ATLAS OF PROCEDURES IN SURGICAL ONCOLOGY WITH CRITICAL,EVIDENCE-BASED COMMENTARY NOTES
ATLAS OF PROCEDURES IN SURGICAL ONCOLOGY WITH CRITICAL,EVIDENCE-BASED COMMENTARY NOTES
Editor
Riccardo A Audisio Whiston Hospital, University of Liverpool, UK
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Library of Congress Cataloging-in-Publication Data Atlas of procedures in surgical oncology with critical, evidence-based commentary notes (with DVD-ROM) / editor, Riccardo A. Audisio. p. ; cm. Includes bibliographical references and index. ISBN-13: 978-981-283-293-1 (hardcover : alk. paper) ISBN-10: 981-283-293-9 (hardcover : alk. paper) 1. Cancer--Surgery--Atlases. I. Audisio, Riccardo A. [DNLM: 1. Neoplasms--surgery--Atlases. QZ 17 A88046 2009] RD651.A765 2009 616.99'4059--dc22 2009011129
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Foreword
THE IMPORTANCE OF SURGICAL TECHNIQUE IN SURGICAL ONCOLOGY Quality surgery is crucial for the management of all solid malignant tumours. A multidisciplinary approach is accepted and therefore chemotherapy and radiotherapy will contribute enormously to a satisfactory outcome. However, very few studies have demonstrated that these or other modalities will correct for inadequate excisional surgery. Surgeons must have a leadership role in multidisciplinary care so that possibilities, but also limitations, of non surgical treatments will be evaluated before a major resection is undertaken. Surgeons have four major responsibilities in dealing with cancers. The cancer should be removed with a clear margin of excision to avoid local recurrence, which can be devastating. The surgeon must excise draining lymph nodes which will improve prognosis but also determine whether adjuvant therapy is required. Thirdly, it is essential to achieve these aims with a low morbidity and mortality. Accordingly, careful and fastidious technique in excision and reconstruction is paramount. Finally, the surgeon must be cognisant of the need for good cosmetic results to improve the quality of life. These procedures should be well documented so that the surgeon can review the results of short- and long-term outcomes.
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Foreword
In this book, Professor Audisio and colleagues have provided surgical oncologists with a practical, clinical and technical reference for dealing with malignant disease. All the common, as well as not so common, malignancies are included and in each case, the contributors are recognised experts in their field. The book provides essential basic information, but in addition, is full of good sense and tips for achieving optimal surgical results. It is highly unlikely that an individual surgeon will attempt all the different procedures described in this book but rather will concentrate on a single specialty field, e.g. a colorectal surgeon might delve into TME for rectal cancer, robotic assisted laparoscopic surgery, total proctocolectomy and ileoanal pouch, reconstruction of the perineum, how to make a good stoma, pelvic extenteration for rectal cancer, extended hepatectomy, and atypical liver resections for colorectal liver metastases. For those wishing to hone their plastic and reconstructive skills as part of a surgical oncological practice, there are important chapters on flap technology and reconstructive techniques, breast reconstructive techniques, skill/nipple sparing mastectomy and reconstruction of the perineum by a gluteal fold flap. There is also much to interest head and neck surgeons with total thyroidectomy, neck dissection for thyroid carcinoma, total laryngectomy, and total paroidectomy. These are merely examples of a comprehensive collection of important technical articles for both the surgeon-in-training and the experienced consultant. The European Society of Surgical Oncology supports training of its members through courses and lectures but also through important initiatives such as this book in the anticipation that outcomes for our patients will be improved.
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The authors are to be congratulated for providing this valuable addition to the literature on crucially important technical aspects of surgical oncology.
Professor Irving Taylor Professor of Surgery Director of Medical Studies & Vice-Dean University College London, UK ESSO Past-President Professor Cornelis J.H. van de Velde Professor of Surgery Leiden University Medical Center Department of Surgery, The Netherlands ESSO President
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Preface
Young surgeons and applicants to the EUMC examination have often been asking for a textbook on surgical oncology; a text they could consider as a standard in their education in cancer surgery. Textbooks on medical oncology were predominantly mentioned but a surgical counterpart could not be identified. This collection of surgical techniques represents our first step in this direction. Surgery, like sailing, is an art, and just as there is no “exact” way to set your sails, there is no exact way to tie your knots. However, in surgery, as in sailing, experience and evidence are pivotal in improving our skills. I am extremely grateful to all of the contributors who took the time to put a short text together, summarising their expert views on the surgical procedures that they have mastered. Importantly, the text is thoroughly referenced and supported by data from the literature, where available. I would like to congratulate the young colleagues who have assisted their mentors in setting this up; this project was always intended to be educational. The true target of a great surgeon is to set up a team around him. The privilege and pleasure of sharing knowledge is immense. In this way, key contributors have been working alongside their supportive teams to make this project possible. A wide range of oncological procedures are taken into account: from urology to breast, colorectal to hepato-biliary, gynaecology, thoracic, and so on. This is the completion of a goal that the European Society of Surgical Oncology (ESSO) had in mind. ESSO was founded ix
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in 1981 to advance the art, science and practice of surgery for the treatment of cancer. I firmly believe that organ-based societies will not be able to represent the opinion of a surgical oncologist who is constantly engaged in a multidisciplinary approach to cancer patients. Scientific knowledge has no boundaries; although there are no geographical limitations to medical progress, this book attempts to collect examples of master knowledge from all around Europe. This knowledge was conceived within the Education & Training Committee at the European Society of Surgical Oncology. It is to this Society to which I am indebted for supporting me and providing a network of information, which has definitively been useful in assembling this collection of surgical procedures. The image on the book cover is an original illustration by Michael Howard, a brilliant visual artist who also contributed to some figures within the book. It is my sincere hope that through this book the readers will expand their knowledge and experience and that this will be reflected in improved care and treatment of patients.
