Laparoscopic Lymph Node Dissection Research Articles

Laparoscopy-assisted distal gastrectomy for gastric cancer after liver transplantation

A case report described a 72-year-old man with a history of a deceased-donor liver transplantation (due to hepatitis B-associated end-stage liver cirrhosis) performed in 1994. The patient was diagnosed with renal cell carcinoma and pulmonary metastasis in 1997 and was successfully treated with radiofrequency ablation and thoracoscopic superior segmentectomy. There was no evidence of newly diagnosed metastatic lesions or recurrence until the 19th post-operative month. Gastric cancer was identified by endoscopy during a routine follow-up examination; the pre-pyloric antral lesion measured 1.5 cm in size and was histologically well-differentiated and confined to the submucosal layers on endoscopic ultrasound. Laparoscopic gastrectomy and lymph node dissection (D1 + β) was successfully performed in March 2009, and the patient was discharged on the 5th post-operative day without complications. This suggests that laparoscopic surgery is one of the feasible methods for resection of gastric cancer in liver transplant patients.

Hybrid natural orifice transluminal endoscopic surgery: endoscopic full-thickness resection of early gastric cancer and laparoscopic regional lymph node dissection - 14 human cases

Minimally invasive treatment has become a mainstay management strategy for early gastric cancer (EGC). Full-thickness incision of the gastric wall using natural orifice transluminal endoscopic surgery (NOTES) has been reported but is not easily applicable in clinical settings at present. The aim of the current study was to assess the feasibility of hybrid NOTES, which consists of endoscopic full-thickness gastric resection and a laparoscopic lymphadenectomy. This was a prospective, pilot study at a single tertiary care referral center. A total of 14 patients with EGC located above the lower third of the stomach underwent hybrid NOTES. Clinically, the patients had contraindications to exclusive treatment using endoscopic submucosal dissection (ESD). The main outcome measure was technical success of hybrid NOTES. All cases were resected en bloc with negative surgical margins. Histologically, four cases were mucosal cancers, and 10 cases were submucosal cancers. The median tumor size was 26 mm (range 12 - 90 mm). Lymphatic vessel invasion was found in four cases without lymph node metastasis (LNM). The median number of obtained lymph nodes was 18 (range 7 - 67). LNM was discovered in one case of undifferentiated submucosal cancer without lymphovascular invasion. Hybrid NOTES was conducted without intraoperative or postoperative adverse events in nine cases. The median operating time and estimated blood loss of successful cases were 143 minutes (range 110 - 253 minutes) and 16 mL (range 5 - 30 mL), respectively. The median hospital stay was 6 days (range 4 - 10 days). Five cases were converted to a subtotal gastrectomy for various reasons. Hybrid NOTES could be a bridge between endoscopic resection and laparoscopic surgery and may prevent extensive gastrectomy in patients with EGC.

Laparoscopic lymph node dissection around the inferior mesenteric artery with preservation of the left colic artery

Curative resection of sigmoid and rectal cancer includes "high tie" of the inferior mesenteric artery (IMA). However, IMA ligation compromises blood flow to the anastomosis, which may increase the leakage rate. Accordingly, some surgeons employ a technique of lymph node (LN) dissection around the IMA, preserving the IMA and left colic artery (LCA). The same technique was reported to need longer time in laparoscopic surgery due to technical difficulties. We present herein a simple and secure method of laparoscopic LN dissection around the IMA that allows preservation of the IMA and LCA, and report the operative results. Our method involves peeling off the vascular sheath from the IMA and dissection of the LN around the IMA together with the sheath. The feasibility of the technique was evaluated in 72 consecutive cases of laparoscopic resection of sigmoid and rectal cancer. The IMA was ligated at its root in 27 cases (high tie, group A). Lymph nodes around the IMA were dissected with preservation of the IMA and LCA in 21 cases (group B). The root of the superior rectal artery was ligated in 24 cases of Tis and T1N0 ("low tie," group C). Mean operative time was 207.6, 221.2, and 198.5 min for group A, B, and C, respectively. Respective blood loss was 47.8, 44.0, and 58.5 g, and mean numbers of harvested LN were 17.3, 16.3, and 10.7. None of the operative results of groups A and B were different statistically. LN dissection was not associated with any morbidity. Our method allows equivalent laparoscopic lymph node dissection to the high tie technique without excessive operative time or bleeding.

