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TENT TECHNIQUE OF LAPAROSCOPIC RETROPERITONEAL LYMPHADENECTOMY- TRANSPERITONEAL APPROACH

Authors:

First author: Dr. Thammineedi Subramanyeshwar Rao, M.S, MCh, FMAS

Corresponding author: Dr. R Rajagopalan Iyer, DNB,FSOG,MNAMS,FMAS

Third author: Dr. Srijan Shukla, M.S,FMAS

Affiliation of all authors: Basavatarakam Indo-American Cancer Institute and Research Centre,

Road no. 10, Banjara Hills, Hyderabad, Telangana, India; PIN: 500034

Corresponding author’s mailing address: Department of Surgical Oncology, 4th floor, Block 1, Basavatarakam Indo American Cancer Hospital, Road no. 10, Banjara Hills, Hyderabad, Telangana, India; PIN: 500034

Corresponding author’s email address: rajagopalan99@hotmail.com

Disclosure/ Conflict of interest: The authors whose names are listed above certify that they have NO affiliations with or involvement in any organisation or entity with any financial interest (such as honoraria; educational grants; participation in speakers ’bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.

NO FUNDING SOURCES .

Retroperitoneal lymphadenectomy is required as a component  of certain Gynecologic Oncosurgical Procedures  like  staging of early ovarian and some types of  endometrial cancers It can  be done by laparotomy or a  Minimal Access approach (Laparoscopic/Robotic). This could be further classified as Transperitoneal or Extraperitoneal . Retroperitoneal lymphadenectomy is  usually combined with removal of the primary site of disease. Hence, transperitoneal approach  avoids  re-draping / changing of the patient position .  We prefer the Minimal Access approach, in Early Ovarian and Endometrial cancers. Patients of endometrial carcinoma are mostly obese and a Minimal Access  is considered the Gold Standard. The procedure, is a technical challenge  for the anesthesiologist  due to co-existent Diabetes Mellitus, Hypertension, Obesity, Poor Cardiopulmonary reserve. The surgical challenges  are tolerance to pneumoperitoneum,  keeping the small intestine away from the operating field, potentially life threatening haemorrhage and chyle leaks. This  video,  demonstrates our  technique of performing this procedure. A  T-Lift device is used to  elevate and retract the mesenteric and peritoneal folds as a tent. This simple step, helps keep the small intestine away from the field without direct traction and avoids  intestinal trauma. We use  the  Karl Storz 3D Laparoscopy system. At the junction of the left gonadal  with the renal vein, hem-o-lok clips are put to  seal  visible lymphatic channels and prevent postoperative chyle leaks. Haemostasis is checked. A tube drain is placed in the pelvis.  The average  postoperative  stay is 5-7 days. This technique can be safely replicated  with a trained and dedicated team of Surgeons,  Anesthesiologists and  Scrub nurses.
AIM :  Retroperitoneal lymphadenectomy is required as a component  of certain gynecologic oncosurgical procedures  like  staging in early ovarian and certain  endometrial cancers . It’s a part of cytoreductive surgery in advanced Ovarian Cancers. It  be done by laparotomy or a Minimal Access approach (Laparoscopic/Robotic). This could be further classified as Transperitoneal or Extraperitoneal  routes. EQUIPMENTS : 1.3D Laparoscopy with two  monitors(A Slave monitor) Standard Laparoscopy Instruments T-lifts Ultrasonic Scalpel 5 mm Vessel Sealer Hem-O-Lok Clips 5-0 Prolene on round body needle (Standby)
In this surgical video, we demonstrate our technique of Laparoscopic Transperitoneal Retroperitoneal Lymphadenectomy. The procedure is done under general anesthesia. The patient is kept in supine position with her legs in cushioned straight Allen’s stirrups. A bolster is placed under the pelvis at the level of the anterior superior iliac spines. Continous bladder drainage is done by an indwelling Foley’s catheter . Indwelling nasogastric tube is placed for gastric decompression. The camera port is placed 3-4 centimetres above the umbilicus in the midline. We use the open technique with the Hasson’s cannula . The abdomen is inspected and the other ports are placed. On the right side , a 10 mm port is placed in the spinoumbilical line 2 cms medial to the anterior superior iliac spine and a 5 mm port is placed in the midclavicular line triangulating between the camera port and the 10 mm port. Identical ports are placed on the left side. The intrabdominal pressure is maintained at 14mm Hg. This procedure can be divided into two parts. The Pelvic part where the surgeon operates from the patient’s right with standard pelvic ports and the Para-aortic part wherein the operating surgeon stands between the patient’s legs . In the Pelvic part, one monitor is placed near the leg end of the patient and the second monitor opposite the surgeon , during the para-aortic part, one monitor is placed near the patient’s left shoulder and the other near the leg end of the patient . We begin by identifying the right common iliac artery and the ureteric crossing . The peritoneum medial to the ureter is cut and the small bowel mesentery is elevated from the retroperitoneum. The cut is continued over the sigmoid mesocolon , which is dissected to identify the