Retroperitoneal Lymph Node Dissection: Difference between revisions

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== Videos ==

*Open

**[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)

*Laparoscopic

** [https://www.youtube.com/watch?v=FYYRkZBdWMg Laparoscopic RPLND] (Dr. Sergey Baydo, full video)

*Robotic

**[https://www.youtube.com/watch?v=mhDHX3Czy3I Robotic RPLND] (Dr. James Porter, full video)

**[https://www.youtube.com/watch?v=d14gOjV8osM Robotic RPLND] (Dr. James Porter, full video)

== Classification of Retroperitoneal Lymph Node Dissection (RPLND) ==

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== Anatomic principles of RPLND[https://pubmed.ncbi.nlm.nih.gov/31059667/] ==

* '''Template'''

* '''Relevant anatomy'''

**'''Lumbar vessels[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5412119/]'''

***See [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5412119/figure/F1/ Figure]

***'''Arteries'''

****'''Four, paired branches'''

*****'''2nd–4th pairs commonly encountered below the level of the left renal vein'''

****'''Regularly spaced'''

***'''Veins'''

****'''Variable, unpaired vessels'''

****'''Preferentially drain into the left-posterior side of the IVC'''

****Positioned at a distance from one another that segmentally increases closer to the iliocaval confluence

**Aortic plexus[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5412119/]

***Supplied by at least two lumbar splanchnic nerves on each side

***Composed of two parallel nerves (cords), each containing two major ganglia

*'''Template'''

** '''Full bilateral template'''

*** '''The boundaries of a full bilateral template include'''

**** '''Superiorly: the crura of the diaphragm''' and skeletonized renal vessels

**** '''Superiorly: the crura of the diaphragm''' '''and skeletonized renal vessels'''

**** '''Inferiorly: the bifurcation of the common iliac arteries/crossing of the ureter over the ipsilateral common iliac artery'''

**** '''Laterally: the ureters'''

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** '''A complete retroaortic and/or retrocaval lymph node dissection with division of lumbar vessels should be performed when within the planned template.'''

** '''The ipsilateral gonadal vessels should be removed in all patients.'''

**

== Open RPLND Technique ==

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**[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'''

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**'''Inspect abdominal viscera'''

** '''Identify and divide the falciform ligament''' to minimize risk of hepatic retraction injury.

** '''Place a self-retaining retractor,''' such as Bookwalter or Wishbone.

** '''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 from the right renal vein to the bifurcation of the IVC''' to include the right inguinal nodes.

**'''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. Lumbar vessels are encountered and may need to be ligated. Identify post-ganglionic sympathetic nerves. Post-ganglionic sympathetic nerve fibers run posterior to the IVC and anterior to the aorta. Dissect nerves free from interaortocaval packet.

**'''Inter-aortocaval packet.''' Use Kitner and Penfield to dissect packet. Remove all retroaortic and retrocaval tissue.

**'''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.

***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.

**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. '''Remove all tissue from the left renal vein to the bifurcation of the aorta''' to include the left inguinal nodes. Identify post-ganglionic sympathetic nerves. Dissect nerves free from para-aortocaval packet.

***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.

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== Minimally Invasive RPLND ==

* Videos

**[https://www.youtube.com/watch?v=FYYRkZBdWMg Laparoscopic RPLND] (Dr. Sergey Baydo, full video)

*'''Rationale and Evolution'''

** Potential advantages of MIS approach vs. open RPLND: decreased blood loss, shorter hospital stays, and faster return to normal activity

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** Approach

*** Most prefer a transperitoneal approach

** Patient positioning and port placement for laparoscopic RPLND (details in Campbell’s)

*** Right-sided dissection

*** Left-side dissection

** Bilateral laparoscopic RPLND

** Robot-assisted RPLND port placement and technique

* '''Postoperative care'''

** The patient may ambulate and resume a liquid diet the night of surgery.

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** '''On the left side, the postganglionic sympathetic fibers are most easily identified at the ganglia as they leave the sympathetic chain and dissect them prospectively as they course anterior to the aorta before joining the hypogastric plexus.'''

** Care should be taken to avoid energy sources such as electrocautery when dissecting nerve fibers

* '''~~Complications~~'''

* '''Adverse Events'''

** Postoperative complication rates of 9-25%

** '''Potential complications include chylous ascites, ileus, lymphocele, nerve injury, pulmonary embolus, Clostridium difficile colitis, retroperitoneal hematoma, and ureteral injury'''

