Journal of Laparoendoscopic Surgery 1992.2:39-44. Downloaded from online.liebertpub.com by Uc Davis Libraries University of California Davis on 01/07/15. For personal use only.
JOURNAL OF LAPAROENDOSCOPIC SURGERY Volume 2, Number 1, 1992 Mary Ann Liebert, Inc., Publishers
Technical Communication
Extraperitoneal Endoscopie Pelvic Lymph Node Dissection GEORGE
FERZLI, M.D., JOSEPH TRAPASSO, M.D., and PETER ALBERT, M.D.
ADLEY
RABOY, M.D.,
ABSTRACT
Laparoscopic pelvic lymphadenectomy has been found to be efficacious in the staging of genitourinary cancers. Technological advances in endoscopie instrumentation have allowed an extraperitoneal approach to be performed. Presented are two patients who underwent an extraperitoneal endoscopie lymph node dissection as a staging procedure for prostatic carcinoma. Technical aspects of the procedure and advantages relative to the laparoscopic intraperitoneal approach are discussed.
INTRODUCTION
inspection of the abdominal cavity in 1901 by Kelling,' has become alternative a to traditional operative approaches in a variety of surgery popular has been utilized in the evaluation of the nonpalpable testis, intersex disorders, staging diseases. of malignant disease of the prostate and bladder, nephrectomy, vesicourethral suspension, and ureterolithotomy.2-6 Through the pioneering work of Vancaille and Schuessler,7 and others, laparoscopic pelvic lymph node dissection has become an integral component in the staging of several urologie and gynecologic malignancies. Herein, we report two cases in which preperitoneal endoscopic pelvic lymph node dissections were performed in the staging of prostatic carcinoma. The technique and its advantages are presented.
Since endoscopie Laparoscopy
the first description of endoscopic
CASE REPORTS Case 1 A 64-year-old male presented with a prostatic nodule found on routine digital rectal examination. Prostate biopsy revealed a Gleason 6 adenocarcinoma. His prostatic-specific antigen (PSA) was 13. Metastatic evaluation of bone scan and CT scan were negative.
Department of EndoLaparoscopic Surgery and Urology, Staten Island University Hospital, a division of SUNY Health Science Center of Brooklyn, Staten Island, NY. 39
Journal of Laparoendoscopic Surgery 1992.2:39-44. Downloaded from online.liebertpub.com by Uc Davis Libraries University of California Davis on 01/07/15. For personal use only.
FERZLI ET AL.
FIG. 1. Using an infraumbilical incision, the anterior fascia is incised, while care is taken not to enter the peritoneum. The extra-peritoneal space is developed first with a finger, followed by insertion of the Hassan trocar into the space. Blunt dissection is completed down to the pubis using the operating laparoscope.
Case 2 A 74-year-old male presented with nocturia x3 and hesitancy of his urinary stream. Digital rectal exam revealed a 1.5 cm nodule. Prostate biopsy revealed a Gleason 7 adenocarcinoma of the prostate. Metastatic evaluation of bone scan and CT scan were negative, with a PSA of 14. Both patients underwent extraperitoneal endoscopic pelvic lymph node dissection.
