The grasping forceps is in the surgeon��s left hand through the midline suprapubic port and the coagulating instrument is in the surgeon��s right hand through the left lower quadrant port. The viewing monitor is placed on the www.selleckchem.com/products/Imatinib-Mesylate.html patient��s right side at the level of the right shoulder. The procedure starts with an incision along the peritoneal surface over the lower aspect of the aorta and vena cava. Please note that the incision must be made medial to the reflection of the right ureter. The patient��s lower extremities are located on the left side of the screen and the right side of the patient is on the top of the screen. Once a fenestration is made on the peritoneal surface, the grasper is used to lift the peritoneum. The incision is extended inferiorly and superiorly while placing gentle upward traction on the peritoneal surface.
Once the peritoneum has been incised, the surgeon should identify the right psoas muscle, which can be easily found lateral to the lymph node bundle overlying the inferior vena cava. The lymph node bundle is then grasped with atraumatic grasper and the pedicles are developed, coagulated, and transected. Dissection is then continued along the entire surface of the inferior vena cava to the level of the reflection of the duodenum. Once the lymphadenectomy over the inferior vena cava has been completed, the dissection is then performed over the surface of the aorta, inferior to the level of the inferior mesenteric artery. The dissection is extended to the level immediately below the aortic bifurcation to remove the lymph nodes over the left common iliac vein.
At this time attention is focused on the left para-aortic lymph nodes. Please note that this dissection is performed without changing either the position of the surgeon or the position of the instrumentation. The assistant should apply gentle traction on the left border of the peritoneum to expose and highlight the inferior mesenteric artery. Dissection is then performed over the aorta superior to the inferior mesenteric artery to the level of the left renal vein. Additional lymph nodes are removed above the inferior mesenteric artery and below the left renal vein. Care must be taken not to injure the ascending lumbar veins and the hemiazygous vein as these often drain into the lower border of the left renal vein (Figure 2).
Figure 2 Situs after finishing infrarenal paraaortic lymphadenectomy in a patient with complete lymph node debulking: AV-951 (1) Vena ovarica dextra; (2) vena cava; (3) aorta; (4) arteria mesenterica inferior; (5) vena renalis sinistra. Reprinted from Gynecologic Oncology, … Surgical Technique: Extraperitoneal Laparoscopic Para-Aortic Lymphadenectomy The patient should be positioned supine without tucking the arms. Trendelenburg position is not necessary. The surgeon should ensure that the abdomen and the left flank are prepared. The operating surgeon should stand on the patient��s left side.