Prof. Riccardo A. Audisio Consultant Surgical Oncologist University of Liverpool St Helens Hospital Marshalls Cross Road St Helens WA9 3DA - UK
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Contents
Foreword
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Preface
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List of Contributors
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Chapter 1.
Axillary Lymph Node Dissection for Breast Cancer Elisabeth A. te Velde and Emiel J. Th. Rutgers
1
Chapter 2.
Breast Reconstructive Techniques Fabricio Brenelli, Umberto Napoli, Stefano Martella and Jean-Yves Petit
7
Chapter 3.
Skin/Nipple-Sparing Mastectomy Leif Perbeck
19
Chapter 4.
Radio-Guided Occult Lesion Localisation of Subclinical Breast Lesions Hodigere S. J. Ramesh, Matilde M. Audisio and Riccardo A. Audisio
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Chapter 5.
Technical Note on Total Parotidectomy Eberhard Stennert and Orlando Guntinas-Lichius
33
Chapter 6.
Total Thyroidectomy Niall O’Higgins
41
Chapter 7.
Neck Dissection for Thyroid Cancer ˇ Jan Betka, Petr Lukeš, Zdenˇek Cada and Jaroslav Betka
45
Chapter 8.
Total Laryngectomy Mohssen Ansarin, Augusto Cattaneo and Fausto Chiesa
55
Chapter 9.
Transcervical Extended Mediastinal Lymphadenectomy Jarosław Ku˙zd˙zał, Marcin Zielinski ´ and Łukasz Hauer
63
Chapter 10. Minimally Invasive Techniques for Early Lung Cancer Contardo Vergani, Luca Despini and Giancarlo Roviaro
71
Chapter 11. Resection of Superior Sulcus Cancers: Anterior Approach Marco Alifano, Salvatore Strano and Olivier Schussler
79
Chapter 12. Surgical Staging for Lung and Mediastinal Cancers Ramón Rami-Porta, Sergi Call-Caja, Roser Saumench-Perramon and Mireia Serra-Mitjans
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Chapter 13. Transthoracic Oesophagectomy and Lymphadenectomy Philippe Nafteux, Willy Coosemans, Herbert Decaluwé, Georges Decker, Paul De Leyn, Dirk Van Raemdonck and Toni Lerut
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Chapter 14. Transhiatal Esophagectomy J. Jan. B. van Lanschot, Khe T. C. Tran, Bas P. L. Wijnhoven and Hugo W. Tilanus
103
Chapter 15. Gastrectomy for Adenocarcinoma Hartgrink H. Hartgrink and Cornelis J. H. van de Velde
109
Chapter 16. Stenting Gastro-Oesophageal Tumours Els M. L. Verschuur, Frank P. Vleggaar and Peter D. Siersema
117
Chapter 17. Total Pancreatectomy Jens Werner and Markus W. Büchler
125
Chapter 18. Radiofrequency Ablation in the Treatment of Liver Tumours Joris Joosten and Theo Ruers
133
Chapter 19. Atypical Liver Resections of Colorectal Metastases Bjarne Ardnor and Peter Naredi
141
Chapter 20. Extended Hepatectomy for Primary and Metastatic Liver Lesions René Adam, Emir Hoti, Dennis A. Wicherts and Robert J. de Haas
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Chapter 21. Isolated Hepatic Perfusion: How It Should Be Done Alexander L. Vahrmeijer, Liselot B. J. van Iersel, Peter J. K. Kuppen and Cornelis J. H. van de Velde
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Chapter 22. Robot-Assisted Laparoscopic Colorectal Surgery Omer Aziz and Ara W. Darzi
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Chapter 23. How to Make a Good Stoma Robin Phillips and Simon Phillips
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Chapter 24. Palliative Stenting for Colorectal Malignant Strictures Thomas M. Raymond, R. Bhardwaj and Mike C. Parker
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Chapter 25. Technical Notes on TME for Rectal Cancer Bill J. Heald
187
Chapter 26. Total Proctocolectomy with Ileoanal Pouch Anastomosis Thomas Lehnert, Silke Schüle and Frank Starp
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Chapter 27. Pouches and Coloanal Anastomosis Sylvain Kirzin, Guillaume Portier and Franck Lazorthes
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Chapter 28. Pelvic Exenteration for Rectal Cancer Klaas Havenga and Theo Wiggers
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Chapter 29. Reconstruction of the Perineum by Gluteal Fold Flap Niri S. Niranjan
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Chapter 30. Local Treatment for Primary Melanoma Omgo E. Nieweg
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Chapter 31. Ilioinguinal Dissection for Melanoma Alessandro Testori and Mark Zonta
223
Chapter 32. Surgical Treatment of Peritoneal Carcinomatosis Marcello Deraco, Dario Baratti, Barbara Laterza, Domenico Sabia and Shigeki Kusamura
229
Chapter 33. Laparoscopic Management of Adnexal Tumours Liselotte Mettler, Ivo Meinhold-Heerlein and Andreas G. Schmutzler
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Chapter 34. Excision of Intra-Abdominal Sarcomas: Technical Notes on Surgical Procedures Beate Rau and Peter M. Schlag
245
Chapter 35. Laparoscopic Adrenalectomy for Tumours in the Adrenal Glands Bergþór Björnsson, Guðjón Birgisson and Margrét Oddsdóttir
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Chapter 36. Isolated Limb Perfusion Harald J. Hoekstra
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Chapter 37. Cone and Wedge Resection in Renal Cell Carcinoma Frederik C. Roos and Joachim W. Thüroff
