GYNECOLOGIC
ONCOLOGY
45, 46-51 (1992)
CASE REPORT Combined Laparoscopic and Vaginal Surgery for the Management of Two Cases of Stage I Endometrial Cancer JOEL M. CHILDERS, M.D.,’
AND EARL A. SURWIT, M.D.
Division of Gynecologic Oncology, University of Arizona,
Tucson, Arizona 85721
Received July 17, 1991
Two postmenopausal patients with stageI adenocarcinomaof the endometriumwho were managedwith a combinedlaparoscopicand vaginal approachare presented.Surgical-pathologic staging wasperformed laparoscopically,with exploration of the abdomenand procurementof peritonealcytology and pelvic and para-aortic lymph nodes.The adnexawereligated and mobilized laparoscopicallyand removedwith the vaginal hysterectomy.This approachoffersdecreased morbidity to the patient yet still obtains the samepathologic information and surgical goal as the traditional transabdominalapproach. 0 1992 Academic h, m.
INTRODUCTION
Carcinoma of the endometrium is now a surgically staged malignancy. The traditional approach is total abdominal hysterectomy and bilateral salpingo-oophorectomy, peritoneal cytology, and pelvic and para-aortic lymph node dissection. Vaginal hysterectomy and removal of the adnexa are reserved for a fraction of patients with this disease, since vaginal surgery does not allow adequate exploration of the intraperitoneal cavity and pelvic lymph nodes cannot be obtained using this approach. Using a newly described technique, the transperitoneal laparoscopic lymphadenectomy [1,2], we have been surgically staging patients with pelvic malignancies. For patients with endometrial cancer, complete surgical-pathological staging information is obtained by a combined laparoscopic-vaginal approach. Two cases of adenocarcinema of the endometrium using a combined laparoscopic-vaginal surgical staging procedure are presented. ’ To whom correspondence and requests for reprints should be addressed at 2350 N. Kibler PI., Tucson, AZ 85712. 46 0090-8258/92$1.50 Copyright 0 1992 by Academic Press,Inc. AI1 rights of reproduction in any form reserved.
CASE REPORT 1
A 74-year-old gravida 5, para 5 had a fractional dilatation and curettage for postmenopausal bleeding. The D&C specimen revealed grade 1 adenocarcinoma of both the endocervical and the endometrial specimens. She was referred to our institution for evaluation and management. On examination there was no tumor seen in the cervix, and a repeat endocervical curettage was positive for welldifferentiated adenocarcinoma, but there was no evidence of invasion of this carcinoma into the cervix. The patient’s past medical history was remarkable for hepatitis at age 37; her past surgical history was remarkable for an appendectomy performed in 1933. Her weight at the time of evaluation was 160 pounds. The patient was prepped and drap.ed in the dorsal lithotomy position. After a pneumoperitoneum was adequately created, the primary trocar, a disposable 12-mm trocar and sleeve, was placed through an umbilical incision. A lo-mm 0” telescope was used with a camera and two monitors. This port was also connected to the highflow insufflating unit to maintain an intra-abdominal pressure of 15 mm Hg. Three ancillary trocars were placed, two 5-mm trocars midway between the umbilicus and the anterior superior iliac crest bilaterally and an 11-mm trocar approximately 4 cm above the pubic symphysis in the midline. The patient was placed in the supine position and sequential compression stockings were used. Laparoscopic exploration of the visceral and parietal peritoneal surfaces was performed, including the anterior and posterior cul-de-sac, the adnexa, the appendix, the paracolic gutters, the gallbladder, the liver surfaces, the stomach, the right and left hemidiaphragms, the supracolic and infracolic omentum, the pelvic colon, and as much of the
CASE
REPORT
47
small bowel and mesentery as possible. There was no turator nerve were removed. The bladder flap was created by sharp dissection using the Endo-Shears. evidence of extrauterine disease. A vaginal hysterectomy was performed through a cirThe patient was then placed in steep Trendelenburg and the small bowel and omentum were placed in the cumferential vaginal incision. The anterior cul-de-sac was upper abdomen. This allowed visualization of the peri- easily entered by blunt dissection since the bladder flap had been taken down laparoscopically. Likewise the pastoneum overlying the iliac vessels, the sacral promontory, terior cul-de-sac was also easily entered, and the uteroand the lower abdominal aorta. There was no obvious nodal enlargement. Pelvic washings were obtained for sacral ligaments, cardinal ligaments, and uterine vessel pedicles were clamped, divided, and suture-ligated using cytology, and the tubes were clipped with the Endo-Clip 0 chromic. The uterus, tubes, and ovaries were removed disposable clip applier (Auto-Suture). intact. The peritoneum was not closed. The vaginal cuff A para-aortic lymph node dissection was performed was closed vertically with figure-of-eight sutures of 0 first with the patient in approximately 30” Trendelenburg chromic. Estimated blood loss was 400 cc. The uterus was position. The small bowel was swept off the sacral proopened in the operating room, and a tumor that did not montory and off the bifurcation of the aorta and into the appear to extend to the cervix but did appear to be inupper abdomen. The peritoneum overlying the right comvasive was seen. The final pathology report revealed no mon iliac artery was incised and the retroperitoneal space endocervical involvement, but the fundal carcinoma was was entered. The ureter was visualized and dissected off moderately well differentiated with deep invasion exthe underlying tissue and retracted laterally. This also tending to within 3 mm of the serosal surface. The washassisted in keeping the small bowel from falling into the ings were negative and all lymph nodes were negative. operative field. The precaval nodal group, which was then There were 23 