Journal of Laparoendoscopic Surgery 1992.2:219-222. Downloaded from online.liebertpub.com by Ucsf Library University of California San Francisco on 01/06/15. For personal use only.
JOURNAL OF LAPAROENDOSCOPIC SURGERY Volume 2, Number 5, 1992 Mary Ann Liebert, Inc., Publishers
Extraperitoneal Endoscopie Pelvic Lymph Node Dissection vs. Laparoscopic Lymph Node Dissection in the Staging of Prostatic and Bladder Carcinoma GEORGE FERZLI, M.D., F.A.C.S., ADLEY RABOY, M.D., DAVID KLEINERMAN, M.D., and PETER ALBERT, M.D., F.A.C.S.
ABSTRACT
Eighteen patients undergoing laparoscopic pelvic lymphadenectomy were compared with eighteen patients undergoing lymph node dissection performed via a totally extraperitoneal approach called extraperitoneal endoscopie pelvic lymph node dissection. Operative time, nodal yield, and hospital stays were essentially the same in both groups. However, the laparoscopic approach had a greater incidence of morbidity, leading the authors to adopt a totally extra-peritoneal endoscopie approach to pelvic lymph node dissection. Advantages of using an extraperitoneal approach are presented.
INTRODUCTION has been shown previously to be an effective modality in the and vesical carcinoma. ' However, this procedure is associated with significant potential complications, e.g. viscus and vessel injury, hypothermia, hypercarbia, adhesion and hernia formation, and peritonitis.2'3 The authors have developed a totally extraperitoneal approach to bilateral pelvic lymph node dissection in an effort to obviate the above complications. This technique has been previously published.4 Since this initial description, certain modifications have been made to the procedure to enable it to be performed more efficiently. Reported herein is a comparison between the first 18 patients who underwent laparoscopic lymphadenectomy and the first 18 patients who underwent an extraperitoneal
Laparoscopi staging cprostatic
lymph node dissection
of
endoscopie approach.
Department of Laparoendoscopic Surgery and Urology, Staten Island Health Science Center at Brooklyn, Brooklyn, NY. 219
University Hospital—A
Division of SUN Y
FERZLI ET AL.
MATERIALS AND METHODS
Journal of Laparoendoscopic Surgery 1992.2:219-222. Downloaded from online.liebertpub.com by Ucsf Library University of California San Francisco on 01/06/15. For personal use only.
Operative technique The patient is placed in a dorsal lithotomy position with a rolled towel positioned under the sacral area. Nasogastric tube, Foley catheter, and intermittent compression stockings are secured. After sterile prepping and draping of the abdomen, a 1.5 cm vertical incision is made in the inferior aspect of the umbilicus.
-
Dissection is continued down to the rectus fascia. The fascia is secured on either side of the midline with two 0-vicryl sutures which are later used to secure the Hasson cannula. The fascia is then incised and blunt finger dissection is initially performed extraperitoneally in the midline toward the pubic symphysis. Once this is performed, the blunt 10 mm Hasson trocar and cannula are inserted and secured with the vicryl sutures. The C02 insufflation tubing is then attached to the cannula and the zero degree operative laparoscope with a 5 mm working channel is introduced into the trocar. An insufflation pressure of 8 mmHg is used to insufflate the extraperitoneal space. Using the blunt probe dissector, the preperitoneal space is further dissected to enable the placement of a 10 mm trocar two fingerbreadths above the pubic symphysis. This will facilitate the further dissection of the peritoneum from the lateral pelvic side walls. The dissection is performed with the blunt curved scissors attached to cautery out to the anterior superior iliac spines bilaterally. If perforator vessels are encountered, they are secured with the endoclip applier and divided. Once this space has been developed, two 5 mm trocars are placed lateral to the recti muscles below the linea semicircularis in the right and left lower quadrants, in order to aid in the dissection. Each side is then able to be surgically dissected with the use of an endograsper in the contralateral upper port and a suction dissector in the midline port. Before dissection is started, the operative laparoscope is exchanged for the zero degree 10 mm lens in the umbilical port. The limits of the lymph node dissection are superiorly; the bifurcation of the iliac vessels, inferiorly; the circumflex iliac vessels, and all the nodal tissue, posteromedially to the external iliac vein down to the level of the obdurator nerve. For adequate dissection of the bifurcation on both sides, a 45 degree lens is used to secure the nodal tissue in that location with an endoligature. Once the dissection is completed bilaterally, all trocars are removed under direct observation and the defects closed with vicryl interrupted sutures and dressed with
op-site dressings. Patient selection The first 18 patients who underwent laparoscopic lymph node dissection were compared to the first patients who had their node dissection performed via an extraperitoneal approach. These procedures were performed for pre-treatment staging prior to iodine or palladium radioactive seed implantation or radical perineal prostatectomy. The patients in the laparoscopic group ranged in age from 58-82 years with a mean age of 71, while the patients in the extraperitoneal group ranged in age from 59-79 years with a mean age of 75. 18
RESULTS The two
operative techniques
of node dissection
were
hospital stay, complications, and postoperative pain.