@@ Line 1: / Line 1: @@
+== Videos ==
+*Open
+**[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)
+*Laparoscopic
+** [https://www.youtube.com/watch?v=FYYRkZBdWMg Laparoscopic RPLND] (Dr. Sergey Baydo, full video)
+*Robotic
+**[https://www.youtube.com/watch?v=mhDHX3Czy3I Robotic RPLND] (Dr. James Porter, full video)
+**[https://www.youtube.com/watch?v=d14gOjV8osM Robotic RPLND] (Dr. James Porter, full video)
 == Classification of Retroperitoneal Lymph Node Dissection (RPLND) ==
@@ Line 28: / Line 39: @@
 == Anatomic principles of RPLND[https://pubmed.ncbi.nlm.nih.gov/31059667/] ==
-* '''<span style="color:#ff0000">Template</span>'''
+* '''<span style="color:#ff0000">Relevant anatomy</span>'''
+**'''Lumbar vessels[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5412119/]'''
+***See [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5412119/figure/F1/ Figure]
+***'''Arteries'''
+****'''Four, paired branches'''
+*****'''2nd–4th pairs commonly encountered below the level of the left renal vein'''
+****'''Regularly spaced'''
+***'''Veins'''
+****'''Variable, unpaired vessels'''
+****'''Preferentially drain into the left-posterior side of the IVC'''
+****Positioned at a distance from one another that segmentally increases closer to the iliocaval confluence
+**Aortic plexus[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5412119/]
+***Supplied by at least two lumbar splanchnic nerves on each side
+***Composed of two parallel nerves (cords), each containing two major ganglia
+*'''<span style="color:#ff0000">Template</span>'''
 ** '''<span style="color:#ff0000">Full bilateral template</span>'''
 *** '''<span style="color:#ff0000">The boundaries of a full bilateral template include</span>'''
-**** '''<span style="color:#ff0000">Superiorly: the crura of the diaphragm</span>''' and skeletonized renal vessels
+**** '''<span style="color:#ff0000">Superiorly: the crura of the diaphragm</span>''' '''and skeletonized renal vessels'''
 **** '''<span style="color:#ff0000">Inferiorly: the bifurcation of the common iliac arteries/crossing of the ureter over the ipsilateral common iliac artery</span>'''
 **** '''<span style="color:#ff0000">Laterally: the ureters</span>'''
@@ Line 63: / Line 88: @@
 ** '''A complete retroaortic and/or retrocaval lymph node dissection with division of lumbar vessels should be performed when within the planned template.'''
 ** '''The ipsilateral gonadal vessels should be removed in all patients.'''
+**
 == Open RPLND Technique ==
@@ Line 69: / Line 95: @@
 **[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'''
@@ Line 76: / Line 103: @@
 **'''Inspect abdominal viscera'''
 ** '''Identify and divide the falciform ligament''' to minimize risk of hepatic retraction injury.
-** '''Place a self-retaining retractor,''' such as Bookwalter or Wishbone.
+** '''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 from the right renal vein to the bifurcation of the IVC''' to include the right inguinal nodes.
+**'''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. Lumbar vessels are encountered and may need to be ligated. Identify post-ganglionic sympathetic nerves. Post-ganglionic sympathetic nerve fibers run posterior to the IVC and anterior to the aorta. Dissect nerves free from interaortocaval packet.
+**'''Inter-aortocaval packet.''' Use Kitner and Penfield to dissect packet. Remove all retroaortic and retrocaval tissue.
-**'''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.
+***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.
-**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. '''Remove all tissue from the left renal vein to the bifurcation of the aorta''' to include the left inguinal nodes. Identify post-ganglionic sympathetic nerves. Dissect nerves free from para-aortocaval packet.
+***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.
@@ Line 115: / Line 157: @@
 == Minimally Invasive RPLND ==
-* Videos
-**[https://www.youtube.com/watch?v=FYYRkZBdWMg Laparoscopic RPLND] (Dr. Sergey Baydo, full video)
 *'''Rationale and Evolution'''
 ** Potential advantages of MIS approach vs. open RPLND: decreased blood loss, shorter hospital stays, and faster return to normal activity
@@ Line 133: / Line 173: @@
 ** Approach
 *** Most prefer a transperitoneal approach
-** Patient positioning and port placement for laparoscopic RPLND (details in Campbell’s)
-*** Right-sided dissection
-*** Left-side dissection
-** Bilateral laparoscopic RPLND
-** Robot-assisted RPLND port placement and technique
 * '''Postoperative care'''
 ** The patient may ambulate and resume a liquid diet the night of surgery.
@@ Line 147: / Line 182: @@
 ** '''<span style="color:#ff0000">On the left side, the postganglionic sympathetic fibers are most easily identified at the ganglia as they leave the sympathetic chain</span> and dissect them prospectively as they course anterior to the aorta before joining the hypogastric plexus.'''
 ** Care should be taken to avoid energy sources such as electrocautery when dissecting nerve fibers
-* '''<span style="color:#ff0000">Complications</span>'''
+* '''<span style="color:#ff0000">Adverse Events</span>'''
 ** Postoperative complication rates of 9-25%
 ** '''Potential complications include chylous ascites, ileus, lymphocele, nerve injury, pulmonary embolus, Clostridium difficile colitis, retroperitoneal hematoma, and ureteral injury'''