lymph nodes identified, 11 from the left exposed quite adequately, was dissected off the right comside, 10 from the right side, and 2 from the para-aortic mon iliac artery and low aorta and then and off the roof area. of the vena cava. Several perforating veins were identified Postoperatively the patient did well. She was passing during this dissection and clipped with the Endo-Clip and flatus and was on a regular diet on the third postoperative cut with scissors. The dissection was carried inferiorly to day and was discharged to home on the morning of the where the ureter crosses the right common iliac artery. fifth postoperative day. The nodal chain was then transected at its caudad extent using the monopolar electrocautery unit and sharp disCASE REPORT 2 section with scissors. By dissecting the nodal bundle in a cephalad direction, the tissue was completely cleaned off A 65year-old gravida 2, para 2, who was 15 years the roof of the vena cava and the cephalad end of the postmenopausal, had a routine pap smear that was susnodal chain was transected with the clips and scissors and picious for adenocarcinoma. She then underwent endowith the aid of the monopolar cautery unit attached to cervical curettage and endometrial biopsy in the office, the scissors. The vena cava was unroofed up to the second which confirmed a grade 2 to 3 adenocarcinoma in the part of the duodenum in this patient. The site was irriendometrial specimen. The patient’s past medical history gated; hemostasis was satisfactory, and attention was was unremarkable; however, her past surgical history was drawn to the pelvic nodes. remarkable for four prior abdominal procedures. She had A right-sided pelvic node dissection was performed had a ruptured diverticulum resulting in a colostomy, first. The round ligament was desiccated and divided using which required a second surgery for colostomy takedown. Endo-Shears (Auto-Suture). The broad ligament was Her third abdominal procedure was an abdominal heropened and the infundibulopelvic ligament near the ovary niorrhaphy with placement of mesh for a large incisional was isolated and transected with the Endo-GIA 30 dis- hernia. This became infected postoperatively and reposable surgical stapler using 30V staples. The retroperquired her fourth abdominal procedure for removal of itoneal space was then opened, the right common iliac the infected mesh. Her abdominal exam was remarkable and external iliac artery were visualized, and the nodal for a midline incision that extended from the symphysis and adipose tisue over these vessels was removed. The to the xiphoid process, and her umbilicus had been surtechnique for removal is similar to that in open laparotgically removed. She had a large, 18 x 20-cm incisional omy in that the adventitia is incised with scissors over hernia from the symphysis to near the umbilicus that the vessels and the nodal tissue is removed by blunt and extended bilaterally. She weighed 162 pounds. General sharp dissection. Only the anterior and medial chain of surgical consultation was obtained prior to surgery and external iliac nodes was removed, and care was taken to recommendations were to attempt to perform the proremove the nodal tissue at the bifurcation of the internal cedure laparoscopically. and iliac artery. Only the obturator nodes above the obThe patient was taken to the operating room, where a
48
CASE
pneumoperitoneum was created by placing the Veress needle in the left upper quadrant approximately 2 cm below the costochondral margin in the midclavicular line. Following establishment of the pneumoperitoneum, a 7mm laparoscopic trocar and sleeve were placed through this same incision and a 7-mm telescope was used to explore the peritoneal cavity. With this pneumoperitoneum the patient’s lower abdominal hernia became grossly obvious because of the protuberance. Intraperitoneally there was a wall of adhesions in the left lower quadrant to the previous colostomy site and all along the midline abdominal incision from the symphysis to the xiphoid process. An ancillary trocar using a 5-mm disposable instrument was placed in the midabdomen on the left; laparoscopic scissors were used to lyse the omental adhesions to the anterior abdominal wall on the left side and in the midline. The adhesions were taken up above the fascial defect in the midline; a needle was placed through this area transabdominally to determine an appropriate site for a 12-mm trocar and sleeve. This was placed in the midline above the fascial defect and below the omental adhesions. The fourth and fifth ancillary trocars were placed: a 5-mm trocar was placed on the right side midway between the umbilicus and the anterior superior iliac spine, and in the midline near the symphysis an 11-mm trocar was placed. These last two ancillary trocars were placed through the incisional hernia. Laparoscopic exploration of the visceral and peritoneal surfaces was performed as previously described. There was no evidence of extrauterine disease. The patient was placed in steep Trendelenburg position as described for Case 1 and a bilateral pelvic and para-aortic lymphadenectomy was performed in the following fashion. The right-sided pelvic and para-aortic lymph nodes were dissected first. This was accomplished by incising the peritoneum over the right common iliac artery and opening the space between the triangle created by the external iliac artery, the infundibulopelvic ligament, and The retroperitoneal space was the round ligament. opened and the pelvic lymph node dissection was performed as described for Case 1. In this instance, the para-aortic nodes were removed by retracting the ureter medially and in a cephalad direction and approaching the high common and low paraaortic lymph nodes through the incision made in the peritoneum below where the ureter crosses the iliac artery. To accomplish this, it was necessary to extend the peritoneal incision in a cephalad direction to the point where the ureter crosses.
