Laparoscopic Extraperitoneal Total Retroperitoneal Dissection- the Right Approach.

Abstract

<h3>Study Objective</h3> To demonstrate our minimally invasive para-aortic and pelvic lymphadenectomy via the retroperitoneal approach. This technique is performed entirely from the renal vein to the circumflex iliac vein extraperitoneally for cases with mainly endometrial cancer, selected cases of ovarian cancer and in rarer situations for advanced cervical cancer cases as a staging procedure. <h3>Design</h3> Analysis of a technique via video. <h3>Setting</h3> Urban general hospital in Japan. <h3>Patients or Participants</h3> More than 900 cases have undergone laparoscopic or robotic extraperitoneal para-aortic dissection and around 19 of these cases have also undergone extraperitoneal pelvic lymphadenectomy. <h3>Interventions</h3> The extraperitoneal approach is performed using a 5mm EndoTIP cannula. We place all 4 retroperitoneal ports along the left flank. For dissection we use a monopolar hook equipped with an aspiration device and advanced bipolar for retroperitoneal dissection. <h3>Measurements and Main Results</h3> The estimated blood loss for para-aortic dissection was only 30ml and 160ml in the pelvic procedure. Only 3 cases of the total 900 cases required a conversion to open laparotomy. We experienced 23 cases of peritoneal tent perforation, but did not abandon the original procedure, rather suture-repaired the hole and continued. <h3>Conclusion</h3> The advantage of this approach is that the operative filed is bowel-free as the peritoneum acts as a natural retractor. This means that there is minimally impact to the bowel. Patients are not required to be placed in a deep Trendelenburg position. Even extensive intraperitoneal adhesion cases have been successfully managed with this procedure making it a patient friendly option.