British Journal of Urology (1990), 66,523-525
0007-1 33 1/90/006~523/$10.00
01990 British Journal of Urology
Surgical Approach to the Retrocrural Lymph Nodes W. HOELTL and S. AHARINEJAD Department of Urology, Rudolfstiftung Hospital, and First Department of Anatomy, University of Vienna, Vienna, Austria
Summary-Removal of retrocrural lymph nodes requires an approach other than the infradiaphragmatic retroperitoneal access generally used in the surgical management of testicular tumours. The transperitoneal route given access, at best, to the origin of the superior mesenteric artery, but advanced testicular tumours occasionally require retrocrural node dissection. We describe a useful surgical approach to these nodes and the underlying anatomy. As the management of advanced testicular neoplasms has improved, the need to remove clinically detectable residual disease persisting after chemotherapy has increased. Residual disease usually consists of mature teratoma tissue which failed to respond to chemotherapy. Mature teratomas are known to have a slow but definite progressive growth potential (growing teratoma syndrome) (Merrin et al., 1975; Logothetis et af., 1982) and a tendency towards later malignant degeneration, the extent of which is still poorly understood (Mostofi, personal communication). Thus their surgical removal is inevitable. In cadaver dissection studies the anatomy was reviewed to establish the best approach to the retrocrural lymph nodes associated with minimal surgical trauma to the vessels and nerves of the diaphragm and the adrenal gland.
Materials and Methods Anatomy Preservation of the vessels and nerves during diaphragmatic incision requires a full understanding of the blood supply to the diaphragm. The diaphragm is supplied by 4 arteries : (1) The pericardiacophrenic artery which accompanies the phrenic nerve towards caudal. ( 2 ) The musculophrenic artery which, like (1) originates from the internal thoracic artery. ~
Accepted for publication 27 February 1990
( 3 ) The superior phrenic arteries from the thoracic aorta. (4) The (abdominal) phrenic arteries, i.e. the first branches given off by the abdominal aorta after passing through the aortic hiatus of the diaphragm. In planning surgery it is important to know that the lumbaLr part of the diaphragm will not suffer any perfusion deficits if the left (abdominal) phrenic artery is cut. This artery arises from the aorta just above the coeliac trunk. It is the first branch given off by the abdominal aorta and it courses posteriorly and superiorly along the crura of the diaphragm. During its course upwards the left phrenic artery passes behind the oesophagus and supplies the lumbar part of the diaphragm on its abdominal side.
Surgical technique Cadaver studies were done initially in order to obtain the best possible exposure of the operative field by the surgical approach chosen. Experiments were also made with an approach from the right side. This proved to be more difficult, however, both because of the liver and because access to the left para-aortic retrocrural lymph nodes is impeded by the coeliac trunk, which is extremely short and drastically reduces manoeuvrability in the operative field. Patients are placed in a 30" right lateral position (left side up). A left thoraco-abdominal incision is made. Beginning at the level of the seventh intercostal space in the anterior axillary line, it is
523
524
BRITISH JOURNAL OF UROLOGY
\
Fig. 2
Fig. 1
w Fig. 3
Fig. 1 Left thoraco-abdominal incision, peritoneum opened. Interrupted line indicates incision in parietal peritoneum. Fig. 2 Asi = inferior suprarenal artery. Asm =medial suprarenal artery. Api = inferior phrenic artery. Ass= superior suprarenal artery. Fig. 3 Incision in the crus of the diaphragm. Large arrowhead marks superior mesenteric artery; coeliac trunk taped. Small arrowhead marks right inferior phrenic artery; left inferior phrenic artery cut.