FIG. 1. (a) The right common iliac artery and its bifurcation after a laparoscopic nodal dissection. (b) The high right common iliac artery with oxycel placed on the inferior vena cava.
49
REPORT
The para-aortic nodes were removed as described for Case 1. However, there were no obvious perforating vessels that required clipping or cutting, and the entire transection was carried out with the monopolar electrocautery unit attached to the operating scissors. The infundibulopeivic ligaments were then transected bilaterally by using 0 silk and tying extracorporeal square knots, which were pushed into the abdomen using the Clarke knot pusher. By suture ligating them in two areas, the infundibulopelvic ligament was transected with the scissors, and using the prefabricated slipknots, two additional sutures were placed on each infundibulopelvic ligament. The bladder flap was created as described for Case 1 and a vaginal hysterectomy was performed in a similar fashion. Estimated blood loss was 400 cc. The final pathology report revealed a poorly differentiated tumor that invaded the inner one-third of the myometrium. The washings were negative. Eighteen lymph nodes were identified and were negative for malignancy. Postoperatively the patient did well. She was advanced to a regular diet and was discharged on the morning of Postoperative Day 4.
DISCUSSION Endometrial cancer, like pelvic malignancies in general, has a propensity to metastasize to regional (pelvic) lymph nodes. Since current imaging modalities are suboptimal in detecting these metastases [3-51, a significant percentage of patients with stage I adenocarcinoma of the endometrium are clinically misstaged [6]. This has motivated the gynecologic oncologist to surgically stage these patients, which aided in the subsequent changing of endometrial cancer from a clinically staged to a surgically staged malignancy [7]. Vaginal hysterectomy has been used in the management of endometrial cancer, but its use has basically been limited to the medically compromised patient [&lo]. Several factors have prevented the endorsement of vaginal surgery for patients with endometrial cancer, including the inability to (1) assess the peritoneal cavity, (2) perform a lymphadenectomy, (3) obtain pelvic washings, and (4) consistently perform salpingo-oophorectomy. Blass et al. [ 1 I] published the most recent report on the use of vaginal hysterectomy in these patients. Their data on 31 medically compromised patients with stage I endometrial cancer and their review of the literature suggest that the cure rates with vaginal surgery and abdominal surgery are comparable, while morbidity and mortality rates are lower in those patients undergoing vaginal hysterectomy. While they are careful not to endorse this as a standard approach in all patients, they do suggest a controlled clinical trial
50
CHILDERS
comparing abdominal and vaginal hysterectomy in stage I, grade 1 or 2 disease. Even though operative laparoscopy has been performed for several decades, it has only recently gained widespread popularity outside the gynecologic realm. Now, appendectomies [ 121, cholecystectomies [ 131, herniorrhaphies [ 141, presacral neurectomies [ 151, and selective vagotomies [ 161 are being performed laparoscopically. The doors to laparoscopic surgical staging of pelvic malignancies were opened when it became possible to perform laparoscopic lymphadenectomy. Laparoscopic-assisted management of pelvic malignancies is in its infancy. Laparoscopic pelvic lymphadenectomy was first described in the American literature by Reich et al. in June 1990 in a patient with stage I ovarian carcinoma [l]. Querleu et al. published a study of 39 patients in whom this procedure was performed for cervical cancer [2]. It is also being used to stage patients with clinically localized prostatic cancer [ 171. We are currently using a laparoscopic approach to perform surgical-pathological staging procedures on patients with pelvic malignancies. Our technique is similar to that described by Querleu et al. [2] and Vancaillie and Schuessler [17]. We have used this technique for prostatic, vaginal, cervical, and endometrial malignancies and are optimistic about this approach in these patients. We have performed more than 50 laparoscopic lymphadenectomies for patients with pelvic malignancies. After gaining some expertise and confidence, we developed an approach to the higher common iliacs and para-aortic nodes (Fig. l), This approach was originally limited to patients with cervical cancer, but we now feel that it is applicable to patients with stage I endometrial cancer. We report two different approaches to the para-aortic nodes, but feel that exposure is better and a more thorough lymphadenectomy can be performed if the peritoneum is excised over the high common iliac artery, as described for Case 1. This is currently the technique that we are using and would advise. The combined laparoscopic-vaginal management of patients with endometrial cancer is an attractive alternative to the traditional surgical approach. We feel that this approach offers decreased morbidity for the patient yet at the same time adequately surgically stages the disease. The short- and long-term consequences to patients being treated in this fashion have yet to be determined. Complications, such as death reported from electrosurgical damage during laparoscopic cholecystectomy, may preclude widescale use of this technique [19]. We agree with Sedlacek [18] and Querleu et al. [2] in that this is not a technique that the neophyte laparoscopist/oncologist should attempt, but should be reserved for the surgeon with expertise in gynecologic oncology and op-
AND SURWIT
erative laparoscopy. Patient selection factors, which will obviously be important, have not yet been delineated, and physicians should be reminded that this technique is currently investigational.