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Chapter 38. Transperitoneal Laparoscopic Radical Nephrectomy Hugh F. O’Kane, Alex MacLeod, Christopher Hagan and Thiagarajan Nambirajan
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Chapter 39. Radical Prostatectomy for Locally Advanced Prostate Cancer Marc Claessens, Steven Joniau and Hendrik Van Poppel
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Chapter 40. Flap Technology and Reconstructive Techniques in Urology Milomir Ninkovic and Gustavo Sturtz
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Index
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List of Contributors
René Adam AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, 12 Avenue Paul Vaillant Couturier, F-94804 Villejuif, France Inserm, Unité 785, F-94804 Villejuif, France Université Paris-Sud, UMR-S 785, F-94804 Villejuif, France Marco Alifano Chirurgien des Hôpitaux, Unité de Chirurgie Thoracique, Hôtel-Dieu University Hospital, 1, Place du Parvis Notre-Dame, 75004 Paris, France Mohssen Ansarin Head and Neck Department, European Institute of Oncology, Via Ripamonti, 435 I-20141 Milan, Italy Bjarne Ardnor Department of Surgery, Umea University Hospital, S-90185 Umea, Sweden Matilde M. Audisio Carmel College, Prescot Road, St Helens, Merseyside WA10 3AG, UK Riccardo A. Audisio Department of Surgery, Whiston Hospital, Warrington Road, Prescot L35 5DR, UK
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Omer Aziz Department of Biosurgery and Surgical Technology, Imperial College London, 10th Floor, QEQM Building, St Mary’s Hospital, London W2 1NY, UK Dario Baratti Department of Surgery, National Cancer Institute of Milan, 1, 20133 Milan, Italy Jan Betka Department of Otorhinolaryngology and Head and Neck Surgery, Faculty Hospital Motol, Charles University, 150 06 Prague 5, Czech Republic. Jaroslav Betka Department of Otorhinolaryngology and Head and Neck Surgery, Faculty Hospital Motol, Charles University, 150 06 Prague 5, Czech Republic. Rakesh Bhardwaj Department of Surgery, Darent Valley Hospital, Dartford, Kent DA2 8DA, UK Guðjón Birgisson Department of Medicine, University of Iceland Medical School and Landspitali-University Hospital, Reykjavik, Iceland Bergþór Björnsson Department of Medicine, University of Iceland Medical School and Landspitali-University Hospital, Reykjavik, Iceland Fabricio Brenelli Division of Plastic and Reconstructive Surgery, European Institute of Oncology, Via Ripamonti, 435 20141-Milan-Italy
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Markus W. Büchler Department of General, Visceral, and Transplant Surgery, University of Heidelberg, INF 110, 69120 Heidelberg, Germany ˇ Zdenˇek Cada Department of Otorhinolaryngology and Head and Neck Surgery, 1st Faculty of Medicine, Faculty Hospital Motol, Postgraduate Medical School, Charles University in Prague Sergi Call-Caja Thoracic Surgery Service, Hospital Mutua de Terrassa, Plaza Dr. Robert, 5, 08221 Terrassa, Barcelona, Spain Augusto Cattaneo Head and Neck Department, European Institute of Oncology, 435, I-20141 Milan, Italy Fausto Chiesa Head and Neck Department, European Institute of Oncology, 435, I-20141 Milan, Italy Marc Claessens Department of Urology, University Hospital Leuven, UZ 3000 Leuven, Belgium Willy Coosemans Department of Thoracic Surgery, University Hospital Leuven, UZ 3000 Leuven, Belgium Ara W. Darzi Department of Biosurgery and Surgical Technology, Imperial College London, 10th Floor, QEQM Building, St Mary’s Hospital, London W2 1NY, UK Herbert Decaluwé Department of Thoracic Surgery, University Hospital Leuven, UZ 3000 Leuven, Belgium
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Georges Decker Department of Thoracic Surgery, University Hospital Leuven, UZ 3000 Leuven, Belgium Robert J. de Haas Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands Marcello Deraco Department of Surgery, National Cancer Institute, Via Venezian 1, 20133 Milano, Itally Luca Despini Department of Surgical Sciences, State University of Milan and Department of General Surgery, Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, IRCCS, Milan, Via Francesco Sforza 35, 20122 Milano, Italy Orlando Guntinas-Lichius Department of Otorhinolaryngology, Friedrich-Schiller-University Jena, Lessingstrasse 2, D-07740 Jena, Germany Christopher Hagan Department of Urology, Belfast City Hospital, Lisburn Road, Belfast BT9 7AB, Northern Ireland Hartgrink H. Hartgrink Department of Surgery, Leiden University Medical Center, 2300 RC, Leiden, The Netherlands Łukasz Hauer Department of Thoracic Surgery, Pulmonary Hospital Zakopane, 34-500 Zakopane, Poland Klaas Havenga Department of Surgery, University Medical Center Groningen, 9700 RB Groningen, The Netherlands