SURGICAL APPROACH TO THE RETROCRURAL LYMPH NODES
continued pararectally to the level of the umbilicus. After splitting the ribs the diaphragm is incised as far laterally as possible to avoid injuring the left phrenic nerve, which enters the diaphragm at the level of the cardiac apex on the anterior aspect of the pericardium (Merendino, 1964). On entering the peritoneal cavity the parietal peritoneum is incised lateral to the colon; the incision should curve from about the mid-portion of the descending colon to the oesophageal aperture skirting the spleen laterally and superiorly (Fig. 1) so that the left colonic flexure together with the spleen and the pancreatic tail can be pulled medially and downwards. This exposes the upper pole of the kidney and the left adrenal (Mattox et al., 1975). The superior and medial suprarenal arteries are ligated and cut so that the adrenal can be pushed downwards together with the upper pole of the kidney. The inferior suprarenal artery, which originates from the left renal artery, must not be sacrificed because it will be the only vessel left to supply the adrenal gland. Above the origin of the left renal artery a DeBakey clamp is passed underneath the left crus of the diaphragm and advanced into the aortic hiatus along the lateral wall of the aorta. This manoeuvre should be done with the utmost care lest the left phrenic artery be torn from the aorta at its origin just below the aortic hiatus and above the origin of the coeliac axis. The left phrenic artery is cut together with the left crus of the diaphragm and ligated (Fig. 2). The diaphragmatic incision should be extended upwards to the level of the oesophageal hiatus (Fig. 3). At this level the mediastinal pleura may be opened inadvertently, but minor defects of the mediastinal pleura need not be sutured since a chest drain will have to be left in place. This approach provides excellent exposure of both the left and the right retrocrural lymph nodes up to the lower part of the posterior mediastinum. To get a better view of the right para-aortic nodes it is helpful to tape the coeliac trunk, particularly if massively enlarged nodes on the right side have to be removed. In this area great care should be taken to spare the lumbar arteries, as the artery of Adamkiewicz, which may originate at variable sites on their dorsal aspect (or from the aorta between T6 and L2), must not be injured because of the risk of producing a spinal lesion (Jellinger, 1967). To avoid major bleeding from the azygos vein,
525
which runs behind the right para-aortic retrocrural lymph node group, nodal dissection is best started at the upper end of the tumour. Adequate exposure of the azygos vein can only be obtained at this level so that it can be clamped and ligated in full view, if necessary. Once the involved lymph nodes have been removed, drainage of the retrocrural space is unnecessary because lymph leaking into the peritoneal cavity will be absorbed spontaneously, but the cut edges of the crus of the diaphragm should be meticulously adapted and closed with a continuous suture. This leaves sufficient space for intraperitoneal lymphatic drainage between the diaphiragm and the aorta. The thoracic and abdominal cavities are closed as usual.
Patieats Of 126 patients with testicular tumours treated betwe'en 1977 and 1985,3 were in need of retrocrural lymph node dissection. They presented with the growing teratoma syndrome, i.e. with mature teratoma tissue that had persisted after chemotherapy and continued to grow slowly but did not yet show any signs of malignant degeneration. The tumour mass was 10 cm or more in length and 5 to 7 cm iin diameter in all 3 cases. The mature teratoma tissue was easily shelled out without major blood loss. There were no post-operative complications related to the approach to the diaphragm and postoperative recovery was uneventful.
References Jellinger, K. (1967). Durchblutungsstorungen des Ruckenmarks. Wien. Klin. Wochenschr.,19,41-51. Logothetis, Ch. J., Samuels, M. L., Trindade, A. etal. (1982). The growing teratoma syndrome. Cancer, 50, 1629-1635. Mattox,, K. L., MeCollum, W. B., Beall, A. C. ef af. (1975). Management of penetrating injuries of the suprarenal aorta. J . Trauma, 15,808-812. Merendiino, K. A. (1964). The infradiaphragmatic distribution of the phrenic nerve; surgical significance. Surg. Clin. North. A m . , 4 4 , 1217-1221. Merrin, C., Baumgartner, G . and Wajsman, Z. (1975). Benign transformation of testicular carcinoma by chemotherapy. Lancet, II,43-44.
The Authors W. Hoelltl, MD, Senior Registrar in Urology S. Aharinejad, MD, Resident in Anatomy.
Requests for reprints to: W. Hoeltl, Department of Urology, Rudolfstiftung Vienna, Juchgasse 25, A-1030 Vienna, Austria.