REFERENCES 1. Reich, H., McGlynn, F., and Wilkie, W. Laparoscopic management of stage I ovarian cancer: A case report, J. Reprod. Med. 35, 601604 (1990). 2. Querleu, D., LeBlanc, E., and Castellain, B. Laparoscopic pelvic lymphadenectomy in the staging of early carcinoma of the cervix, Am. J. Obstet. Gynecol. 164, 579-581 (1991). 3. Hricak, H., Stern, J. O., Fisher, M. R., Shapeero, L. G., Winkler, M. L., and Lacey, C. G. Endometrial carcinoma staging by MR imaging, Radiology 162, 297-305 (1987). 4. Page, E., Constant, O., and Parsons, C. The role of abdominal computed tomography in the assessment of patients with malignant tumours of the cervix and body of the uterus, Radiology 39, 273277 (1988). 5. Worthington, J. L., Balfe, D. M., Lee, J. K. T., Gersell, D. J., Heiken, J. P., Ling, D., Glazer, H. S., Jacobs, A. J., Kao, M. S., and McClennan, B. L. Uterine neoplasms: MR imaging, Radiology 159, 725-730
(1986).
6. Creasman, W. T., Morrow, C. P., Bundy, B. N., Homesley, H. D., Graham, J. E., and Heller, P. B. Surgical pathologic spread patterns of endometrial cancer: A Gynecology Oncology Group study, Cancer 60, 2035-2041 (1987). 7. Shepherd, J. H. Revised FIG0 staging for gynecologic cancer, Br. J. Obstet. Gynecol. %, 889-892 (1989). 8. Angirella, W., and Cosmi, E. V. Vaginal hysterectomy for the treatment of cancer of the corpus uteri, Am. J. Obstet. Gynecol. 100, 541-543
(1968).
9. Peters, W. A., Andersen, W. A., Thornton, W. N., and Morley, G. W. The selective use of vaginal hysterectomy in the management of adenocarcinoma of the endometrium, Am. J. Obstet. Gynecol. 146, 285-291
(1983).
10. Candiani, B. G., Belloni, C., Maggi, R., Colombo, G., Grigoli, A., and Carinelli, S. G. Evaluation of different surgical approaches in the treatment of endometrial cancer at FIG0 stage I, Gynecol. Oncol.
14, 185-193
(1982).
11. Blass, J. D., Berman, M. L., Blass, L. P., and Buller, R. E. Use of vaginal hysterectomy for the management of stage I endometrial cancer in the medically compromised patient, Gynecol. Oncol. 40, 74-77 (1991). 12. Semm, K. Advances in pelviscopic surgery, Curr. Probl. Obstet. Gynecol.
13. 14.
15. 16.
10, 7-42
(1982).
Dubois, F., Berthelot, G., and Levard, H. Cholecystectomie sous coelioscope, Nouv. Presse. Med. 18, 980-982(1989). Bogojavlensky, S. Laparoscopic treatment of inguinal and femoral hernia (video presentation), in Proceedings, 18th Annual Meeting, American Association of Gynecologic Laparoscopists, Washington, DC (1989). Perez, J. J. Laparoscopic presacral neurectomy: Results of the first 25 cases, J. Reprod. Med. 35, 625-630 (1990). Katkhouda, N., and Mouiel, J. A new technique of surgical treat-
51
CASE REPORT ment of chronic duodenal ulcer without laparotomy by videocoelioscopy, Am. J. Surg., in press. 17. Vancaillie, T. G., and Schuessler, W. W. Laparoscopic pelvic lymphadenectomy, in Surgical laparoscopy (K. A. Zucker, R. W. Bailey and E. J. Reddick, Eds.), Quality Medical Publishing, St. Louis, MO, pp. 241-261 (1991).
18. Sedlacek, T. V. Editorial comments, J. Reprod. (1990).
Med.
35, 604-605
19. Wolfe, B. M., Gardener, B., and Frey, C. Laparoscopic cholecystectomy: A remarkable development, JAMA 265, 1573-1574 (1991).
