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Laparoscopic Lymphadenectomy — 437
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Figure 16.2.1. The paravesical space is developed to aid in identification of the obturator nerve, vessels, and pelvic vessels.
Figure 16.2.2. The nodes are dissected from the common iliac artery
bifurcation to the circumflex iliac vein caudally.
Figure 16.2.4. The ureter is identified crossingthecommoniliac artery
at the pelvic brim.
the hypogastric vessels are excised up to the bifurcation of
the common iliac vessels. Caution is necessary to avoid injury
to the obturator nerve and hypogastric vein. To excise the
lymph nodes around the common iliac artery, a plane is created
between the posterior peritoneum and the adventitia overlying
the common iliac artery. Another option is to extend the
dissection over the common iliac vessels when removing the
proximal portion of the external iliac nodes. Before the nodes
are detached, the orientation of the ureter and ovarian vessels
crossing the common iliac artery is identified (Figure 16.2.4).
The uterine artery and vein can be isolated originating from
the hypogastric vessels when necessary (Figure 16.2.5). When
one is performing a left pelvic lymph node dissection, it may be
necessary to take down rectosigmoid colon from the left pelvic
side wall to allow visualization of the pelvic vessels.[3–5]
Para-aortic Lymphadenectomy
There are several ways to begin thepara-aortic lymphadenectomy
dissection: incising the peritoneum overlying the aorta, opening the peritoneum over the sacral promontory, or extending a
Figure 16.2.3. The obturator vessels and nerve are identified once the
obturator space is opened.
Obturator
Fossa
Obturator
Vessels
External
Iliac
Vein
Obturator
Nerve
Psoas
muscle
External
Iliac
Artery
Paravesical
Space
Hypogastric
Artery
External
Iliac Artery
Figure 16.2.5. The uterine artery is identified at its origin from the
hypogastric artery.
Uterine Artery
Uterine Vein
Pararectal
Space
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Inferior
Mesenteric
Artery
I.V.C.
Left
Para-Aortic
Lymph nodes
Bifurcation
of the Aorta
Figure 16.2.6. Para-aortic dissection seen here extends to the inferior
mesenteric artery.
preexisting incision over the common iliac artery toward the
aorta. This incision is extended up to the inferior mesenteric
artery (Figure 16.2.6) or up to the left renal vein in cases of ovarian or fallopian tubecarcinoma.Theunderlying retroperitoneum
is developed by blunt and sharp dissection. Next, the retroperitoneal space is created by using sharp and blunt dissection to
develop the space lateral to the aorta. Before cutting, it is essential to identify the right ureter, separate it from underlying tissue,
and retract it laterally. The nodal tissue overlying the aorta, right
common iliac artery, and sacral promontory is removed laterally
toward the psoas muscle. Fatty and nodal tissue overlying the
sacral promontory is removed. This tissue may contain hypogastric nerves. The left common iliac vein must be observed before
starting this dissection (Figure 16.2.7). This maneuver allows the
nodal tissue anterior to the vena cava to be detached. The dissection is continued cephalad to the level of the inferior mesenteric
artery, removing all lymphatic tissue anterior to and between the
aorta and inferior vena cava. Again, it is essential to identify the
Bifurcation
of the Aorta
Right Common
Inferior
Vena
Cava
Iliac Artery
Left Common
Iliac Artery
Inferior
Vena Cava
Aorta
Figure 16.2.8. For para-aorticlymphadenectomyabove the mesenteric
artery, the peritoneal incision is extended to the level of the left renal
vein and right ovarian vein.
Right
Gonadal Vein
ureter along the inferior border of the dissection and the transverse duodenum along the superior margin of the dissection.
Perforating vessels from the vena cava are electrocoagulated or
ligated with hemoclips.
The removal of the left para-aortic nodes may be more difficult because of the location of the sigmoid colon. Attention is
necessary to avoid injury to the inferior mesenteric artery, ovarian vessels, and ureter. The left common iliac vein lies at the
bifurcation of the aorta. The dissection proceeds from the aorta
laterally toward the psoas muscle, excising the lymph nodes from
above the inferior mesenteric artery to below the left common
iliac artery. This allows the surgeon to dissect laterally in a plane
that is beneath the inferior mesenteric artery and the mesentery
of the sigmoid colon. It is important not to dissect laterally until
the adventitia ofthe aorta isincised to prevent entering thewrong
plane.
