Where Are Ovaries Compared To Iliac Crest

Figure 7

A stapler is used to transect the round ligament, ovarian ligament and fallopian tube

Figure 7

A stapler is used to transect the round ligament, ovarian ligament and fallopian tube

Figure 8

The anterior leaf of the broad ligament is dissected

Omentectomy

Introduction

Omentum frequently is involved with metastatic lesions whenever there is intra-abdominal spread of cancer. Omentectomy is part of the staging of ovarian cancer and is often performed in treating or staging other gynecologic cancers such as uterine papillary serous adenocarcinoma.

Staging For Ovarian Cancer

Figure 9

Hydrodessication of the bladder

Ovaries Attached Bowel

Figure 10

Uterine vessel dessication

Anatomic considerations

The grater omentum is a fatty apron attached to the transverse colon and draped over coils of the small intestine. It is attached along the first part of the duodenum; its left border is continuous with the gastrolienal ligament. If it is lifted and turned back over the stomach and liver, it can be seen to adhere to the transverse colon along the latter's whole length across the abdomen.

The omentum receives its blood supply from the gastro-omental arcade which is formed by the anastomosis of the left (a branch of the splenic artery) and right (a branch of the gastroduodenal artery) gastro-omental arteries.

Gastrolienal Ligament

Figure 11

The cardinal and uterosacral ligaments are electrodessicated

Operative procedure

1. Patient position and trocar placement: the patient should be lying flat or in a slightly reversed Trendelenburg position for better access to the omentum. Primary and secondary trocar placement is similar to that described for appendectomy. Although stapling or bipolar electrodesiccation can be used for hemostasis of the omental vasculature, the harmonic scalpel is preferable because of its unique advantages of reducing both tissue damage and smoke plume production.

2. The omentum is elevated using two atraumatic grasping forceps introduced through the 5 mm trocar sleeves. After exposure of the omentum and assessment of its relation to the transverse colon, a harmonic scalpel is introduced through the midline trocar and the omentectomy is started from the middle or the hepatic flexure, proceeding towards the splenic flexure at the line of reflection onto the transverse colon. Attention should be paid to avoiding injury to the colon and its mesentery and the short gastric vascular cascades (Figures 25 and 26), especially if the anatomy has been distorted by the tumor deposit or adhesions.

3. After the omentum has been detached it can be extracted from the abdominal cavity in different ways. Following laparoscopic or laparoscopically assisted vaginal hysterectomy, it can be extracted through the vagina either directly or after placing it in a bag. Alternatively, the omentum can be removed through a 12 mm trocar sleeve or an enlarged anterior abdominal trocar site after enclosure in an endoscopic bag.

Before termination of the procedure, hemostasis should be assured by decreasing the pneumoperitoneum pressure and evaluating the site of the resection (Figure 27). Individual bleeding sites can be treated with bipolar electrocoagulation, application of clips or suture techniques.

Figure 12

Performing posterior culdotomy

Palliative end colostomy Introduction

In palliative end colostomy the fecal stream is diverted above the rectum. End sigmoid colostomy with a Hartmann pouch or distal exteriorization of the distal portion of the rectosigmoid colon as a fistula in lieu of the Hartmann pouch may be utilized. Palliative end sigmoid colostomy with the Hartmann pouch is most frequently employed in gynecologic oncology when permanent diversion is required.

Indications

Palliative end colostomy in gynecologic oncology is required when the distal bowel has been removed or is permanently unusable, as in the case of non-resectable pelvic tumor causing rectosigmoid obstruction or irreparable fistula caused by tumor or radiation necrosis.

Low Anterior Rectosigmoid Resection

Figure 13

Anterior culdotomy

Anatomic considerations

The blood supply of the entire large intestine comes from the superior and inferior mesenteric arteries, with the former mainly supplying the midgut-derived right and transverse colon whereas the latter supplies the hindgut-derived left colon. The marginal artery of Drummond serves to connect the vascular territories of the two arteries.

The inferior mesenteric artery (IMA) arises from the dorsal side of the aorta often to the left at the level of L3, about 3-4 cm proximal to the bifurcation of aorta. After veering to the left it gives off the left colic artery which divides into ascending and descending branches. The sigmoid colon is supplied by two to four arteries. The first one, which is the largest, comes from the left colic artery (30% of cases) or the IMA. From this first sigmoid vessel, second or third vessels may originate, or may arise directly from the IMA. As the IMA enters the pelvis, it becomes the superior rectal (hemorrhoidal) artery.

