| SLIDES
& TRANSCRIPTS
Saturday,
December 14, 2002
Anatomy,
Technique, and Results of Laparoscopic Retroperitoneal Lymph Node
Dissection
Georg
Bartsch, M.D. |
| Slide
1: |
 First
of all, I would like to thank the organizers for inviting me.
TOP
|
| Slide
2: |
|  Then
I would like to give credit to the many authors of the presentation.
This is Dr.’s Hobisch, Janetschek and Peschel, who did most
of the procedures.
TOP |
| Slide
3: |
|  In
this presentation I would like to address the following aspects:
anatomy, nerve preserving lymph node dissections, surgical technique,
TOP |
| Slide
4: |
|  learning
curve, and standardization of surgical and oncological efficacy,
and quality of life.
TOP |
| Slide
5: |
|  In
an anatomical study performed almost 15 years ago, 12 retroperitoneal
cadaver specimens were dissected. The right sympathetic trunk is
situated dorsal to the inferior vena cava. By the left trunk is
located dorsal and lateral to the abdominal aorta.
TOP |
| Slide
6: |
|  The
postganglionic fibers travel to the paraaortic nerve plexus and
reach the superior hypogastric plexus.
TOP |
| Slide
7: |
| 
On the right side, and you see the vena cava. It is elevated. The
nerve fibers run dorsal to the inferior vena cava and unite with
the left paraaortic fibers caudal to the inferior mesenteric artery.
TOP |
| Slide
8: |
|  In
1951, Whitelaw and Smitwick, two vascular surgeons out of Boston,
demonstrated in their study on secondary affects on sympathectomy
that unilateral resection of the L1-L3 ganglia did not result in
aspermia.
TOP |
| Slide
9: |
|  On
the basis of this study, the results of mapping studies, and several
anatomical studies,(first started by Paul Lange) template techniques
were developed for stages 1 and 2A. And on the other side, nerve
sparing techniques for the stage 1 and 2 tumors were also performed.
TOP |
| Slide
10: |
|  As
you can see here in 2B lesion.
TOP |
| Slide
11: |
|  In
the laparoscopic approach, and you see this for the right side,
the operating table is rotated to bring the patient into nearly
full flank position with the right side elevated.
TOP |
| Slide
12: |
|  Four
trocars are used for the procedure, and the two trocars for the
surgeon are placed slightly lateral to the rectus muscle.
TOP |
| Slide
13: |
|  The
split and role technique is performed in the same way as in open
surgery. There is no difference.
There is a primary
dissection of all the lumbar vessels.
TOP |
| Slide
14: |
|  You
can see on the right side the vein is pushed away with a sponge
stick, and the lumbar vein is clipped.
TOP |
| Slide
15: |
|  The
operative technique is now shown for the right side. The peritoneum
is incised along the white line of Toldt, to the foramen of Winslow.
And you can see the inferior vena cava, the aorta, and the left
renal vein. Also visualized is the duodenum.
TOP |
| Slide
16: |
| 
Next, the spermatic vein is dissected from the internal inguinnal
ring into its opening to the vena cava.
TOP |
|
Slide 17: |
|  The
tissue surrounding the vena cava is split open, and by rolling the
vena cava, the anterior and lateral surfaces can be dissected free.
TOP |
| Slide
18: |
|  Then
the right side, and you see the renal artery, and you see the renal
vein, and you see all of the vena cava lumbar veins are dissected
free, is dissected.
TOP |
| Slide
19: |
|  Now,
the right ureter is separated from the nodal package down to the
junction with the iliac vessels.
TOP |
| Slide
20: |
Next, the tissue overlying the aorta is clipped and dissected
as far as the renal hilum - the left renal vein is seen.
TOP
|
| Slide
21: |
|  Then
the interaortocaval tissue is removed.
In this patient
is the right-sided tumor, all vessels were transected and it's like
in the open approach.
TOP |
| Slide
22: |
|  And
as it is with a right sided tumor, the vena cava is elevated, you
see the spinous ligament. Also seen is the right renal artery, and
the left renal vein.
TOP |
| Slide
23: |
|  This
is the fast learning curve of the first surgeon Dr Janetschek, who
developed the laparoscopic approach in our department. He started
out with an operative time of 480 minutes, and dropped down to 270
minutes in his last 20 patients.
Now that the
procedure
TOP |
| Slide
24: |
| 
has been standardized, the second surgeon, Dr. Peschel, has become
even faster than his teacher. In his most recent 20 patients the
operative time was 204 minutes. The patients are discharged on the
second day.
TOP |
| Slide
25: |
| 
Surgical efficacy was assessed in 181 patients, including 112 patients
with stage 1, and 69 patients with stage 2 following chemotherapy.
You can see the blood loss of the stage 1 patients is low. You can
see the operative time. The conversion rate of the 4 patients was
in between patients 1 and 6, and these were caval injuries, which
would todaybe sutured suture it, without conversion.
TOP |
| Slide
26: |
|  You
see the results in the stage 2 patients. It's 69 patients. There
were no conversions.
TOP |
| Slide
27: |
|  With
regards to complications, you see in stage 1 we had in 4 patients
with chylous ascites, all treated safely with conservative management.
One patient had caval thrombosis, which was managed by medical management.
In stage 2, one patient had chylous ascites and a lymphocele, respectively,
but no difference to the open operation.
TOP |
| Slide
28: |
|  As
far as nerve preservation, in stage 1 and stage 2A and 2B, we had
100 percent rate of nerve preservation.
TOP |
| Slide
29: |
| 
Now, what is the oncological efficacy? In stage 1 we had one retroperitoneal
and one pulmonary metastases in a mean follow-up of 51 months. I'm
coming later on to these results, because this is a weak point.
TOP |
| Slide
30: |
| 
In the chemotherapy stage 2B, we didn't have a relapse in retroperitoneum,
nor any pulmonary metastasis.
TOP |
| Slide
31: |
|  We
also did some life quality studies, performed by a psychologist.
We had 118 patients who were asked 39 questions. For lack of time,
I will discuss only 4 questions.
The question concerning
return to normal activities, time to resuming gentle physical exercise,
and time to becoming free of symptoms viewed as significantly better
results in the laparoscopic group.
TOP |
| Slide
32: |
|  Then,
91 out of the 118 patients report difference in morbidity from the
retroperitoneal lymph node dissection, compared to chemotherapy.
So in our series, people did not like chemotherapy.
TOP |
| Slide
33: |
|  In
conclusion, once the learning curve has been overcome, the laparoscopic
approach is not difficult or demanding. In our department, laparoscopic
surgery has now entered a phase where it is primarily performed
by oncological surgeons. It is also going into the residency training
as well.
The laparoscopic approach
is associated with a steep learning curve, but lower morbidity than
with open surgery, with equal surgical efficacy. Furthermore, in
some places this technique is used in a high percentage of stage
1 patients, a patient can now be spared chemotherapy.
TOP |
| Slide
34: |
|  Now,
the weak points are the 2A patients. Initially, we were very anxious,
and we gave the stage 2A patients chemotherapy. However, starting
in March 2000, we changed this concept, now doing both sided nerve-sparing
technique in those patients, without chemotherapy.
TOP |
| Slide
35: |
|  To
show you this technique - you see this is the vena cava put to the
medial side, with the sponge stick. And you see the sympathetic
trunk and the ganglion.
TOP |
| Slide
36: |
| 
With the cava on this side, and you see here the nerve plexus going
posteriorally behind the cava as the periaortic plexus. So far,
18 patients have been operated on, and we have not seen a recurrence.
Thank you.
TOP |
| |
