Editing Retroperitoneal Lymph Node Dissection (section)

== Open RPLND Technique ==

* Videos
**[https://auau.auanet.org/content/v06-03-retroperitoneal-lymph-node-dissection-learning-module-trainees-0 Open transperitoneal RPLND] (Cleveland Clinic, abbreviated)
**[https://www.youtube.com/watch?v=wYj_bT4Igqw Open transperitoneal RPLND] (University of Chicago, abbreviated)
**[https://www.youtube.com/watch?v=P0iVMgY6_i4 Open transperitoneal RPLND] (Tata Memorial Hospital, abbreviated)
**[https://www.youtube.com/watch?v=Oor2NRQT1FE Open extraperitoneal RPLND] (USC, abbreviated)
*'''Position: supine'''
* '''Incision: ventral midline''', from subxiphoid to pubis
* '''Steps after incision (transperitoneal):'''
** '''Enter peritoneal cavity'''
**'''Inspect abdominal viscera'''
** '''Identify and divide the falciform ligament''' to minimize risk of hepatic retraction injury.
** '''Place a self-retaining retractor,''' such as Bookwalter, Thompson, or Wishbone.
**'''Expose retroperitoneum.''' Retract small bowel superiorly. Incise line of Toldt to medialize ascending colon. Make incision in posterior peritoneum from the cecum to the ligament of Treitz (suspensory muscle of duodenum). Medialize duodenum. Place bowel on chest. Place retractor.
**'''Divide ("split") tissue anterior to IVC''' using cautery. Superior aspect of incision is the superior aspect of the left renal vein. Use clips on lymphatic tissue.
**'''Para-caval packet.''' Identify right ureter and reflect it laterally. Identify right renal vein. "Roll" the IVC medially and develop the paracaval packet off the IVC (split and role technique). '''Remove all tissue anterior to the anterior spinous ligament from the right renal vein to the bifurcation of the IVC''' to include the right inguinal nodes. 
***This region is void of sympathetic nerves. 
***With the IVC rolled left, a variable number of lumbar veins (usually 2–3) may be encountered draining the right side. 
****Typically, the right superior lumbar vein (usually of large diameter) will be located near the right reno-caval junction, often superior to the right gonadal vein. 
****Midway along the infrarenal IVC, a smaller lumbar vein may be encountered that has a tendency to drain into the left side of the IVC or form a common trunk with one of the left-sided lumbar veins. 
****Lastly, the right inferior lumbar vein may be encountered draining near the level of the iliocaval confluence.
**Identify the right gonadal vein. If right-sided disease, ligate at its insertion into the IVC. Dissect gonadal vein distally and excise right spermatic cord to internal inguinal ring. If left-sided disease, need to excise left spermatic cord to internal inguinal ring.
**'''Inter-aortocaval packet.''' Use Kitner and Penfield to dissect packet. Remove all retroaortic and retrocaval tissue. 
***Using the split-and-roll technique on the IVC, the plane between the interaortocaval nodal tissue and the caval adventitia can be separated without encountering sympathetic nerves. 
***Lumbar vessels are encountered and may need to be ligated. 
****The left lumbar veins (variable) are often observed draining centrally (i.e., ''between'' the most cranial and caudal right lumbar veins) and into the left side of the IVC. 
****Usually, two left lumbar veins are observed; the largest and most prevalent of which (common lumbar trunk) may be landmarked using the IMA, and often receives multiple left-sided tributaries. 
****The second most common vessel, the left inferior lumbar vein, is located closer to the iliocaval confluence, approximately where the right common iliac artery crosses the IVC.
****If a right inferior lumbar vein was present, the left is typically slightly rostral.
****Once ligated, full control of the lumber veins should be achieved and the IVC can be fully mobilized
***The right gonadal vein may be useful to approximate the location of the right superior lumbar vein (if present) and/or the 2nd pair of lumbar arteries. The IMA may be useful to approximate the location of the common lumbar trunk (if present) and/or the 3rd pair of lumbar arteries[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5412119/].
***Identify post-ganglionic sympathetic nerves. Post-ganglionic sympathetic nerve fibers run posterior to the IVC and anterior to the aorta. With the right sympathetic chain exposed, meticulous dissection should be made anterior to identify the lumbar splanchnic nerves. Usually, there are two lumbar splanchnic nerves joining the infrarenal portion of the aortic plexus, spaced approximately one vertebral level apart. Dissect nerves free from interaortocaval packet.
***Usually three pairs of lumbar arteries are present along the infrarenal abdominal aorta, with the position of the middle pair (3rd lumbar arteries) approximated using the origin of the IMA. Once identified, the adjacent pairs of lumbar arteries can be identified at a distance away equal to one third of the length of the infrarenal abdominal aorta
**'''Divide ("split") tissue anterior to aorta''' using cautery. Superior aspect of incision is the superior aspect of the left renal vein. Use clips on lymphatic tissue. Identify and preserve IMA. To aid dissection, the IMA may be sacrificed if adequate blood supply to the colon is maintained by the marginal artery (of Drummond)
**'''Para-aortic packet.''' Identify left ureter and reflect it laterally. Identify left renal vein. "Roll" the aorta medially and develop the para-aortic packet off the aorta. Identify inferior mesenteric vein. Identify lumbar arteries; strong tendency for paired lumbar arteries to be positioned at similar levels. '''Remove all tissue from the left renal vein to the bifurcation of the aorta''' to include the left inguinal nodes. The packet can be divided above vs. below the inferior mesenteric artery. Identify post-ganglionic sympathetic nerves. Dissect nerves free from para-aortocaval packet.
**Obtain hemostasis.
**Return small bowel to anatomic position.
**Closure.
*'''Postoperative care'''
** Alvimopan
**Low-fat diet POD#2 and maintained for 30 days to reduce risk of chylous ascites