Retromesenteric para-aortic lymphadenectomy in gynecologic malignancy

In gynecologic oncology lymphadenectomy is of prognostic and therapeutic importance because recurrence-free time and survival depend on the metastatic involvement of lymph nodes. Lymphadenectomies are not performed to such an extent as they are indicated. This might be due to a laborious or problematic preparation. The authors therefore report their experience in a seldom taught preparation of the left para-aortic compartment in the form of a learning curve. Materials and Methods: To access the left para-aortic area, the descending colon is lifted to open the retroperitoneum along the line of Toldt. The mesentery of the descending colon was separated from the kidney along the fascia of Gerota by blunt preparation. Time was measured from the incision of the peritoneum until the renal vein was clearly visible. Results: The authors collected the data from the first 25 preparations. Mean duration for the left para-aortic preparation was 7.8 minutes compared to 5.9 minutes for the right side. Duration of preparation of the left area dropped from 11.0 minutes within the first patients (#1 to #5) to 3.8 minutes in the last patients (#20 to #25). No complications were observed in the study group linked to the retromesenteric approach described. Conclusion: Retromesenteric para-aortic lymphadenectomy is quick to learn. The authors needed 20 preparations to observe a significant drop in the time needed for preparation. Retromesenteric para-aortic lymphadenectomy offers an excellent overview that lightens lymphadenectomy and therefore reduces the risks for patients.

Para-aortic lymphadenectomy

[1] Berek J., Hacker N.: “Practical Gynecologic Oncology”. Philadelphia: Lippincott Williams & Wilkins, 2005.

[2] Abu-Rustum N., Iasonos A., Zhou Q., Oke E., Soslow R.A., Alektiar K.M. et al.: “Is there a therapeutic impact to regional lymphadenectomy in the surgical treatment of endometrial cancer?”. Am. J. Obstet. Gynecol., 2008, 198, 457.e1.

[3] Mariani A., Webb M., Keeny G., Aletti G., Podratz K.: “Predictors of lymphatic failure in endometrial cancer”. Gynecol. Oncol., 2002, 84, 437.

[4] di Re F., Baiocchi G., Fontanelli R., Grosso G., Cobellis L., Raspagliesi F., di Re E.: “Systematic pelvic and paraaortic lymphadenectomy for advanced ovarian cancer: prognostic significance of node metastases”. Gynecol. Oncol., 1996, 62, 360.

[5] Wang Z., Xiong Z., Wang S.J.: “Effect of retroperitoneal lymphadenectomy on prognosis of patients with epithelial ovarian cancer”. Chin. Med. J., 2003, 116, 588.

[6] Mariani A., Dowdy S.C., Cliby W.A., Gostout B.S., Jones M.B., Wilson T.O., Podratz K.C.: “Prosepective assessment of lymphatic dissemination in endometrial cancer: A paradigm shift in surgical staging”. Gynecol. Oncol., 2008, 109, 11.

[7] Maggino T., Romagnolo C., Landoni F., Sartori E., Zola P., Gadducci A.: “An analysis of approaches to the management of endometrial cancer in North America: a CTF Study”. Gynecol. Oncol., 1998, 68, 274.

[8] Benedetti-Panici P., Maneschi F., Scambia G., Manusco S.: “A new transabdominal approach to the left retroperitoneum for systematic removal of lymph-nodes left of the aorta in gynecologic malignancies”. Obstet. Gynecol., 1994, 83, 1060.

[9] Benedetti-Panici P., Calcagno M., Plotti F., Arrivi C., Di Donato V., Montera R., Angioli R.: “Aortic lymphadenectomy in cervical cancer: Anatomy, classification and technique”. Gynecol. Oncol., 2007, 107 (1 suppl. 1), S30.

[10] Hirsch H., Käser O., Iklé F.: “Lymphonodektomie”. In: Hirsch H., Käser O., Iklé F. (eds.). Atlas der gynäkologischen Operationen. Stuttgart, New York: Georg Thieme Verlag, 1995, 356.

[11] Herd J., Fowler J., Shenson D., Lacy S., Montz F.: “Laparoscopic para-aortic lymph node sampling: development of a technique”. Gynecol. Oncol., 1992, 44, 271.

[12] Childers J., Surwitt E.: “Combined laparoscopic and vaginal surgery for the management of two cases of Stage I endometrial cancer”. Gynecol. Oncol., 1992, 45, 46.

[13] Fowler J., Johnson P.: “Transperitoneal para-aortic lymphadenectomy”. Operat. Techn. Gynecol. Surg., 1996, 1, 8.

[14] Lubicz S.: “Approach to the abdominal retroperitoneum in patients with gynecologic malignancies”. Gynecol. Oncol., 1985, 22, 32.

[15] Childers J., Hatch K.D., Tran A.-N., Surwit E.: “Laparoscopic para-aortic lymphadenectomy in gynecologic malignancies”. Obstet. Gynecol., 1993, 82, 741.

[16] Köhler C., Klemm P., Schau A., Possover M., Krause N., Tozzi R., Schneider A.: “Introduction of transperitoneal lymphadenectomy in a gynecologic oncology center: analysis of 650 laparoscopic pelvic and/or paraaortic transperitoneal lymphadenectomies”. Gynecol. Oncol., 2004, 95, 52.

[17] Vasilev S.: “A modified incision and technique for total retroperitoneal access and lymph node dissection”. Gynecol. Oncol., 1995, 56, 226.

[18] Querleu D., Dargent D., Ansquer Y., Leblanc E., Narducci F.: “Extraperitoneal endosurgical aortic and common iliac dissection in the staging of bulky or advanced cervical carcinomas”. Cancer, 2000, 88, 1883.

[19] Burnett A., O’Meara A., Bahador A., Roman L., Morrow P.: “Extraperitoneal laparoscopic lymph node staging: the University of Southern California experience”. Gynecol. Oncol., 2004, 95, 189.

[20] Vasilev S., McGonigle K.: “Extraperitoneal laparoscopic paraaortic lymph node dissection”. Gynecol. Oncol., 1996, 61, 315.

[21] Dubuisson J., De Dycker Y., Yaron M.: “The retroperitoneal approach in minimally pelvic surgery”. Ann. N.Y. Acad. Sci., 2006, 1092, 187.

[22] Raatz D., Börner P.: “Die laparoskopisch assistierte vaginale Radikaloperation LAVRO des Zervixkarzinoms - Perioperative Parameter und Komplikationsraten”. Zentralblatt für Gynäkologie, 2001, 123, 136.

[23] Altgassen C., Possover M., Krause N., Plaul K., Michels W., Schneider A.: “Establishing a new technique of laparoscopic pelvic and para-aortic lymphadenactomy”. Obstet. Gynecol., 2000, 95, 348.

[24] Schneider A., Possover M., Kamprath S., Endisch U., Krause N., Nöschel H.: “Laparoscopy-assisted radical hysterectomy modified according to Schauta-Stoeckel”. Obstet. Gynecol., 1996, 88, 1057.

[25] Spirtos N., Schlaerth J., Spirtos T., Schlaerth A., Indman P., Kimball R.: “Laparoscopic bilateral pelvic and paraaortic lymph nodesampling: An evolving technique”. Am. J. Obstet. Gynecol., 1995, 173, 105.