0007-1 33 1/90/006~523/$10.00
01990 British Journal of Urology
Surgical Approach to the Retrocrural Lymph Nodes W. HOELTL and S. AHARINEJAD Department of Urology, Rudolfstiftung Hospital, and First Department of Anatomy, University of Vienna, Vienna, Austria
Summary-Removal of retrocrural lymph nodes requires an approach other than the infradiaphragmatic retroperitoneal access generally used in the surgical management of testicular tumours. The transperitoneal route given access, at best, to the origin of the superior mesenteric artery, but advanced testicular tumours occasionally require retrocrural node dissection. We describe a useful surgical approach to these nodes and the underlying anatomy. As the management of advanced testicular neoplasms has improved, the need to remove clinically detectable residual disease persisting after chemotherapy has increased. Residual disease usually consists of mature teratoma tissue which failed to respond to chemotherapy. Mature teratomas are known to have a slow but definite progressive growth potential (growing teratoma syndrome) (Merrin et al., 1975; Logothetis et af., 1982) and a tendency towards later malignant degeneration, the extent of which is still poorly understood (Mostofi, personal communication). Thus their surgical removal is inevitable. In cadaver dissection studies the anatomy was reviewed to establish the best approach to the retrocrural lymph nodes associated with minimal surgical trauma to the vessels and nerves of the diaphragm and the adrenal gland.
Materials and Methods Anatomy Preservation of the vessels and nerves during diaphragmatic incision requires a full understanding of the blood supply to the diaphragm. The diaphragm is supplied by 4 arteries : (1) The pericardiacophrenic artery which accompanies the phrenic nerve towards caudal. ( 2 ) The musculophrenic artery which, like (1) originates from the internal thoracic artery. ~
Accepted for publication 27 February 1990
( 3 ) The superior phrenic arteries from the thoracic aorta. (4) The (abdominal) phrenic arteries, i.e. the first branches given off by the abdominal aorta after passing through the aortic hiatus of the diaphragm. In planning surgery it is important to know that the lumbaLr part of the diaphragm will not suffer any perfusion deficits if the left (abdominal) phrenic artery is cut. This artery arises from the aorta just above the coeliac trunk. It is the first branch given off by the abdominal aorta and it courses posteriorly and superiorly along the crura of the diaphragm. During its course upwards the left phrenic artery passes behind the oesophagus and supplies the lumbar part of the diaphragm on its abdominal side.
Surgical technique Cadaver studies were done initially in order to obtain the best possible exposure of the operative field by the surgical approach chosen. Experiments were also made with an approach from the right side. This proved to be more difficult, however, both because of the liver and because access to the left para-aortic retrocrural lymph nodes is impeded by the coeliac trunk, which is extremely short and drastically reduces manoeuvrability in the operative field. Patients are placed in a 30" right lateral position (left side up). A left thoraco-abdominal incision is made. Beginning at the level of the seventh intercostal space in the anterior axillary line, it is
523
524
BRITISH JOURNAL OF UROLOGY
\
Fig. 2
Fig. 1
w Fig. 3
Fig. 1 Left thoraco-abdominal incision, peritoneum opened. Interrupted line indicates incision in parietal peritoneum. Fig. 2 Asi = inferior suprarenal artery. Asm =medial suprarenal artery. Api = inferior phrenic artery. Ass= superior suprarenal artery. Fig. 3 Incision in the crus of the diaphragm. Large arrowhead marks superior mesenteric artery; coeliac trunk taped. Small arrowhead marks right inferior phrenic artery; left inferior phrenic artery cut.
