Single-port laparoscopic transperitoneal infrarenal para-aortic lymphadenectomy as part of staging operation for early ovarian cancer and high grade endometrial cancer / 부인종양

OBJECTIVE: The aim of this paper was to demonstrate the techiniqes of single-port laparoscopic transperitoneal infrarenal paraaortic lymphadenectomy as part of surgical staging procedure in case of early ovarian cancer and high grade endometrial cancer. METHODS: After left upper traction of rectosigmoid, a peritoneal incision was made caudad to inferior mesenteric artery. Rectosigmoid was mobilized, and then the avascular space of the lateral rectal portion was found by using upward traction of rectosigmoid mesentery. Inframesenteric nodes were removed without injury to the ureter and the left common iliac nodes were easily removed due to the upward traction of the rectosigmoid. The superior hypogastric plexus was found overlying the aorta and sacral promontory, and presacral nodes were removed at subaortic area. Peritoneal traction suture to right abdomen was needed for right para-aortic lymphadenectomy. After right lower para-aortic node dissection, operator was situated between the patient's legs. After upper traction of the small bowel, left upper para-aortic nodes were removed. To prevent chylous ascites, we used hemolock or Ligasure application (ValleyLab Inc.) to upper part of infrarenal and aortocaval nodes. RESULTS: Single-port laparoscopic transperitoneal infrarenal para-aortic lymphadenectomy was performed without serious perioperative complications. CONCLUSION: Even though the technique of single-port surgery is still a difficult operation, the quality of single-port laparoscopic transperitoneal infrarenal para-aortic node dissection is excellent, especially mean number of para-aortic nodes. In cases of staging procedures for ovary and endometrial cancer, single-port transperitoneal para-aortic lymphadenectomy is acceptable as an oncologic procedure.

Analysis of para-aortic lymphadenectomy up to the level of the renal vessels in apparent early-stage ovarian cancer / 부인종양

OBJECTIVE: The aim of this study was to evaluate the impact of para-aortic lymphadenectomy up to the renal vessels on the accurate staging in ovarian cancer patients presumed preoperatively to be confined to the ovary. METHODS: We retrospectively analyzed data on 124 patients with primary epithelial ovarian cancer who were preoperatively thought to have tumor confined to the ovary and underwent primary staging surgery. The distribution of lymph node metastasis and various risk factors for nodal involvement were investigated. RESULTS: Surgical staging yielded: 87 (70.2%) patients had International Federation of Gynecology and Obstetrics (FIGO) stage I disease and 37 (29.8%) patients had stage II-III disease: 4 IIA, 6 IIB, 9 IIC, 1 IIIA, and 17 IIIC. Eighty-six patients had pelvic lymphadenectomy only and 69 had pelvic and para-aortic lymphadenectomy. Lymph node metastases were found in 17 (24.6%) of 69 patients; 5 (7.2%) patients had lymph node metastasis in the pelvic lymph nodes only, 8 (11.6%) in the para-aortic lymph nodes only, and 4 (5.8%) in both pelvic and para-aortic lymph nodes. Six (8.7%) patients had lymph node metastasis in the para-aortic lymph node above the level of the inferior mesenteric artery. On multivariate analysis, grade 3 tumor (p=0.01) and positive cytology (p=0.03) were independent predictors for lymph node metastasis. CONCLUSION: A substantial number of patients with apparently early ovarian cancer had upstaged disease. Of patients who underwent lymphadenectomy, some patients had lymph node metastasis above the level of the inferior mesenteric artery. Para-aortic lymphadenectomy up to the renal vessels may detect occult metastasis and be of help in tailoring appropriate adjuvant treatment as well as giving useful information about the prognosis.

Laparoscopy-assisted gastrectomy with para-aortic lymphadenectomy after palliative chemotherapy for advanced gastric cancer with isolated para-aortic lymph node metastasis / 대한외과학회지

Prophylactic para-aortic lymphadenectomy is not recommended in curable advanced gastric cancer. However, there are few reports on therapeutic para-aortic lymphadenectomy after palliative chemotherapy in far advanced gastric cancer. We report three cases of laparoscopy-assisted gastrectomy with para-aortic lymphadenectomy after palliative chemotherapy for the first time in Korea. Three gastric cancer patients with isolated para-aortic lymph node (PAN) metastasis showed partial response to capecitabine-based chemotherapy, and laparoscopy-assisted gastrectomy with para-aortic lymphadenectomy was performed with curative intent. The mean total operation time was 365 minutes (range, 310 to 415 minutes), and the mean estimated blood loss was 158 mL (range, 125 to 200 mL). The mean number of retrieved PAN was 9 (range, 8 to 11), and all pathologic results showed no metastasis of para-aortic region. All patients recovered and were discharged without any significant complications.

Laparoscopic pelvic and para-aortic lymphadenectomy / 한양의대학술지

Laparoscopic surgery has many benefits over a conventional abdominal approach. These include less blood loss, low morbidity, shorter recovery time, shorter hospital stay, and shorter time interval to adjuvant therapy. With advances of laparoscopic instruments and surgical skills, laparoscopic surgery is becoming a dominant paradigm in the surgical management of gynecologic cancers. Advanced laparoscopic procedures including radical hysterectomy and trachelectomy with pelvic and para-aortic lymphadenectomy are now used in the management of early cervical cancer. For patients with apparent early-stage endometrial and ovarian cancer, laparoscopic complete staging operation including pelvic and para-aortic lymphadenectomy can be applied. Of several laparoscopic surgical procedures, laparoscopic pelvic and para-aortic lymphadenectomy is a cornerstone in the management of gynecological cancers cancers. The evaluation of lymph node status has an important role in diagnosis, treatment, and prognosis of gynecologic cancers because lymphatics are the main pathways of dissemination of gynecologic cancers. Laparoscopic pelvic and para-aortic lymphadenectomy is feasible and safe without increase of perioperative complications and decrease in patient's survival in gynecologic cancers, if it is performed by an experienced laparoscopic oncologic surgeon. During the last 10 years, laparoscopic procedures including pelvic and para-aortic lymphadenectomy in over 600 patients with gynecologic cancers were underwent in our department. We have found that the surgical and oncologic outcomes were similar or even better compared to conventional laparotomic procedures. In conclusion, the gynecologic oncologist should be familiar with lymphatic anatomy and laparoscopic skills to perform pelvic and para-aortic lymphadenectomy, because laparoscopic management of gynecologic cancers will be the choice of surgical treatment in the near future.