Laparoscopic Excision of Recurrent Pelvic Lymphocyst Following Pelvic Lymph Node Dissection for Clear Cell Carcinoma of Ovary

Abstract

Study ObjectiveDemonstration of safe laparoscopic technique for definitive excision of recurrent pelvic lymphocyst developing following pelvic lymph node dissection for clear cell carcinoma of the ovary; overcoming the additional surgical challenges of close proximity to vital anatomical structures and dense post-operative adhesions.DesignSurgical video detailing a systematic approach to laparoscopic excision of pelvic lymphocyst - describing individual surgical steps and highlighting relevant anatomy.SettingSurgery was undertaken by a gynae-oncology consultant with one surgical assistant. The patient was positioned in modified Lloyd-Davis – with table height and stack adjusted for optimal ergonomics.Patients or ParticipantsA 68 year old lady underwent total abdominal hysterectomy, bilateral salpingo-oophrectomy and omentectomy in April 2018 for stage 1A clear cell carcinoma of ovary; followed by completion laparoscopic pelvic and para-aortic lymphadenectomy. The patient subsequently developed a right pelvic lymphocyst, causing pain. Pre-operative imaging described a 3.9 × 3.3 × 3 centimetre right pelvic lymphocyst, with internal septations and thick wall. Two attempts at percutaneous drainage were unsuccessful due to difficulty penetrating the cyst capsule and loculated interior.InterventionsLaparoscopic excision of pelvic lymphocyst was undertaken. Pneumoperitoneum was maintained at a pressure of 12mmHG throughout. The pelvic peritoneum overlying the lymphocyst was opened and plane developed using a combination of monopolar, bipolar and advanced energy devices. The ureter and iliac vessels were systematically identified to avoid inadvertent injury; and avascular pelvic spaces developed to aid cleavage of the capsule with minimal blood loss.Measurements and Main ResultsNo intra or post-operative complications occurred. Histopathology confirmed a benign lymphocyst. At post-operative review, the patient reported resolution of pain and improved mobility.ConclusionThis video demonstrates a safe laparoscopic approach to excision of a densely adherent pelvic lymphocyst, abutting important pelvic structures – facilitated by the step-wise identification of pelvic anatomy and relevant pelvic spaces.