SURGEONS CORNER
Single-Port Laparoscopic Extraperitoneal Para-aortic Lymphadenectomy Sara Iacoponi, MD, Javier De Santiago, MD, PhD, Maria D. Diestro, MD, PhD, Alicia Hernandez, MD, PhD, and Ignacio Zapardiel, MD, PhD
Objective: The aim of this study was to evaluate the feasibility and the safety of single-port extraperitoneal laparoscopic para-aortic lymphadenectomy for patients with gynecologic cancer. Methods: From July 2012 to January 2013, a total of 7 patients with gynecologic cancer underwent a laparoscopic pelvic and para-aortic lymphadenectomy with a single-port device. An extraperitoneal approach was performed for para-aortic lymphadenectomy using only one 2.5-cm incision on the left side. In 6 patients, additionally, hysterectomy and pelvic lymphadenectomy with conventional laparoscopy were performed to complete the treatment. Results: Aortic dissection was complete in all cases without complications. The median age of the patients was 63 years (range, 48Y78 years), and the median patient body mass index was 31 kg/m2 (range, 19Y38 kg/m2). The median number of para-aortic nodes was 17 (range, 10Y25); the median operative time was 204 minutes (range, 120Y300 minutes). The median hospital stay was 4 days (range, 3Y6 days). No patient encountered postoperative complications. Conclusions: This study demonstrates the feasibility of single-port laparoscopic extraperitoneal para-aortic lymphadenectomy. Key Words: Single port, Laparoscopic para-aortic lymphadenectomy, Extraperitoneal surgery Received June 20, 2013. Accepted for publication August 21, 2013. (Int J Gynecol Cancer 2013;23: 1712Y1716)
advancement of optics, instrumentation, and surgical T heexpertise during the last decade has expanded and con-
firmed the advantages of minimally invasive surgery in the treatment of many gynecologic malignancies. Numerous studies have demonstrated that laparoscopic approaches to various gynecologic oncology conditions are comparable with surgical and oncologic outcomes of the abdominal staging,
Gynecologic Oncology Unit, La Paz University Hospital, Madrid, Spain. Address correspondence and reprint requests to Sara Iacoponi, MD, Gynecologic Oncology Unit, La Paz University Hospital, Paseo de la Castellana n-261, 28046, Madrid, Spain. E-mail: [email protected]. The authors declare no conflicts of interest. Copyright * 2013 by IGCS and ESGO ISSN: 1048-891X DOI: 10.1097/IGC.0000000000000006
1712
with the advantages of shorter hospital stays and improved quality of life.1,2 In case of para-aortic lymphadenectomy, it is accepted in literature that laparoscopic transperitoneal lymphadenectomy can be performed in most patients. Although transperitoneal laparoscopy is less traumatic than laparotomy and can be performed without significant complications, this kind of approach has a strong association with bowel adhesion formation and wound healing complications.3 In 1996, Vasilev and McGonigle4 described the laparoscopic extraperitoneal para-aortic lymphadenectomy. This approach theoretically combines the benefits of laparoscopy and the extraperitoneal approach. It can decrease the risk for direct bowel injury, adhesion formation, and wound complications and possibly decrease the length of hospital stay and treatment delay.5 It is also accepted that the risk for radiation enteritis is reduced after extraperitoneal para-aortic lymphadenectomy.6
International Journal of Gynecological Cancer
& Volume 23, Number 9, November 2013
Copyright © 2013 by IGCS and ESGO. Unauthorized reproduction of this article is prohibited.
International Journal of Gynecological Cancer
& Volume 23, Number 9, November 2013
Recently, an even less invasive alternative to conventional laparoscopic surgery has been developed: laparoscopicendoscopic single-site surgery. Single-port laparoscopy is an attempt to further enhance the cosmetic benefits of minimally invasive surgery while minimizing the potential morbidity associated with multiple incisions. Preliminary advances of this technique applied to the management of malignant disorders in gynecology demonstrated the feasibility of this approach.7Y10 In 2010, Escobar and colleagues8 were the first to report a para-aortic lymphadenectomy procedure for gynecologic cancer using a single port via a transperitoneal approach. Proposed advantages of single-port over conventional multiport laparoscopy include better cosmetic results from a relatively hidden umbilical scar and improved postoperative pain management. Other authors9Y11 developed and adopted this new procedure using an extraperitoneal single-port approach. The extraperitoneal approach was the best way to perform the lymphadenectomy, which specifically targeted the left-sided supramesenteric and inframesenteric para-aortic space. The extraperitoneal approach could be used even in overweight patients, in whom dissection of the supramesenteric nodes was more difficult in this context using a transperitoneal approach. Finally, a randomized study on pigs suggested a reduced adhesion rate with the retroperitoneal approach compared with the transperitoneal approach.12 The aim of this study was to evaluate the feasibility and the safety of single-port extraperitoneal laparoscopic para-aortic lymphadenectomy for patients with gynecologic cancer.