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Bill J. Heald Department of Colorectal Surgery, Pelican Cancer Foundation, North Hampshire Hospital, Basingstoke RG24 9NA, UK Harald J. Hoekstra Division of Surgical Oncology, Department of Surgery, Groningen University Hospital, University of Groningen, PO Box 30.001, 9700 RB Groningen, The Netherlands Emir Hoti AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, 12 Avenue Paul Vaillant Couturier, F-94804 Villejuif, France Liver Transplant Unit, Saint Vincent’s University Hospital, Dublin 4, Ireland Steven Joniau Department of Urology, University Hospital Leuven, UZ 3000 Leuven, Belgium Joris Joosten Department of Surgery, CanisiusWilhelmina Hospital, 6500 HB, Nijmegen, The Netherlands Department of Surgical Oncology, The Netherlands Cancer Institute, Amsterdam, The Netherlands Sylvain Kirzin Service de chirurgie digestive CHU Purpan, Place du Dr Baylac, 31059 Toulouse, France Peter J. K. Kuppen Department of Surgery, Leiden University Medical Center, 2300 RC, Leiden, The Netherlands Shigeki Kusamura Department of Surgery, National Cancer Institute of Milan, 1, 20133 Milan, Italy
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Jarosław Ku˙zd˙zał Department of Thoracic Surgery, Pulmonary Hospital Zakopane, 34-500 Zakopane, Poland Barbara Laterza Department of Surgery, National Cancer Institute of Milan, 1, 20133 Milan, Italy Franck Lazorthes Service de chirurgie digestive CHU Purpan, Place du Dr Baylac, 31059 Toulouse, France Thomas Lehnert Departments of General, Visceral, Vascular and Oncology Surgery, Klinikum Bremen-Mitte, St Juergen Strasse, 1, DE 28205 Bremen, Germany Toni Lerut Department of Thoracic Surgery, University Hospital Leuven, UZ 3000 Leuven, Belgium Paul De Leyn Department of Thoracic Surgery, University Hospital Leuven, UZ 3000 Leuven, Belgium Petr Lukeš Department of Otorhinolaryngology and Head and Neck Surgery, 1st Faculty of Medicine, Faculty Hospital Motol, Postgraduate Medical School, Charles University, 150 06 Prague 5, Czech Republic Alexander MacLeod Department of Urology, Belfast City Hospital, Lisburn Road, Belfast BT9 7AB, Northern Ireland Stefano Martella Division of Plastic and Reconstructive Surgery, European Institute of Oncology, Via Ripamonti, 435 20141-Milan-Italy
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Ivo Meinhold-Heerlein Department of Obstetrics and Gynecology, Christian-AlbrechtsUniversity of Kiel, Klinikum Schleswig-Holstein, Campus Kiel, Michaelisstr. 16, 24105 Kiel, Germany Liselotte Mettler Department of Obstetrics and Gynecology, Christian-AlbrechtsUniversity of Kiel, Klinikum Schleswig-Holstein, Campus Kiel, Michaelisstr. 16, 24105 Kiel, Germany Philippe Nafteux Department of Thoracic Surgery, University Hospital Leuven, UZ 3000 Leuven, Belgium Thiagarajan Nambirajan Department of Urology, Belfast City Hospital, Lisburn Road, Belfast BT9 7AB, Northern Ireland Umberto Napoli Division of Plastic and Reconstructive Surgery, European Institute of Oncology, Via Ripamonti, 435 20141-Milan-Italy Peter Naredi Department of Surgery, Umea University Hospital, S-90185 Umea, Sweden Omgo E. Nieweg Department of Surgery, The Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
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Milomir Ninkovic Department of Plastic, Reconstructive, Hand and Burns Surgery, Hospital Bogenhausen — Technical University Munich, Munich 81925, Germany Niri S. Niranjan Department of Plastic and Reconstructive Surgery, St. Andrews Centre for Plastic Surgery, Broomsfield Hospital, Broomsfield, Chelmsford CM1 7ET, Essex, UK Margrét Oddsdóttir Department of Surgery, Landspitali-University Hospital, 101 Reykjavik, Iceland Niall O’Higgins Department of Surgery, RCSI Medical University of Bahrain, Busaiteen 436, Kingdom of Bahrain Hugh F. O’Kane Department of Urology, Belfast City Hospital, Lisburn Road, Belfast, Northern Ireland Mike C. Parker Department of Surgery, Darent Valley Hospital, Dartford, Kent DA2 8DA, UK Leif Perbeck Department of Surgery, Karolinska University Hospital, SE-171 76 Stockholm, Sweden Jean-Yves Petit Division of Plastic and Reconstructive Surgery, European Institute of Oncology, Via Ripamonti, 435 20141-Milan-Italy Robin Phillips Department of Surgery, Imperial College London, South Kensington Campus, London SW7 2AZ
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Simon Phillips Department of Surgery, Imperial College London, South Kensington Campus, London SW7 2AZ Hendrik Van Poppel Department of Urology, University Hospital Leuven, UZ 3000 Leuven, Belgium Guillaume Portier Service de chirurgie digestive CHU Purpan, Place du Dr. Baylac, 31059 Toulouse, France Dirk Van Raemdonck Department of Thoracic Surgery, University Hospital Leuven, UZ 3000 Leuven, Belgium Hodigere S. J. Ramesh Department of Surgery, Whiston Hospital, Warrington Road, Prescot L35 5DR, UK Ramón Rami-Porta Thoracic Surgery Service, Hospital Mutua de Terrassa, Plaza Dr. Robert, 5, 08221 Terrassa, Barcelona, Spain Beate Rau Department of Surgery and Surgical Oncology, University of Berlin, Charité Campus Milte, Charite platz 1, 10 M7 Berlin, Germany Thomas M. Raymond Department of Surgery, Darent Valley Hospital, Dartford, Kent DA2 8DA, UK Frederik C. Roos Department of Urology, Johannes Gutenberg-University Mainz Medical School, 55101 Mainz, Germany