Venous and lymphatic drainage of the large intestine follows the general pattern of the arterial supply.

Operative procedure

1. Patient position and trocar placement: the patient is placed in a supine position or slightly turned toward the right side. A principal intraumbilical trocar for video laparoscopy is inserted, with three or four other trocars for introduction of the ancillary instruments (Figure 28). Two trocars are placed on the left side: one 12 mm trocar between the umbilicus and iliac crest for introduction of a Babcock clamp or linear stapling device, and one 5 mm trocar at the level of the iliac crest for introduction of a grasping forceps. One 12 mm midline trocar is placed 5 cm above the symphysis pubis for introduction of the stapler, clip applier, scissors or harmonic scalpel, and one 5 mm trocar on the right side at the level of the iliac crest for introduction of a grasping forceps (Figure 28).

Detachment Right Iliac Crest

Figure 14

Detachment of uterus

2. After thorough evaluation of the abdominal and pelvic cavity the sigmoid colon is identified and mobilized from its attachment to the pelvic side wall. By means of a Babcock grasping forceps introduced through the left trocar incision, the sigmoid colon is elevated. Electrosurgery, a harmonic scalpel or a stapling device is used to divide the mesentery of the sigmoid colon and a window is made. Vascularity of the proximal end of the bowel should not be compromised. While the bowel is elevated with the Babcock clamp, a laparoscopic linear stapling cutter introduced through the left lower quadrant trocar is passed across the bowel, which is then divided (Figures 29 and 30).

3. After removal of the left lower quadrant trocar cannula, a disk of the subcutaneous fat at this site is incised and removed in preparation for location of the stoma. The fascia is incised and is enlarged using two fingers. Under direct laparoscopic visualization, a Babcock clamp is introduced through the left quadrant incision and the proximal portion of the sigmoid colon is grabbed and brought out through the incision (Figure 31).

4. The stapled end of the proximal colon is removed and a 'rosebud' stitch is used to evert the colon onto the skin, creating the stoma (Figure 32). Laparoscopically the serosa of the sigmoid colon is sutured to the peritoneum for prevention of internal hernia, using 2-0 polyglactin.

Lymphadenectomy Introduction

Since the initial descriptions of laparoscopic pelvic and para-aortic lymphadenectomy in the late 1980s and early 1990s, numerous reports have verified the feasibility and safety of this technique. Its advocates point to the better magnification, fewer complications and superior visualization of the anatomy of blood vessels and lymph nodes provided by the video laparoscope in comparison with conventional techniques. In the

Cervical Lymphadenectomy Anatomy

Figure 15

The uterus is removed transvaginally hands of the experienced laparoscopist the efficacy of laparoscopic lymphadenectomy is equal to—if not better than—that achieved during laparotomy, with fewer complications.

Indications

Laparoscopic lymph node resection is performed as part of the treatment of cervical cancer, and node sampling is performed as part of the staging for endometrial or ovarian cancer.

Anatomic considerations

Para-aortic nodes

The landmarks which should be kept in mind for paraaortic lymphadenectomies (Figure 33) are as follows, from right to left:

• right ureter, which is medial to the psoas muscle, lateral to the inferior vena cava and crosses the bifurcation of the common iliac artery

• vena cava (which is lateral to the aorta)

• aorta and both common iliac arteries

Figure 16

The vaginal cuff is closed in the middle

• below the bifurcation of the aorta superficially is the superior hypogastric nerve plexus and beneath it is the left common iliac vein crossing from the left to the right

• on the left side of the aorta are the inferior mesenteric artery, the ureter, sigmoid colon and its mesentery; the lumbar veins and artery are deep and can be seen after left lymphadenectomy

• on the far left is the left psoas muscle.

Pelvic nodes

The important landmarks for pelvic lymphadenectomy (Figure 34) are:

• laterally, the psoas muscle, the genitofemoral nerve, and the external iliac artery and vein

• distally, the deep circumflex vein, superior pubic ramus, and obturator internus fascia

• proximally, the common iliac bifurcation and bowel

• anteriorly, paravesical space, obturator nerve and superior vesical artery

• medially, the anterior division of the hypogastric artery and the ureter and paravesical space

• inferiorly, the sacral plexus, hypogastric vein, and pararectal space.

