Hospital Universitario Donostia, San Sebastián, Spain.
Hospital 12 de Octubre, Madrid, Spain.
Gynecol Oncol. 2018 Jan;148(1):233-234. doi: 10.1016/j.ygyno.2017.10.030. Epub 2017 Nov 11.
To describe our technique for excision of the pre-caval and laterocaval nodes using an extraperitoneal approach. This technique was developed to make the dissection and excision of the less accessible nodes in an easier and safer way by minimizing the risk of great vessels injury and bleeding.
Step-by-step description of the surgical procedure using video (Canadian Task Force classification III).
The procedure was performed at a teaching hospital, Hospital Universitario Donostia (Spain).
A 52-year-old woman with a body mass index of 33 underwent endoscopic extraperitoneal paraaortic lymphadenectomy for advanced high grade cervical adenocarcinoma FIGO IIB.
The patient underwent an endoscopic extraperitoneal para-aortic lymphadenectomy. An anatomical dissection is being performed being the upper limit of the dissection the left renal vein. Focus of the video involves the challenging dissection of the right nodes.
Firstly we complete a dissection of all the anatomical aortic limits until the renal vein and exeresis of aortic nodes. A plane just above the cava vein is carefully developed by pushing all the lymph nodes to the roof of the dissection. Special care must be taken close to the aortic bifurcation due to the perforating vessels that can be found more frequently in this location. Once all this space is dissected, nodes attached to the roof are easily pushed down. It is useful to use a clip in the upper part, close to the renal vein, to prevent lymphorrhea. Nodes are excised in four blocks, supramesenteric and inframesenteric aortic and precaval nodes. The proximity to the peritoneal roof and the chance for a peritoneal hole and loss of pneumoperitoneum can be less problematic if the right dissection is performed at the end of the procedure.
A complete para-aortic retroperitoneal dissection can be achieved with this extraperitoneal approach. Benefits of this technique are based on the absence of the bowel or other intraperitoneal structures invading the operative field given the barrier-free nature of the retroperitoneal space. Despite the challenge of the access to the right nodes in a retroperitoneal paraaortic lymphadenectomy they can be successfully excised reaching the renal vein including obese patients.
描述我们使用腹膜外入路切除腔静脉前和腔静脉外侧淋巴结的技术。该技术旨在通过最大限度地降低大血管损伤和出血的风险，以更简单、更安全的方式对较难触及的淋巴结进行解剖和切除。
使用视频逐步描述手术过程（加拿大任务组分类 III）。
该手术在一所教学医院，即西班牙的 Donostia 大学医院进行。
一位 52 岁的女性，体重指数为 33，患有高级别宫颈腺癌 FIGO IIB，接受了内镜下腹膜外腔旁腹主动脉淋巴结切除术。
患者接受了内镜下腹膜外腔旁腹主动脉淋巴结切除术。解剖的上界为左肾静脉。本视频的重点是右淋巴结的挑战性解剖。
首先，我们完成了所有解剖学主动脉边界的解剖，直到肾静脉，并切除了主动脉淋巴结。通过将所有淋巴结推向解剖屋顶，仔细开发了一个刚好位于腔静脉上方的平面。由于在这个位置可能更频繁地发现穿支血管，因此必须特别注意靠近主动脉分叉处。一旦所有这些空间被解剖，附着在屋顶上的节点很容易被推下。在上部靠近肾静脉处使用夹子以防止淋巴漏是有用的。节点被分为四个块切除，肠系膜上和肠系膜下主动脉及腔静脉前节点。如果在手术结束时进行右侧解剖，腹膜顶的接近和腹膜孔及气腹损失的机会可能会减少问题。
这种腹膜外入路可以实现完整的腹膜后主动脉旁逆行解剖。该技术的优点基于腹膜后空间无阻碍的性质，避免了肠或其他腹腔结构侵入手术区域。尽管在腹膜后腔旁腹主动脉淋巴结切除术时进入右侧淋巴结存在挑战，但可以成功切除包括肥胖患者在内的到达肾静脉的淋巴结。