compared
for
operative time, lymph
node
yield,
The mean operative time for the laparoscopic lymph node dissection patients was 2 h and 15 min with a range of 70 to 185 min as compared to the extraperitoneal lymph node dissection group whose mean operative time was 2 h and 30 min with a range from 95 to 198 min. Average lymph node yield for both operative approaches was approximately equal, with 8 being the average number of nodes obtained. In the laparoscopic approach, the lymph node yield ranged from 1-22, while in the extraperitoneal approach it ranged from 2-23. The average length of stay of patients in the laparoscopic group was 3.2 days with a range of 1-11 days, while in the extraperitoneal group, the average length of stay was 2.7 days with a range of 1-7 days. 220
EXTRAPERITONEAL VS. LAPAROSCOPIC LYMPH NODE DISSECTION
Complications were more common and significant in the laparoscopic group. They included two patients required multiple transfusions, one patient with an umbilical omental hernia, one with a prolonged postoperative ileus, and one patient with an infected lymphocele requiring CT scan guided percutaneous drainage. In the extraperitoneal group, one patient required conversion to an open operative procedure due to extensive adhesion formation from prior exploratory laparotomy and colostomy for perforated diverticular disease. Another patient was converted to a laparoscopic lymphadenectomy because of inadvertent entrance of the peritoneal cavity due to adhesions secondary to a prior perforated appendicitis. No patient required a
Journal of Laparoendoscopic Surgery 1992.2:219-222. Downloaded from online.liebertpub.com by Ucsf Library University of California San Francisco on 01/06/15. For personal use only.
who
transfusion. More of the patients in the laparoscopic group complained of abdominal fullness and subdiaphragmatic pain radiating to the shoulder in the early postoperative period. These symptoms were noticeably absent in the patients undergoing the extraperitoneal dissection.
DISCUSSION
Techniques of endoscopie extraperitoneal pelvic lymph node dissection were first investigated in Denmark in the 1970s. Hald and Rasmussen5 were the first to report this approach to stage patients with prostate and bladder neoplasms, but due to difficulties of visualization and lack of adequate instrumentation, their procedure was limited to only palpable node sampling. However, in many cases, insufficient surgical specimens were obtained. With the advent of technological advances in laparoscopic and endoscopie instrumentation, progress has made it possible to readdress the previous limitations of the extraperitoneal approach to the pelvic lymph node dissection. Laparoscopic pelvic lymphadenectomy has been shown to provide comparable tissue samples to those obtained at open Recently, the authors reported a technique of total extraperitoneal hernia repair as a better tolerated As a result, definite advantages were found in performing approach than the laparoscopic method of the pelvic lymph node dissection via a totally extraperitoneal approach. Here, no inadvertent vessel or hollow viscus injury should be encountered. Because the procedure is totally extraperitoneal, the patient is not at risk for hypercarbia because of the low partial pressure of C02 (8 mmHg) that is used, as compared to the laparoscopic approach which utilizes a pressure of up to 15 mmHg. There is also less risk for the patient to develop hypothermia. Obviously, no postoperative ileus, hernia formation, or adhesions occur with this operative approach. In addition, a major technical advantage over the laparoscopic procedure is that the sigmoid colon and its commonly associated adhesions do not have to be surgically addressed. This has allowed the patients to feel more comfortable postoperatively and require a minimum of analgesic medication. As the authors' experience has progressed, many patients recently operated on have been discharged from the hospital on the first postoperative day. Moreover, postoperatively, it has been found that because the lymph node dissection is performed in a confined space, there is a tamponade effect once desufflation occurs, thus minimizing blood loss. It is believed that this factor has contributed to the lack of need of transfusions in the extraperitoneal patient group. Though it is reported that lymphocele formation may be seen more often with the extraperitoneal approach, this can be avoided due to the added magnification of the camera which allows the operator to readily identify the lymphatic channels which are endoclipped or cauterized. In this series, the only symptomatic lymphocele occurred in the laparoscopic patient group. It is imperative that the operating surgeon be familiar with performing the lymph node dissection via the laparoscopic approach, in case the peritoneal cavity is inadvertently entered during the extraperitoneal dissection. This can occur in patients who have had prior operative procedures causing adhesions between the extraperitoneal space and the peritoneal cavity. The extraperitoneal approach also allows the surgeon to repair a concomitant inguinal hernia if found at the time of lymph node dissection. One patient with a femoral hernia had his repair done in this fashion. In reviewing the operative time and lymph node yield there was no significant difference between the two procedures. The authors feel that the extraperitoneal endoscopie approach should be the procedure of choice when performing a bilateral pelvic lymph node dissection for staging of prostatic or vesical malignancies.