When para-aortic lymphadenectomy above the mesenteric
artery is being performed, the peritoneal incision is extended
to the level of the left renal vein and right ovarian vein (Figure 16.2.8). If necessary, the ovarian vessels and the mesenteric
artery are ligated for better exposure and to prevent bleeding.
After the lymphadenectomy is completed, evaluation of the area
under decreased pneumoperitoneal pressure is done to ensure
hemostasis. As with pelvic lymphadenectomy, the peritoneum is
not closed and drains are not placed. Adhesion barriers may be
applied to decrease postoperative adhesions.[3–5]
COMPLICATIONS
Figure 16.2.7. The left common iliac vein must be clearly identified
during para-aortic lymphadenectomy.
Left Common
Iliac Vein
Complications oflaparoscopic lymphadenectomy canbe divided
into two general categories. The first includes complications that
are inherent to laparoscopy itself, regardless of the specific procedure being performed. This category includes subcutaneous
emphysemaand trocar injuries to the bowel or the inferiorepigastric vessels.Thesecondgroupofcomplicationsincludes thosethat
are inherent to the procedure, regardless of the method by which
it is performed. Obturator nerve injury, deep venous thrombosis, and postoperative lymphocele areallcomplications of a pelvic
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Table 16.2.1: Complications of Laparoscopic Lymphadenectomy Performed for Gynecologic Malignancy [6–9]
Pelvic Aortic Major
No. Nodes Nodes Intraoperative Postoperative
Pts. Indication (n) (n) Complications Complications Conversion
Possover et al., 150 Various Gyn 26.8 7.3 vascular injury 7 lymphedema 2 4
1997 Cancers (10–56) (0–19) small bowel injury 1 temporary
obturator nerve
impairment 1
Dottino et al., 94 Various Gyn 11.9 3.7 vascular injury 1 UTI 1 3
1998 Cancers (0–57) (0–14) fever 1
Renaud et al., 102 Cervical 25 5.5 vascular injury 3 UTI 1 6
2000 Cancer cystotomy 4 bladder atony 1
pelvic abscess 1
hematoma 1
lymphocele 2
Scribner et al., 103 Endometrial Pel + 6.8 vascular injury 1 DVT 1 29%
2001 and Ovarian Comm ureteral injury 1 PE 2 30/103
Cancer Iliac bladder injury 1 1 death
23.2 wound infect 6
TOTAL/MEAN 449 Various 21.7 5.8 vascular 12 (2.6%) Minor 16 42 (9.3%)
Gyn ureteral 1 (.2%) (3.5%)
Cancers bladder 4 (.8%) Major 4
bowel 1 (.2%) (1.81%)
and para-aortic lymphadenectomy. Initial studies indicate a low
incidence of complications for laparoscopic lymphadenectomy
(Tables 16.2.1, 16.2.2).[6–9]
To prevent complications, adequate exposure is critical to
optimize surgical dissection.This is abasic surgical tenetfor open
abdominal surgery and is alsoa necessary component of effective
laparoscopic technique. For a laparoscopic lymphadenectomy,
adequate exposure requires a thorough preoperative bowel prep,
steep Trendelenburg patient positioning, and adequate pneumoperitoneum. These steps are essential to effectively sweep the
bowel away from the operative field and to reduce the opportunity for bowel injury. Bowel decompression with an orogastric or
nasogastric tube andbladder decompressionwithaFoleycatheter
should be performed at the start of the procedure. The patient
should be placed in lithotomy position with the thighs no higher
than the level of the anterior abdominal wall. This allows free
range of motion of the lower-quadrant laparoscopic instruments
without interference from the legs. Full mobility of the lower
quadrant instruments allows for optimal traction and countertraction of tissue planes for dissection.
Vascular Injuries
Vascular injuries related to lymphadenectomy are potentially
life-threatening complications. Perhaps the most common vascular injury of laparoscopy in general, and laparoscopic lymphadenectomyinparticular,is injurytotheinferiorepigastric and
other superficial anterior abdominal wall vessels (Figure 16.2.9).
Kavoussiet al. [10], in a series of laparoscopic lymphadenectomy,
reported seven out of nine vascular complications occurred as a
result of trocar injury to the anterior abdominal wallvasculature.