SURGICAL APPROACH TO THE RETROCRURAL LYMPH NODES
continued pararectally to the level of the umbilicus. After splitting the ribs the diaphragm is incised as far laterally as possible to avoid injuring the left phrenic nerve, which enters the diaphragm at the level of the cardiac apex on the anterior aspect of the pericardium (Merendino, 1964). On entering the peritoneal cavity the parietal peritoneum is incised lateral to the colon; the incision should curve from about the mid-portion of the descending colon to the oesophageal aperture skirting the spleen laterally and superiorly (Fig. 1) so that the left colonic flexure together with the spleen and the pancreatic tail can be pulled medially and downwards. This exposes the upper pole of the kidney and the left adrenal (Mattox et al., 1975). The superior and medial suprarenal arteries are ligated and cut so that the adrenal can be pushed downwards together with the upper pole of the kidney. The inferior suprarenal artery, which originates from the left renal artery, must not be sacrificed because it will be the only vessel left to supply the adrenal gland. Above the origin of the left renal artery a DeBakey clamp is passed underneath the left crus of the diaphragm and advanced into the aortic hiatus along the lateral wall of the aorta. This manoeuvre should be done with the utmost care lest the left phrenic artery be torn from the aorta at its origin just below the aortic hiatus and above the origin of the coeliac axis. The left phrenic artery is cut together with the left crus of the diaphragm and ligated (Fig. 2). The diaphragmatic incision should be extended upwards to the level of the oesophageal hiatus (Fig. 3). At this level the mediastinal pleura may be opened inadvertently, but minor defects of the mediastinal pleura need not be sutured since a chest drain will have to be left in place. This approach provides excellent exposure of both the left and the right retrocrural lymph nodes up to the lower part of the posterior mediastinum. To get a better view of the right para-aortic nodes it is helpful to tape the coeliac trunk, particularly if massively enlarged nodes on the right side have to be removed. In this area great care should be taken to spare the lumbar arteries, as the artery of Adamkiewicz, which may originate at variable sites on their dorsal aspect (or from the aorta between T6 and L2), must not be injured because of the risk of producing a spinal lesion (Jellinger, 1967). To avoid major bleeding from the azygos vein,
525
which runs behind the right para-aortic retrocrural lymph node group, nodal dissection is best started at the upper end of the tumour. Adequate exposure of the azygos vein can only be obtained at this level so that it can be clamped and ligated in full view, if necessary. Once the involved lymph nodes have been removed, drainage of the retrocrural space is unnecessary because lymph leaking into the peritoneal cavity will be absorbed spontaneously, but the cut edges of the crus of the diaphragm should be meticulously adapted and closed with a continuous suture. This leaves sufficient space for intraperitoneal lymphatic drainage between the diaphiragm and the aorta. The thoracic and abdominal cavities are closed as usual.
Patieats Of 126 patients with testicular tumours treated betwe'en 1977 and 1985,3 were in need of retrocrural lymph node dissection. They presented with the growing teratoma syndrome, i.e. with mature teratoma tissue that had persisted after chemotherapy and continued to grow slowly but did not yet show any signs of malignant degeneration. The tumour mass was 10 cm or more in length and 5 to 7 cm iin diameter in all 3 cases. The mature teratoma tissue was easily shelled out without major blood loss. There were no post-operative complications related to the approach to the diaphragm and postoperative recovery was uneventful.
References Jellinger, K. (1967). Durchblutungsstorungen des Ruckenmarks. Wien. Klin. Wochenschr.,19,41-51. Logothetis, Ch. J., Samuels, M. L., Trindade, A. etal. (1982). The growing teratoma syndrome. Cancer, 50, 1629-1635. Mattox,, K. L., MeCollum, W. B., Beall, A. C. ef af. (1975). Management of penetrating injuries of the suprarenal aorta. J . Trauma, 15,808-812. Merendiino, K. A. (1964). The infradiaphragmatic distribution of the phrenic nerve; surgical significance. Surg. Clin. North. A m . , 4 4 , 1217-1221. Merrin, C., Baumgartner, G . and Wajsman, Z. (1975). Benign transformation of testicular carcinoma by chemotherapy. Lancet, II,43-44.
The Authors W. Hoelltl, MD, Senior Registrar in Urology S. Aharinejad, MD, Resident in Anatomy.
Requests for reprints to: W. Hoeltl, Department of Urology, Rudolfstiftung Vienna, Juchgasse 25, A-1030 Vienna, Austria.