surgery.6
repair.7
221
FERZLI ET AL.
REFERENCES
Journal of Laparoendoscopic Surgery 1992.2:219-222. Downloaded from online.liebertpub.com by Ucsf Library University of California San Francisco on 01/06/15. For personal use only.
1.
VancailleT, SchuesslerW: Program and Abstracts of Eighth World Congress on Endourology and ESWL. JEndoUrol (supp) 1., Aug. 1990.
Urological laparoscopic surgery. J Urol 1991 ;I46:941. Zucker K: Surgical Laparoscopy. St. Louis: Q.M. Publishing, Inc, 1990:258-260. Ferzli G, Trapasso J, Raboy A, Albert P: Extraperitoneal endoscopie pelvic lymph node dissection. J Laparoendosc Surg 1992;2:39. Hald T, Rasmussen F: Extraperitoneal pelvioscopy. A new aid in staging of lower urinary tract tumors. A preliminary
2. Winfield HN:
3. 4. 5.
report. J Urol 1979; 124:245. 6. Schuessler WW, Vancaille TG, Reich H, Griffith DP: Transperitoneal endosurgical lyphadenectomy in patients with localized prostate cancer. J Urol 1991;145:988-991. 7. Ferzli G, Albert P:
Technique of total extraperitoneal hernia repair, accepted, J Lapendo Surgery. Address reprint requests to: Peter Albert, M.D., F.A.C.S. 1460 Victory Blvd. Staten Island, NY 10301
222
JOURNAL OF LAPAROENDOSCOPIC SURGERY Volume 2, Number 5, 1992 Mary Ann Liebert, Inc., Publishers
Extraperitoneal Endoscopie Pelvic Lymph Node Dissection vs. Laparoscopic Lymph Node Dissection in the Staging of Prostatic and Bladder Carcinoma GEORGE FERZLI, M.D., F.A.C.S., ADLEY RABOY, M.D., DAVID KLEINERMAN, M.D., and PETER ALBERT, M.D., F.A.C.S.
ABSTRACT
Eighteen patients undergoing laparoscopic pelvic lymphadenectomy were compared with eighteen patients undergoing lymph node dissection performed via a totally extraperitoneal approach called extraperitoneal endoscopie pelvic lymph node dissection. Operative time, nodal yield, and hospital stays were essentially the same in both groups. However, the laparoscopic approach had a greater incidence of morbidity, leading the authors to adopt a totally extra-peritoneal endoscopie approach to pelvic lymph node dissection. Advantages of using an extraperitoneal approach are presented.
INTRODUCTION has been shown previously to be an effective modality in the and vesical carcinoma. ' However, this procedure is associated with significant potential complications, e.g. viscus and vessel injury, hypothermia, hypercarbia, adhesion and hernia formation, and peritonitis.2'3 The authors have developed a totally extraperitoneal approach to bilateral pelvic lymph node dissection in an effort to obviate the above complications. This technique has been previously published.4 Since this initial description, certain modifications have been made to the procedure to enable it to be performed more efficiently. Reported herein is a comparison between the first 18 patients who underwent laparoscopic lymphadenectomy and the first 18 patients who underwent an extraperitoneal
Laparoscopi staging cprostatic
lymph node dissection
of
endoscopie approach.
Department of Laparoendoscopic Surgery and Urology, Staten Island Health Science Center at Brooklyn, Brooklyn, NY. 219
University Hospital—A
Division of SUN Y
FERZLI ET AL.
MATERIALS AND METHODS
Journal of Laparoendoscopic Surgery 1992.2:219-222. Downloaded from online.liebertpub.com by Ucsf Library University of California San Francisco on 01/06/15. For personal use only.