Potential vascular compromise specific to a pelvic lymphadenec-
tomy includes injury to the obturator, internal iliac, externaliliac,
or the common iliac vessels. In the male, the testicular artery
and vein should be carefully identified during a laparoscopic
lymphadenectomy to maintain their integrity. Vessels at risk for
injury during a para-aortic lymphadenectomy include the aorta
and vena cava, as well as the common iliac, inferior mesenteric,
lumbar, and renal vessels.
Fortunately, injury to major pelvic vessels during laparoscopic pelvic lymphadenectomy is an uncommon occurrence.
In Kavoussi’s series [10], seven of nine vascular injuries resulted
from trocar injuries to the abdominal wall vessels as reported by
the combined experienceof eight institutionsperforming laparoscopic pelvic lymphadenectomy for early prostatic carcinoma. In
the remaining cases, one patient sustained injury to the obturator vein and the other case involved interruption of the external
iliac artery. Querleu et al. [2] reported their initial experience
with laparoscopic lymphadenectomy in 39 women with cervical
carcinoma. Although none of these patients suffered major vascular injury, one patient developed a large pelvic hematoma due
to an unspecified vessel injury. This was managed conservatively
and resolved spontaneously without any requirement for blood
transfusion. Burney et al. [11] reported a combined experience
with laparoscopic pelvic lymphadenectomy for prostatic carcinoma. One of these patients developed a pelvic hematoma that
subsequently became infected after percutaneous drainage.
In Childers’s experience [12,13] with more than 300 pelvic
lymphadenectomies for gynecologic malignancy,injury to major
pelvic vesselswas a rare event. The vessel mostlikely to be injured
is an aberrant obturator vein emerging from the obturator canal,
across the nodal bundle, to empty into the external iliac vein.
On one occasion, a 5-mm laceration in the external iliac vein
was sustained with a lymphadenectomy during a second-look
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Table 16.2.2: Selected Series of Laparoscopic Pelvic and Para-aortic Lymphadenectomy
Series Modality Patients, no. PLND (mean) PALND (mean) Complications
Childers et al. [12] Electrosurgery 29 Not indicated Not indicated 1 ureteral, 1 cystotomy
1 pneumothorax, 3 minor
Chu et al. Not indicated 67 26.7 8 1 vascular
Dottino et al. [7] Electrosurgery 94 11.9 3.7 1 vascular, 2 minor
Vidaurretta et al. [27] Electrosurgery 84 18.5 — 1 vascular,
2lymphocele
Altgassen et al. [28] Not indicated 99 21–24.3 5.1–10.6 3 vascular, 1 enterotomy
1 ureteral, 1 hemorrhage
2 nerve impairment
3 intestinal obstruction
5 minor
Scribner et al. [9] Not indicated 103 23.2 6.8 1 vascular (fatal)
2ureteral
1 bladder laceration
1DVT
2 pulmonary embolus
(1 fatal)
1 Richter’s hernia
Schlaerth et al. [22] Electrosurgery
and ABC
Abu-Rustum et al. [29] Monopolar
and ABC
Kohler et al. [30] Electrosurgery 650 18.8 10.8 19 (2.9%) intraoperative (7
Holub et al. [26] Ultrasonic
shears (LCS)
Electrosurgery 32 13.7
Nezhat et al. [15] Ultrasonic
shears (LCS)
∗
67 32.1 12.1 7 vascular
1 ureteral, 8 infectious
2 hematomas
2 lymphoceles
114 10.3 5.3 1 vascular, 1 enterotomy,
1 cystotomy,
1 uterine perforation,
3 intestinal
4 infectious
1DVT
vascular, 3 bowel).
35 (5.8%) postoperative (16
irritation of nerves, 6 lymphedema,
3 symptomatic lymphoceles, 3
chylocysts)
27 17.5 — 1 inflammation of obturator nerve,
1 febrile morbidity
†
100 20 15 2 vascular
1 injury to epigastric artery
1fever
1 cystotomy
1 trocar-site hernia
1DVT
1 port-site metastasis
1 bowel obstruction (minor)
∗
Ethicon EndoSurgery.
†P = 0.0008.
