Disclosure/ Conflict of interest: The authors whose names are listed above certify that they have NO affiliations with or involvement in any organisation or entity with any financial interest (such as honoraria; educational grants; participation in speakers ’bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.
NO FUNDING SOURCES .
Retroperitoneal lymphadenectomy is required as a component of certain Gynecologic Oncosurgical Procedures like staging of early ovarian and some types of endometrial cancers
It can be done by laparotomy or a Minimal Access approach (Laparoscopic/Robotic). This could be further classified as Transperitoneal or Extraperitoneal .
Retroperitoneal lymphadenectomy is usually combined with removal of the primary site of disease. Hence, transperitoneal approach avoids re-draping / changing of the patient position . We prefer the Minimal Access approach, in Early Ovarian and Endometrial cancers.
Patients of endometrial carcinoma are mostly obese and a Minimal Access is considered the Gold Standard. The procedure, is a technical challenge for the anesthesiologist due to co-existent Diabetes Mellitus, Hypertension, Obesity, Poor Cardiopulmonary reserve. The surgical challenges are tolerance to pneumoperitoneum, keeping the small intestine away from the operating field, potentially life threatening haemorrhage and chyle leaks.
This video, demonstrates our technique of performing this procedure. A T-Lift device is used to elevate and retract the mesenteric and peritoneal folds as a tent. This simple step, helps keep the small intestine away from the field without direct traction and avoids intestinal trauma.
We use the Karl Storz 3D Laparoscopy system. At the junction of the left gonadal with the renal vein, hem-o-lok clips are put to seal visible lymphatic channels and prevent postoperative chyle leaks. Haemostasis is checked. A tube drain is placed in the pelvis. The average postoperative stay is 5-7 days.
This technique can be safely replicated with a trained and dedicated team of Surgeons, Anesthesiologists and Scrub nurses.
AIM : Retroperitoneal lymphadenectomy is required as a component of certain gynecologic oncosurgical procedures like staging in early ovarian and certain endometrial cancers . It’s a part of cytoreductive surgery in advanced Ovarian Cancers. It be done by laparotomy or a Minimal Access approach (Laparoscopic/Robotic). This could be further classified as Transperitoneal or Extraperitoneal routes.
EQUIPMENTS :
1.3D Laparoscopy with two monitors(A Slave monitor)
Standard Laparoscopy Instruments
T-lifts
Ultrasonic Scalpel
5 mm Vessel Sealer
Hem-O-Lok Clips
5-0 Prolene on round body needle (Standby)
In this surgical video, we demonstrate our technique of Laparoscopic Transperitoneal Retroperitoneal Lymphadenectomy.
The procedure is done under general anesthesia.
The patient is kept in supine position with her legs in cushioned straight Allen’s stirrups. A bolster is placed under the pelvis at the level of the anterior superior iliac spines. Continous bladder drainage is done by an indwelling Foley’s catheter . Indwelling nasogastric tube is placed for gastric decompression.
The camera port is placed 3-4 centimetres above the umbilicus in the midline. We use the open technique with the Hasson’s cannula . The abdomen is inspected and the other ports are placed. On the right side , a 10 mm port is placed in the spinoumbilical line 2 cms medial to the anterior superior iliac spine and a 5 mm port is placed in the midclavicular line triangulating between the camera port and the 10 mm port. Identical ports are placed on the left side. The intrabdominal pressure is maintained at 14mm Hg.
This procedure can be divided into two parts. The Pelvic part where the surgeon operates from the patient’s right with standard pelvic ports and the Para-aortic part wherein the operating surgeon stands between the patient’s legs . In the Pelvic part, one monitor is placed near the leg end of the patient and the second monitor opposite the surgeon , during the para-aortic part, one monitor is placed near the patient’s left shoulder and the other near the leg end of the patient .
We begin by identifying the right common iliac artery and the ureteric crossing . The peritoneum medial to the ureter is cut and the small bowel mesentery is elevated from the retroperitoneum. The cut is continued over the sigmoid mesocolon , which is dissected to identify the inferior mesenteric artery. The mesocolon is then elevated from the retroperitoenum and the left ureter and gonadal vessels are identified. This marks the left border of dissection. Superiorly the flap is continued till the duodenum is reached.
Lymphadenectomy is commenced by harvesting the nodes from the right common iliac group. Thef irst T lift is inserted through the flap of the small bowel mesentery and is retracted. This gives space for dissection and keeps the small bowel away from the operative field. Similar dissection is continued on the left side and the nodes harvested. Inter iliac nodes are also cleared. This completes the first part of the dissection. A suprapubic camera port is now placed in the midline.
In the second part, the surgeon stands between the patients legs with the camera now shifted to the suprapubic port. The laparoscopic view now gives us a caudal to cranial view of the operative field. The already dissected anatomy is examined. The right side T lift keeps the terminal ileal loops from falling into the surgical field . A second T-lift is placed in the sigmoid mesocolon and it is retracted laterally . A tent analogy can be used to understand this principle. The elevated small bowel mesentery and mesocolon keep the small bowel loops from falling into the operative field and create room for instrumentation along the great vessels. The assistant retracts the third part of duodenum cranially holding a gauze piece.
