A direct endoscopic approach for left-sided infrarenal para-aortic lymphadenectomy immediately after hysterectomy for endometrial cancer treatment: left dome formation (LDF)

Abstract

Background Endoscopic surgery for infrarenal para-aortic lymphadenectomy has been widely accepted. Two major approaches, "transperitoneal" and "extraperitoneal", are generally used; however, they have several disadvantages. A "transperitoneal" approach to the left para-aortic region is usually indirect, often performed after wide extension of the right para-aortic region. An "extraperitoneal" approach is unsuitable when a peritoneal tear exists after a prior surgical procedure such as hysterectomy. Here, we propose a modified transperitoneal technique, "Left dome formation (LDF)," which directly provides a surgical field for left infrarenal para-aortic lymphadenectomy even after hysterectomy. Methods The LDF procedure comprised three processes: (1) setting, (2) dissection of inframesenteric lymph nodes (step 1), and (3) dissection of infrarenal lymph nodes (step 2). Setting: two trocars were added 4 cm bilateral to the low-mid abdominal trocar that was used in prior hysterectomy. Step 1: The posterior layer of the renal fascia along with the left ureter and left ovarian vessel were separated from the left common iliac artery and iliopsoas. Left inframesentric nodes were removed from the surgical field. Step 2: The left ureter was isolated from the posterior renal fascia, and the dome was expanded cranially to the left renal vein, with the ovarian vein always visualizable at the dome ceiling. Left infrarenal nodes were removed. Results We applied LDF to ten endometrial cancer patients, recommended for additional dissection of para-aortic nodes based on intraoperative evaluation using the laparoscopically removed uterus. The operative time and number of removed lymph nodes in Step 1 and Step 2 were 28.8 (20-49) min and 5.3 (2-10) and 54.6 (52-70) min and 6.5 (1-11), respectively. Blood loss was below 50 ml. No serious organ injury occurred during procedures. Conclusion Since the left ureter is always observable, LDF procedure facilitates effective surgery to overcome the anatomical complexity of the left para-aortic region and is potentially useful for sentinel node sampling.

Ureter Injury in Laparoscopic Para-Aortic Lymphadenectomy for Endometrial Cancer by the Transperitoneal Approach

“…Peng et al reported EPA with an umbilical single port, which allows EPA to have a view from the caudal side, similar to TPA [ 9 ]. For TPA, Mizumoto et al reported an approach from the left side of the descending colon called left dome formation, in which the left ovarian vein and left ureter can be followed all the way from the caudal side, ultimately providing a view exactly like that of the left-sided approach of EPA [ 10 ]. In the approach from the right side of the descending colon of TPA (our case), it is difficult to follow the left ovarian vein from the caudal side to the left renal vein, and it would be better to follow it in the opposite direction from the left renal vein to the caudal side.…”