Single-Port Para-aortic Lymphadenectomy
Medical, Tokyo, Japan) is introduced into the extraperitoneal space (Fig. 1). The peritoneal cavity is deflated, whereas the extraperitoneal space is inflated with carbon dioxide up to a maximum pressure of 10 mm Hg. After retroperitoneal identification of the psoas muscle, the iliac vessels, and the ureter, additional development of the retroperitoneal space could be accomplished safely with blunt dissection until the identification of the left renal vein. The para-aortic lymphadenectomy follows the steps described by Querleu et al.13 The dissection is carried along the lateral and anterior aspects of the common iliac artery caudally to the level of its bifurcation and cephalically up to the level of aortic bifurcation and the left renal vessels. The left common iliac and aortic lymph nodes can be dissected from the bifurcation of the common iliac artery caudally to the renal vessels. The sacral promontory, the bifurcation of the aorta, the inferior part of the vena cava, and the right common iliac artery are identified. Then, the right ureter is identified and lifted up together with the overlying peritoneal sac, and the right lateral common iliac nodes, the precaval nodes, and the presacral nodes are dissected off. The para-aortic lymph nodes of both sides have been resected from the left and extracted in a laparoscopic bag. The inferior mesenteric artery was preserved in all cases (Fig. 2). At the end of the procedure, the extraperitoneal space was communicated to intraperitoneal one to reduce the risk for symptomatic l extraperitoneal lymphocele.7 Conventional instruments and a 10-mm 0-degree laparoscope were used in all cases. In the case in which hysterectomy with bilateral adnexectomy and pelvic lymphadenectomy were performed
METHODS From July 2012 to January 2013, a total of 7 patients with gynecologic cancer underwent single-port laparoscopic para-aortic lymphadenectomy at La Paz University Hospital in Madrid, Spain. The inclusion criteria comprised patients with gynecologic malignancies who required pelvic and/or para-aortic lymphadenectomy and who were candidates for minimally invasive surgery. The patient is placed in low lithotomy position to allow both perineal and abdominal access. The arms are positioned at the patient’s sides, and the legs are abducted with the feet and the calves in boots and the knees slightly flexed. The table is tilted in 15-degree Trendelenburg. The surgeon is positioned to the left of the patient during the procedure. The assistant stands on the left of the patient and the left of the surgeon. The procedure starts with conventional transperitoneal laparoscopy to explore the abdominal cavity. For the extraperitoneal approach, only one 2.5-cm incision is necessary on the patient’s left side between the iliac crest and the last rib. The skin, the fascia, the transverse muscles, and the deep fascia are incised, with care taken not to open the peritoneum. The landmarks for finger dissection are well known and included the iliac fossa; the psoas muscle; and, more medially, the left common iliac artery. When the dissection is complete, the single-port device (Triport; Olympus
FIGURE 1. External view of the Triport device introduced in the extraperitoneal space.
* 2013 IGCS and ESGO
Copyright © 2013 by IGCS and ESGO. Unauthorized reproduction of this article is prohibited.
1713
International Journal of Gynecological Cancer
Iacoponi et al
FIGURE 2. Lack of triangulation at the level of the inferior mesenteric artery.
after extraperitoneal para-aortic lymphadenectomy, a classic transperitoneal approach was used to complete the procedure. We placed 2 extra 5-mm trocars, 1 in midline and 1 in the right side of the lower abdomen. Estimated blood loss was calculated as the difference between the previous and the postsurgery hemoglobin level.
RESULTS Seven patients underwent an extraperitoneal aortic lymphadenectomy using a single-port approach. The median age and body mass index were 63 years (range, 48Y78) and 31 kg/m2 (range 19Y38), respectively. Six patients had endometrial adenocarcinoma (International Federation of Gynecology and Obstetrics IB-IIIC), and 1 had cervical adenocarcinoma (International Federation of Gynecology and Obstetrics IIIB). Four patients with endometrial adenocarcinoma underwent hysterectomy, adnexectomy, and para-aortic and pelvic lymphadenectomy, and 2 patients with endometrial adenocarcinoma had only pelvic and para-aortic lymphadenectomy (hysterectomy and adnexectomy were performed in a previous surgery). In the patient with cervical adenocarcinoma, only para-aortic lymphadenectomy was performed. The median operative time was 204 minutes (range, 120Y300). The median number of para-aortic and pelvic nodes removed was 17 (range, 10Y25) and 21 (range, 12Y34), respectively. Two patients had node metastasis, 1 in the para-aortic and pelvic nodes and 1 in the para-aortic nodes. Aortic dissection was completed in all cases. No perioperative major complications and no laparotomic conversion occurred. The median blood loss was 1.9 g/dL of hemoglobin (range, 0.4Y3). No patient required blood transfusion. The median postoperative hospital stay was 4 days (range 3Y6), without any complications.