Gastric lymphatic basin dissection for sentinel node biopsy using hybrid natural orifice transluminal endoscopic surgery (NOTES)

The aim of the present study was to describe a method of gastric lymphatic basin dissection for sentinel node biopsy using natural orifice transluminal endoscopic surgery with laparoscopic assistance (hybrid NOTES) in a porcine model. Lymph node dissection was performed in three healthy female domestic farm pigs (each around 40 kg) between October, 2007, and December, 2007. The pigs were administered a general anesthetic and laparoscopy-guided transvaginal colpotomy was performed. A two-channel endoscope was then inserted through the incision into the peritoneal cavity via the transvaginal route. An endoscope was inserted simultaneously into the mouth and indocyanine green solution was injected into the submucosal layer of the gastric wall at four sites. Dyed omentum and lymphatics were dissected using a laparoscopic dissector and the grasping forceps of a transvaginal endoscope. Lymphatics and omentum (mean 13.3 cm, range 8–20 cm) were removed transvaginally. The mean number of detected and resected sentinel nodes was 2.6 (range 1–4, diameter 2∼12 mm). Sentinel lymphatic basin dissection was performed successfully and without intraoperative complications in all three cases. Hybrid NOTES is technically feasible, and this procedure may represent an alternative to laparoscopic sentinel lymph node dissection of the stomach.

Impact of age on morbidity and outcome of concurrent radiochemotherapy in high-risk FIGO stage I to IVA carcinoma of the uterine cervix following laparoscopic surgery

PurposeTo evaluate the impact of age on treatment-related acute morbidity, on modifications of drug doses and radiotherapy and on disease-free and overall survival in non-elderly and elderly with high-risk cervical cancer treated with concurrent radiochemotherapy following laparoscopic surgery.MethodsOne hundred and two patients with high-risk FIGO I – IVA cervical cancer (77 non-elderly [<60 years] and 25 elderly [≥60 years]) were treated by radical hysterectomy with lymphadenectomy (n = 91) and postoperative radiochemotherapy or radical radiochemotherapy alone after laparoscopic lymph node dissection (n = 11) patients received five to six cycles of cis-platin, 40 mg/sqm weekly, given concurrently to pelvic radiotherapy of 45–50.4 Gy in 5–6 weeks. Paraaortic radiotherapy with 45 Gy was performed when laparoscopic staging revealed paraaortic node metastases. Acute morbidity was prospectively scored weekly. Toxicity-related protocol violations (treatment breaks or dose reduction) were related with age, 5-year overall survival (OS) and progression-free survival (PFS) rates.ResultsClinical stages and histologic subtypes were equally distributed. Grade 3/4 leukopenia, anemia, diarrhea and nausea occurred more frequently in the elderly. 16 (22%) non-elderly and 6 (25%) elderly needed a modification of drug dose. 10/77 (13%) non-elderly patients and 11/25 (44%) of the elderly needed an unscheduled treatment break (p = 0.002). OS and PFS were not different between age groups. The 5-year OS rate was 47 ± 6% for non-elderly patients and 45 ± 10% for the elderly. Patients with/without treatment breaks had a 5-year OS rate of 39 ± 11%/48 ± 6%. The 5-year PFS rate is 49 ± 6% for non-elderly patients and 47 ± 11% for the elderly. Patients with/without treatment breaks had a 5-year PFS probability of 50 ± 12%/48 ± 6%. FIGO stage retains its prognostic significance irrespective of age.ConclusionsConcurrent radiochemotherapy caused slightly higher acute toxicity with increasing age. Adjustment of treatment intensity was more frequent in the elderly but did not result in detrimental outcome figures.

