SURGICAL ANATOMY OF RETROPERITONEUM AND LYMPHADENECTOMY

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1 SURGICAL ANATOMY OF RETROPERITONEUM AND LYMPHADENECTOMY P. De Iaco S.Orsola-Malpighi Hospital - Bologna Unit Oncological Gynecology

2 PELVIC AND AORTIC LYMPH NODE METASTASIS IN EPITHELIEL OVARIAN CANCER Pereira A, Gynecologic Oncology 2007

3 NODAL INVOLVEMENT IN UNILATERAL EPITHELIAL OVARIAN CANCER : Initially the lymphatic spread is ipsilateral Controlateral nodal involvement in stage IA occurs in 30% of patients Pereira A, Gynecologic Oncology 2007

4 PROGRESSION FREE SURVIVAL AND OVERALL SURVIVAL IN OVARIAN CANCER Benedetti Panici, 2005

5 ROUTES OF LYMPH FLOW Ovarian Cancer Endometrial cancer Cervical cancer ENDOMETRIAL CANCER OVARIAN CANCER CERVICAL CANCER C. Alboni,2005

6 NODAL SIZE RELATED TO THE PRESENCE OF METASTATIC DISEASE Pereira A, Gynecologic Oncology 2007

7 PARAORTIC LYMPH NODE are the lymph nodes of a normal adult body >250 of them are located in the abdomen and pelvis About 81 lymph nodes are distributed between: the pelvis (50) the aortic area (31) Node Group Mediam Range Paracaval Precaval Retrocaval Intercavoaortic superficial Intercavoaortic deep Preaortic Paraaortic Retroaortic Benedetti-Panici, 1992

8 AREA Paracaval Precaval Retrocaval Intercavo-aortic deep Intercavo-aortic superficial Para-aortic Pre-aortic Retro-aortic

9 PARAORTIC LYMPH NODE AREA Paracaval

10 PARAORTIC LYMPH NODE AREA Paracaval Precaval

11 PARAORTIC LYMPH NODE AREA Paracaval Precaval Retrocaval

12 PARAORTIC LYMPH NODE AREA Paracaval Precaval Retrocaval Inter-cavo-aortic deep Inter-cavo-aortic superficial

13 PARAORTIC LYMPH NODE AREA Paracaval Precaval Retrocaval Inter cavoaortic deep Inter cavoaortic superficial Pre-aortic

14 PARAORTIC LYMPH NODE AREA Paracaval Precaval Retrocaval Inter cavoaortic deep Inter cavoaortic superficial Pre-aortic Para-aortic

15 PARAORTIC LYMPH NODE AREA Paracaval Precaval Retrocaval Inter cavoaortic deep Inter cavoaortic superficial Pre-aortic Para-aortic Retro-aortic

16 SURGICAL APPROAC TO THE RETROPERITONEUM: LOMBOAORTIC LYMPHADENECTOMY Paracaval Intercavo-aortic Para-aortic

17 Dissection SURGICAL TECHNIQUE

18 SURGICAL TECHNIQUE Ascending colon Dissections of the mesentery Retroperitoneal exposure C. Alboni,2005

19 SURGICAL APPROAC TO THE RETROPERITONEUM: LOMBOAORTIC LYMPHADENECTOMY Paracaval Intercavo-aortic Para-aortic

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22 Autonomic nerves

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25 SURGICAL APPROAC TO THE RETROPERITONEUM: LOMBOAORTIC LYMPHADENECTOMY Paracaval Intercavo-aortic Para-aortic

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27 ANATOMY OF THE INFERIOR VENA CAVA, THE COMMON ILLIAC C. Alboni,2005 Jason, et al

28 LUMBAR VEIN ANOMALIES C. Alboni,2005 Lumbar vein entering in left gonadal vein Lumbar and gonadal vein entering in left renal vein at same point Lumbar vein entering in left renal vein from posterior wall Lumbar vein entering in left renal vein from anterior wall

29 VENTRAL TRIBUTARIES OF INFRARENAL VENA CAVA NO tributaries in 21.5% of patients In patient WITH tributaries: in level in level in level 3 Possover M, Am J Obstet Gynecol 1998

30 In 58% of patients examined in our series tributaries flow into the inferior vena cava in level 1 with an average of vessels. Concomitantly, the surgeon finds other tributaries in level 2 in 9.8% of patients. If no tributaries are in level 1, tributaries in level 2 occur in approximately 10% of patients. Possover M, Am J Obstet Gynecol 1998

31 SURGICAL APPROAC TO THE RETROPERITONEUM: LOMBOAORTIC LYMPHADENECTOMY Paracaval Intercavo-aortic Para-aortic

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34 Thank you

35 VASCULAR ANOMALIES Incidence % Sample General population Left-sides IVC Retro-aortic left renal vein Right gonadal draining to right renal vein Left gonadal draining to IVC Pre-caval right renal artery Benedetti Panici, 1994

36 OVARIAN VEIN ANOMALIES Sometimes (1,3%) right ovarian vein can join renal vein. C. Alboni,2005 Benedetti Panici, 1994

37 OVARIAN VEIN ANOMALIES Ovarian vein in quite rare number of patients (0,3%), could enter in cava above the level of renal vessels. C. Alboni,2005 Benedetti Panici, 1994

38 RENAL VEIN ANOMALIES Circum-aortic renal vein. C. Alboni,2005

39 RENAL ARTERY ANOMALIES A right renal lower polar artery could be observed in around 2% of patient. Usually it crosses caval vein frontally. This anomalous vessel can be ligated with no postoperative sequelae if accidentally damaged during surgery. C. Alboni,2005

40 POST-CHEMOTHERAPY LYMPH NODE DISSECTION: MORBILITY A subadventitial plane of dissection can be obtained leading to devastating consequences Control of the proximal and distal aorta should be obtained before resecting new or residual aortic masses Chylous ascites may develop postoperatively Higher percentage of ascites if repeated dissection of the retroperitoneal space Perioperative mortality is 0.8% to 1% for post-chemotherapy lymph node dissection Perioperative mortality is 0% to 10% for repeated retroperitoneal lymph node dissection Sexton WJ, The Journal of Urology 2003