ABC, argon beam coagulator; DVT, deep venous thrombosis; PLND, pelvic lymph node; PALND, para-aortic lymph node.
laparoscopic procedure. The patient had undergone a previous
lymph node sampling at the time of ovarian cancer cytoreductive
surgery. The external iliac vein was injured while opening the
retroperitoneal space. The laceration was repaired laparoscopically with a clip applicator.Thepatientdid not requiretransfusion
or experience any postoperative complications.[14] Three other
patients had vena cava injuries complicating their laparoscopic
lymphadenectomy. The firstrequiredopenlaparotomyfor vascular repair,wastransfused with fourunitsofpackedredblood cells,
and went on todevelopa deep venous thrombosis. Theremaining
two cases were managed laparoscopically with endoscopic vascular clip applicators (Figure 16.2.10). Neitherof these two patients
Figure 16.2.9. Extensive postoperative ecchymosis extending from the
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suprapubic port site.
received a transfusion or had any other postoperative complications. Experience with external iliac and vena cava injuries has
revealed that bleeding in the presence of adequate pneumoperitoneum (i.e., 15 mm H
O), even from large veins, is relatively
2
limited. In our experience with 100 cases of laparoscopic lymphadenectomy for gynecologic malignancies using ultrasonically
Laparoscopic Lymphadenectomy — 441
activated shears, there were two vascular injuries.[15] The first
was an injury to the branch of the inferior mesenteric artery
during surgical staging of a cervical stage IIB cancer, which was
controlled with bipolar forceps. The second vascular injury,
involving the right hypogastric vein, occurred during a laparoscopically assisted radical hysterectomyand pelvic lymphadenectomy and was repaired laparoscopically without any postoperative sequelae.
A theoretic but nonetheless important concern is the possibility of an air embolus, especially with damage to larger vascular
structures. This is especially a concern if the lymphadenectomy
is performed using an argon beam coagulator because this gas
is not readily absorbed into the circulation. The diagnosis of gas
embolism is made via auscultation with a conventional or transesophageal stethoscope. A “wheel-mill” murmur is presumptive
evidence of air entrapment in the right heart. Management consists of the placement of a central line into the right ventricle and
subsequent aspiration oftheembolizedgas.Althoughsuchacomplication has yet to be reported for laparoscopic lymphadenectomy, CO
embolism has been reported with other laparoscopic
2
procedures.
Management of Vascular Injuries
Laparoscopicmanagementofvascularinjuriesvaries accordingto
the type(artery orvein) and size ofthe vessel injured. Themodalities used in managing these vascular injuries include pressure,
monopolar and bipolar electricity, clips, and sutures. Depending
on the caliber of the injured vessel, any one of these modalities
may achieve hemostasis satisfactorily.
When a vessel is injured, it is important to control the bleeding as quickly as possible. This usually can be accomplished by
using a laparoscopic grasper to occlude the bleeding vessel. If
Figure 16.2.10. Endoscopic clip applied to the lower vena cava following a small venotomy created during a low
right para-aortic laparoscopic lymphadenectomy.
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visualization is obscured, or if the vessel is a large vein in which
grasping may result in further laceration, pressure should be
applied. Laparoscopic instruments, lymph node pads, 4- × 4-
inch gauze, or minilaparotomy pads can be placed to achieve
immediate control. To be prepared for any bleeding, a 4- × 4-
inch gauze padcan be placed through a10- to 12-mm port before
beginning the lymph node dissection.
Small venous bleeds can be controlled with pressure alone.
A minilaparotomy pad can be packed into the retroperitoneal
space whilethe procedure is continued in anotherpart of the surgical field. Later in the operative procedure, the packing can be
removed and the area inspected for hemostasis. Placing pads into
the abdomen laparoscopically may be a helpful technique; however, it also produces a new potential complication of retained
laparotomy pads. Laparotomy rings, such as those used when a
laparotomy is performed, cannot be used laparoscopically, so the
surgeon must rely primarily on the operative pad count. If the
count is incorrect, or ifthe surgeon wants toincludean additional
safety measure, a postoperative radiograph should be obtained.
Figure 16.2.11 illustrates a radiograph of the abdomen demonstrating two retained retroperitoneal laparotomy pads. These
pads were placed during a laparoscopic bilateral para-aortic lymphadenectomy.
Arterial bleeds should be quicklycontrolled, as blood loss may
be rapid.Care should betaken to avoid arterial pumping of blood
onto the laparoscope. When this occurs, visualization ofthe operative field is obscured and the laparoscope must be removed for
cleaning, which expends valuable time and increases blood loss.