Laparoscopic Approach for Correction of Chylous Fistula after Pelvic and Paraaortic Lymphadenectomy

Chylous fistula is an uncommon but challenging complication after lymphadenectomy for treatment of gynecologic cancers. Its presence contributes substantially to increased morbidity and may retard the onset of adjuvant therapies. Treatment options include dietary modifications or surgical intervention. A 68-year-old woman with renal insufficiency developed chylous ascites after pelvic und para-aortic laparoscopic lymph node dissection followed by chemoradiation for treatment of class IIb cervical cancer. Conservative treatment failed, and the patient underwent laparoscopic exploration. The leakage was identified near the cisterna chyle, and was closed with sutures. There was no evidence of recurrence after 2-month follow-up. This case demonstrates successful laparoscopic management of chylous ascites after para-aortic lymphadenectomy and chemoradiation, using suturing.

Re: JSLS(2009)13(4):484–488. Hand-assist Laparoscopic Surgery for the Gynecologic Surgeon

We read with interest the article “Hand-assist laparoscopic surgery for the gynecologic surgeon” by Brothertonet al.1 We agree with their conclusions that hand-assisted laparoscopy is underutilized in gynecology and pelvic surgery despite its potential benefits. However, we were surprised and disappointed by the authors’ failure to acknowledge our extensive seminal contributions on the use of hand-assisted laparoscopy in benign pelvic conditions and gynecologic cancer. All of our work has been published in peer review journals, and in 2004 we also contributed a book chapter on the use of hand-assisted laparoscopy in pelvic surgery.2 The first contribution to the medical literature regarding the use of hand-assisted laparoscopy in gynecology was published by us in 1999.3 That same year, we reported our experience with hand-assisted laparoscopic cholecystectomy for cesarean section.4 In 2000, we reported for the first time the value of hand-assisted laparoscopy for the performance of megamyomectomy.5 The authors quoted 4 papers related to the use of hand-assisted laparoscopy in gynecologic cancer while ignoring the first contribution to the literature on the subject published by us in 2000.6 We were the first to report the value of the technique as an effective and safe method to facilitate the completion of complex oncologic procedures that may otherwise require a lengthy, difficult and risky conventional laparoscopic surgery or conversion to laparotomy. At the time–exactly one decade ago–we had already reported the value of hand-assisted laparoscopy in surgical staging and the value of the hand port to allow a simplified, uncontaminated, and rapid removal of an intact tumor, omentum, and lymph nodes. We also reported the simplicity of hand-assisted omentectomy and lymph node dissection. Brothertonet al1 wrote, “The use of the intraperitoneal hand may provide a minimally invasive alternative for gynecological oncologists not comfortable in laparoscopic lymph node dissection.” The statement is quite similar to the one that we stated a decade ago, “Oncologic surgeons reluctant to adopt conventional laparoscopic surgery may find the hand-assisted approach an appealing minimally access modality.” Sincerely,

Recent Advances in the Surgical Management of Cervical Cancer

Recent advances in the surgical management of early cervical cancer, including abdominal, laparoscopic, vaginal, and robotic approaches to radical hysterectomy as well as fertility-sparing radical trachelectomy, are reviewed. The nerve-sparing abdominal radical hysterectomy technique allows for a significant reduction in postoperative bladder morbidity. Radical vaginal hysterectomy with laparoscopic lymph node dissection is a well-recognized technique that offers excellent cure rates without abdominal entry as well as reduced postoperative febrile and gastrointestinal morbidity. Total laparoscopic radical hysterectomy is a minimally invasive alternative to the traditional abdominal radical hysterectomy approach and yields a comparable safety profile with a significant reduction in blood loss and hospital stay. Robotic surgery is becoming more widely accepted in the management of gynecologic cancers, including radical hysterectomy for early cervical cancer. Young women desiring to bear children in the future may be candidates for fertility preservation options, and the radical trachelectomy operation has been described and performed with abdominal, vaginal, laparoscopic, and robotic techniques. There are a number of surgical options for the treatment of women with early cervical cancer. The feasibility and safety of some of these techniques have been well established, whereas for others, the oncological outcome data are only preliminary. The decision to use newer techniques should be directed by patient variables as well as the surgeon's training and competence with laparoscopy, robotics, or vaginal surgery.

