Extraperitoneal laparoscopic para-aortic lymph node dissection.

Extraperitoneal cervical cancer "staging" is considered superior to a transperitoneal approach. We developed an entirely extraperitoneal laparoscopic technique for para-aortic lymph node dissection in a pig model, followed by human subject application. Using latex balloon dissection technology, the technique is as follows. A retroperitoneal space is created via a 15-mm left flank incision. The collapsed balloon trochar is inserted and the balloon is inflated under direct visualization. Subsequently, a CO2 pneumoretroperitoneum is established with 12-15 mm Hg and dissection is carried out using a total of three to four left flank port sites. For initial technique development and improvement, four pigs were used. Excellent bilateral retroperitoneal exposure was achieved. A complete dissection was performed from the renal to the iliac vessels. Subsequently, a bilateral sampling procedure from the level of the inferior mesenteric artery to the liac vessels was performed in four human subjects. A mean of 5 nodes (range 1-9) was removed with an EBL of <50 cc. Operative times were 120-140 min. There were no intra- or postoperative complications. This initial experience demonstrates that laparoscopic extraperitoneal para-aortic access and node sampling is feasible. Further study is ongoing to determine the extent of dissection possible using this approach. However, since this approach mimics the extraperitoneal laparotomy technique, it may have all the advantages of adhesion avoidance combined with an outpatient procedure.