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Giancarlo Roviaro Department of Surgical Sciences, State University of Milan and Department of General Surgery, Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, IRCCS, Milan, Via Francesco Sforza 35, 20122 Milano, Italy Theo Ruers Department of Surgical Oncology, The Netherlands Cancer Institute, 1066 CX Amsterdam, The Netherlands Emiel J. Th. Rutgers Department of Surgical Oncology, Antoni van Leeuwenhoek Hospital, PO Box 90203, 1006 BE Amsterdam, The Netherlands Domenico Sabia Department of Surgery, National Cancer Institute of Milan, Via Venezian 1, 20133 Milano, Italy Roser Saumench-Perramon Thoracic Surgery Service, Hospital Mutua de Terrassa, Plaza Dr. Robert, 5, 08221 Terrassa, Barcelona, Spain Peter M. Schlag Department of Surgery and Surgical Oncology, University of Berlin, Charité Campus Milte, Charite platz 1, 10 M7 Berlin, Germany Andreas G. Schmutzler Department of Obstetrics and Gynecology, Christian-AlbrechtsUniversity of Kiel, Klinikum Schleswig-Holstein, Campus Kiel, Michaelisstr. 16, 24105 Kiel, Germany Silke Schüle Departments of General, Visceral, Vascular and Oncology Surgery, Klinikum Bremen-Mitte, St. Juergen Strasse, 1, DE 28205 Bremen, Germany
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Olivier Schussler Chirurgien des Hôpitaux, Unité de Chirurgie Thoracique, Hôtel-Dieu University Hospital, 1, Place du Parvis Notre-Dame, 75004 Paris, France Mireia Serra-Mitjans Thoracic Surgery Service, Hospital Mutua de Terrassa, Plaza Dr. Robert, 5, 08221 Terrassa, Barcelona, Spain Peter D. Siersema Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, The Netherlands Department of Gastroenterology and Hepatology, University Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands Frank Starp Departments of General, Visceral, Vascular and Oncology Surgery, Klinikum Bremen-Mitte, St. Juergen Strasse, 1, DE 28205 Bremen, Germany Eberhard Stennert Department of Otorhinolaryngology, Jean-Uhrmacher-Institute, University of Cologne, Geibelstrasse 29-31, Koeln, Germany Salvatore Strano Chirurgien des Hôpitaux, Unité de Chirurgie Thoracique, Hôtel-Dieu University Hospital, 1, Place du Parvis Notre-Dame, 75004 Paris, France Gustavo Sturtz Department of Plastic, Reconstructive, Hand and Burns Surgery, Hospital Bogenhausen – Technical University Munich, Munich, Germany
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Alessandro Testori Division of Melanoma and Soft Tissue Sarcoma, European Institute of Oncology, Italy European Institute of Oncology, via Ripamonti 435, 20141 Milano, Italy Elisabeth A. te Velde Department of Surgical Oncology, Antoni van Leeuwenhoek Hospital, 1006 BE Amsterdam, The Netherlands Joachim W. Thüroff Department of Urology, Johannes Gutenberg-University Mainz Medical School, 55101 Mainz, Germany Hugo W. Tilanus Department of Surgery, Suite H-996, Erasmus Medical 2040, 3000 CA Rotterdam, the Netherlands Khe T. C. Tran Department of Surgery, Suite H-996, Erasmus Medical 2040, 3000 CA Rotterdam, the Netherlands Alexander L. Vahrmeijer Department of Surgery, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands Cornelis J. H. van de Velde Department of Surgery, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands Liselot B. J. van Iersel Department of Clinical Oncology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands J. Jan. B. van Lanschot Department of Surgery, Suite H-996, Erasmus Medical 2040, 3000 CA Rotterdam, the Netherlands
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Contardo Vergani Department of Surgical Sciences, State University of Milan and Department of General Surgery, Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, IRCCS, Milan, Via Francesco Sforza 35, 20122 Milano, Italy Els M. L. Verschuur Department of Gastroenterology and Hepatology, University Utrecht, 3508 GA Utrecht, The Netherlands Frank P. Vleggaar Department of Gastroenterology and Hepatology, University Medical Centre Utrecht, Heidelberglann 100, 3584 cx Utrecht, The Netherlands Jens Werner Department of General, Visceral, and Transplant Surgery, University of Heidelberg, INF 110, 69120 Heidelberg, Germany Dennis A. Wicherts AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, 12 Avenue Paul Vaillant Couturier, F-94804 Villejuif, France Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands Theo Wiggers Department of Surgery, University Medical Center Groningen, 9700 RB Groningen, The Netherlands Bas P. L. Wijnhoven Department of Surgery, Suite H-996, Erasmus Medical 2040, 3000 CA Rotterdam, The Netherlands Marcin Zielinski ´ Department of Thoracic Surgery, Pulmonary Hospital Zakopane, 34-500 Zakopane, Poland
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Mark Zonta Division of Melanoma and Soft Tissue Sarcoma, European Institute of Oncology, Italy European Institute of Oncology, via Ripamonti 435, 20141 Milano, Italy
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1
Axillary Lymph Node Dissection for Breast Cancer Elisabeth A. te Velde and Emiel J. Th. Rutgers∗,†
INDICATIONS Nowadays, for diagnostic staging of the axilla, dissection of the sentinel lymph node is the advised procedure, preferably preceded by ultrasound of the axilla with fine needle aspiration (FNA) if suspicious lymph nodes are seen. Consequently, axillary lymph node dissection for breast cancer is indicated mainly for treatment of (early) lymph node metastases. An axillary dissection is performed if: • The sentinel node is considered positive, with a tumour load of more than 0.2 mm1 ; • FNA cytology or core biopsy confirms lymph node metastases; • The sentinel node cannot be found or is not performed.