Another common pitfall in controlling vascular injuries occurs
during aspiration of pooled blood. While the pooled blood is
being suctioned, the pneumoperitoneum frequently is suctioned
as well if the suction tip is not completely submerged. This may
result in poor exposure of the operative site and can create a
cascade of time-consuming events including inadequate pneumoperitoneum, bowel falling out of the upper abdomen, and the
laparoscope lens becoming obscured by blood.
Monopolar electricity maybe used toachievecontrol of small
arterial and venous bleeds. Bipolar desiccation is especially useful to control venous and arterial bleeds of a larger caliber. The
bipolar method may be used to coapt vessels or may be applied
along the length of the instrument to provide surface cauterization over a friable area.[16] Bipolar electrocautery, however, is an
unacceptableformofvascular injury control in vessels that should
not be sacrificed or vessels of extremely large caliber, such as the
iliac and the vena cava. In these situations, clips or suturing techniques shouldbe used.Laparoscopically applied clipscan control
large venous bleeds adequately. Prefabricated slipknots may be
used tocontrol moderate-sized arterial bleeds. In these instances,
a grasper is placed through the prefabricated loop and affixed to
the injured vessel. The loop is slipped over the grasper and onto
the vessel. Suturing techniques using needles most often require
laparotomy. In certain conditions, in the hands of very experienced surgeons, small vascular injuries can be repaired using
laparoscopic suturing. In the instance of vascular injury, consideration should be given to intraoperative consultation with a
vascular surgeon.
Gastrointestinal Injuries
Bowel injury is a potential complication of any laparoscopic procedure. Bowel can be easily damaged at trocar insertion, adhesiolysis, or thermal injury during dissection (Figure 16.2.12). This
complication can be avoided in all laparoscopic procedures by
appropriate patient selection, preoperative preparation including
a complete mechanical bowel preparation, andthe intraoperative
placement of anorogastric or nasogastrictube. The neteffect is to
keep the bowel flat and empty, resulting in easier “packing” into
the upper abdomen, where it is less likely to enter the operative
field.
Delayed bowel morbidity may occur throughout the postoperative period. Bowel herniation may result as a consequence of
Figure 16.2.11. Radiograph demonstrating the radiolucent tags of a
retained minilaparotomy pad. These pads were initially placed following a laparoscopic bilateral low para-aortic lymphadenectomy.
TD
VC
A
Figure 16.2.12. Laparoscopic photographfromthe umbilicalport. The
surgeon is placing an imbricating silk suture on the transverse duodenum (t) to imbricate an area that was superficially burned during a
para-aortic lymphadenectomy. TD, transverse duodenum; VC, vena
cava; A, aorta.
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absent or inadequate fascial closure of the trocar defects. In one
report, two small bowel herniations occurred in a series of
35 laparoscopic pelvic and para-aortic lymphadenectomies performed forgynecologic malignancies.[17]These two small bowel
herniations presented clinically with intestinal obstruction. It
is notable that both occurred at lateral 12-mm trocar sites
where stabilizing fascial screws were used followed by attempted
fascial closure. Both cases were managed laparoscopically.
Although not reported, bowel obstruction may occur as a result
of post-laparoscopic adhesion formation.
Management of Gastrointestinal Injuries
Laparoscopic management of gastrointestinal injuries has been
covered in previous chapters. Consideration of laparoscopic hernia reduction is not unreasonable,depending onthe clinical situation, and has been accomplished and reported in the literature.
Large and small bowel injuries can be repaired intracorporeally
or extracorporeally through a slightly enlarged port site, particularly for small bowel. These techniques are discussed in detail in
other chapters.
Genitourinary Injury
Laparoscopic injury to the urinary tract is well described in
the literature. Cystotomy during trocar insertion, adhesiolysis, or dissection with endoscopic scissors with or without
electrocautery has been described as a complication of laparoscopiclymphadenectomy,although not specific to this procedure.
Cystotomy may occur during hysterectomy or when opening the
obturator space, ifthe obliterated umbilical artery is not retracted
medially. Meticulous surgical technique and decompression of
the bladder with a Foley catheter are the cornerstones of the prevention of this type of injury. Ureterovaginal and vesicovaginal
fistulae, aswell as injury to thepatent urachus, are otherpotential
though as yet unreported complications.
Perhapsofmostconcern,andcertainlygermanetothelaparoscopic lymphadenectomy, is the possibility of ureteral injury.
