Technical development and results of left extraperitoneal laparoscopic paraaortic lymphadenectomy for cervical cancer

Objective. The aim of this study was to describe the development of our technique for laparoscopic paraaortic lymphadenectomy for cervical cancer and to evaluate the accuracy of the left extraperitoneal route to perform complete paraaortic lymphadenectomy. Methods. A retrospective study of a consecutive series of 44 patients with cervical cancer undergoing laparoscopic paraaortic lymphadenectomy between July 1992 and November 1998 was performed, as well as a comparison of the three routes successively used to perform paraaortic lymphadenectomy: transperitoneal, bilateral extraperitoneal, and left extraperitoneal. Results. The initial choice of surgical access was transperitoneal (n = 9) in 20%, bilateral extraperitoneal(n = 14) in 32%, and left extraperitoneal (n = 21) in 48% of cases. Success rates of laparoscopic paraaortic lymphadenectomy were 78% for the transperitoneal approach, 93% for the bilateral extraperitoneal approach, and 95% for the left extraperitoneal approach. Conversion from extraperitoneal to transperitoneal laparoscopic paraaortic lymphadenectomy, because of a peritoneal tear, was necessary in 3 cases (21.4%) for the bilateral extraperitoneal route and in 3 cases (14.35) for the left extraperitoneal route (P = 0.43). The extent of dissection varied with experience. Systematic paraaortic lymphadenectomy (up to the left renal vein) was performed via the transperitoneal route in 1 case with 19 aortic nodes removed (common iliac nodes excluded) in 160 min, via the bilateral extraperitoneal route in 6 cases with a mean of 16 +/- 2 (range: 14-19) aortic nodes removed in 153 +/- 22 min (range: 130-180), and via the left extraperitoneal route in 12 cases with a mean of 15 +/- 3 (range: 10-19) aortic nodes removed in 119 +/- 14 min (range: 100-150). There were no statistically significant differences in the total number of nodes removed between the two extraperitoneal routes, although the bilateral extraperitoneal route yielded more right-sided aortic nodes (P < 0.01). The operating time was significantly shortened using the left extraperitoneal route (P < 0.05). Conclusion. Systematic paraaortic lymphadenectomy by a left extraperitoneal route is feasible. Information on right-sided aortic nodes can be obtained although the sampling is reduced compared to that of bilateral extraperitoneal route. It provides the advantages related to the use of the extraperitoneal route while reducing manipulations and thus the risk of peritoneal tearing compared to those of the bilateral extraperitoneal route. (C) 2000 Academic Press.