经腹淋巴结切除术在妇科肿瘤中心的应用:腹腔镜下盆腔和(或)主动脉旁经腹淋巴结切除术的650例分析

Lymphadenectomy is an integral part of staging and treatment of gynecologic malignancies.We evaluated the feasibility and oncologic value of l aparoscopic transperi-toneal pelvic and paraaortic lymphadenectomy in correla-tion to complication rate and body ma ss index.Between August 1994and September 2003,pelv ic and /or paraaortic transperitoneal laparo scopic lymphadenectomy was performed in 650patients at the D epartment of Gy-necology of the Friedrich -Schiller University of Jena.Retrospective and prospective data collection and evalua-tion of videotapeswere possible in 606patients.Laparo-scopic lymphadenectomy was part of t he following surgi-cal procedures:staging laparoscop y in patientswith ad-vanced cervical cancer(n =133)or early ovarian cancer(n =44),trachelectomy in patients with early cervical cancer(n =42),laparoscopic -assisted radical vaginal hysterectomy in patients with cervical cancer(n =221),laparoscopy before exenteration in patients with pelvic re-currence(n =20),laparoscopic -assisted vaginal hys-terectomy or laparoscopic -assiste d radical vaginal hys-terectomy in patients with endometr ial cancer(n =112),and operative procedures for other i ndications(n =34).After a learning period of approxima tely 20procedures,a constant number of pelvic lymph nodes(16.9-21.9)was removed over the years.Pelvic lymphadenectomy took 28min,and parametric lymphadenectom y took 18min for each side.The number of removed para aortic lymph nodes increased continuously over the yea rs from 5.5to 18.5.Right -sided paraaortic,left -sided inframesenteric and left -sided infrarenal lymphadenec tomy took an average of36,28,and 62min,respectively.The number of removed lymph nodeswas independent from the body mass index of the patient.Duration of pelvic lymp hadenectomywas inde-pendent of body mass index,but right -sided paraaortic lymphadenectomy lasted significan tly longer in obese women(35vs.41min,P =0,011).The overall com-plication rate was 8.7%with 2.9%int raoperative(vessel or bowel injury)and 5.8%postoperative complicatio ns.No major intraoperative complicati on was encountered during the last 5years of the study.B y transperitoneal laparoscopic lymphadenectomy,an a dequate number of lymph nodes can be removed in an adequate time and independent from body mass index.The complication rate is low and can be minimized by standardization of theprocedure.

通过腹腔镜检出妇科恶性肿瘤患者的主动脉旁脉管病变

Paraaortic infrarenal lymphadenectomy is indicated in patients with gynecologic tumors of high metastasising potential and can be done successfully by laparoscopic approach. Vascular anomalies in this region are incidental findings during these approaches and may increase the surgical complication rate. In this study, we have documented the frequency and pattern of the vascular anomalies in paraaortic region intraoperatively and on cadavers in an attempt to increase surgical safety. A total of 86 consecutive patients underwent laparoscopic infrarenal paraaortic lymphadenectomy by a standardised technique between 1st of January 2002 and 1st of March 2004. Of the 86, 52 were primary cervical, 5 recurrent cervical, 14 endometrial, 14 early ovarian and 1 vulvar tumor with positive groin and pelvic lymph nodes. In the same time, anatomical dissections of the paraaortic region on 18 cadavers were performed at the Institute of Anatomy. Arterial or venous abnormalities were identified in 30.2% (26/86) of patients by laparoscopy. The most frequent anomalies were related to atypical renal arteries (pole arteries- 9 patients) and an abnormal course of lumbar veins directly draining in the left renal vein (15 patients). In one of the patients, the complete left renal vein went retroaortic to the inferior vena cava. In cadaveric dissections, vascular anomalies were noted in 44.4% (8/18) which included variations in renal and lumbar vessels and ovarian vessels. Duplicated inferior vena cava was the least common anomaly and was detected in only one case. During laparoscopic paraaortic inframesenteric and infrarenal lymphadenectomy, care must be taken because of possible abnormalities in arterially and venous system to avoid massive hemorrhage, transfusion and conversion to laparotomy.

根治性子宫颈切除术是否影响子宫血液供应

Radical trachelectomy in combination with pelvic and parametric lymphadenectomy is indicated in young patients with early cervical cancer and planned pregnancy. If pregnancy occurs, premature delivery is a known problem in these patients. We evaluated if uterine blood supply is decreased after radical trachelectomy as one of various possible causes of preterm birth. Between October 2003 and April 2004, 14 consecutive patients with early cervical cancer underwent radical trachelectomy with pelvic and parametric lymphadenectomy. The uterine blood supply was measured as resistance index (RI) by Doppler sonography pre- and postoperatively. Doppler sonography of the uterine artery was also performed in 14 healthy students as a control cohort. Fourteen patients with histologically confirmed adenocarcinoma or squamous carcinoma of the cervix uteri stage Ia1 L1 to 1b1 underwent radical trachelectomy. Mean age of patients was 33.4 years (31- 37). On average, 11.5 mm (5- 23) of cervical length and 24.6 (14- 35) tumor- free lymph nodes were removed. Decrease of RI of the uterine artery was 0.06 on the right side (0.76- 0.70) and 0.07 (0.75- 0.68) on the left side. The absolute RI values after radical trachelectomy were not different compared to the values in the control group (0.76 versus 0.70 right side, 0.74 versus 0.68 left side). Uterine perfusion after radical trachelectomy with pelvic and parametric lymphadenectomy remains unchanged.