MATERIALS AND METHODS
patients are placed in lithotomy position with a roll towel placed across the sacral area. Nasogastric tube, Foley catheter, and pneumatic compression stockings are placed. The abdomen and penoscrotal areas are prepped and draped. A 1.5-cm vertical incision is made in the lower aspect of the umbilicus with a No. 15 scalpel blade. Dissection is performed through the subcutaneous tissue until the rectus fascia is identified and its fusion at the umbilical area is easily seen. The fascia is grasped with two Adson forceps and incised with a curved Mayo scissors, yielding access to the preperitoneal cavity. The dissection which ensues will be totally preperitoneal, leaving the peritoneal cavity and its contents undisturbed. Blunt finger dissection is utilized initially in order to dissect the fibrous attachments between the rectus muscles and the peritoneum. This maneuver is used to create a preperitoneal circumferential space of 4 cm. A single 0-vicryl suture is placed on each side of the fascial edges as stay sutures. A 10-mm Hassan cannula is then introduced into the preperitoneal space and anchored under tension to the previously placed sutures to firmly secure the cannula sleeve at the skin and to the created fascial defect. The C02 insufflation tubing is then attached to the cannula, and a 10 mm 0 degree operative scope with a 5 mm working channel is introduced into the trocar (Fig. 1). A blunt probe dissector is then used to further develop the preperitoneal space down to the level of the pubic symphysis. C02 insufflation pressure is maintained at 8 mmHg. Once this space is dissected, a second 10 mm trocar is inserted two fingerbreadths above the pubic symphysis; this will further facilitate dissection of the peritoneum from the lateral pelvic side walls and cephalad to the level of the umbilicus (Fig. 2). Positioning of the patient at 10 to 15 degree Trendelenburg aids in the dissection. Right and left pelvic lymph nodal areas are readily accessed. Identification of the bladder, inguinal rings, vas deferentia, and spermatic vessels is The
40
Journal of Laparoendoscopic Surgery 1992.2:39-44. Downloaded from online.liebertpub.com by Uc Davis Libraries University of California Davis on 01/07/15. For personal use only.
ENDOSCOPIC NODE DISSECTION
Once the extraperitoneal space is developed, two additional operating trocars can be inserted in the midline for purpose of lymph node dissection.
FIG. 2.
i ^ FIG. 3.
As
an
alternative, the operating trocars can be placed lateral to the rectus muscle. 41
Journal of Laparoendoscopic Surgery 1992.2:39-44. Downloaded from online.liebertpub.com by Uc Davis Libraries University of California Davis on 01/07/15. For personal use only.
FERZLI ET AL.
Clipped
vas FIG. 4. Dissection of the pelvic up to the obturator nerve.
deferens
lymph nodes is carried out from the bifurcation of the iliac vein distally, and posteriorly
performed. Pelvic lymph node dissection is aided by the placement of two 55 mm working trocars introduced along a semicircular line halfway between the umbilicus and the pubis (Fig. 3). Dissection is continued using the endoscopie scissors and blunt grasping forceps to expose the external iliac vessels and obdurator nerves bilaterally (Fig. 4). Meticulous dissection is facilitated by enhanced visualization with the use of a 30 degree scope. A thorough dissection is performed using the standard anatomical boundaries. The use of an endoallis clamp grasper facilitates traction while dissecting the lymphatic bundle. Once the specimen is removed, the operative area is inspected to address any persistent bleeding. Trocars are removed under direct observation and the 10 mm fascial defects are closed with 0-vicryl sutures. The patients were placed on antibiotics for 24 h postoperatively. RESULTS
patients tolerated their procedures well, had no abdominal complaints, and were discharged on the following day. Pathologic examination of the nodal tissue revealed no evidence of metastatic extension of their prostatic carcinoma. Both
DISCUSSION
Techniques to allow endoscopie extraperitoneal dissection of the pelvic lymph nodes were first investigated in Denmark in the 1970s. Hald and Rasmussen8 were the first to report this type of approach for patients with 42
ENDOSCOPIC NODE DISSECTION
Journal of Laparoendoscopic Surgery 1992.2:39-44. Downloaded from online.liebertpub.com by Uc Davis Libraries University of California Davis on 01/07/15. For personal use only.
prostate and bladder cancer, but due to difficulties of visualization and lack of adequate instrumentation, their
procedure was limited to sampling only palpable nodes. In many cases, insufficient specimens were obtained. With the advent of new technology in laparoscopic and endoscopie instrumentation, progress has made it possible to readdress the previous limitations of the extra or preperitoneal approach to the pelvic lymph nodes in the staging of prostatic and bladder carcinoma. Pelvic lymph node dissection, via an open low-midline surgical approach, has the benefits of maximal exposure, thus allowing the surgeon to remain extraperitoneal. This decreases the likelihood of operative and postoperative intraperitoneal complications, but warrants an average hospital stay of 6.8 days as well as substantial risks such as blood transfusions, thromboembolic accidents, wound infection, and lymphocele 9~" formation.