Operative technique The patient is placed in a dorsal lithotomy position with a rolled towel positioned under the sacral area. Nasogastric tube, Foley catheter, and intermittent compression stockings are secured. After sterile prepping and draping of the abdomen, a 1.5 cm vertical incision is made in the inferior aspect of the umbilicus.
-
Dissection is continued down to the rectus fascia. The fascia is secured on either side of the midline with two 0-vicryl sutures which are later used to secure the Hasson cannula. The fascia is then incised and blunt finger dissection is initially performed extraperitoneally in the midline toward the pubic symphysis. Once this is performed, the blunt 10 mm Hasson trocar and cannula are inserted and secured with the vicryl sutures. The C02 insufflation tubing is then attached to the cannula and the zero degree operative laparoscope with a 5 mm working channel is introduced into the trocar. An insufflation pressure of 8 mmHg is used to insufflate the extraperitoneal space. Using the blunt probe dissector, the preperitoneal space is further dissected to enable the placement of a 10 mm trocar two fingerbreadths above the pubic symphysis. This will facilitate the further dissection of the peritoneum from the lateral pelvic side walls. The dissection is performed with the blunt curved scissors attached to cautery out to the anterior superior iliac spines bilaterally. If perforator vessels are encountered, they are secured with the endoclip applier and divided. Once this space has been developed, two 5 mm trocars are placed lateral to the recti muscles below the linea semicircularis in the right and left lower quadrants, in order to aid in the dissection. Each side is then able to be surgically dissected with the use of an endograsper in the contralateral upper port and a suction dissector in the midline port. Before dissection is started, the operative laparoscope is exchanged for the zero degree 10 mm lens in the umbilical port. The limits of the lymph node dissection are superiorly; the bifurcation of the iliac vessels, inferiorly; the circumflex iliac vessels, and all the nodal tissue, posteromedially to the external iliac vein down to the level of the obdurator nerve. For adequate dissection of the bifurcation on both sides, a 45 degree lens is used to secure the nodal tissue in that location with an endoligature. Once the dissection is completed bilaterally, all trocars are removed under direct observation and the defects closed with vicryl interrupted sutures and dressed with
op-site dressings. Patient selection The first 18 patients who underwent laparoscopic lymph node dissection were compared to the first patients who had their node dissection performed via an extraperitoneal approach. These procedures were performed for pre-treatment staging prior to iodine or palladium radioactive seed implantation or radical perineal prostatectomy. The patients in the laparoscopic group ranged in age from 58-82 years with a mean age of 71, while the patients in the extraperitoneal group ranged in age from 59-79 years with a mean age of 75. 18
RESULTS The two
operative techniques
of node dissection
were
hospital stay, complications, and postoperative pain.
compared
for
operative time, lymph
node
yield,
The mean operative time for the laparoscopic lymph node dissection patients was 2 h and 15 min with a range of 70 to 185 min as compared to the extraperitoneal lymph node dissection group whose mean operative time was 2 h and 30 min with a range from 95 to 198 min. Average lymph node yield for both operative approaches was approximately equal, with 8 being the average number of nodes obtained. In the laparoscopic approach, the lymph node yield ranged from 1-22, while in the extraperitoneal approach it ranged from 2-23. The average length of stay of patients in the laparoscopic group was 3.2 days with a range of 1-11 days, while in the extraperitoneal group, the average length of stay was 2.7 days with a range of 1-7 days. 220
EXTRAPERITONEAL VS. LAPAROSCOPIC LYMPH NODE DISSECTION
Complications were more common and significant in the laparoscopic group. They included two patients required multiple transfusions, one patient with an umbilical omental hernia, one with a prolonged postoperative ileus, and one patient with an infected lymphocele requiring CT scan guided percutaneous drainage. In the extraperitoneal group, one patient required conversion to an open operative procedure due to extensive adhesion formation from prior exploratory laparotomy and colostomy for perforated diverticular disease. Another patient was converted to a laparoscopic lymphadenectomy because of inadvertent entrance of the peritoneal cavity due to adhesions secondary to a prior perforated appendicitis. No patient required a
Journal of Laparoendoscopic Surgery 1992.2:219-222. Downloaded from online.liebertpub.com by Ucsf Library University of California San Francisco on 01/06/15. For personal use only.
who
transfusion. More of the patients in the laparoscopic group complained of abdominal fullness and subdiaphragmatic pain radiating to the shoulder in the early postoperative period. These symptoms were noticeably absent in the patients undergoing the extraperitoneal dissection.