Robot assisted laparoscopic transperitoneal para-aortic lymphadenectomy in the management of advanced cervical carcinoma

Objectives Adequate staging of advanced cervical cancer is essential in order to optimally treat the patient. FIGO clinical staging, imaging techniques such as CT scan, MRI and PET sometimes underestimate the extension of tumors. The presence of para-aortic lymph node metastases in advanced cervical cancer identifies patients with poor prognosis who need to be treated aggressively. Laparoscopic para-aortic lymph node dissection is now proposed as a diagnostic tool in many guidelines. We evaluated the feasibility and safety of a robot assisted laparoscopic transperitoneal approach to para-aortic lymph node dissection. Study design Eight patients with advanced cervical carcinoma who were eligible for primary pelvic radiotherapy combined with concurrent cisplatin chemotherapy or pelvic exenteration underwent a pre-treatment robot assisted transperitoneal laparoscopic para-aortic lymphadenectomy. Results We isolated from 1 to 38 para-aortic nodes per patient and had one para-aortic node positive patient who was treated with extended doses of pelvic radiotherapy. We did not encounter any major complications and post-operative morbidity was low. Conclusions Robot assisted transperitoneal laparoscopic para-aortic lymphadenectomy is feasible and provides the surgeon with greater precision than classical laparoscopy. Larger prospective multicentric trials are needed to validate the generalised usefulness of this technique.

Does extended lymphadenectomy preclude laparoscopic or robot-assisted radical cystectomy in advanced bladder cancer?

Open radical cystectomy with an appropriate bilateral lymph node dissection (LND) is currently the standard treatment for patients with muscle-invasive bladder cancer. Approximately 25% of patients with stages T1-T4 N0 M0 harbour metastatic lymph nodes at the time of radical cystectomy. Results from open high volume radical cystectomy series suggest that a more extended LND provides the best survival outcomes and the lowest local recurrence rates. Currently, there is controversy whether laparoscopic or robot-assisted extended LND at radical cystectomy is technically feasible and whether it can provide oncological control equivalent to open LND series at the time of radical cystectomy. Laparoscopic LND is technically demanding and requires prolonged operation time. Most studies to date indicate that fewer nodes are removed than with an open approach, putting a question mark to this surgical approach from an oncological point of view. Limited data on lymph node yield using a robot-assisted approach are available; however, several series found similar results as in open series. At present, there is no conclusive evidence showing that laparoscopic LND gives similar results than open LND. Robot-assisted LND is still in its learning curve and more patient series are needed.

Évaluation ganglionnaire chirurgicale dans les cancers du col utérin

Lymph-nodal involvement is a major prognostic factor of cervical cancer. Lymph-node status is classically evaluated by lymph-node dissection. This surgical approach has mainly a prognostic interest. The morbidity related to the lymph-node dissection is not nil, so numerous imaging or surgical techniques have been recently developed in order to reduce this morbidity. Currently, even with the progress of the imaging techniques, surgical lymph-node dissection is the standard approach. For the management of early cervical cancer, surgery is usually the sole treatment. In association with a laparoscopic lymph-node dissection, the sentinel node technique is a new approach that gives interesting data: possibility of performing frozen sections on the sentinel nodes in order to improve the management, discovery in an important proportion of cases of abnormal lymphatic pathways that are a potential aetiology of recurrence, and identification of lymph-node micrometastases that seem to be an important independent prognostic factor. In the future, evaluation of only the sentinel nodes may replace the pelvic lymph-node dissection. For advanced cervical cancers, the treatment is based on chemoradiotherapy. The paraaortic lymph-node status is an important prognostic factor that helps for defining the radiotherapy fields. New imaging techniques as PET Scan, may help for the evaluation of paraaortic lymph-node status. If the PET Scan is positive at the paraaortic level, there is no need for paraaortic lymph-node dissection and radiotherapy should be performed with pelvic and abdominal fields. But the false negative rate of the PET Scan is high and laparoscopic paraaortic lymph-node dissection is required in case of negative PET Scan at the paraaortic level.

What technique is suitable for laparoscopic suprapancreatic lymph node dissection?

What technique is suitable for laparoscopic suprapancreatic lymph node dissection?