ONCOLOGY
45, 46-51 (1992)
CASE REPORT Combined Laparoscopic and Vaginal Surgery for the Management of Two Cases of Stage I Endometrial Cancer JOEL M. CHILDERS, M.D.,’
AND EARL A. SURWIT, M.D.
Division of Gynecologic Oncology, University of Arizona,
Tucson, Arizona 85721
Received July 17, 1991
Two postmenopausal patients with stageI adenocarcinomaof the endometriumwho were managedwith a combinedlaparoscopicand vaginal approachare presented.Surgical-pathologic staging wasperformed laparoscopically,with exploration of the abdomenand procurementof peritonealcytology and pelvic and para-aortic lymph nodes.The adnexawereligated and mobilized laparoscopicallyand removedwith the vaginal hysterectomy.This approachoffersdecreased morbidity to the patient yet still obtains the samepathologic information and surgical goal as the traditional transabdominalapproach. 0 1992 Academic h, m.
INTRODUCTION
Carcinoma of the endometrium is now a surgically staged malignancy. The traditional approach is total abdominal hysterectomy and bilateral salpingo-oophorectomy, peritoneal cytology, and pelvic and para-aortic lymph node dissection. Vaginal hysterectomy and removal of the adnexa are reserved for a fraction of patients with this disease, since vaginal surgery does not allow adequate exploration of the intraperitoneal cavity and pelvic lymph nodes cannot be obtained using this approach. Using a newly described technique, the transperitoneal laparoscopic lymphadenectomy [1,2], we have been surgically staging patients with pelvic malignancies. For patients with endometrial cancer, complete surgical-pathological staging information is obtained by a combined laparoscopic-vaginal approach. Two cases of adenocarcinema of the endometrium using a combined laparoscopic-vaginal surgical staging procedure are presented. ’ To whom correspondence and requests for reprints should be addressed at 2350 N. Kibler PI., Tucson, AZ 85712. 46 0090-8258/92$1.50 Copyright 0 1992 by Academic Press,Inc. AI1 rights of reproduction in any form reserved.
CASE REPORT 1
A 74-year-old gravida 5, para 5 had a fractional dilatation and curettage for postmenopausal bleeding. The D&C specimen revealed grade 1 adenocarcinoma of both the endocervical and the endometrial specimens. She was referred to our institution for evaluation and management. On examination there was no tumor seen in the cervix, and a repeat endocervical curettage was positive for welldifferentiated adenocarcinoma, but there was no evidence of invasion of this carcinoma into the cervix. The patient’s past medical history was remarkable for hepatitis at age 37; her past surgical history was remarkable for an appendectomy performed in 1933. Her weight at the time of evaluation was 160 pounds. The patient was prepped and drap.ed in the dorsal lithotomy position. After a pneumoperitoneum was adequately created, the primary trocar, a disposable 12-mm trocar and sleeve, was placed through an umbilical incision. A lo-mm 0” telescope was used with a camera and two monitors. This port was also connected to the highflow insufflating unit to maintain an intra-abdominal pressure of 15 mm Hg. Three ancillary trocars were placed, two 5-mm trocars midway between the umbilicus and the anterior superior iliac crest bilaterally and an 11-mm trocar approximately 4 cm above the pubic symphysis in the midline. The patient was placed in the supine position and sequential compression stockings were used. Laparoscopic exploration of the visceral and parietal peritoneal surfaces was performed, including the anterior and posterior cul-de-sac, the adnexa, the appendix, the paracolic gutters, the gallbladder, the liver surfaces, the stomach, the right and left hemidiaphragms, the supracolic and infracolic omentum, the pelvic colon, and as much of the
CASE
REPORT
47
small bowel and mesentery as possible. There was no turator nerve were removed. The bladder flap was created by sharp dissection using the Endo-Shears. evidence of extrauterine disease. A vaginal hysterectomy was performed through a cirThe patient was then placed in steep Trendelenburg and the small bowel and omentum were placed in the cumferential vaginal incision. The anterior cul-de-sac was upper abdomen. This allowed visualization of the peri- easily entered by blunt dissection since the bladder flap had been taken down laparoscopically. Likewise the pastoneum overlying the iliac vessels, the sacral promontory, terior cul-de-sac was also easily entered, and the uteroand the lower abdominal aorta. There was no obvious nodal enlargement. Pelvic washings were obtained for sacral ligaments, cardinal ligaments, and uterine vessel pedicles were clamped, divided, and suture-ligated using cytology, and the tubes were clipped with the Endo-Clip 0 chromic. The uterus, tubes, and ovaries were removed disposable clip applier (Auto-Suture). intact. The peritoneum was not closed. The vaginal cuff A para-aortic lymph node dissection was performed was closed vertically with figure-of-eight sutures of 0 first with the patient in approximately 30” Trendelenburg chromic. Estimated blood loss was 400 cc. The uterus was position. The small bowel was swept off the sacral proopened in the operating room, and a tumor that did not montory and off the bifurcation of the aorta and into the appear to extend to the cervix but did appear to be inupper abdomen. The peritoneum overlying the right comvasive was seen. The final pathology report revealed no mon iliac artery was incised and the retroperitoneal space endocervical involvement, but the fundal carcinoma was was entered. The ureter was visualized and dissected off moderately well differentiated with deep invasion exthe underlying tissue and retracted laterally. This also tending to within 3 mm of the serosal surface. The washassisted in keeping the small bowel from falling into the ings were negative and all lymph nodes were negative. operative field. The precaval nodal group, which was then There were 23 lymph