∗ Corresponding
author. of Surgical Oncology, Antoni van Leeuwenhoek Hospital, PO Box 90203, 1006 BE Amsterdam, The Netherlands. E-mail:
[email protected] † Department
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TECHNIQUE We prefer the following technique for axillary lymph node dissection for breast cancer: • The patient is in a supine position, tilted away from the surgeon. The lateral chest wall of the patient is placed close to the side of the table. The ipsilateral arm is in maximal abduction on an arm board and can be draped separately. • Curvilinear incision is cranial along the lateral border of the pectoralis major muscle and distal towards the posterior axillary line. • Dissect the dorsal skin flap down to Scarpa’s fascia to reach the free anterior border of the latissimus dorsi (LD) muscle. • Free the LD muscle from the anterior by lifting the muscle upwards by traction to the skin with the free hand. This is the lateral border of the dissection. • Free the thoracodorsal bundle (nerve and vessels) and secure crossing vessels until the axillary vein. Usually, by retracting the axillary fat pad ventrally, the nerve is medial to the vessels at the cranial part (Fig. 1).
FIGURE 1 The thoracodorsal bundle (nerve and vessels) has been freed. The axillary fat pad is retracted ventrally.
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• Intercostobrachial nerves are sensory nerves for the medial aspect of the upper arm, and the posterior aspect of the axilla and can be preserved.2,3 It is uncertain whether this will lead to less sensory disturbances. • From dorsolateral the fascia of the serratus anterior muscle can be cleared. • The long thoracic nerve can be identified at the level of the highest descending branch of the intercostobrachial vessels towards the thoracic wall. It should not be dissected from the thoracic wall. • The ventral skin flap is dissected to free the lateral border of the pectoralis major muscle and further dorsal to the pectoralis minor muscle. The crossing vessels can be spared, harvesting the interpectoral nodes (Rotter’s nodes). • Cranially, the axillary vein’s inferior margin is dissected and forms the cranial border of the dissection. The small motor nerves to the lateral part of the pectoralis minor muscle should be spared. The descending ventral branch(es) of the vein usually needs to be dissected. Care should be taken not to clear completely the perivascular fascia and the fatty tissue surrounding the vein. • The total content of the axilla dorsal from the pectoralis minor muscle is removed (level II). • The caudal border of the dissection is the axillary tail of the breast tissue. • Finally, the axillary specimen is cleared from the serratus anterior muscle fascia, the proximal part of the thoracodorsal nerve and of the anterior plane of the subscapular muscle (Fig. 2). • If level III needs to be dissected (in the case of palpable nodes), the complete proximal part of the minor pectoral muscle is lifted by a large Langenbeck’s retractor and the area boarded medially by the clavipectoral fascia, which can be palpated as a bridging fascia, cranially by the subclavian vein, and the medial border of the pectoralis minor muscle cleared and the fat pad removed. • Remove the specimen. It is advised to mark the medial apex (top) and the axillary tail of the breast specimen for orientation by the pathologist.
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FIGURE 2 The axillary dissection is completed and the apex is marked.
• Closure of Scarpa’s fascia by absorbable sutures. Obliteration of dead space of the axilla by tagging down the subcutis to the serratus anterior fascia is optional.4 • Skin closure by running subcuticular absorbable sutures (Fig. 3). • There is no need for external compression dressing.
FIGURE 3 Skin is closed by running sutures without a dressing. The axilla is drained for 24 hours.
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• Different drain policies are advocated: — None5 ; — 24-hour suction drainage6 ; — 3–5 days. An alternative — more traditional — method is described by Ung et al.7 Our dorsal approach has the great advantage that the important motoric nerves are easily identified and spared, also in obese patients.
REFERENCES 1. Lyman GH, Giuliano AE, Somerfield MR, et al.; American Society of Clinical Oncology. (2005) American Society of Clinical Oncology guideline recommendations for sentinel lymph node biopsy in early-stage breast cancer. J Clin Oncol 23(30): 7703–7720. 2. Muscolino G, Leo E, Sacchini V, et al. (1988) Resectable breast cancer: axillary dissection sparing pectoralis muscles and nerves. Eur J Surg Oncol 14(5): 429–433. 3. Salmon RJ, Ansquer Y, Asselain B. (1998) Preservation versus section of intercostal-brachial nerve (IBN) in axillary dissection for breast cancer — a prospective randomized trial. Eur J Surg Oncol 24(3): 158–161. 4. Chilson TR, Chan FD, Lonser RR, et al. Seroma prevention after modified radical mastectomy. Am Surg 58(12): 750–754. 5. Garbay JR, Picone O, Baron-Merle G, et al. (2004) Axillary lymphadenectomy with muscular padding, without drainage. Gynecol Obstet Fertil 32(12): 1039–1046. 6. Baas-Vrancken Peeters MJ, Kluit AB, Merkus JW, Breslau PJ. (2005) Short versus long-term postoperative drainage of the axilla after axillary lymph node dissection: a prospective randomized study. Breast Cancer Res Treat 93(3): 271–275. 7. Ung O, Tan M, Chua B, Barraclough B. (2006) Complete axillary dissection: a technique that still has relevance in contemporary management of breast cancer. ANZ J Surg 76(6): 518–521.