Laparoscopic pelvic lymphadenectomy has been shown to provide tissue samples comparable to those Obvious benefits include a relatively short average length of hospital stay (2.6 obtained at open and initial series reveal a lower incidence of morbidity and complications than in open operative days), Intraoperative complications have been reported to include large vessel injury and bowel Postoperative complihemorrhage, injury, hypercarbia, respiratory insufficiency, and cations include: bowel adhesions, peritonitis, hernia formation, postoperative pain, and lymphocele
surgery.7
approaches.1213
hypothermia.6
formation.14
We found that there are distinct and identifiable advantages to using an extraperitoneal approach versus the intraperitoneal laparoscopic technique. These include: no Veress needle-associated complication (bowel or vessel injury); less postoperative pain; no hypercarbia or hypothermia; no postoperative ileus or adhesion formation; and less tendency toward hernia formation. Another technical advantage includes excellent exposure to the iliac bifurcation with the ability to repair a concomitant inguinal hernia. Moreover, the left-sided approach is made easier because the sigmoid colon, and its often encountered adhesions, do not need to be disturbed. Though lymphocele formation has been reported in the open surgically performed extraperitoneal dissection in 5 to 10% of patients,915 we feel this can be avoided because the added magnification allows the surgeon to readily identify small lymphatic channels which are endoclipped or cauterized. In reviewing our initial experience with this procedure, we feel consideration should be given to this endoscopie extraperitoneal technique in the surgical approach to pelvic lymph node dissection.
REFERENCES 1. 2. 3. 4. 5.
6. 7.
8.
Kelling G:
Über Oesophagokopie,
Gastroskopie und Coliodopie. Munch Med Wochenschr 1901 ;49:21-24. Lowe DH, Brock WA, Kaplan GW: Laparoscopy for localization of non-palpable testes. J Urol 1984; 131:728. Das S, Amar AD: The impact of laparoscopy on modern urologie practice. Urol Clin N Am 1988; 15:537. Eshghi AM, Roth JS, Smith AD: Percutaneous transperitoneal approach to a pelvic kidney for endourological removal of staghorn calculus. J Urol 1985;134:525. Raboy A, Ferzli G, George S, Ioffveda R, Albert PS: Laparoscopic Ureterolithotomy. J Urol, in press. Winfield HN, Donovan JF, Loening WA, Williams RD: Urológica! Laparoscopic Surgery. J Urol 1991; 146:941. Vancaille T, Schuessler W: Program and Abstracts of Eighth World Congress on Endourology and ESQL. J Endourol (Suppl) 1., August 1990. Hald T, Rasmussen F: Extraperitoneal pelviscopy: A new aid in staging of lower urinary tract tumors. A preliminary report. J Urol 1979;124:245.
9. 10.
McCullough DL, McLaughlin AP, Gittes RF: Morbidity of pelvic lymphadenectomy and radical prostatectomy for prostatic cancer. J Urol 1977; 117:206. Grossman IC, Carpinello V, Greenberg FH, Malloy TR, Wein AJ: Staging pelvic lymphadenectomy for carcinoma of the prostate. J Urol 1980;124:632.
11.
Pistenma DA, Castellino RA, Kempson RL, Mears E, Bagshaw MA: Operative staging of apparently localized adenocarcinoma of the prostate: Results in fifty unselected patients. I. Experimental design and preliminary results. Cancer 1976;38:73.
Ray GR,
43
FERZLI ET AL. 12.
Laparoscopic pelvic lymphadenectomy. Presented at the Thirteenth International Workshop on Surgery in Gynecology, Leuven, Belgium, 1989. Gershman A, Daykhovsky L, Chandra M: Laparoscopic pelvic lymphadenectomy. J Laparosc Surg 1990;1:63. Zucker K: Surgical Laparoscopy. St. Louis, MO: Q.M. Publishing, Inc, 1991:258-260. Sogani PC, Watson RC, Whitmore WF: Lymphocele after pelvic lymphadenectomy for urologie cancer. Urology Querleu
D:
Reconstructive Pelvic
13.
Journal of Laparoendoscopic Surgery 1992.2:39-44. Downloaded from online.liebertpub.com by Uc Davis Libraries University of California Davis on 01/07/15. For personal use only.
14. 15.