inferior mesenteric artery. The mesocolon is then elevated from the retroperitoenum and the left ureter and gonadal vessels are identified. This marks the left border of dissection. Superiorly the flap is continued till the duodenum is reached. Lymphadenectomy is commenced by harvesting the nodes from the right common iliac group. Thef irst T lift is inserted through the flap of the small bowel mesentery and is retracted. This gives space for dissection and keeps the small bowel away from the operative field. Similar dissection is continued on the left side and the nodes harvested. Inter iliac nodes are also cleared. This completes the first part of the dissection. A suprapubic camera port is now placed in the midline. In the second part, the surgeon stands between the patients legs with the camera now shifted to the suprapubic port. The laparoscopic view now gives us a caudal to cranial view of the operative field. The already dissected anatomy is examined. The right side T lift keeps the terminal ileal loops from falling into the surgical field . A second T-lift is placed in the sigmoid mesocolon and it is retracted laterally . A tent analogy can be used to understand this principle. The elevated small bowel mesentery and mesocolon keep the small bowel loops from falling into the operative field and create room for instrumentation along the great vessels. The assistant retracts the third part of duodenum cranially holding a gauze piece. Dissection is then continued along the inferior mesenteric artery upto its origin. The right gonadal vein is followed upto its termination into the inferior vena cava and paracaval nodes cleared. The left gonadal vein is dissected upto its junction with the left renal vein . Interaortocaval , para and pre aortic nodes are cleared. Special care is taken to clip the lymphatics around the left renal vein to avoid post operative lymph leaks. Lumbar branches from aorta are identified and safeguarded. Specimen is excised and placed in an endobag. Pneumoperitoneum pressure is lowered to check for hemostasis and lymph leaks. All 10 mm ports are closed under vision with a port closure cone and needle.
The patients are out of bed on the first postoperative day. The average postoperative hospital stay is 5-6 days. In our series, there were no postoperative mortality.We have performed nearly 75 procedures of Laparoscopic Retroperitoneal Lymph Node Clearanace. There have been five chyle leaks, of which only one required surgical intervention.
Retroperitoneal lymphadenectomy is usually combined with removal of the primary site of disease in gynecologic oncology . Hence, transperitoneal approach would avoid changing of the patient position and re-draping. We prefer the Laparoscopic approach in Early Ovarian and Endometrial cancers. For endometrial carcinoma, retroperitoneal lymphadenectomy used to be an indication for laparotomy in patients otherwise being managed by minimal access surgery. However, using effective strategies to encounter ergonomic difficulties, this procedure can be safely performed by laparoscopy. The  patients are mostly obese and a Minimal Access approach is considered the Gold Standard. The procedure, is a technical challenge for the anesthesiologist on various counts (co-existent Diabetes Mellitus, Hypertension, Obesity, Poor Cardiopulmonary reserve). The surgical challenges are tolerance to pneumoperitoneum, keeping the small intestine away from the operating field, potentially life threatening haemorrhage and chyle leaks. Our emphasis in this technique, has been minmal direct handling of the small intestine. We push in surgical Laparoscopy gauze pieces and retract the duodenum /small intestine over a gauze. This avoids intestinal trauma. Small intestine coming in the surgical field, is the main drawback of the transperitoneal approach. We use  disposable plastic T Tube, this device is loaded into a  sharp metal introducer. The tube is introduced transdermally and the mesentric/peritoneal fold is punctured. The metal  introducer is removed and the T tube is kept anchored to the skin under traction. Other ways of doing the same : 1. A free suture in  the mesentric/peritoneal fold and anchoring it to the skin(Requires a needle to be introduced into the abdomen and is more cumbersome). 2. Direct retraction on the small intestine (Intestine keeps slipping into the field and gets traumatised).
The authors whose names are listed above certify that they have NO affiliations with or involvement in any organisation or entity with any financial interest (such as honoraria; educational grants; participation in speakers ’bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.
We acknowledge the contributions of the Anesthesiology department, Colleagues in the department of Surgical Oncology, Staff nurses and technicians. Without their support, these procedures are not possible.
1. Zivanovic, O., Sheinfeld, J. & Abu-Rustum, N. R. (2008). ;RPLND Gynecologic Oncology, 111(2), S66–S69. doi:10.1016/j.ygyno.2008.07.043 2. El Meligy MH, El Kased AF, El Sisy AA, El Gammal AS. The role of pelvic and para-aortic lymphadenectomy in gynecological malignancies. Menoufia Med J 2015;28:833-7

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