nodes identified, 11 from the left exposed quite adequately, was dissected off the right comside, 10 from the right side, and 2 from the para-aortic mon iliac artery and low aorta and then and off the roof area. of the vena cava. Several perforating veins were identified Postoperatively the patient did well. She was passing during this dissection and clipped with the Endo-Clip and flatus and was on a regular diet on the third postoperative cut with scissors. The dissection was carried inferiorly to day and was discharged to home on the morning of the where the ureter crosses the right common iliac artery. fifth postoperative day. The nodal chain was then transected at its caudad extent using the monopolar electrocautery unit and sharp disCASE REPORT 2 section with scissors. By dissecting the nodal bundle in a cephalad direction, the tissue was completely cleaned off A 65year-old gravida 2, para 2, who was 15 years the roof of the vena cava and the cephalad end of the postmenopausal, had a routine pap smear that was susnodal chain was transected with the clips and scissors and picious for adenocarcinoma. She then underwent endowith the aid of the monopolar cautery unit attached to cervical curettage and endometrial biopsy in the office, the scissors. The vena cava was unroofed up to the second which confirmed a grade 2 to 3 adenocarcinoma in the part of the duodenum in this patient. The site was irriendometrial specimen. The patient’s past medical history gated; hemostasis was satisfactory, and attention was was unremarkable; however, her past surgical history was drawn to the pelvic nodes. remarkable for four prior abdominal procedures. She had A right-sided pelvic node dissection was performed had a ruptured diverticulum resulting in a colostomy, first. The round ligament was desiccated and divided using which required a second surgery for colostomy takedown. Endo-Shears (Auto-Suture). The broad ligament was Her third abdominal procedure was an abdominal heropened and the infundibulopelvic ligament near the ovary niorrhaphy with placement of mesh for a large incisional was isolated and transected with the Endo-GIA 30 dis- hernia. This became infected postoperatively and reposable surgical stapler using 30V staples. The retroperquired her fourth abdominal procedure for removal of itoneal space was then opened, the right common iliac the infected mesh. Her abdominal exam was remarkable and external iliac artery were visualized, and the nodal for a midline incision that extended from the symphysis and adipose tisue over these vessels was removed. The to the xiphoid process, and her umbilicus had been surtechnique for removal is similar to that in open laparotgically removed. She had a large, 18 x 20-cm incisional omy in that the adventitia is incised with scissors over hernia from the symphysis to near the umbilicus that the vessels and the nodal tissue is removed by blunt and extended bilaterally. She weighed 162 pounds. General sharp dissection. Only the anterior and medial chain of surgical consultation was obtained prior to surgery and external iliac nodes was removed, and care was taken to recommendations were to attempt to perform the proremove the nodal tissue at the bifurcation of the internal cedure laparoscopically. and iliac artery. Only the obturator nodes above the obThe patient was taken to the operating room, where a
48
CASE
pneumoperitoneum was created by placing the Veress needle in the left upper quadrant approximately 2 cm below the costochondral margin in the midclavicular line. Following establishment of the pneumoperitoneum, a 7mm laparoscopic trocar and sleeve were placed through this same incision and a 7-mm telescope was used to explore the peritoneal cavity. With this pneumoperitoneum the patient’s lower abdominal hernia became grossly obvious because of the protuberance. Intraperitoneally there was a wall of adhesions in the left lower quadrant to the previous colostomy site and all along the midline abdominal incision from the symphysis to the xiphoid process. An ancillary trocar using a 5-mm disposable instrument was placed in the midabdomen on the left; laparoscopic scissors were used to lyse the omental adhesions to the anterior abdominal wall on the left side and in the midline. The adhesions were taken up above the fascial defect in the midline; a needle was placed through this area transabdominally to determine an appropriate site for a 12-mm trocar and sleeve. This was placed in the midline above the fascial defect and below the omental adhesions. The fourth and fifth ancillary trocars were placed: a 5-mm trocar was placed on the right side midway between the umbilicus and the anterior superior iliac spine, and in the midline near the symphysis an 11-mm trocar was placed. These last two ancillary trocars were placed through the incisional hernia. Laparoscopic exploration of the visceral and peritoneal surfaces was performed as previously described. There was no evidence of extrauterine disease. The patient was placed in steep Trendelenburg position as described for Case 1 and a bilateral pelvic and para-aortic lymphadenectomy was performed in the following fashion. The right-sided pelvic and para-aortic lymph nodes were dissected first. This was accomplished by incising the peritoneum over the right common iliac artery and opening the space between the triangle created by the external iliac artery, the infundibulopelvic ligament, and The retroperitoneal space was the round ligament. opened and the pelvic lymph node dissection was performed as described for Case 1. In this instance, the para-aortic nodes were removed by retracting the ureter medially and in a cephalad direction and approaching the high common and low paraaortic lymph nodes through the incision made in the peritoneum below where the ureter crosses the iliac artery. To accomplish this, it was necessary to extend the peritoneal incision in a cephalad direction to the point where the ureter crosses.