Significance of Laparoscopic D2 Gastrectomy: Reply to Letter

My co-authors and I are grateful for the interest in our article shown by Dr. Liakakos and colleagues. In it, we reported the safety and accuracy of D2 lymph node dissection—the standard operation for advanced gastric cancer in East Asia—in laparoscopy-assisted distal gastrectomy using early gastric cancer cases, as the first step in operating on advanced gastric cancer [1]. Liakakos et al. [2] make two suggestions and pose one question about our account of laparoscopic gastrectomy and lymph node dissection for gastric cancer. What follows is my response. Their first suggestion is that a randomized control trial (RCT) is needed to test the benefit of laparoscopic gastrectomy. We believe the benefit is short-term quality of life after laparoscopic gastrectomy. However, because we do not have data from long-term follow-up for laparoscopic gastrectomy in treating advanced gastric cancer, we agree that a RCT is needed for the scientific verification of the survival benefit of the procedure. Next, they ask about the efficacy of D2 lymph node dissection. The problems associated with D2 lymph node dissection were demonstrated in RCTs released in 1990 s. Those RCTs concluded that D2 lymph node dissection was associated with a high postoperative morbidity rate and had no survival benefit [3–5]. However, two RCTs released in recent years, both of which were performed by well-trained and experienced surgeons, reported a low postoperative morbidity rate and better survival benefit in D2 lymph node dissection than in D1 lymph node dissection [6, 7]. A RCT performed by the Japan Clinical Oncology Group proved that there is no survival benefit from prophylactic D3 lymph node dissection (para-aortic lymph node dissection), so we should aim to perform D2 lymph node dissection in cases of advanced gastric cancer if curative resection is possible [8]. Finally, Liakakos et al. suggest prophylactic gastrectomy for the genetically high-risk patient. We think this is an interesting idea, but there are associated ethical problems (gastrectomy for patients without cancer or possibility of other modalities). If the ethical questions can be resolved, laparoscopic gastrectomy would be the first recommended modality.

A COMPARISON OF LYMPH NODE DISSECTION IN LAPAROSCOPIC NEPHROURETERECTOMY AND OPEN NEPHROURETERECTOMY FOR TRANSITIONAL CELL CARCINOMA OF THE RENAL PELVIS AND URETER

You have accessJournal of Urology1 Apr 2009A COMPARISON OF LYMPH NODE DISSECTION IN LAPAROSCOPIC NEPHROURETERECTOMY AND OPEN NEPHROURETERECTOMY FOR TRANSITIONAL CELL CARCINOMA OF THE RENAL PELVIS AND URETER Tomonori Komatsu, Ryohei Hattori, Yoshihisa Matsukawa, and Momokazu Gotoh Tomonori KomatsuTomonori Komatsu More articles by this author , Ryohei HattoriRyohei Hattori More articles by this author , Yoshihisa MatsukawaYoshihisa Matsukawa More articles by this author , and Momokazu GotohMomokazu Gotoh More articles by this author View All Author Informationhttps://doi.org/10.1016/S0022-5347(09)60366-9AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail "A COMPARISON OF LYMPH NODE DISSECTION IN LAPAROSCOPIC NEPHROURETERECTOMY AND OPEN NEPHROURETERECTOMY FOR TRANSITIONAL CELL CARCINOMA OF THE RENAL PELVIS AND URETER." The Journal of Urology, 181(4S), p. 128 © 2009 by American Urological AssociationFiguresReferencesRelatedDetails Volume 181Issue 4SApril 2009Page: 128 Advertisement Copyright & Permissions© 2009 by American Urological AssociationMetricsAuthor Information Tomonori Komatsu More articles by this author Ryohei Hattori More articles by this author Yoshihisa Matsukawa More articles by this author Momokazu Gotoh More articles by this author Expand All Advertisement PDF downloadLoading ...

