Scribner D R, Walker J L, Johnson G A, McMeekin S D, Gold M A, Mannel R S
Department of Gynecologic Oncology, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma 73190, USA.
Gynecol Oncol. 2001 Sep;82(3):498-503. doi: 10.1006/gyno.2001.6314.
The aim of this study was to analyze the first 100 cases of planned laparoscopic pelvic and paraaortic lymph node dissection (LND) done for staging of gynecologic cancers. The goal of the study was to assess prognostic factors for conversion to laparotomy and document complications.
A retrospective review of patients who had planned laparoscopic bilateral pelvic and bilateral paraaortic LND for staging of their gynecologic cancer was performed. Patients were identified by our institutional database and data were collected by review of their medical records. Data were obtained regarding demographics, stage, histology, length of stay, and procedural information including completion rates, operating room time, estimated blood loss, assistant, lymph node count, and complications. Associations between variables were analyzed using Student t tests, analysis of variance, and chi(2) testing (Excel v7.0).
A total of 103 patients were identified from 12/15/95 to 8/28/00. Demographics included mean age of 66.2 (25-92) and mean Quetelet index (QI) of 30.8 (15.9-56.1). A total of 34/103 (33.0%) had > or =1 previous laparotomy. Ninety-five patients had endometrial cancer and 8 had ovarian cancer. Eighty-six of 103 (83.5%) were stage I or II. The length of stay was shorter for those who had laparoscopy than for those who needed conversion to laparotomy (2.8 vs 5.6 days, P < 0.0001). Laparoscopy was completed in 73/103 (70.9%) of the cases. Completion rates were 62/76 (81.6%) with QI < 35 vs 11/27 (40.7%) with QI > or = 35, P < 0.001. Significantly more patients had their laparoscopy completed when an attending gynecologic oncologist was the first assistant compared to a fellow or a community obstetrician/gynecologist (92.9%, 69.0%, 64.5%, P < 0.0001). The top three reasons for conversion to laparotomy were obesity, 12/30 (29.1%), adhesions, 5/30 (16.7%), and intraperitoneal disease, 5/30 (16.7%). Pelvic, common iliac, and paraaortic lymph node counts did not differ when compared to those of patients who had conversion to laparotomy (18.1, 5.1, 6.8 vs 17.3, 5.7, 6.8, P = ns). Complications included 2 urinary tract injuries, 2 pulmonary embolisms, and 6 wound infections (all in the laparotomy group). Two deaths occurred, 1 due to a vascular injury on initial trocar insertion and 1 due to a pulmonary embolism after a laparotomy for bowel herniation through a trocar incision.
Laparoscopic bilateral pelvic and paraaortic LND can be completed successfully in 70.9% of patients. Age, obesity, previous surgery, and the need to perform this procedure in the community were not contraindications. Advantages include a shorter hospital stay, similar nodal counts, and acceptable complications.
本研究旨在分析为妇科癌症分期而进行的前100例计划性腹腔镜盆腔及腹主动脉旁淋巴结清扫术（LND）。本研究的目的是评估转为开腹手术的预后因素并记录并发症情况。
对因妇科癌症分期而计划进行腹腔镜双侧盆腔及双侧腹主动脉旁LND的患者进行回顾性研究。通过机构数据库识别患者，并通过查阅其病历收集数据。获取了有关人口统计学、分期、组织学、住院时间以及手术信息的数据，包括完成率、手术时间、估计失血量、助手、淋巴结计数和并发症。使用学生t检验、方差分析和卡方检验（Excel v7.0）分析变量之间的关联。
从1995年12月15日至2000年8月28日共识别出103例患者。人口统计学数据包括平均年龄66.2岁（25 - 92岁）和平均体重指数（QI）30.8（15.9 - 56.1）。103例中有34例（33.0%）曾接受过≥1次开腹手术。95例患者患有子宫内膜癌，8例患有卵巢癌。103例中的86例（83.5%）为I期或II期。接受腹腔镜手术的患者住院时间比需要转为开腹手术的患者短（2.8天对5.6天，P < 0.0001）。103例中的73例（70.9%）完成了腹腔镜手术。QI < 35时完成率为62/76（81.6%），而QI≥35时为11/27（40.7%），P < 0.001。与住院医师或社区妇产科医生作为第一助手相比，当妇科肿瘤主治医生作为第一助手时，完成腹腔镜手术的患者明显更多（92.9%、69.0%、64.5%，P < 0.0001）。转为开腹手术的三大主要原因是肥胖，12/30（29.1%）；粘连，5/30（16.7%）；以及腹腔内疾病，5/30（16.7%）。与转为开腹手术的患者相比，盆腔、髂总及腹主动脉旁淋巴结计数无差异（18.1、5.1、6.8对17.3、5.7、6.8，P = 无显著差异）。并发症包括2例泌尿道损伤、2例肺栓塞和6例伤口感染（均在开腹手术组）。发生2例死亡，1例因初次插入套管针时血管损伤，1例因开腹手术治疗套管针切口处肠疝后发生肺栓塞。
70.9%的患者能够成功完成腹腔镜双侧盆腔及腹主动脉旁LND。年龄、肥胖、既往手术史以及在社区进行该手术的需求均不是禁忌证。优点包括住院时间较短、淋巴结计数相似以及并发症可接受。
