal, common, and internal iliac arteries. The blood travels cephalad and caudad along
the ureter via ne arterioles located in the periureteral adventitial sheath. Careful manipulation
of the ureter with a noncrushing technique is
important to minimize damage to this collateral
circulation within the ureteral wall.
Prevention
Identify and mobilize the ureters prior to beginning the lymphadenectomy, and keep them
retracted out of the operative eld during the dissection. When unusual difculty is encountered
(left paraaortic nodes in obese patients, grossly
positive nodes), consideration can be given to
pre-procedural stenting or the use of ureteral ICG
dye in concert with a near-infrared camera.
Recognition
Continual focus on the operative eld throughout
the procedure and careful inspection of the ure-
ters immediately upon completion will usually
allow intraoperative recognition. Additional
adjuvant methods to facilitate intraoperative recognition of ureteral injury include administration
of intravenous dye (such as uorescein) that is
excreted by the urinary tract (allowing for identication of a gross leak into the peritoneal cavity
or lack of efux from a ureteral orice visualized
cystoscopically.
Management
Management of ureteral injury is covered in
Chap. 17.
Disruption oftheMesentery
Background
The mesentery of the sigmoid colon may inadvertently be damaged during paraaortic lymphadenectomy, especially from the midline approach
as the surgeon attempts to gain exposure to the
left paraaortic and common iliac lymph nodes.
Prevention
Proceed cautiously when exposing the left common iliac and paraaortic region from the midline
and when retracting in a cephalad direction under
the inferior mesenteric artery (IMA). Misdirected
dissection into the sigmoid colon mesentery may
be avoided by following the right common iliac
artery to the bifurcation and then exposing the
left common iliac artery.
Recognition
Laceration or avulsion of the IMA will result in
hemorrhage, which may be severe. Damage to
the sigmoid colon mesentery may only be recognized after re-directing an initial incorrect pane
of dissection. Inspection of the tissues that have
been disrupted may reveal damage to mesenteric
blood vessels supplying the sigmoid colon.
Duodenum
paraaortic region.
32 Pelvic andParaaortic Lymphadenectomy
Fig. 32.5 Anatomic
relationship of
duodenum to paraaortic
basin
Aorta
359
Relationship of the duodenum to the
Management
Management of injury to the IMA has already
been addressed. Damage to the sigmoid colon
mesentery requires careful clinical assessment of
the adequacy of the remaining blood supply. In
the unlikely event of loss of viability, surgical
resection is required.
Duodenum
Background
The third portion of the duodenum begins to
emerge from the retroperitoneum and typically
crosses the aorta at about the level of the IMA
(Fig.32.5). The level of crossing is variable and
may be as low as the common iliac vessels.
During exposure of the retroperitoneum to
access the common iliac and paraaortic lymph
nodes (especially on the right side), the duodenum may not be recognized or otherwise inadvertently injured [22].
Prevention
As lymphadenectomy proceeds cephalad to the
aorta, it is important to recognize the crossing
of the duodenum and mobilize it out of harm’s
wa y.
360
M. Homan et al.
Recognition
Spillage of bilious material during dissection
of the paraaortic region should prompt an
immediate search for the source. Assuming the
remainder of the bowel has been kept out of the
operative eld, injury to the duodenum is
likely.
Management
Mobilize the defect in the duodenum so that the
full extent of the injury can be assessed and properly repaired. Assuming a small hole on the caudal side of the bowel, repair proceeds as with any
enterotomy. The placement of a drain is considered depending on the clinical scenario.
Arterial Embolization
Background
During the course of a pelvic lymphadenectomy,
manipulation of an arteriosclerotic external iliac
artery may rarely result in the dislodging of a
plaque, which embolizes and obstructs the distal
arterial supply to a portion of the lower extremity
[23].
Prevention
When performing a lymphadenectomy in a
patient with known or suspected arteriosclerotic
vascular disease, manipulation of the major arteries should be avoided to the extent possible.
Recognition
Very early in the postoperative course, the patient
may develop evidence of progressive loss of viability of the lower extremity.
Management
This is a medical emergency requiring immediate
evaluation by a vascular surgeon.
Lymphocyst andChylous Ascites
Background
During PPLND, lymphatic channels are invariably disrupted. Leakage of lymphatic uid is generally self-limited and of no clinical consequence.
Small areas of trapped lymphatic uid or lowvolume chylous ascites are common and require
no intervention. A lymphocyst may become large
and problematic and require intervention. This is
more likely in patients who have also received
radiation therapy or have lymph node metastases.
Likewise, chylous ascites may persist in large volumes and be clinically problematic.
Prevention
Avoiding closure of the peritoneum following
pelvic lymphadenectomy has been shown to
reduce the incidence of a subsequent lymphocyst
[15]. Meticulous ligation or clipping of afferent
and efferent lymphatic channels may reduce the
likelihood of these complications. The low likelihood of a problematic lymphocyst or chylous
ascites and the prevalence of performing lymphadenectomy with an energy device, particularly
with minimally invasive surgery, are among the
factors that may dissuade surgeons from these
methods. The surgical approaches described earlier to reduce the likelihood of lymphedema,
especially limiting the extent of dissection, apply
here as well. However, randomized trial data in
bladder cancer patients undergoing limited versus extended pelvic lymphadenectomy have
found relatively small added morbidity associated with the more extensive dissection [24].
Only a modest increase in lymphoceles requiring
drainage was observed.
32 Pelvic andParaaortic Lymphadenectomy
361
Management
Small asymptomatic lymphocysts are common
following lymphadenectomy and are often seen
on imaging done for unrelated reasons.
Indications for drainage of a lymphocyst include
the development of deep vein thrombosis, attributable ureteral obstruction or lymphedema, pain,
or secondary infection. An infected lymphocyst
is managed as any abscess. Following drainage of
a lymphocyst, a drain should be left in place until
reimaging suggests resolution. When persistent
or recurrent, a sclerosing agent or marsupialization is considered [25].
Chylous ascites is often self-limited and
resolves spontaneously or with conservative
management (diet modication +/− Somatostatin,
paracentesis) [26]. If these measures fail lymphangiography with embolization is performed,
and very occasionally surgery is considered.
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