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Breast Reconstructive Techniques Fabricio Brenelli† , Umberto Napoli† , Stefano Martella† and Jean-Yves Petit∗,†
The reconstruction of the breast is a hallmark in the surgical management of breast cancer. It reduces the anxiety of the patient and thereby improves the quality of life. It can be done at the time of mastectomy (immediate reconstruction) or any time after (delayed reconstruction). It can be performed either using prosthesis or an autogenous tissue. If the preference is for a prosthesis, either a temporary implant (tissue expander) or a definitive implant (silicone or saline prosthesis or a definitive expander) can be used. If reconstruction with autogenous tissue is preferred, a latissimus dorsi (LD) or a transverse rectus abdominal muscle (TRAM) flap can be used. Pedicle free flaps are gaining space, mainly the free TRAM flap and the deep inferior epigastric (DIEP) flap, both of them require a microsurgery-trained team, this will be not discussed in this chapter.
RECONSTRUCTION WITH PROSTHESIS Breast Reconstruction with a Definitive Prosthesis Technique: Drawing of both inframammary fold and sternal line must be done preoperatively as an anatomical reference. Measurement of the breast’s base helps to program the width of the prosthesis to be placed (Fig. 1). ∗ Corresponding
author.
† Division of Plastic and Reconstructive Surgery, European Institute of Oncology, Via
Ripamonti, 435 20141-Milan-Italy. E-mail:
[email protected] 7
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FIGURE 1 Pre-operative drawing of the inframammary fold and sternal line.
The technique consists of a complete or partial muscular pocket. After mastectomy, smooth dissection of the space between the pectoralis major and minor muscle is performed. This is followed by a sharp dissection, undermining the subpectoral space, cutting the muscle’s insertion medially from the sternum up to 4–5 cm from the mammary fold. Inferiorly, dissection is completed achieving the inframammary fold after complete severance of the pectoralis fibbers. The lateral extent of the dissection continues beneath the serratus anterior muscle, and stops at the predetermined lateral border of the breast (Figs. 2 and 3). If the lateral skin of the mastectomy is thick and well irrigated, a complete muscular pocket can be avoided, in order to give more lateral projection to the breast. The implant is placed in the subpectoralis
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FIGURE 2 Mastectomy defect and exposure of the pectoralis major muscle.
FIGURE 3 Dissection of the sub-pectoralis space: Medially, severance of the pectoralis major fibers from the sternum; inferiorly: Severance of the pectoralis fibers achieving the inframmary fold; lateraly: Completion of the muscular pocket with dissection of the serratus anterior muscle.
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FIGURE 4 Partial pocket; lateraly, the prosthesis is covered by the lateral skin flap of the mastectomy.
space as well, and just an inferior portion of the anterior serratus is dissected. Then the pocket is closed with the pectoralis major and the lateral part of the mastectomy (Fig. 4). Indications: Cases of small and medium breasts, where mastectomy does not require extent skin removal or partial removal of muscular tissue. Contraindications: When muscular invasion exists, or when a large amount of skin must be excised, making it impossible to build a muscular pocket or having an adequate skin envelope. Adjuvant radiotherapy is a relative contraindication.
Breast Reconstruction with Tissue Expander This technique consists of the placement of a temporary or definitive implant which is inflated with saline solution until the desired volume is reached, and is exactly the same technique as described above. After the expander is positioned inside the muscular pocket, the catheter and port are tunnelled and brought to a position under the skin in
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FIGURE 5 Temporary tissue expander. Expantion is performed with saline solution through the port.
the axilla. As an alternative, in some expanders the port is located on the surface of the implant itself. In such cases a magnetic device can help to localize the port and thereby guide the inflation. The expander is inflated by passing a needle through the port and injecting saline solution through it (Fig. 5). After suitable expansion, the expander is replaced by a permanent prosthesis.
RECONSTRUCTION WITH LATISSIMUS DORSI FLAP (L. D.) Technique: The donor site skin must correspond to the quantity of breast skin that will be removed. The drawing should be elliptical to provide adequate closure, minimising scar defect. It can be horizontal (better aesthetical result as the scar remains under the bra), or oblique (facilitates the closure) (Fig. 6). The patient’s position is very important. A lateral decubitus position provides the surgeon an easy access to the L.D. muscle and surrounding tissues. Its position is secured with a bean bag.
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FIGURE 6 Different possibilities of skin pad donation in the L.D. flap. In the left, horizontal scar that can be hidden by the bra.
The flap comprises skin paddle, underlying fat and L.D. muscle. After skin incision, flap is taken down to the muscle, and the area of adjacent skin is undermined. The flap is mobilised by incising muscle along its anterior margin and continuing the dissection posteriorly, and the flap is thus liberated from the underlying rib cage. Peripheral attachments are severed by sharp dissection, beginning inferiorly and continuing superiorly. Along the superior aspect of the dissection, particular attention must be taken to identify and preserve the thoracodorsal pedicle which provides the flap’s blood supply (Fig. 7). Finally, a tunnel is created with blunt dissection between the axilla, from the donor site to the mastectomy defect, allowing the rotation of the flap. Suction drain is positioned and the back wound is closed in two layers. The patient is rotated to a supine position. The final step is shaping of the flap, fixing it to the muscular chest wall, creating a pocket. A prosthesis is placed in order to achieve a symmetric breast volume (Fig. 8).