Pelvic lymphadenectomy places the ureter at riskfor sharp, crush,
or thermal injury, which has beendescribed inthe urologic literature. The lumbar portionof the ureter is at riskduring para-aortic
lymphadenectomy; injury may occur if the lateral dissectionoverlying the psoas muscle is carried out above the ureter instead of
in the correct surgical plane, thus incorporating the ureter into
the nodal bundle. In our experience, injection of 10 mL of intravenous indigo carmine is very useful for recognition of ureteral
perforation. If this injury occurs, management can be accomplished by placing a transureteral stent, oversewing the defect,
and placing a retroperitoneal drain laparoscopically. Although
it is an area of current investigation, there is no proven role for
prophylactic ureteral stent placement before laparoscopic lymphadenectomy.
Neurologic Injury
Operative nerve injury can complicate any surgical procedure in
the pelvis. There are, however,concernsthatareparticular to lymphadenectomy. Genitofemoral nerve injuryis most likely to occur
during removal of the lateral pelvic lymph nodes. Such an injury
results in medial thigh numbness but is otherwise of little clinical
consequence. It is arguably the most common injury encoun-
tered by thegynecologic oncologist. Injury of theobturator nerve
is a more concerning, though extremely rare, complication that
may occur during laparoscopiclymph node dissection.[10,11,18]
Patients suffer from pain, weaknessin leg adduction, and sensory
loss of the medial thigh. This injury occurs only if the obturator
nerve is not reliably identified before the resection of the obturator lymph node package. Theoretically, the femoral nerve, which
lies within the body of the psoas muscle in the pelvis, is at risk
during lymphadenectomy. This is particularly true if the nerve
is not deep in the belly of the muscle and is exposed to extensive electrocautery during the dissection. Though not a direct
operative injury, the ulnar nerve may also be traumatized if not
properly padded in the course of tucking the arms for operative
laparoscopy.
Other Complications
Various other injuries and complications may result as a consequence of this procedure. Both lymphocele and lymphedema
have been reported to occur with laparoscopic lymphadenectomy [10,11,18], as they may also occur with open procedures.
In Childers’s experience [12,13] with more than 300 pelvic
lymphadenectomies, there have been two symptomatic lymphoceles. As might be expected with any operative procedure, infectious complications have been reported with laparoscopic lymphadenectomy, including infected pelvic hematoma,Clostridium
difficile infection, and wound complications.[10,11,19] Likewise,
retained foreign bodies and equipmentfailure can complicate the
conduct of this safe and effective procedure.
Perhaps of most concern are thromboembolic events, which
can complicate any major operative procedure in the pelvis,
especially in the cancer patient. Two separate series of laparoscopic lymphadenectomies performed for urologic malignancies
reported three instances of deep venous thrombosis (1.5%) and
no pulmonary emboli among 203 procedures.[17,18] Pomelet al.
[20] reported a case of lower-extremity thrombophlebitis complicated by a subsequent pulmonary embolism following a staging
laparoscopy for ovarian carcinoma.[19] More recently, Spirtos
et al. [17] reported on a series of 40 patients who underwent
bilateral pelvic and para-aortic lymphadenectomy for endometrial and ovarian cancer. Of the 35 patients whose operations
werecompletedlaparoscopically, two(5.7%)developed deep vein
thrombosis during the postoperative period.
COMPLICATIONS REQUIRING LAPAROTOMY
Complications resulting in laparotomyhave been related to damage to theureter, bladder,bowel and vascularstructures. Kavoussi
et al. [10]reported a 4%(13/372) incidence of laparotomy related
to laparoscopic pelvic lymphadenectomy. Complications were
recognizedatinitiallaparoscopicsurgeryinsevenpatients,andsix
individuals required secondary laparotomy. Reasons for laparotomy included transection of the ureter (two patients), cystotomy(twopatients),bowelinjuriesorobstruction(fourpatients),
vascular injury (four patients), and wound dehiscence (one
patient).
Burney et al. [11] reported a laparotomy rate of 8% (4/54)
for patients undergoing laparoscopic pelvic lymphadenectomy
for urologic indications. One of four patients required laparotomy at the time of the procedure. Indications for laparotomy
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included ureteral damage (one patient), small bowel obstruction
(two patients), andmesenterichematoma (one patient). Anoverall major complication rate of 16.7% (9/54) was estimated, with
the inclusion of a large fascial hematoma, two bladder perforations, and two patients requiring blood transfusion.