Operative procedure

Para-aortic lymphadenectomy

The room set-up, the patient's position, and the equipment may require minor variations. This includes additional 5 mm or 10 mm trocars and positioning the video monitor at the head of the operating table, or using two monitors, one on each side of the patient —one for the surgeon's view and the other for the

Figure 17

Final appearance assistant's. The surgeon can stand on the right or left side of the patient, although some prefer to stand between the patient's legs. Besides the umbilical port, three to four additional ports are necessary for introduction of the grasping forceps, scissors, and clip applier or bipolar electrocoagulator. The location of the ancillary trocars is adjusted according to the surgeon's preference. The patient is rotated to the left side for better exposure of the para-aortic area.

After insertion of the ancillary instruments and evaluation of the para-aortic area, the aorta is identified under the peritoneum up to the level of the mesenteric root. An incision is made over the posterior peritoneum at the level of the aortic bifurcation and extended towards the right iliac artery. The peritoneal incision is extended to the root of the mesenteric artery and, in the case of ovarian cancer, to the root of the left renal vein. Using two atraumatic grasping forceps, the peritoneum on each side is lifted and retracted laterally. Using blunt and occasionally sharp dissection with the tip of the suction irrigator or scissors, the retroperitoneal fatty tissue is dissected and the retroperitoneal vessels are identified (Figure 35).

For left para-aortic lymphadenectomy the rectosigmoid colon is retracted laterally and, after identification of the inferior mesenteric artery and ureter, the nodal packet lateral to the aorta and above the left common iliac artery is resected using blunt and occasionally sharp dissection. Careful attention should be paid to avoid injury to lumbar vessels, the left common iliac vein, left ureter and inferior mesenteric artery. For ovarian cancer staging, the lymphadenectomy can be extended to the level of the left renal vein (Figures 36 and 37).

For resection of the paracaval nodes, the right ureter is identified and, while gentle traction is applied using atraumatic grasping forceps, the peritoneum and the ureter are retracted laterally over the psoas muscle. The nodal packet attached to the right common iliac artery is dissected off the vessels using blunt and occasionally sharp dissection. Using a laparoscopic Babcock clamp, the nodal packet is elevated and, using blunt and sharp dissection, the nodal packet is removed from the inferior vena cava. Care must be taken to avoid injury to the perforator veins. Clips or bipolar electrodesiccation can be used for achieving hemostasis. The level of the paracaval lymphadenectomy can be extended to the level of the right ovarian

Lymphadenectomy Pelvic

Figure 18

The cul-de-sac peritoneum is incised laparoscopically

Figure 19

The vesicouterine ligament is dissected vein and, at times, the ovarian vein can be clipped and dissected for a better approach to the nodal packet in this area (see Figure 37).

Figure 20

The paravesical space is developed

Figure 21

The uterine artery is identified and electrodessicated

Pelvic lymphadenectomy

Besides the primary intraumbilical trocar which is used for introduction of the video laparoscope, two ancillary 5 mm ports in the right and the left lower quadrants lateral to the inferior epigastric vessels at the level of the iliac crest and an additional 10mm port in the midline 5 cm above the symphysis pubis are required. The lymphadenectomy may be performed either before or after hysterectomy. The procedure begins with an incision of the peritoneum between the round and infundibulopelvic ligaments, parallel to

Uterine Artery Ascending Branch

Figure 22

The uterine artery is transected

Parametrium

Figure 23

The parametrium is freed the axis of the external iliac vessels (Figure 38). The round ligament is electrodesiccated and cut, the broad ligament between the round and the infundibulopelvic ligament is opened, and the psoas muscle, genitofemoral nerve, iliac vessels, and ureter are identified. Next the paravesical space is entered and widened by blunt dissection between the umbilical artery medially and external iliac vessels laterally. Caution should be exercised to avoid injuries to the external iliac vein and aberrant obturator veins (Figures 39 and 40).

