Laparoscopic para-aortic lymph node sampling: development of a technique

Clinical staging is woefully inadequate in predicting lymph node metastasis and dictating prudent radiation ports in women undergoing therapy for cervical malignancies. Surgical staging with evaluation of the precaval lymph nodes (via a transperitoneal or extraperitoneal approach) has associated rates of complication that are felt by many clinicians to be excessive. A laparoscopic approach could avoid many of these complications while still obtaining valuable information regarding spread of disease. After experimentation with different forms of laparoscopic approaches in the swine model, we have found an easy and efficient way to visualize and sample the infrarenal precaval lymph nodes. The laparoscope is placed suprapubically, and accessory operating trocars are placed suprapubically and periumbilically. Laparoscopically placed sutures are placed on the incised posterior peritoneum. The sutures exit through the periumbilical trocars. When drawn taut, the sutures pull the peritoneum in a cephalad and ventral fashion so as to act as a tent, retracting the intraperitoneal contents and exposing the precaval area. Using this technique in the swine, we were able to remove 88% of all right-side common iliac and paraaortic nodes laparoscopically without injuring surrounding structures. Evaluation of this technique in humans should be considered.