In a series reported by Boitke et al. [21], laparotomy was
requiredin10%of patients (3/29) undergoing laparoscopicpelvic
and/or para-aortic lymphadenectomy for endometrial cancer.
Two patients underwent secondary operations because of small
bowel obstruction, and another patient had a vascular injury
to a small branch of the aorta recognized intraoperatively and
required minilaparotomy but no transfusion at the time of the
primary surgery. In both patients with small bowel obstruction,
the obstructions were related to herniations through trocar sites,
both of which were greater than or equal to 10 mm. No complications directly resulting from the pelvic lymphadenectomy
were observed, although two of 22 patients undergoing paraaortic lymphadenectomyhadmajorcomplications.Anadditional
patient required percutaneous nephrostomy 3 weeks postoperativelybecauseof a leak in the left lumbar ureter; this was attributed
to thermal injury from monopolar current during a left paraaortic lymphadenectomy.
Spirtos et al. [17] reported a series of 40 patients undergoing pelvic and para-aortic lymphadenectomy for gynecologic
malignancies including 35 endometrial carcinomas, four ovarian cancers, and one tubal malignancy. Five patients required
laparotomy at the time of the initial operation. In two cases,
this was secondary to vascular injury to perforating branches
of the vena cava and right iliac vessels, respectively. Two other
patients required debulking at laparotomy for unsuspectedintraabdominal metastaticdisease. A finalpatient was opened because
of equipment failure.
Other authors reported significantly lower incidences of
laparotomyconsequent to laparoscopic lymphadenectomy.None
of the 39 patients who underwent laparoscopic lymphadenectomy for cervical cancerin the seriesby Querleu etal. [2] required
laparotomy. Pomel et al. [20] reported on 10 cases of pelvic
and para-aortic laparoscopic lymphadenectomies performed for
early-stage carcinoma of the ovary. They described one laparotomy at a second surgery, for postoperative hemoperitoneum.
Childers et al. [12] reported a 1.7% (1/60) laparotomy rate for
patients undergoing para-aortic lymphadenectomy for cervical,
endometrial, and ovarian carcinoma. A single patient required
laparotomy for an injury to the vena cava, which was created
during a right-sided para-aortic lymphadenectomy.She required
four units of blood and subsequently developed a deep venous
thrombosis following surgery. In our experience of 100 cases of
laparoscopic lymphadenectomy in gynecologic malignancyusing
ultrasonically activated shears, there were no unplanned conversions to laparotomy. Three intraoperative complications were all
managed laparoscopically, and one postoperative trocar-site hernia and one small bowel obstructionwere managed witha second
laparoscopy.[15]
ADEQUACY OF NODE RETRIEVAL
Lymphadenectomy is performed primarily to evaluate for
micrometastasis in the setting of a malignancy. It is therefore
essential that the lymph node dissection achieve adequate node
retrieval despite the operative approach, either by laparotomy or
by laparoscopy. Gynecologic Oncology Group (GOG) protocol
9207 examined laparoscopic para-aortic lymph node sampling
and therapeutic pelvic lymphadenectomy in women with stage
IA, IB, and IIA cervical cancer. In 69 patients across seven institutions, the average lymph node retrieval was up to 70 (mean
of 32) for pelvic nodes and up to 37 (mean of 12) for paraaortic nodes. The complication rate was 10% for major vascular injury and 1.4% for ureteral injury. The study thereby concluded that a laparoscopic approach is a feasible alternative for
laparoscopiclymphadenectomy.[22] Atourinstitution,inaseries
of 100 laparoscopic lymphadenectomies for gynecologic malignancy using the harmonic scalpel, up to 80 lymph nodes were
retrieved and there were no conversions to laparotomy. Further,
it is our experience that the nodal count is directly related to the
surgical goals at the time of procedure. Cases are selected for full
lymphadenectomy or for a more limited lymph node sampling
depending on the indication for the procedure rather than on
technical limitation.[15]
Patient outcomes and survival data support the utility
of laparoscopic lymphadenectomy for gynecologic malignancy.
Malur et al. [23] reported on a prospective randomized study
comparing a laparoscopic approach with open laparotomy for
the staging and treatment of endometrial cancer (Table 16.2.3).