DISCUSSION
Techniques of endoscopie extraperitoneal pelvic lymph node dissection were first investigated in Denmark in the 1970s. Hald and Rasmussen5 were the first to report this approach to stage patients with prostate and bladder neoplasms, but due to difficulties of visualization and lack of adequate instrumentation, their procedure was limited to only palpable node sampling. However, in many cases, insufficient surgical specimens were obtained. With the advent of technological advances in laparoscopic and endoscopie instrumentation, progress has made it possible to readdress the previous limitations of the extraperitoneal approach to the pelvic lymph node dissection. Laparoscopic pelvic lymphadenectomy has been shown to provide comparable tissue samples to those obtained at open Recently, the authors reported a technique of total extraperitoneal hernia repair as a better tolerated As a result, definite advantages were found in performing approach than the laparoscopic method of the pelvic lymph node dissection via a totally extraperitoneal approach. Here, no inadvertent vessel or hollow viscus injury should be encountered. Because the procedure is totally extraperitoneal, the patient is not at risk for hypercarbia because of the low partial pressure of C02 (8 mmHg) that is used, as compared to the laparoscopic approach which utilizes a pressure of up to 15 mmHg. There is also less risk for the patient to develop hypothermia. Obviously, no postoperative ileus, hernia formation, or adhesions occur with this operative approach. In addition, a major technical advantage over the laparoscopic procedure is that the sigmoid colon and its commonly associated adhesions do not have to be surgically addressed. This has allowed the patients to feel more comfortable postoperatively and require a minimum of analgesic medication. As the authors' experience has progressed, many patients recently operated on have been discharged from the hospital on the first postoperative day. Moreover, postoperatively, it has been found that because the lymph node dissection is performed in a confined space, there is a tamponade effect once desufflation occurs, thus minimizing blood loss. It is believed that this factor has contributed to the lack of need of transfusions in the extraperitoneal patient group. Though it is reported that lymphocele formation may be seen more often with the extraperitoneal approach, this can be avoided due to the added magnification of the camera which allows the operator to readily identify the lymphatic channels which are endoclipped or cauterized. In this series, the only symptomatic lymphocele occurred in the laparoscopic patient group. It is imperative that the operating surgeon be familiar with performing the lymph node dissection via the laparoscopic approach, in case the peritoneal cavity is inadvertently entered during the extraperitoneal dissection. This can occur in patients who have had prior operative procedures causing adhesions between the extraperitoneal space and the peritoneal cavity. The extraperitoneal approach also allows the surgeon to repair a concomitant inguinal hernia if found at the time of lymph node dissection. One patient with a femoral hernia had his repair done in this fashion. In reviewing the operative time and lymph node yield there was no significant difference between the two procedures. The authors feel that the extraperitoneal endoscopie approach should be the procedure of choice when performing a bilateral pelvic lymph node dissection for staging of prostatic or vesical malignancies.
surgery.6
repair.7
221
FERZLI ET AL.
REFERENCES
Journal of Laparoendoscopic Surgery 1992.2:219-222. Downloaded from online.liebertpub.com by Ucsf Library University of California San Francisco on 01/06/15. For personal use only.
1.
VancailleT, SchuesslerW: Program and Abstracts of Eighth World Congress on Endourology and ESWL. JEndoUrol (supp) 1., Aug. 1990.
Urological laparoscopic surgery. J Urol 1991 ;I46:941. Zucker K: Surgical Laparoscopy. St. Louis: Q.M. Publishing, Inc, 1990:258-260. Ferzli G, Trapasso J, Raboy A, Albert P: Extraperitoneal endoscopie pelvic lymph node dissection. J Laparoendosc Surg 1992;2:39. Hald T, Rasmussen F: Extraperitoneal pelvioscopy. A new aid in staging of lower urinary tract tumors. A preliminary
2. Winfield HN:
3. 4. 5.
report. J Urol 1979; 124:245. 6. Schuessler WW, Vancaille TG, Reich H, Griffith DP: Transperitoneal endosurgical lyphadenectomy in patients with localized prostate cancer. J Urol 1991;145:988-991. 7. Ferzli G, Albert P:
Technique of total extraperitoneal hernia repair, accepted, J Lapendo Surgery. Address reprint requests to: Peter Albert, M.D., F.A.C.S. 1460 Victory Blvd. Staten Island, NY 10301
222