The fat and the lymphatic pad between the psoas muscle and external iliac artery are elevated, dissected, and removed distally and proximally towards the circumflex vein and common iliac artery respectively. The nodal packet below the external iliac vein is grasped medially and, using blunt dissection, separated from the vein. While gentle traction is applied on the nodal packet medially, the obturator nerve is identified

Cervix Equino

Figure 24

The dissection is taken to 2-3 cm below the cervix

Figure 25

1 Omentum is under the stretch

2 Transverse colon

3 Small bowel

4 Omentectomy is started from the hepatic flexure inferiorly and the obturator nodal packet is dissected and removed from the obturator nerve up to the level of the bifurcation of the external iliac artery; care is taken to avoid the hypogastric vein which often comes directly up from the pelvic floor. Inferiorly the nodal packet is removed at the level where the obturator nerve exits from the pelvis. The fatty and nodal tissue between the obturator nerve and the external iliac vein is grasped and thoroughly separated from the pelvic wall by blunt dissection using the suction irrigator or the closed tip of the grasping forceps. Clips can be applied before the removal of the nodal tissue. After removal, the pelvic bone and internal obturator muscle can be seen.

The lymphatic nodal package of the hypogastric artery is grasped and gently separated using blunt dissection from the external and internal iliac artery to the level of the division of the common iliac artery. Interiliac nodes between the external iliac artery and vein are removed (Figure 41).

Figure 27

1 Omentum being elevated for exposure of transverse colo

2 Harmonic scalpel

3 Transverse colon

4 Splenic flexure and part of omentum

Figure 27

1 Omentum being elevated for exposure of transverse colo

2 Harmonic scalpel

3 Transverse colon

4 Splenic flexure and part of omentum

Figure 26

1 Grasping forceps elevate the omentum

2 Harmonic scalpel

3 Segment of detached omentum

4 Transverse colon

At the end of the procedure, the nodal package is removed through the trocar using a Babcock clamp or after placement inside the laparoscopic bag, and the area is thoroughly irrigated. Pneumoperitoneal pressure is decreased for evaluation of hemostasis; the peritoneum is not closed, and no retroperitoneal drain is applied.

Figure 28

Portals for trocars

References

Childers J, Surwit E, Tran A, Hatch K (1993) Laparoscopic para-aortic lymphadenectomy in gynecologic malignancies, Obstet Gynecol 82:741-7.

Dargent D, Mathevet P (1992) Hystérectomie élargie laparoscopico-vaginale, J Gynecol Obstet Biol Reprod 21: 709-10.

Leahy PF (1989) Technique of laparoscopic appendectomy, Br J Surg 76:616.

Morrow CP, Curtin JP (1996) Surgical anatomy. In: Morrow CP, Curtin JP, Osa EL, editors, Gynecologic cancer surgery, Edinburgh: Churchill Livingstone, 67-139, 181-268. Nezhat C, Nezhat F (1991) Incidental appendectomy during videolaseroscopy, Am J Obstet Gynecol 165: 559-64. Nezhat C, Nezhat F, Silfen SL (1990) Laparoscopic hysterectomy and bilateral salpingo-ophorectomy using multifire

GIA surgical stapler, J Gynecol Surg 6:287. Nezhat C, Nezhat F, Gordon S et al (1992) Laparoscopic versus abdominal hysterectomy , J Reprod Med 37:247-50. Nezhat C, Siegler A, Nezhat F et al (2000) The role of laparoscopy in the management of gynecologic malignancy. In: Nezhat C, Nezhat F, Luciano A, editors, Operative gynecologic laparoscopy principles and techniques, second edition, New York: McGraw-Hill, 301-27. Piver MA, Rutledge FN, Smith JP (1974) Five classes of extended hysterectomy for women with cervical cancer, Obstet Gynecol 44:265-70.

Querleu D, Leblanc E (1991) Laparoscopic pelvic lymphadenectomy in the staging of early carcinoma of the cervix, Am J Obstet Gynecol 164:579-81.

Figure 29

A linear stapling cutter is used to divide the bowel

Figure 30

Division of the bowel

Laminectomy Surgery
Figure 32

The serosa of the sigmoid colon is sutured to the peritoneum

Anatomy Cervix Intestine

Figure 33

Retroperitoneal anatomy during para-aortic lymphadenectomy

Figure 33

Retroperitoneal anatomy during para-aortic lymphadenectomy

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