Laparoscopy-Assisted Distal Gastrectomy with D2 Lymph Node Dissection Following Standardization—A Preliminary Study

BackgroundLaparoscopy-assisted distal gastrectomy (LADG) with standard D2 dissection is a complex procedure usually performed only by experienced surgeons, and the feasibility of this procedure still remains unclear. MethodPatients who underwent LADG at the Cancer Institute Hospital between April 2006 and October 2008 were recruited for this study. Early surgical outcomes were compared between patients who underwent complete D2 dissection (complete D2 group; n = 42) and those who underwent D1 + beta dissection (D1 + beta group; n = 179) to determine the feasibility of laparoscopic D2 lymph node dissection. ResultsIn complete D2 group, the operation time was longer (253 ± 10 vs 224 ± 4 min; P = 0.005), and the number of retrieved lymph nodes was larger (41 ± 2 vs 35 ± 1; P = 0.002) compared with those in D1 + beta group. The other early surgical outcomes monitored for the two groups were not different between groups. ConclusionsLADG with complete D2 lymph node dissection can be performed safely if the procedure is standardized and an experienced laparoscopic surgeon performs the surgery. To be accepted as a standard treatment for advanced gastric cancer, well-designed prospective trial is necessary.

Robot-assisted laparoscopic total and partial gastric resection with D2 lymph node dissection for adenocarcinoma

Lymph node dissection and esophageal anastomosis, considered the more demanding steps of laparoscopic gastrectomy for gastric adenocarcinoma, can be performed with the use of a remote-controlled robot. Thirteen patients with a histologically proved gastric cancer (six stage I, six stage II, and one stage III) were enrolled in a prospective study to assess feasibility and safety of the Da Vinci surgical system in total and partial gastrectomy with extended lymph node dissection. Outcome measures were conversion rate, intra- and postoperative morbidity and mortality, operative time, blood loss, number of lymph nodes harvested, and macroscopic and microscopic evaluation of resection margins. Eight distal, four total, and one proximal laparoscopic gastrectomies were completed without conversion. Extended lymph node dissection, and esophagojejunal and esophagogastric anastomoses were successfully carried out using the da Vinci System. Mean operative time was 286 +/- 32.6 min and blood loss was 103 +/- 87.5 ml. Mean number of nodes retrieved was 28.1 +/- 8.3 and all resection margins were negative. There was no mortality. Trocar bleeding requiring laparoscopy was the only major complication encountered. No recurrence occurred during a mean follow-up time of 12.2 +/- 4.5 months. Robot-assisted laparoscopic lymph node dissection and esophageal anastomosis are feasible and safe. Longer follow-up time and randomized studies are needed to evaluate long-term outcome and clinical advantages of this new technology.

Laparoscopic sentinel node dissection for prostate carcinoma: technical and anatomical observations

To report experience with sentinel node (SN) lymphadenectomy which allows an assessment of the exact location of radioactive and of tumour-bearing lymph nodes, and evaluate differences in timing of the scintigraphy and surgery. The study included 35 patients who opted for external beam radiation therapy for prostate carcinoma of intermediate or poor prognosis. Agreement was reached between the participating urologists and the physicians of the nuclear medicine department on the definition of the relevant anatomical areas. The time between a transrectal intraprostatic injection with the radioactive nanocolloid and the laparoscopic SN procedure varied from 5 h to 26 h. Scintigrams were merged with the computed tomography scans until combined methods became available. A laparoscopic gamma-probe was used to identification the SNs, and an extensive laparoscopic node dissection undertaken in the same procedure. Lymph nodes were submitted to the pathologist in such a way that their exact location could be reconstructed. After surgery a graphic report was produced showing the exact location of the lymph nodes. Of the 35 patients 40% were node positive; a mean of 13.5 nodes were resected, and there were no false-negative results. The location of the vast majority of the tumour-positive SNs was around the bifurcation of the external and internal iliac artery, and so involved nodes from the internal iliac, external iliac, communis and obturator basins. Of the six SNs outside the extended node dissection area, two were positive but only one of them exclusively so (lateral to the external iliac artery). The scintigrams did not change after 4 h, and the operation should be done within 24 h to have sufficient radioactivity in the nodes to be detected by the probe. There were eight complications (23%) but only one could be attributed to the SN procedure; the others were thought to be related to the extended laparoscopic node dissection. The laparoscopic SN procedure is a reliable tool for diagnosing prostate cancer-bearing lymph nodes, but the extended laparoscopic node dissection has, in this series and others, too many complications for it to be attractive for diagnostic purposes. The SN procedure makes an extended node dissection unnecessary in most patients.

