Retroperitoneal laparoscopic paraaortic lymphadenectomy in paraaortical staging of locally advanced cervical cancer

STUDY OBJECTIVE:
The objective was to review/learn a surgical technique not very well known by gynecologic oncologists.

DESIGN:
Level of evidence: III SETTING: Review of a surgical technique with emphasis on the paraaortic sentinel lymph nodes using indocyanine green.

INTERVENTION:
The film features the following steps to perform the procedure:

1. Creating a retroperitoneal window.

2. What to do if the peritoneum is torn.

3. Finding the psoas muscle, right ureter, and common iliac artery. Dissecting the right common iliac artery caudally to the bifurcation of the external iliac artery and internal iliac artery and cranially to the inferior mesenteric artery, the ovarian arteries, and the left renal vein.

4. View of all of the nodes with fluorescence when indocyanine green is injected into the cervix. At present, the sentinel lymph nodes are not the standard of care for locally advanced cervical cancer. If the nodes are metastatic at this stage, all the paraaortic area will undergo radiation therapy.

5. Dissecting the inferior vena cava from the intersection of the left ureter to the right and left renal veins.

6. Performing the lateroaortic, preaortic, and precaval lymphadenectomy.

7. Final view with all of the elements: bifurcation of the common iliac artery, the left renal vein, and both ureters.

8. In the final part of the video, we open the peritoneal window to decrease the incidence of lymphoceles.

CONCLUSION:
The real novelty of this video is how the paraaortic area's nodes are seen when green indocyanine is injected in cervix. This video demonstrates a simplified technique of retroperitoneal paraaortic lymphadenectomy using an advanced bipolar sealant.

Some tips and tricks to facilitate the procedure are emphasized, especially in cases of accidental peritoneal tears. To decrease the incidence of lymphoceles before completing the surgery, the peritoneal window should be opened. This surgical technique is especially useful in endometrial cancer for staging the paraaortic area in obese patients and in advanced cervical cancer to determine the field of radiotherapy.

CITATION  J Minim Invasive Gynecol. 2018 Feb 7. pii: S1553-4650(18)30110-9. doi: 10.1016/j.jmig.2018.01.033