DISCUSSION Several studies have demonstrated that the single-port approach to various gynecologic conditions is feasible, with
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& Volume 23, Number 9, November 2013
shorter hospital stays, less pain, and improved quality of life and the same surgical outcome compared with conventional laparoscopy.7Y10,13 There are very few reports describing the single-port laparoscopic para-aortic lymphadenectomy,7Y11,14 which are summarized in Table 1. The first experience was described by Escobar et al,8 who performed 21 single-port transperitoneal pelvic and para-aortic lymphadenectomies. The median pelvic lymph node count was 14 (range, 7Y19) and the para-aortic lymph node count was 6 (range 2Y14), compared with open surgery. Lambaudie et al7 describe, for the first time, an extraperitoneal para-aortic lymphadenectomy in 14 patients using the Gelpoint device (Applied, Rancho San Margarita, CA), with the median para-aortic lymph node count of 16 (range, 7Y40). In our cases, the median para-aortic lymph node count was 17 (range, 10Y25), which is comparable with the lymph node count reported by Lambaudie et al7 and by Querleu et al13 using conventional laparoscopic extraperitoneal approach. Gouy et al9 used the same single port for the transperitoneal step and the extraperitoneal approach for the paraaortic lymphadenectomy. The authors analyzed 14 consecutive patients with cervical cancer and performed a laparoscopic staging procedure. The median operative time was 190 minutes (range, 135Y250). The median number of lymph nodes removed was 14 (range, 2Y23). The median operative time in our report was 204 minutes, comparable with the literature.15 The operative time was longer compared with conventional extraperitoneal laparoscopic paraaortic lymphadenectomy (119 minutes).9,15 Even if our results referred to the realization of pelvic and para-aortic lymphadenectomy, in the only case of para-aortic lymphadenectomy, the operative time was 120 minutes. Analyzing our data, we observed that the group is mostly composed of obese patients with more postoperative complications. Thus, the realization of transperitoneal lymphadenectomy is hindered by the presence of more abdominal fat. This technique could facilitate lymph node dissection, with less incision and less risk for infection and without increasing surgical time. The main disadvantage of single-port surgery is the collision of instruments; this, however, is not significant in this situation because with the extraperitoneal left side approach, we are already close to and in front of the para-aortic space, so conventional instruments can be used without crossing them. Most of our patients had endometrial cancer and often were morbidly obese. Successful minimally invasive surgery will reduce postoperative wound complications and will most likely reduce other postoperative morbidities because of faster recovery and resumption of normal activities of daily living.16 In view of the results of the literature, the single-port approach for para-aortic lymphadenectomy may be a valid alternative in selected cases and in the hands of a skilled surgeon. More data are necessary to determine the reproducibility and the clinical advantages of extraperitoneal singleport para-aortic lymphadenectomy. * 2013 IGCS and ESGO
Copyright © 2013 by IGCS and ESGO. Unauthorized reproduction of this article is prohibited.
51
47
33
58
63 (48Y78)
11
13
1
100
7
Lambaudie et al7 2012
Schuman et al11 2011 Fagotti et al14 2012 Endometrial cancer
1 Ovarian cancer Cervical cancer
14 Endometrial cancer 4 Ovarian cancer 3 Cervical cancer 14 Cervical cancer 10 Cervical cancer 1 Endometrial cancer 9 Cervical cancer 3 Endometrial cancer
Gynecologic Cancer
31 6 Endometrial (19Y38) cancer 1 Cervical cancer
26
25
24
21
30
BMI, kg/m2 Type of PAL
Extraperitoneal NA
Extraperitoneal NA
4 HT + BSO 6 PL 7 PAL
100 HT + BSO 48 PL 27 PAL
1 PAL
16 (1Y33)
NP
NP
NP
NP
7 (2Y28)
10
16 (7Y40)
16 (7Y35)
14 (2Y23)
6 (2Y14)
129 (45Y321)
125
180 (120Y263)
240 (135Y270)
190 (135Y250)
120 (60Y180)
Operative Time, min
Extraperitoneal 1.9 g/dL of 21 (12Y34) 17 (10Y25) 204 (120Y300) hemoglobin (0.4Y3)
Transperitoneal 70 mL (10Y500)
Extraperitoneal 10 mL
Extraperitoneal n = 40 13 PAL (7 mL) (complete in 11)
11 PAL
14 PAL
11 HT + PL Transperitoneal 9 (minimal) 14 (7Y19) 9 PAL? n=8 (G100 mL) n=4 (100 mL)
Surgery
Estimated Blood Loss
Median Median Pelvic Lymph Para-aortic Node Lymph Node
4 (3Y6)
NA
NA
1.7 (1Y4)
3 (2Y26)
2 (1Y4)
NA
0
4 (2 conversion to conventional laparoscopy and laparotomy)
0
0
0
0
2 conversion to conventional laparoscopy (1 vascular injury)
Postoperative Hospital Stay, d Complication
& Volume 23, Number 9, November 2013
* 2013 IGCS and ESGO
Copyright © 2013 by IGCS and ESGO. Unauthorized reproduction of this article is prohibited.