FIG. 1. (a) The right common iliac artery and its bifurcation after a laparoscopic nodal dissection. (b) The high right common iliac artery with oxycel placed on the inferior vena cava.
49
REPORT
The para-aortic nodes were removed as described for Case 1. However, there were no obvious perforating vessels that required clipping or cutting, and the entire transection was carried out with the monopolar electrocautery unit attached to the operating scissors. The infundibulopeivic ligaments were then transected bilaterally by using 0 silk and tying extracorporeal square knots, which were pushed into the abdomen using the Clarke knot pusher. By suture ligating them in two areas, the infundibulopelvic ligament was transected with the scissors, and using the prefabricated slipknots, two additional sutures were placed on each infundibulopelvic ligament. The bladder flap was created as described for Case 1 and a vaginal hysterectomy was performed in a similar fashion. Estimated blood loss was 400 cc. The final pathology report revealed a poorly differentiated tumor that invaded the inner one-third of the myometrium. The washings were negative. Eighteen lymph nodes were identified and were negative for malignancy. Postoperatively the patient did well. She was advanced to a regular diet and was discharged on the morning of Postoperative Day 4.
DISCUSSION Endometrial cancer, like pelvic malignancies in general, has a propensity to metastasize to regional (pelvic) lymph nodes. Since current imaging modalities are suboptimal in detecting these metastases [3-51, a significant percentage of patients with stage I adenocarcinoma of the endometrium are clinically misstaged [6]. This has motivated the gynecologic oncologist to surgically stage these patients, which aided in the subsequent changing of endometrial cancer from a clinically staged to a surgically staged malignancy [7]. Vaginal hysterectomy has been used in the management of endometrial cancer, but its use has basically been limited to the medically compromised patient [&lo]. Several factors have prevented the endorsement of vaginal surgery for patients with endometrial cancer, including the inability to (1) assess the peritoneal cavity, (2) perform a lymphadenectomy, (3) obtain pelvic washings, and (4) consistently perform salpingo-oophorectomy. Blass et al. [ 1 I] published the most recent report on the use of vaginal hysterectomy in these patients. Their data on 31 medically compromised patients with stage I endometrial cancer and their review of the literature suggest that the cure rates with vaginal surgery and abdominal surgery are comparable, while morbidity and mortality rates are lower in those patients undergoing vaginal hysterectomy. While they are careful not to endorse this as a standard approach in all patients, they do suggest a controlled clinical trial
50
CHILDERS
comparing abdominal and vaginal hysterectomy in stage I, grade 1 or 2 disease. Even though operative laparoscopy has been performed for several decades, it has only recently gained widespread popularity outside the gynecologic realm. Now, appendectomies [ 121, cholecystectomies [ 131, herniorrhaphies [ 141, presacral neurectomies [ 151, and selective vagotomies [ 161 are being performed laparoscopically. The doors to laparoscopic surgical staging of pelvic malignancies were opened when it became possible to perform laparoscopic lymphadenectomy. Laparoscopic-assisted management of pelvic malignancies is in its infancy. Laparoscopic pelvic lymphadenectomy was first described in the American literature by Reich et al. in June 1990 in a patient with stage I ovarian carcinoma [l]. Querleu et al. published a study of 39 patients in whom this procedure was performed for cervical cancer [2]. It is also being used to stage patients with clinically localized prostatic cancer [ 171. We are currently using a laparoscopic approach to perform surgical-pathological staging procedures on patients with pelvic malignancies. Our technique is similar to that described by Querleu et al. [2] and Vancaillie and Schuessler [17]. We have used this technique for prostatic, vaginal, cervical, and endometrial malignancies and are optimistic about this approach in these patients. We have performed more than 50 laparoscopic lymphadenectomies for patients with pelvic malignancies. After gaining some expertise and confidence, we developed an approach to the higher common iliacs and para-aortic nodes (Fig. l), This approach was originally limited to patients with cervical cancer, but we now feel that it is applicable to patients with stage I endometrial cancer. We report two different approaches to the para-aortic nodes, but feel that exposure is better and a more thorough lymphadenectomy can be performed if the peritoneum is excised over the high common iliac artery, as described for Case 1. This is currently the technique that we are using and would advise. The combined laparoscopic-vaginal management of patients with endometrial cancer is an attractive alternative to the traditional surgical approach. We feel that this approach offers decreased morbidity for the patient yet at the same time adequately surgically stages the disease. The short- and long-term consequences to patients being treated in this fashion have yet to be determined. Complications, such as death reported from electrosurgical damage during laparoscopic cholecystectomy, may preclude widescale use of this technique [19]. We agree with Sedlacek [18] and Querleu et al. [2] in that this is not a technique that the neophyte laparoscopist/oncologist should attempt, but should be reserved for the surgeon with expertise in gynecologic oncology and op-
AND SURWIT
erative laparoscopy. Patient selection factors, which will obviously be important, have not yet been delineated, and physicians should be reminded that this technique is currently investigational.