1981;17:39. Address reprint requests to: Peter S. Albert, M.D. Staten Island Urological Associates, P.C. 1460 Victory Blvd. Staten Island, NY 10301
44
JOURNAL OF LAPAROENDOSCOPIC SURGERY Volume 2, Number 1, 1992 Mary Ann Liebert, Inc., Publishers
Technical Communication
Extraperitoneal Endoscopie Pelvic Lymph Node Dissection GEORGE
FERZLI, M.D., JOSEPH TRAPASSO, M.D., and PETER ALBERT, M.D.
ADLEY
RABOY, M.D.,
ABSTRACT
Laparoscopic pelvic lymphadenectomy has been found to be efficacious in the staging of genitourinary cancers. Technological advances in endoscopie instrumentation have allowed an extraperitoneal approach to be performed. Presented are two patients who underwent an extraperitoneal endoscopie lymph node dissection as a staging procedure for prostatic carcinoma. Technical aspects of the procedure and advantages relative to the laparoscopic intraperitoneal approach are discussed.
INTRODUCTION
inspection of the abdominal cavity in 1901 by Kelling,' has become alternative a to traditional operative approaches in a variety of surgery popular has been utilized in the evaluation of the nonpalpable testis, intersex disorders, staging diseases. of malignant disease of the prostate and bladder, nephrectomy, vesicourethral suspension, and ureterolithotomy.2-6 Through the pioneering work of Vancaille and Schuessler,7 and others, laparoscopic pelvic lymph node dissection has become an integral component in the staging of several urologie and gynecologic malignancies. Herein, we report two cases in which preperitoneal endoscopic pelvic lymph node dissections were performed in the staging of prostatic carcinoma. The technique and its advantages are presented.
Since endoscopie Laparoscopy
the first description of endoscopic
CASE REPORTS Case 1 A 64-year-old male presented with a prostatic nodule found on routine digital rectal examination. Prostate biopsy revealed a Gleason 6 adenocarcinoma. His prostatic-specific antigen (PSA) was 13. Metastatic evaluation of bone scan and CT scan were negative.
Department of EndoLaparoscopic Surgery and Urology, Staten Island University Hospital, a division of SUNY Health Science Center of Brooklyn, Staten Island, NY. 39
Journal of Laparoendoscopic Surgery 1992.2:39-44. Downloaded from online.liebertpub.com by Uc Davis Libraries University of California Davis on 01/07/15. For personal use only.
FERZLI ET AL.
FIG. 1. Using an infraumbilical incision, the anterior fascia is incised, while care is taken not to enter the peritoneum. The extra-peritoneal space is developed first with a finger, followed by insertion of the Hassan trocar into the space. Blunt dissection is completed down to the pubis using the operating laparoscope.
Case 2 A 74-year-old male presented with nocturia x3 and hesitancy of his urinary stream. Digital rectal exam revealed a 1.5 cm nodule. Prostate biopsy revealed a Gleason 7 adenocarcinoma of the prostate. Metastatic evaluation of bone scan and CT scan were negative, with a PSA of 14. Both patients underwent extraperitoneal endoscopic pelvic lymph node dissection.
MATERIALS AND METHODS
patients are placed in lithotomy position with a roll towel placed across the sacral area. Nasogastric tube, Foley catheter, and pneumatic compression stockings are placed. The abdomen and penoscrotal areas are prepped and draped. A 1.5-cm vertical incision is made in the lower aspect of the umbilicus with a No. 15 scalpel blade. Dissection is performed through the subcutaneous tissue until the rectus fascia is identified and its fusion at the umbilical area is easily seen. The fascia is grasped with two Adson forceps and incised with a curved Mayo scissors, yielding access to the preperitoneal cavity. The dissection which ensues will be totally preperitoneal, leaving the peritoneal cavity and its contents undisturbed. Blunt finger dissection is utilized initially in order to dissect the fibrous attachments between the rectus muscles and the peritoneum. This maneuver is used to create a preperitoneal circumferential space of 4 cm. A single 0-vicryl suture is placed on each side of the fascial edges as stay sutures. A 10-mm Hassan cannula is then introduced into the preperitoneal space and anchored under tension to the previously placed sutures to firmly secure the cannula sleeve at the skin and to the created fascial defect. The C02 insufflation tubing is then attached to the cannula, and a 10 mm 0 degree operative scope with a 5 mm working channel is introduced into the trocar (Fig. 1). A blunt probe dissector is then used to further develop the preperitoneal space down to the level of the pubic symphysis. C02 insufflation pressure is maintained at 8 mmHg. Once this space is dissected, a second 10 mm trocar is inserted two fingerbreadths above the pubic symphysis; this will further facilitate dissection of the peritoneum from the lateral pelvic side walls and cephalad to the level of the umbilicus (Fig. 2). Positioning of the patient at 10 to 15 degree Trendelenburg aids in the dissection. Right and left pelvic lymph nodal areas are readily accessed. Identification of the bladder, inguinal rings, vas deferentia, and spermatic vessels is The
40
Journal of Laparoendoscopic Surgery 1992.2:39-44. Downloaded from online.liebertpub.com by Uc Davis Libraries University of California Davis on 01/07/15. For personal use only.