BMI, Body mass index; BSO, bilateral salpingo-oophorectomy; HT, hysterectomy; NA, not available; NP, not performed; PAL, para-aortic lymphadenectomy; PL, pelvic lymphadenectomy.
Iacoponi et al (current work)
41
14
Gouy et al9 2011 Gouy et al10 2012
58
21
Escobar et al8 2010
Authors
No. Patients Age
TABLE 1. Summary of single-portYsite lymphadenectomy publications
International Journal of Gynecological Cancer Single-Port Para-aortic Lymphadenectomy
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International Journal of Gynecological Cancer
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REFERENCES 1. Malzoni M, Tinelli R, Cosentino F, et al. Total laparoscopic radical hysterectomy versus abdominal radical hysterectomy with lymphadenectomy in patients with early cervical cancer: our experience. Ann Surg Oncol. 2009;16:1316Y1323. 2. Eltabbakh GH, Shamonki MI, Moody JM, et al. Hysterectomy for obese women with endometrial cancer: laparoscopy or laparotomy? Gynecol Oncol. 2000;78:329Y335. 3. Ko¨hler C, Klemm P, Schau A, et al. Introduction of transperitoneal lymphadenectomy in a gynecologic oncology center: analysis of 650 laparoscopic pelvic and/or paraaortic transperitoneal lymphadenectomies. Gynecol Oncol. 2004; 95:52Y56. 4. Vasilev SA, McGonigle KF. Extraperitoneal laparoscopic para-aortic lymph node dissection. Gynecol Oncol. 1996; 61:315Y320. 5. Nagao S, Fujiwara K, Kagawa R, et al. Feasibility of extraperitoneal laparoscopic para-aortic and common iliac lymphadenectomy. Gynecol Oncol. 2006;103:732Y735. 6. Weiser EB, Bundy BN, Hoskins WJ, et al. Extraperitoneal versus transperitoneal selective paraaortic lymphadenectomy in the pretreatment surgical staging of advanced cervical carcinoma (a Gynecologic Oncology Group study). Gynecol Oncol. 1989;33:283Y289. 7. Lambaudie E, Cannone F, Bannier M, et al. Laparoscopic extraperitoneal aortic dissection: does single-port surgery offer the same possibilities as conventional laparoscopy? Surg Endosc. 2012;26:1920Y1923. 8. Escobar PF, Fader AN, Rasool N, et al. Single-port laparoscopic pelvic and para-aortic lymph node sampling or lymphadenectomy: development of a technique and instrumentation. Int J Gynecol Cancer. 2010;20:1268Y1273.
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9. Gouy S, Kane A, Uzan C, et al. Single-port laparoscopy and extraperitoneal para-aortic lymphadenectomy: about fourteen consecutive cases. Gynecol Oncol. 2011;123:329Y332. 10. Gouy S, Uzan C, Kane A, et al. A new single-port approach to perform a transperitoneal step and an extraperitoneal para-aortic lymphadenectomy with a single incision. J Am Coll Surg. 2012;214:e25Ye30. 11. Schuman S, Lucci JA III, Twiggs LB. Laparoendoscopic single-site extraperitoneal aortic lymphadenectomy: first experience. J Laparoendosc Adv Surg Tech A. 2011;21: 251Y254. 12. Occelli B, Narducci F, Lanvin D, et al. De novo adhesions with extraperitoneal endosurgical para-aortic lymphadenectomy versus transperitoneal laparoscopic para-aortic lymphadenectomy: a randomized experimental study. Am J Obstet Gynecol. 2000;183:529Y533. 13. Querleu D, Dargent D, Ansquer Y, et al. Extraperitoneal endosurgical aortic and common iliac dissection in the staging of bulky or advanced cervical carcinomas. Cancer. 2000;88: 1883Y1891. 14. Fagotti A, Boruta DM II, Scambia G, et al. First 100 early endometrial cancer cases treated with laparoendoscopic single-site surgery: a multicentric retrospective study. Am J Obstet Gynecol. 2012;206:353. 15. Dargent D, Ansquer Y, Mathevet P. Technical development and results of left extraperitoneal laparoscopic paraaortic lymphadenectomy for cervical cancer. Gynecol Oncol. 2000; 77:87Y92. 16. Scribner D, Walker J, Johnson G, et al. Laparoscopic pelvic and paraaortic lymph node dissection in the obese. Gynecol Oncol. 2002;84:426Y430.
* 2013 IGCS and ESGO
Copyright © 2013 by IGCS and ESGO. Unauthorized reproduction of this article is prohibited.