REFERENCES 1. Reich, H., McGlynn, F., and Wilkie, W. Laparoscopic management of stage I ovarian cancer: A case report, J. Reprod. Med. 35, 601604 (1990). 2. Querleu, D., LeBlanc, E., and Castellain, B. Laparoscopic pelvic lymphadenectomy in the staging of early carcinoma of the cervix, Am. J. Obstet. Gynecol. 164, 579-581 (1991). 3. Hricak, H., Stern, J. O., Fisher, M. R., Shapeero, L. G., Winkler, M. L., and Lacey, C. G. Endometrial carcinoma staging by MR imaging, Radiology 162, 297-305 (1987). 4. Page, E., Constant, O., and Parsons, C. The role of abdominal computed tomography in the assessment of patients with malignant tumours of the cervix and body of the uterus, Radiology 39, 273277 (1988). 5. Worthington, J. L., Balfe, D. M., Lee, J. K. T., Gersell, D. J., Heiken, J. P., Ling, D., Glazer, H. S., Jacobs, A. J., Kao, M. S., and McClennan, B. L. Uterine neoplasms: MR imaging, Radiology 159, 725-730
(1986).
6. Creasman, W. T., Morrow, C. P., Bundy, B. N., Homesley, H. D., Graham, J. E., and Heller, P. B. Surgical pathologic spread patterns of endometrial cancer: A Gynecology Oncology Group study, Cancer 60, 2035-2041 (1987). 7. Shepherd, J. H. Revised FIG0 staging for gynecologic cancer, Br. J. Obstet. Gynecol. %, 889-892 (1989). 8. Angirella, W., and Cosmi, E. V. Vaginal hysterectomy for the treatment of cancer of the corpus uteri, Am. J. Obstet. Gynecol. 100, 541-543
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9. Peters, W. A., Andersen, W. A., Thornton, W. N., and Morley, G. W. The selective use of vaginal hysterectomy in the management of adenocarcinoma of the endometrium, Am. J. Obstet. Gynecol. 146, 285-291
(1983).
10. Candiani, B. G., Belloni, C., Maggi, R., Colombo, G., Grigoli, A., and Carinelli, S. G. Evaluation of different surgical approaches in the treatment of endometrial cancer at FIG0 stage I, Gynecol. Oncol.
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11. Blass, J. D., Berman, M. L., Blass, L. P., and Buller, R. E. Use of vaginal hysterectomy for the management of stage I endometrial cancer in the medically compromised patient, Gynecol. Oncol. 40, 74-77 (1991). 12. Semm, K. Advances in pelviscopic surgery, Curr. Probl. Obstet. Gynecol.
13. 14.
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Dubois, F., Berthelot, G., and Levard, H. Cholecystectomie sous coelioscope, Nouv. Presse. Med. 18, 980-982(1989). Bogojavlensky, S. Laparoscopic treatment of inguinal and femoral hernia (video presentation), in Proceedings, 18th Annual Meeting, American Association of Gynecologic Laparoscopists, Washington, DC (1989). Perez, J. J. Laparoscopic presacral neurectomy: Results of the first 25 cases, J. Reprod. Med. 35, 625-630 (1990). Katkhouda, N., and Mouiel, J. A new technique of surgical treat-
51
CASE REPORT ment of chronic duodenal ulcer without laparotomy by videocoelioscopy, Am. J. Surg., in press. 17. Vancaillie, T. G., and Schuessler, W. W. Laparoscopic pelvic lymphadenectomy, in Surgical laparoscopy (K. A. Zucker, R. W. Bailey and E. J. Reddick, Eds.), Quality Medical Publishing, St. Louis, MO, pp. 241-261 (1991).
18. Sedlacek, T. V. Editorial comments, J. Reprod. (1990).
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19. Wolfe, B. M., Gardener, B., and Frey, C. Laparoscopic cholecystectomy: A remarkable development, JAMA 265, 1573-1574 (1991).