Dissection is then continued along the inferior mesenteric artery upto its origin. The right gonadal vein is followed upto its termination into the inferior vena cava and paracaval nodes cleared. The left gonadal vein is dissected upto its junction with the left renal vein . Interaortocaval , para and pre aortic nodes are cleared. Special care is taken to clip the lymphatics around the left renal vein to avoid post operative lymph leaks. Lumbar branches from aorta are identified and safeguarded. Specimen is excised and placed in an endobag.
Pneumoperitoneum pressure is lowered to check for hemostasis and lymph leaks.
All 10 mm ports are closed under vision with a port closure cone and needle.
The patients are out of bed on the first postoperative day. The average postoperative hospital stay is 5-6 days. In our series, there were no postoperative mortality.We have performed nearly 75 procedures of Laparoscopic Retroperitoneal Lymph Node Clearanace. There have been five chyle leaks, of which only one required surgical intervention.
Retroperitoneal lymphadenectomy is usually combined with removal of the primary site of disease in gynecologic oncology . Hence, transperitoneal approach would avoid changing of the patient position and re-draping. We prefer the Laparoscopic approach in Early Ovarian and Endometrial cancers.
For endometrial carcinoma, retroperitoneal lymphadenectomy used to be an indication for laparotomy in patients otherwise being managed by minimal access surgery. However, using effective strategies to encounter ergonomic difficulties, this procedure can be safely performed by laparoscopy. The patients are mostly obese and a Minimal Access approach is considered the Gold Standard. The procedure, is a technical challenge for the anesthesiologist on various counts (co-existent Diabetes Mellitus, Hypertension, Obesity, Poor Cardiopulmonary reserve). The surgical challenges are tolerance to pneumoperitoneum, keeping the small intestine away from the operating field, potentially life threatening haemorrhage and chyle leaks.
Our emphasis in this technique, has been minmal direct handling of the small intestine. We push in surgical Laparoscopy gauze pieces and retract the duodenum /small intestine over a gauze. This avoids intestinal trauma.
Small intestine coming in the surgical field, is the main drawback of the transperitoneal approach. We use disposable plastic T Tube, this device is loaded into a sharp metal introducer. The tube is introduced transdermally and the mesentric/peritoneal fold is punctured. The metal introducer is removed and the T tube is kept anchored to the skin under traction.
Other ways of doing the same :
1. A free suture in the mesentric/peritoneal fold and anchoring it to the skin(Requires a needle to be introduced into the abdomen and is more cumbersome).
2. Direct retraction on the small intestine (Intestine keeps slipping into the field and gets traumatised).
The authors whose names are listed above certify that they have NO affiliations with or involvement in any organisation or entity with any financial interest (such as honoraria; educational grants; participation in speakers ’bureaus; membership, employment, consultancies, stock ownership, or other equity interest; and expert testimony or patent-licensing arrangements), or non-financial interest (such as personal or professional relationships, affiliations, knowledge or beliefs) in the subject matter or materials discussed in this manuscript.
We acknowledge the contributions of the Anesthesiology department, Colleagues in the department of Surgical Oncology, Staff nurses and technicians. Without their support, these procedures are not possible.
1. Zivanovic, O., Sheinfeld, J. & Abu-Rustum, N. R. (2008). ;RPLND
Gynecologic Oncology, 111(2), S66–S69. doi:10.1016/j.ygyno.2008.07.043
2. El Meligy MH, El Kased AF, El Sisy AA, El Gammal AS. The role of pelvic and para-aortic lymphadenectomy in gynecological malignancies. Menoufia Med J 2015;28:833-7
Authors
Carol Li, MD1*, Apoorva T. Ramaswamy, MD1*, Sallie M. Long, MD 1 , Alexander Chern, MD 1 , Sei Chung, MD 1 , Brendon Stiles, MD 2 , Andrew B. Tassler, MD 1
1Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medicine, New York, NY 2Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
*Co-First authors
Overview
The COVID-19 pandemic is an unprecedented global healthcare emergency. The need for prolonged invasive ventilation is common amid this outbreak. Despite initial data suggesting high mortality rates among those requiring intubation, United States data suggests better outcomes for those requiring invasive ventilation. Thus, many of these patients requiring prolonged ventilation have become candidates for tracheotomy. Considered aerosol generating procedures (AGP), tracheotomies performed on COVID-19 patients theoretically put health care workers at high risk for contracting the virus. In this video, we present our institution’s multidisciplinary team-based methodology for the safe performance of tracheotomies on COVID-19 patients. During the month of April 2020, 32 tracheotomies were performed in this manner with no documented cases of COVID-19 transmission with nasopharyngeal swab and antibody testing among the surgical and anesthesia team.