Single-Port Laparoscopic Extraperitoneal Para-aortic Lymphadenectomy Sara Iacoponi, MD, Javier De Santiago, MD, PhD, Maria D. Diestro, MD, PhD, Alicia Hernandez, MD, PhD, and Ignacio Zapardiel, MD, PhD
Objective: The aim of this study was to evaluate the feasibility and the safety of single-port extraperitoneal laparoscopic para-aortic lymphadenectomy for patients with gynecologic cancer. Methods: From July 2012 to January 2013, a total of 7 patients with gynecologic cancer underwent a laparoscopic pelvic and para-aortic lymphadenectomy with a single-port device. An extraperitoneal approach was performed for para-aortic lymphadenectomy using only one 2.5-cm incision on the left side. In 6 patients, additionally, hysterectomy and pelvic lymphadenectomy with conventional laparoscopy were performed to complete the treatment. Results: Aortic dissection was complete in all cases without complications. The median age of the patients was 63 years (range, 48Y78 years), and the median patient body mass index was 31 kg/m2 (range, 19Y38 kg/m2). The median number of para-aortic nodes was 17 (range, 10Y25); the median operative time was 204 minutes (range, 120Y300 minutes). The median hospital stay was 4 days (range, 3Y6 days). No patient encountered postoperative complications. Conclusions: This study demonstrates the feasibility of single-port laparoscopic extraperitoneal para-aortic lymphadenectomy. Key Words: Single port, Laparoscopic para-aortic lymphadenectomy, Extraperitoneal surgery Received June 20, 2013. Accepted for publication August 21, 2013. (Int J Gynecol Cancer 2013;23: 1712Y1716)
advancement of optics, instrumentation, and surgical T heexpertise during the last decade has expanded and con-
firmed the advantages of minimally invasive surgery in the treatment of many gynecologic malignancies. Numerous studies have demonstrated that laparoscopic approaches to various gynecologic oncology conditions are comparable with surgical and oncologic outcomes of the abdominal staging,
Gynecologic Oncology Unit, La Paz University Hospital, Madrid, Spain. Address correspondence and reprint requests to Sara Iacoponi, MD, Gynecologic Oncology Unit, La Paz University Hospital, Paseo de la Castellana n-261, 28046, Madrid, Spain. E-mail: [email protected]. The authors declare no conflicts of interest. Copyright * 2013 by IGCS and ESGO ISSN: 1048-891X DOI: 10.1097/IGC.0000000000000006
1712
with the advantages of shorter hospital stays and improved quality of life.1,2 In case of para-aortic lymphadenectomy, it is accepted in literature that laparoscopic transperitoneal lymphadenectomy can be performed in most patients. Although transperitoneal laparoscopy is less traumatic than laparotomy and can be performed without significant complications, this kind of approach has a strong association with bowel adhesion formation and wound healing complications.3 In 1996, Vasilev and McGonigle4 described the laparoscopic extraperitoneal para-aortic lymphadenectomy. This approach theoretically combines the benefits of laparoscopy and the extraperitoneal approach. It can decrease the risk for direct bowel injury, adhesion formation, and wound complications and possibly decrease the length of hospital stay and treatment delay.5 It is also accepted that the risk for radiation enteritis is reduced after extraperitoneal para-aortic lymphadenectomy.6
International Journal of Gynecological Cancer
& Volume 23, Number 9, November 2013
Copyright © 2013 by IGCS and ESGO. Unauthorized reproduction of this article is prohibited.
International Journal of Gynecological Cancer
& Volume 23, Number 9, November 2013
Recently, an even less invasive alternative to conventional laparoscopic surgery has been developed: laparoscopicendoscopic single-site surgery. Single-port laparoscopy is an attempt to further enhance the cosmetic benefits of minimally invasive surgery while minimizing the potential morbidity associated with multiple incisions. Preliminary advances of this technique applied to the management of malignant disorders in gynecology demonstrated the feasibility of this approach.7Y10 In 2010, Escobar and colleagues8 were the first to report a para-aortic lymphadenectomy procedure for gynecologic cancer using a single port via a transperitoneal approach. Proposed advantages of single-port over conventional multiport laparoscopy include better cosmetic results from a relatively hidden umbilical scar and improved postoperative pain management. Other authors9Y11 developed and adopted this new procedure using an extraperitoneal single-port approach. The extraperitoneal approach was the best way to perform the lymphadenectomy, which specifically targeted the left-sided supramesenteric and inframesenteric para-aortic space. The extraperitoneal approach could be used even in overweight patients, in whom dissection of the supramesenteric nodes was more difficult in this context using a transperitoneal approach. Finally, a randomized study on pigs suggested a reduced adhesion rate with the retroperitoneal approach compared with the transperitoneal approach.12 The aim of this study was to evaluate the feasibility and the safety of single-port extraperitoneal laparoscopic para-aortic lymphadenectomy for patients with gynecologic cancer.
