How to performlaparoscopic multi-port for LND in EM ca

영남대학교산부인과구유진

2020.1.19.

제 3회대한부인종양학회 Gynecologic Cancer Surgery Symposium

1

2

History of Lps LND

• 1987, the French GY oncologist Dr Daniel Dargent.− First to report endoscopic surgery in the GY oncologic field

by using retroperitoneal pelvicoscopy in performing PLNS in patients with Cx ca.

• 1992, Childers et al. and Nezhat et al.− First to report the efficacy of transperitoneal PALND for staging surgery of invasive

GY malignancies

3

Transperitoneal vs. Extraperitoneal

• Transperitoneal approach− Greater working space− Familiar landmarks− Excellent access to the PLNs− Sometimes requires bowel mobilization.

• Extraperitoneal approach− Excellent exposure to the PALNs− Excellent exposure even in obese Pt. and Pt. with s/p abdo. op.− Decreased risk of direct bowel injury, and bowel adhesion formation

• No significant differences in the frequency of complications

4

Trocar placements

for transperitoneal PALND for extraperitoneal PALND

5

Peritoneal incision for Transperitoneal LND

Book. Surg Gynecol Oncol, 1st Ed, 1993, p.283

Transverse incision Longitudinal incision Circular incision

to Treitz’s fossafrom Treitz’s fossa to the cecum

6

Target LNs in EM ca

Ann Surg Oncol (2014) 21:2755–27617

Pelvic LND

Book. Atlas of Operative Surgical Oncology. 2017

• Most of PLNs lie anterior, medially, & posteriorly to the external & internal iliac vessels & ON.− A few nodes that lie lateral to these structures,

between the vessels & the pelvic sidewall

8

Level of PALND

• b2: between the upper margin of the IMA and the bifurcation of the abdominal aorta

• b1: between the lower margin of the left renal v. and the upper margin of the IMA

b2

b1

9

Level of PALND

• Level 3: IMA ~ Origin of the Rt ov v.− mean No. of IVC tributaries: 1

• Level 2: Aortic bifurcation ~Origin of the IMA− mean No. of IVC tributaries: 1.7

• Level 1: Area of the bifurcation of the vena cava− mean No. of IVC tributaries: 3

Am J Obstet Gynecol. 1998;179:1295e1297.10

Level of LND

Level I• Cephalad: IIA• Caudal: Cloquet LN• Lateral: genito-femoral nerve• Posterior: Pre-rectal nodes and nodes

posterior to the obturator nerve. • includes nodes in the regions of the

internal and external iliac vessels, obturator fossa, pre-sciatic fossa of Marseilles and prerectal nodes.

Ann Surg Oncol (2014) 21:2755–276111

Level of LND

Level II• Cephalad: aortic bifurcation• includes nodes in the regions of the

common iliac vein and artery, upper presciatic nodes, pre-sacral nodes and nodes in the region of the aortic bifurcation.

Ann Surg Oncol (2014) 21:2755–276112

Level of LND

Level III• Cephalad: IMA• Lateral: bilateral ureters• includes the distal para-caval, pre-

caval, retro-caval, inter-aorto-caval, pre-aortic, retro-aortic and para-aortic nodes up to and including the IMA.

Ann Surg Oncol (2014) 21:2755–276113

Level of LND

Level IV• Cephalad: Lt renal v. and Rt renal a.

along the undersurface of the 3rd part of duodenum

• Lateral: bilateral ureters• includes nodes in the proximal para-

caval, pre-caval, retro-caval, inter-aorto-caval, pre-aortic, retro-aortic and para-aortic tissue cephalad to the IMA.

Ann Surg Oncol (2014) 21:2755–276114

LNM sites in EM ca

N=266

Ann Surg Oncol (2014) 21:2755–276115

Vascular anomalies in PALND

• Prevalence: venous anomalies 0.1-43%, arterial anomalies 9-31%• m/c arterial anomaly: accessory renal a.

• 86 patients

Gynecologic Oncology 96 (2005) 278–282

Accessory lumbar v.

16

17

Case (F/62)

• EM ca. endometrioid• BMI: 20.4 kg/m2

18

10mm

10mm

5mm

5mm

5mm

5mm

19

PALND

10mm

10mm

5mm

5mm

5mm

5mm

Operator1st assist

2nd assist

Scope

20

PLND

10mm

10mm

5mm

5mm

5mm

5mm

Operator1st assist

2nd assist

21

22

Outcomes

• OP time: 3h 50m• No. LN: 57 (PALN 27, PLN 37)• OPD #6: Drain 1개가지고퇴원

23

Further discussion

• Where is the best position for operator?

• Which energy device is the best?

• Do coagulants increase the risk of infected lymphocele?

• What is the best techniques for surgical exposure during PALND?

24

• Suturing (port closure 2.5mm, straight long needle)• Fan retractor with five fingers

25

Complications of PLND

• Intra-OP− Obturator nerve injury: 0-5.1%− Ureteral injury: <1% (d/t misapplication of a clamp, ligation with a suture)− Vascular injury: rare (mainly from IIV & obturator venous plexus)

• Post-OP− Lymphedema: 1.5-28%− Lymphocele: overall incidence 20%, symptomatic 6%− DVT± PTE: 0-8%− Lymphorrhea from the vagina− Lymphatic fistula, chylous ascites: uncommon

Book. Atlas of Operative Surgical Oncology. 201726

(psoas minor tendon)

27

Learning curve

• 10 cases, necessary for each approach to become proficient• Extraperitoneal LND has a steep learning curve similar to that for transperitoneal LND.

Gynecol Oncol. 2003;91:139e148

Book. Atlas of Operative Surgical Oncology. 201728

경청해주셔서감사합니다.

29