Procedure Details
The patient is positioned with a shoulder roll to place the neck in extension. The neck is prepped and draped in a sterile fashion with a clear plastic drape across the jawline extending superiorly to cover the head. An institutional timeout is performed. The patient is pre-oxygenated on 100% FiO2. A 2-cm vertical incision is made extending inferiorly from the lower border of the palpated cricoid cartilage. Subcutaneous tissues and strap muscles are divided in the midline. When the thyroid isthmus is encountered, it is either retracted out of the field or divided using electrocautery. The remaining fascia is then cleared off the anterior face of the trachea.
Prior to airway entry, the anesthesiologist pauses all ventilation and turns off oxygen flow. The endotracheal tube (ETT) is advanced distally past the planned tracheotomy incision, without deflating the cuff, if possible. If necessary, the endotracheal cuff is deflated partially to advance the tube, with immediate reinflation once in position. The surgical team then creates a tracheotomy using cold steel instruments. The cricoid hook is placed in the tracheotomy incision and retracted superiorly for exposure of the lumen. The tube is withdrawn under direct visual guidance, without deflating the endotracheal cuff if possible. The tracheotomy tube is placed, and to minimize aerosolization of respiratory secretions, the cuff is inflated prior to re-initiation of ventilation. The tracheotomy tube is then sewn to the skin using 2-0 prolene suture. A total of five simple stitches are placed around the tube to prevent accidental decannulation.
Indications/Contraindications
Candidacy for tracheotomy was determined on a case by case basis with consideration for progression of ventilator weaning, viral load, and overall prognosis. All patients who underwent tracheotomy were intubated prior to the surgery for a minimum of 14 days, able to tolerate a 90-second period of apnea without significant desaturation or hemodynamic instability, and expected to recover. Optimal ventilator settings included FiO2 = 50% and PEEP = 10 cm H20.
Instrumentation
A standard tracheostomy instrument tray was utilized, including the following: tonsil dissector, DeBakey forceps, right-angle retractors, cricoid hook, and tracheal dilator. Bovie electrocautery was also utilized.
Setup
Please refer to the diagrams depicted in the accompanying video.
Preoperative Workup
An apnea test was performed for 90 seconds to ensure that the patient had adequate reserve. Ventilator settings were optimized. If possible, systemic anticoagulation was paused.
Anatomy and Landmarks
Important landmarks include the thyroid cartilage, cricoid cartilage, and sternal notch. A high-riding innominate artery can be detected on imaging and with palpation during the surgery.
Advantages/Disadvantages
Given the unique benefits of tracheotomy in avoiding the laryngeal trauma associated with prolonged intubation, decreased dead space, and ease of trialing patients off of the ventilator, there is high motivation to perform tracheotomies in COVID-19 patients requiring intubation and prolonged mechanical ventilation. Major disadvantages include the risk of virus transmission among the surgical and anesthesia team.
Complications/Risks
Short-term complications include bleeding and infection, such as peristomal cellulitis. Long-term complications of tracheostomy include cartilage destruction or deformity, granulation tissue formation, and superficial scarring.
References: N/A
As technique and technology have evolved in the modern age, surgical emphasis has shifted steadily towards minimally invasive alternatives. In colon surgery, laparoscopy has been shown to improve multiple outcome metrics, including reductions in post-operative morbidity, pain, and hospital length of stay, while maintaining surgical success rates. Unfortunately, despite the minimally invasive approach, elective laparoscopic sigmoidectomy typically requires an abdominal wall extraction site, leaving a large incision in addition to the laparoscopic port sites. It also utilizes three different types of intestinal staplers, leading to an anastomosis that may have multiple intersecting staple lines, thereby potentially influencing the anastomotic integrity, as well as increasing procedural costs substantially.
We present a case of a totally robotic sigmoidectomy utilizing a single stapler technique and natural orifice specimen extraction in a patient with multiple, severe, recurrent episodes of sigmoid diverticulitis over a 2-year period.
Gastrointestinal stromal tumors (GIST) occur most frequently at the gastric level. Surgical resection is the mainstay of treatment and can usually be performed using laparoscopic approaches (1). The resection strategy must be adjusted to each case, the selection of location, size and growth pattern of the tumor (2).
We present the case of a 78-year-old female patient who, after going to the Emergency Department due to symptoms of upper gastrointestinal bleeding, showed a 5 cm heterogeneous tumor depending on the muscular layer itself in a posterior gastric wall, endoluminal growth, and without objectifying others injuries in the study of extension. A wide posterior resection of the gastric posterior wall and primary closure with a barbed suture was performed laparoscopically. The postoperative evolution was satisfactory. The histopathological study shows low-risk GIST (5 mitosis / 50 CGA) with free margins; during follow-up, no recurrence was observed. Simple laparoscopic resection of gastric GIST tumors seems to be a useful strategy in terms of oncological safety, reducing excessive resection of tumor-free tissue and increasing gastric remnant.
Review TENT TECHNIQUE OF LAPAROSCOPIC RETROPERITONEAL LYMPHADENECTOMY- TRANSPERITONEAL APPROACH.