Single-Port Para-aortic Lymphadenectomy
Medical, Tokyo, Japan) is introduced into the extraperitoneal space (Fig. 1). The peritoneal cavity is deflated, whereas the extraperitoneal space is inflated with carbon dioxide up to a maximum pressure of 10 mm Hg. After retroperitoneal identification of the psoas muscle, the iliac vessels, and the ureter, additional development of the retroperitoneal space could be accomplished safely with blunt dissection until the identification of the left renal vein. The para-aortic lymphadenectomy follows the steps described by Querleu et al.13 The dissection is carried along the lateral and anterior aspects of the common iliac artery caudally to the level of its bifurcation and cephalically up to the level of aortic bifurcation and the left renal vessels. The left common iliac and aortic lymph nodes can be dissected from the bifurcation of the common iliac artery caudally to the renal vessels. The sacral promontory, the bifurcation of the aorta, the inferior part of the vena cava, and the right common iliac artery are identified. Then, the right ureter is identified and lifted up together with the overlying peritoneal sac, and the right lateral common iliac nodes, the precaval nodes, and the presacral nodes are dissected off. The para-aortic lymph nodes of both sides have been resected from the left and extracted in a laparoscopic bag. The inferior mesenteric artery was preserved in all cases (Fig. 2). At the end of the procedure, the extraperitoneal space was communicated to intraperitoneal one to reduce the risk for symptomatic l extraperitoneal lymphocele.7 Conventional instruments and a 10-mm 0-degree laparoscope were used in all cases. In the case in which hysterectomy with bilateral adnexectomy and pelvic lymphadenectomy were performed
METHODS From July 2012 to January 2013, a total of 7 patients with gynecologic cancer underwent single-port laparoscopic para-aortic lymphadenectomy at La Paz University Hospital in Madrid, Spain. The inclusion criteria comprised patients with gynecologic malignancies who required pelvic and/or para-aortic lymphadenectomy and who were candidates for minimally invasive surgery. The patient is placed in low lithotomy position to allow both perineal and abdominal access. The arms are positioned at the patient’s sides, and the legs are abducted with the feet and the calves in boots and the knees slightly flexed. The table is tilted in 15-degree Trendelenburg. The surgeon is positioned to the left of the patient during the procedure. The assistant stands on the left of the patient and the left of the surgeon. The procedure starts with conventional transperitoneal laparoscopy to explore the abdominal cavity. For the extraperitoneal approach, only one 2.5-cm incision is necessary on the patient’s left side between the iliac crest and the last rib. The skin, the fascia, the transverse muscles, and the deep fascia are incised, with care taken not to open the peritoneum. The landmarks for finger dissection are well known and included the iliac fossa; the psoas muscle; and, more medially, the left common iliac artery. When the dissection is complete, the single-port device (Triport; Olympus
FIGURE 1. External view of the Triport device introduced in the extraperitoneal space.
* 2013 IGCS and ESGO
Copyright © 2013 by IGCS and ESGO. Unauthorized reproduction of this article is prohibited.
1713
International Journal of Gynecological Cancer
Iacoponi et al
FIGURE 2. Lack of triangulation at the level of the inferior mesenteric artery.
after extraperitoneal para-aortic lymphadenectomy, a classic transperitoneal approach was used to complete the procedure. We placed 2 extra 5-mm trocars, 1 in midline and 1 in the right side of the lower abdomen. Estimated blood loss was calculated as the difference between the previous and the postsurgery hemoglobin level.
RESULTS Seven patients underwent an extraperitoneal aortic lymphadenectomy using a single-port approach. The median age and body mass index were 63 years (range, 48Y78) and 31 kg/m2 (range 19Y38), respectively. Six patients had endometrial adenocarcinoma (International Federation of Gynecology and Obstetrics IB-IIIC), and 1 had cervical adenocarcinoma (International Federation of Gynecology and Obstetrics IIIB). Four patients with endometrial adenocarcinoma underwent hysterectomy, adnexectomy, and para-aortic and pelvic lymphadenectomy, and 2 patients with endometrial adenocarcinoma had only pelvic and para-aortic lymphadenectomy (hysterectomy and adnexectomy were performed in a previous surgery). In the patient with cervical adenocarcinoma, only para-aortic lymphadenectomy was performed. The median operative time was 204 minutes (range, 120Y300). The median number of para-aortic and pelvic nodes removed was 17 (range, 10Y25) and 21 (range, 12Y34), respectively. Two patients had node metastasis, 1 in the para-aortic and pelvic nodes and 1 in the para-aortic nodes. Aortic dissection was completed in all cases. No perioperative major complications and no laparotomic conversion occurred. The median blood loss was 1.9 g/dL of hemoglobin (range, 0.4Y3). No patient required blood transfusion. The median postoperative hospital stay was 4 days (range 3Y6), without any complications.