ENDOSCOPIC NODE DISSECTION
Once the extraperitoneal space is developed, two additional operating trocars can be inserted in the midline for purpose of lymph node dissection.
FIG. 2.
i ^ FIG. 3.
As
an
alternative, the operating trocars can be placed lateral to the rectus muscle. 41
Journal of Laparoendoscopic Surgery 1992.2:39-44. Downloaded from online.liebertpub.com by Uc Davis Libraries University of California Davis on 01/07/15. For personal use only.
FERZLI ET AL.
Clipped
vas FIG. 4. Dissection of the pelvic up to the obturator nerve.
deferens
lymph nodes is carried out from the bifurcation of the iliac vein distally, and posteriorly
performed. Pelvic lymph node dissection is aided by the placement of two 55 mm working trocars introduced along a semicircular line halfway between the umbilicus and the pubis (Fig. 3). Dissection is continued using the endoscopie scissors and blunt grasping forceps to expose the external iliac vessels and obdurator nerves bilaterally (Fig. 4). Meticulous dissection is facilitated by enhanced visualization with the use of a 30 degree scope. A thorough dissection is performed using the standard anatomical boundaries. The use of an endoallis clamp grasper facilitates traction while dissecting the lymphatic bundle. Once the specimen is removed, the operative area is inspected to address any persistent bleeding. Trocars are removed under direct observation and the 10 mm fascial defects are closed with 0-vicryl sutures. The patients were placed on antibiotics for 24 h postoperatively. RESULTS
patients tolerated their procedures well, had no abdominal complaints, and were discharged on the following day. Pathologic examination of the nodal tissue revealed no evidence of metastatic extension of their prostatic carcinoma. Both
DISCUSSION
Techniques to allow endoscopie extraperitoneal dissection of the pelvic lymph nodes were first investigated in Denmark in the 1970s. Hald and Rasmussen8 were the first to report this type of approach for patients with 42
ENDOSCOPIC NODE DISSECTION
Journal of Laparoendoscopic Surgery 1992.2:39-44. Downloaded from online.liebertpub.com by Uc Davis Libraries University of California Davis on 01/07/15. For personal use only.
prostate and bladder cancer, but due to difficulties of visualization and lack of adequate instrumentation, their
procedure was limited to sampling only palpable nodes. In many cases, insufficient specimens were obtained. With the advent of new technology in laparoscopic and endoscopie instrumentation, progress has made it possible to readdress the previous limitations of the extra or preperitoneal approach to the pelvic lymph nodes in the staging of prostatic and bladder carcinoma. Pelvic lymph node dissection, via an open low-midline surgical approach, has the benefits of maximal exposure, thus allowing the surgeon to remain extraperitoneal. This decreases the likelihood of operative and postoperative intraperitoneal complications, but warrants an average hospital stay of 6.8 days as well as substantial risks such as blood transfusions, thromboembolic accidents, wound infection, and lymphocele 9~" formation.