Notably, the operative time and the number of pelvic and paraaortic lymph nodes harvested were independent of the surgical approach; however, the estimated blood loss, transfusion
Table 16.2.3: Results Adaptedfrom Malur etal. Reporting the
Only RandomizedProspective StudyEvaluatingLaparoscopy
versusLaparotomyfortheStaging and Treatment ofEndometrial Cancer
Variable Laparoscopy Laparotomy
No. of Patients 37 33
Mean age 68.3 67.7 NS
BMI 29.7 29.7 NS
Pelvic lymphadenectomy 25 24 NS
Pelvic lymph nodes
(Mean)
Para-aortic Lymph Nodes
(Mean) (20 Pts.)
OP. time 176.4 ± 85.4 166.1 ± 61 NS
EBL 229.2 ±
Transfusion 1 11 0.005
LOS 8.6 ± 2.7 11.7 ± 3.8 <0.001
Complications 11 (29.7%) 13 (39.3%) NS
Follow up (Mon.) 16.5 (2–43) 21.6 (2–48)
Recurrences 1 2 NS
Recurrence related death 1 1 NS
Recurrence-Free Survival 97.3% 93.3% NS
Overall Survival 83.9% 90.9% NS
16.1 ± 7.6 15.4 ± 7.6 NS
9.6 ±4.7 8.4 ± 6.4 NS
190.2
594.2 ±
629.9
0.003
Laparoscopic Lymphadenectomy — 445
https://t.me/med1917
requirements, and length of hospital stay were significantly less
for the patients who underwent a laparoscopic procedure.
THE LEARNING CURVE
Most surgeons report a decrease in the number and severity of
complications, as well as operating times, as experience is gained
with laparoscopic lymphadenectomy.[10,11,18,19,24] Eightyeight percent (14/16) of aborted laparoscopic lymphadenectomies reported by Kavoussi et al. [10] occurred during the initial experience at each contributing institution. Lang et al. [18]
reported a significantly higher complication rate for the first 50
laparoscopic lymphadenectomies (14%), as compared with the
next 50 such surgeries (4%). In fact, five of the nine total complications occurredamong the first 20 patients. The adequacy of the
procedure also increases with experience. Fowler et al. [24] and
Rukstalis et al. [19]reported a clear improvement in theadequacy
of the dissection, as estimated by the percentage of lymph nodes
removed, as operators gained experience with the technique. The
experience of Melendez et al. [25] with laparoscopically assisted
staging for endometrial carcinoma demonstrated a significant
decrease in operating time with increasing experience. Notably,
the major complication rate was unaffected, although the rate
of conversion to laparotomy decreased significantly. With time,
laparoscopic lymphadenectomy becomes a safer and more timeefficient procedure.
MODALITY
Various modalities, such as electrosurgery, laser, and argon beam
coagulation, have been used for dissection and hemostasis during laparoscopic lymphadenectomy. Laser and electrical energies operate at 150
◦
Cto400◦C to desiccate and oxidize tissue,
forming an eschar to seal bleeding vessels. Ultrasonic dissection
occurs through conversion of mechanical vibration into thermal
energy, breaking down tissue with high water content and sparing tissue with high collagen content, such as blood vessels and
nerves. Ultrasonic techniques can be used to simultaneously cut
and coagulate tissue at lower temperatures (≤100
◦
C), causing
less thermal damage and smoke. Most studies of safety and efficacy employ electrosurgery. We analyzed the largest cohort in a
single institution, 100 cases of lymphadenectomy using ultrasonically activated shears, and found lymph node retrieval rates and
acceptable safety profiles similar to those of studies using electrosurgery (Table 16.2.3).[15] Interestingly, there were no lymphoceles, potentially because of effective sealing of small lymphatic
channels with this instrumentation. Thus far, only Holub et al.
[26] directly compared the two modalities of electrosurgery and
ultrasonic shears for laparoscopic lymphadenectomy in a retrospective comparative study of 59 patients. This trial illustrated
efficient coagulation, cutting, dissection, and grasping during
laparoscopic lymphadenectomy in cervical and endometrial cancer cases.
CONCLUSION
Laparoscopic lymphadenectomy is an evolving technique that
plays an increasingly important role in the management of
gynecologic malignancies. Pelvic and para-aortic laparoscopic
lymphadenectomy appears to be a safe, adequate, and feasible
procedure, with a low complication rate. The risks include those
traditionally attributed tolaparoscopy,aswellas those inherent to
open lymphadenectomy. The use of simple preventive measures
allows the patient to benefit from this technique while diminishing the likelihood of complication.
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