DISCUSSION Several studies have demonstrated that the single-port approach to various gynecologic conditions is feasible, with
1714
& Volume 23, Number 9, November 2013
shorter hospital stays, less pain, and improved quality of life and the same surgical outcome compared with conventional laparoscopy.7Y10,13 There are very few reports describing the single-port laparoscopic para-aortic lymphadenectomy,7Y11,14 which are summarized in Table 1. The first experience was described by Escobar et al,8 who performed 21 single-port transperitoneal pelvic and para-aortic lymphadenectomies. The median pelvic lymph node count was 14 (range, 7Y19) and the para-aortic lymph node count was 6 (range 2Y14), compared with open surgery. Lambaudie et al7 describe, for the first time, an extraperitoneal para-aortic lymphadenectomy in 14 patients using the Gelpoint device (Applied, Rancho San Margarita, CA), with the median para-aortic lymph node count of 16 (range, 7Y40). In our cases, the median para-aortic lymph node count was 17 (range, 10Y25), which is comparable with the lymph node count reported by Lambaudie et al7 and by Querleu et al13 using conventional laparoscopic extraperitoneal approach. Gouy et al9 used the same single port for the transperitoneal step and the extraperitoneal approach for the paraaortic lymphadenectomy. The authors analyzed 14 consecutive patients with cervical cancer and performed a laparoscopic staging procedure. The median operative time was 190 minutes (range, 135Y250). The median number of lymph nodes removed was 14 (range, 2Y23). The median operative time in our report was 204 minutes, comparable with the literature.15 The operative time was longer compared with conventional extraperitoneal laparoscopic paraaortic lymphadenectomy (119 minutes).9,15 Even if our results referred to the realization of pelvic and para-aortic lymphadenectomy, in the only case of para-aortic lymphadenectomy, the operative time was 120 minutes. Analyzing our data, we observed that the group is mostly composed of obese patients with more postoperative complications. Thus, the realization of transperitoneal lymphadenectomy is hindered by the presence of more abdominal fat. This technique could facilitate lymph node dissection, with less incision and less risk for infection and without increasing surgical time. The main disadvantage of single-port surgery is the collision of instruments; this, however, is not significant in this situation because with the extraperitoneal left side approach, we are already close to and in front of the para-aortic space, so conventional instruments can be used without crossing them. Most of our patients had endometrial cancer and often were morbidly obese. Successful minimally invasive surgery will reduce postoperative wound complications and will most likely reduce other postoperative morbidities because of faster recovery and resumption of normal activities of daily living.16 In view of the results of the literature, the single-port approach for para-aortic lymphadenectomy may be a valid alternative in selected cases and in the hands of a skilled surgeon. More data are necessary to determine the reproducibility and the clinical advantages of extraperitoneal singleport para-aortic lymphadenectomy. * 2013 IGCS and ESGO
Copyright © 2013 by IGCS and ESGO. Unauthorized reproduction of this article is prohibited.
51
47
33
58
63 (48Y78)
11
13
1
100
7
Lambaudie et al7 2012
Schuman et al11 2011 Fagotti et al14 2012 Endometrial cancer
1 Ovarian cancer Cervical cancer
14 Endometrial cancer 4 Ovarian cancer 3 Cervical cancer 14 Cervical cancer 10 Cervical cancer 1 Endometrial cancer 9 Cervical cancer 3 Endometrial cancer
Gynecologic Cancer
31 6 Endometrial (19Y38) cancer 1 Cervical cancer
26
25
24
21
30
BMI, kg/m2 Type of PAL
Extraperitoneal NA
Extraperitoneal NA
4 HT + BSO 6 PL 7 PAL
100 HT + BSO 48 PL 27 PAL
1 PAL
16 (1Y33)
NP
NP
NP
NP
7 (2Y28)
10
16 (7Y40)
16 (7Y35)
14 (2Y23)
6 (2Y14)
129 (45Y321)
125
180 (120Y263)
240 (135Y270)
190 (135Y250)
120 (60Y180)
Operative Time, min
Extraperitoneal 1.9 g/dL of 21 (12Y34) 17 (10Y25) 204 (120Y300) hemoglobin (0.4Y3)
Transperitoneal 70 mL (10Y500)
Extraperitoneal 10 mL
Extraperitoneal n = 40 13 PAL (7 mL) (complete in 11)
11 PAL
14 PAL
11 HT + PL Transperitoneal 9 (minimal) 14 (7Y19) 9 PAL? n=8 (G100 mL) n=4 (100 mL)
Surgery
Estimated Blood Loss
Median Median Pelvic Lymph Para-aortic Node Lymph Node
4 (3Y6)
NA
NA
1.7 (1Y4)
3 (2Y26)
2 (1Y4)
NA
0
4 (2 conversion to conventional laparoscopy and laparotomy)
0
0
0
0
2 conversion to conventional laparoscopy (1 vascular injury)
Postoperative Hospital Stay, d Complication
& Volume 23, Number 9, November 2013
* 2013 IGCS and ESGO
Copyright © 2013 by IGCS and ESGO. Unauthorized reproduction of this article is prohibited.