Laparoscopic pelvic lymphadenectomy has been shown to provide tissue samples comparable to those Obvious benefits include a relatively short average length of hospital stay (2.6 obtained at open and initial series reveal a lower incidence of morbidity and complications than in open operative days), Intraoperative complications have been reported to include large vessel injury and bowel Postoperative complihemorrhage, injury, hypercarbia, respiratory insufficiency, and cations include: bowel adhesions, peritonitis, hernia formation, postoperative pain, and lymphocele
surgery.7
approaches.1213
hypothermia.6
formation.14
We found that there are distinct and identifiable advantages to using an extraperitoneal approach versus the intraperitoneal laparoscopic technique. These include: no Veress needle-associated complication (bowel or vessel injury); less postoperative pain; no hypercarbia or hypothermia; no postoperative ileus or adhesion formation; and less tendency toward hernia formation. Another technical advantage includes excellent exposure to the iliac bifurcation with the ability to repair a concomitant inguinal hernia. Moreover, the left-sided approach is made easier because the sigmoid colon, and its often encountered adhesions, do not need to be disturbed. Though lymphocele formation has been reported in the open surgically performed extraperitoneal dissection in 5 to 10% of patients,915 we feel this can be avoided because the added magnification allows the surgeon to readily identify small lymphatic channels which are endoclipped or cauterized. In reviewing our initial experience with this procedure, we feel consideration should be given to this endoscopie extraperitoneal technique in the surgical approach to pelvic lymph node dissection.
REFERENCES 1. 2. 3. 4. 5.
6. 7.
8.
Kelling G:
Über Oesophagokopie,
Gastroskopie und Coliodopie. Munch Med Wochenschr 1901 ;49:21-24. Lowe DH, Brock WA, Kaplan GW: Laparoscopy for localization of non-palpable testes. J Urol 1984; 131:728. Das S, Amar AD: The impact of laparoscopy on modern urologie practice. Urol Clin N Am 1988; 15:537. Eshghi AM, Roth JS, Smith AD: Percutaneous transperitoneal approach to a pelvic kidney for endourological removal of staghorn calculus. J Urol 1985;134:525. Raboy A, Ferzli G, George S, Ioffveda R, Albert PS: Laparoscopic Ureterolithotomy. J Urol, in press. Winfield HN, Donovan JF, Loening WA, Williams RD: Urológica! Laparoscopic Surgery. J Urol 1991; 146:941. Vancaille T, Schuessler W: Program and Abstracts of Eighth World Congress on Endourology and ESQL. J Endourol (Suppl) 1., August 1990. Hald T, Rasmussen F: Extraperitoneal pelviscopy: A new aid in staging of lower urinary tract tumors. A preliminary report. J Urol 1979;124:245.
9. 10.
McCullough DL, McLaughlin AP, Gittes RF: Morbidity of pelvic lymphadenectomy and radical prostatectomy for prostatic cancer. J Urol 1977; 117:206. Grossman IC, Carpinello V, Greenberg FH, Malloy TR, Wein AJ: Staging pelvic lymphadenectomy for carcinoma of the prostate. J Urol 1980;124:632.
11.
Pistenma DA, Castellino RA, Kempson RL, Mears E, Bagshaw MA: Operative staging of apparently localized adenocarcinoma of the prostate: Results in fifty unselected patients. I. Experimental design and preliminary results. Cancer 1976;38:73.
Ray GR,
43
FERZLI ET AL. 12.
Laparoscopic pelvic lymphadenectomy. Presented at the Thirteenth International Workshop on Surgery in Gynecology, Leuven, Belgium, 1989. Gershman A, Daykhovsky L, Chandra M: Laparoscopic pelvic lymphadenectomy. J Laparosc Surg 1990;1:63. Zucker K: Surgical Laparoscopy. St. Louis, MO: Q.M. Publishing, Inc, 1991:258-260. Sogani PC, Watson RC, Whitmore WF: Lymphocele after pelvic lymphadenectomy for urologie cancer. Urology Querleu
D:
Reconstructive Pelvic
13.
Journal of Laparoendoscopic Surgery 1992.2:39-44. Downloaded from online.liebertpub.com by Uc Davis Libraries University of California Davis on 01/07/15. For personal use only.
14. 15.
1981;17:39. Address reprint requests to: Peter S. Albert, M.D. Staten Island Urological Associates, P.C. 1460 Victory Blvd. Staten Island, NY 10301
44