Results of Bilateral Nerve Sparing Laparoscopic Retroperitoneal Lymph Node Dissection for Testicular Cancer

We evaluated the feasibility and early oncological outcome of a laparoscopic nerve sparing bilateral retroperitoneal lymph node dissection. The surgical technique is described. From July 2004 to December 2007 a total of 42 patients with nonseminomatous germ cell tumor (21 with stage I, 2 with stage IIA marker negative and 19 with post-chemotherapy stage IIB disease) underwent transperitoneal bilateral laparoscopic retroperitoneal lymph node dissection. The sympathetic trunk and postganglionic nerves were identified, and lymphatic tissue was dissected between the nerves. Patients with clinical stage I and IIA disease that was lymph node positive at laparoscopic retroperitoneal lymph node dissection did not receive additional chemotherapy. Surgery was successfully completed in all patients and no conversion to open surgery was necessary. Mean operative time was 323 minutes. No intraoperative complications occurred. Of patients with stage I and marker negative stage IIA disease active tumor was found in 5 retroperitoneal lymph node dissection specimens, and no patients had recurrence. Of 19 patients with post-chemotherapy stage IIB disease teratoma was found in the lymphatic tissue in 4 (21.0%). No retroperitoneal recurrence was observed. Pulmonary metastases developed 9 months after surgery in 1 patient with stage I disease and negative retroperitoneal histology, and were treated successfully. All patients are currently free of disease at a mean followup of 17.2 months. Antegrade ejaculation was preserved in 36 patients (85.7%). Bilateral nerve sparing laparoscopic retroperitoneal lymph node dissection is feasible and associated with low morbidity if performed by experienced hands. The oncological efficacy of this approach is promising and currently under evaluation.

A novel laparoscopic approach for safe and simplified suprapancreatic lymph node dissection of gastric cancer

Lymph node dissection is a crucial procedure for curative resection of gastric cancer [1]. To avoid portal vein injury during laparoscopic extended lymph node dissection for gastric cancer, taping of the common hepatic artery and subsequent confirmation of the portal vein have been recommended [2, 3]. This taping method, however, makes laparoscopic nodal dissection technically complicated. This study introduces a novel procedure for safe and simple laparoscopic suprapancreatic nodal dissection without taping of the common hepatic artery. The authors' novel, simplified method consists of four steps: (1) dissection along the cranial edge of the pancreas from right to left, (2) dissection along the splenic artery with exposure of the left renal fascia, (3) dissection along the left gastric and the common hepatic arteries, and (4) retraction of the lymph nodes surrounding the common and proper hepatic arteries and their complete dissection from the portal vein. This procedure is reversely directed compared with conventional open gastrectomy (i.e., the nodal dissection is from left to right). For this study, the lymph node stations and groups were defined according to the 13th edition of the Japanese Classification for Gastric Carcinoma. The described procedures were performed for 58 consecutive patients with gastric cancer. The indication for this operation is primary T1/T2 gastric cancer without clinical nodal metastasis. In all cases, safely extended suprapancreatic lymph node dissection was successfully accomplished using the described technique. A total of 43.5 +/- 18 lymph nodes were retrieved, including 14.4 +/- 6.3 second-tier lymph nodes. The overall number of retrieved lymph nodes in this study was similar to that reported previously [4]. Postoperative morbidity occurred at a rate of 22.3%, and the mortality rate was 0%. There was no conversion to open surgery. The mean blood loss was 127 ml (range, 0-490 ml), and the mean operative time was 289 min (range, 104-416 min) in the last 20 consecutive cases. To date, no tumor recurrence has been observed. The median postoperative observation period was 1.4 years (range, 0.4-2.4 years). The described novel procedure would be sufficient and convenient for dissection of the suprapancreatic lymph nodes.

Endometriosis entrapment of the obturator nerve after previous cervical cancer surgery

A 26-year-old patient underwent pelvic lymphadenectomy and trachelectomy because of cervical cancer stage IB. Later she developed symptoms from obturator nerve entrapment. Examinations could not reveal metastatic cancer disease, but endometriosis surrounding the obturator nerve was discovered. Laparoscopic removal of the endometriotic tissue surrounding the nerve was performed and the patient's symptoms then disappeared.