BMI, Body mass index; BSO, bilateral salpingo-oophorectomy; HT, hysterectomy; NA, not available; NP, not performed; PAL, para-aortic lymphadenectomy; PL, pelvic lymphadenectomy.
Iacoponi et al (current work)
41
14
Gouy et al9 2011 Gouy et al10 2012
58
21
Escobar et al8 2010
Authors
No. Patients Age
TABLE 1. Summary of single-portYsite lymphadenectomy publications
International Journal of Gynecological Cancer Single-Port Para-aortic Lymphadenectomy
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International Journal of Gynecological Cancer
Iacoponi et al
REFERENCES 1. Malzoni M, Tinelli R, Cosentino F, et al. Total laparoscopic radical hysterectomy versus abdominal radical hysterectomy with lymphadenectomy in patients with early cervical cancer: our experience. Ann Surg Oncol. 2009;16:1316Y1323. 2. Eltabbakh GH, Shamonki MI, Moody JM, et al. Hysterectomy for obese women with endometrial cancer: laparoscopy or laparotomy? Gynecol Oncol. 2000;78:329Y335. 3. Ko¨hler C, Klemm P, Schau A, et al. Introduction of transperitoneal lymphadenectomy in a gynecologic oncology center: analysis of 650 laparoscopic pelvic and/or paraaortic transperitoneal lymphadenectomies. Gynecol Oncol. 2004; 95:52Y56. 4. Vasilev SA, McGonigle KF. Extraperitoneal laparoscopic para-aortic lymph node dissection. Gynecol Oncol. 1996; 61:315Y320. 5. Nagao S, Fujiwara K, Kagawa R, et al. Feasibility of extraperitoneal laparoscopic para-aortic and common iliac lymphadenectomy. Gynecol Oncol. 2006;103:732Y735. 6. Weiser EB, Bundy BN, Hoskins WJ, et al. Extraperitoneal versus transperitoneal selective paraaortic lymphadenectomy in the pretreatment surgical staging of advanced cervical carcinoma (a Gynecologic Oncology Group study). Gynecol Oncol. 1989;33:283Y289. 7. Lambaudie E, Cannone F, Bannier M, et al. Laparoscopic extraperitoneal aortic dissection: does single-port surgery offer the same possibilities as conventional laparoscopy? Surg Endosc. 2012;26:1920Y1923. 8. Escobar PF, Fader AN, Rasool N, et al. Single-port laparoscopic pelvic and para-aortic lymph node sampling or lymphadenectomy: development of a technique and instrumentation. Int J Gynecol Cancer. 2010;20:1268Y1273.
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9. Gouy S, Kane A, Uzan C, et al. Single-port laparoscopy and extraperitoneal para-aortic lymphadenectomy: about fourteen consecutive cases. Gynecol Oncol. 2011;123:329Y332. 10. Gouy S, Uzan C, Kane A, et al. A new single-port approach to perform a transperitoneal step and an extraperitoneal para-aortic lymphadenectomy with a single incision. J Am Coll Surg. 2012;214:e25Ye30. 11. Schuman S, Lucci JA III, Twiggs LB. Laparoendoscopic single-site extraperitoneal aortic lymphadenectomy: first experience. J Laparoendosc Adv Surg Tech A. 2011;21: 251Y254. 12. Occelli B, Narducci F, Lanvin D, et al. De novo adhesions with extraperitoneal endosurgical para-aortic lymphadenectomy versus transperitoneal laparoscopic para-aortic lymphadenectomy: a randomized experimental study. Am J Obstet Gynecol. 2000;183:529Y533. 13. Querleu D, Dargent D, Ansquer Y, et al. Extraperitoneal endosurgical aortic and common iliac dissection in the staging of bulky or advanced cervical carcinomas. Cancer. 2000;88: 1883Y1891. 14. Fagotti A, Boruta DM II, Scambia G, et al. First 100 early endometrial cancer cases treated with laparoendoscopic single-site surgery: a multicentric retrospective study. Am J Obstet Gynecol. 2012;206:353. 15. Dargent D, Ansquer Y, Mathevet P. Technical development and results of left extraperitoneal laparoscopic paraaortic lymphadenectomy for cervical cancer. Gynecol Oncol. 2000; 77:87Y92. 16. Scribner D, Walker J, Johnson G, et al. Laparoscopic pelvic and paraaortic lymph node dissection in the obese. Gynecol Oncol. 2002;84:426Y430.
* 2013 IGCS and ESGO
Copyright © 2013 by IGCS and ESGO. Unauthorized reproduction of this article is prohibited.