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FIGURE 7 Irrigation of the L.D. muscle. The thoracodorsal pedicle and its amplification.
FIGURE 8 Placement of the L.D. muscle over the prosthesis, creating a new pocket.
A total breast reconstruction with L.D. flap is feasible in cases of small or medium breast, with an extended latissimus dorsi flap (ELD). The technique involved is the same as the one described above, but the undermining of the adjacent skin is performed on a subcutaneous
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plane, and the muscle is removed together with the superficial fat lying above it, resulting in a more voluminous flap. Indications: Almost every case of mastectomy and breast reconstruction. Contraindications: Cases where a great amount of skin must be removed and the flap skin is not enough to cover it. Relative contraindication is the presence of homolateral arm lymphedema due to previous axillary dissection.
RECONSTRUCTION WITH TRAM FLAP Technique: The patient must be marked preoperatively with an indelible ink. The donor site is outlined superiorly just above the umbilicus, laterally to the iliac crest, and inferiorly, the position being dependent on the possibility of performing a good closure without much tension (Fig. 9).
FIGURE 9 Pre-operative drawing of the TRAM flap donor site: Superiorly, just above the umbilicus; Lateraly at the Iliac crest; Inferiorly, above the pubis, always when it allows a good closure.
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After incision, sharp dissection is performed just above the rectus abdominal fascia, undermining the subcutaneous space, from the superior incision up to the xiphoid, creating a tunnel. The lateral anatomical reference is the rib cage. The random part of the flap that will not be attached to the muscle is undermined until the rectus is reached, preserving as much perforator vessel as possible. At this point, the rectus fascia is opened on its longitudinal axis up to the xiphoid and the muscle is exposed. The rectus muscle is dissected free posteriorly and the lateral aspect of the rectus sheath is divided with a scalpel up to the superior border of the flap. The medial border of the rectus sheath is divided to the level of the umbilicus, which is then dissected free from the flap. The surgeon places two finger underneath the rectus and lifts it anteriorly with gentle tension, permitting the palpation and vision of the inferior pedicle, which is ligated while the muscle is being divided. The rectus muscle is completely mobilised by sharp and blunt dissection and the superior pedicle is identified. A tunnel is created through the inframammary fold, communicating with the mastectomy defect. The flap is then rotated into the wound (Fig. 10).
FIGURE 10 Positioning the contra-lateral TRAM flap: Attention to avoid tension or strugling of the pedicle. The lateral part of the flap (less irrigated) is placed in the lateral part of the defect, allowing an easier flap ressection in case of partial necrosis.
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FIGURE 11 Positioning of the ipsi-lateral TRAM flap. Attention to avoid torsion of the pedicle, folding the rectus upon itself. The lateral part of the flap remains external to the mastectomy defect.
The pedicle can be ipsi or contralateral to mastectomy (Figs. 10 and 11). Great attention must be paid to its positioning, in order not to cause its distension or strangulation. At the end, shapening of the flap is performed by cutting off the excess tissue from zone 3 and 4 (the farthest zone from the pedicle). When the mastectomy defect is very large, and the flap must be used on its full dimension, it is necessary to perform a bipedicle TRAM flap, using both abdominal rectus (Fig. 12). The technique used is the same as described above, but implicates the use of the two rectus muscles. Abdominal closure is a very important step. The suture of the fascia should be done with the patient in the lying position, while the closure of the cutaneous flaps will be done at the end in a sitting position. The fascia can be closed directly with nonabsorbable stitches under moderate tension in cases of a mono pedicle. Otherwise, in cases of important tension and bipedicle TRAM, we recommend the use of a nonabsorbable mesh.
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FIGURE 12 Bipedicle TRAM flap. Both rectus are dissected, a small amount of midline Fascia being kept, preserving the umbilicus and its irrigation.
Close attention must be paid to the umbilicous repositioning, especially in cases of a mono pedicle TRAM. Centralisation can be obtained, thanks to a plicature of the fascia of the opposite muscle. It is also possible to create the future hole of the umbilicus on the median line and to use its length to centralizate. Indications: Almost every case of breast reconstruction. Contraindications: Relative, in cases of obesity, heavy smokers and previous abdominal surgery.
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Skin/Nipple-Sparing Mastectomy Leif Perbeck∗
INTRODUCTION Skin sparing mastectomy (SSM) and nipple-sparing mastectomy (NSM) followed by immediate breast reconstruction have gained popularity, since they result in a shape of a natural breast with an intact submammary fold and require only one operation, except for the nipple reconstruction in SSM. SSM has been described as an operation including resection of the nipple–areola complex and any existing biopsy scar, and removal of the entire breast parenchyma.1 SSM and NSM require technical expertise to avoid partial or full-thickness loss of skin flaps,2 which can lead to delay in starting chemotherapy or radiotherapy.3 There are concerns about the oncological safety. By preserving the skin there is a large area in which a local recurrence can occur, such as the nipple–areola complex. A local recurrence is a risk factor for systemic relapse and the patients have a survival curve corresponding to that in cases with one metastasis in the axilla at the primary operation.4 The local recurrence can be treated with local excision, followed by radiotherapy and further oncological treatment. However, it is a psychological burden for the patient. There is no
∗ Department
of Surgery, Karolinska University Hospital, SE-171 76 Stockholm, Sweden. E-mail:
[email protected]. 19
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consensus regarding the indications for SSM and NSM, but there are contraindications, such as excessive skin involvement in both cases and additionally for NSM the existence of a retro-nipple area cancer within 2.5 cm from the base of the nipple.5 There have been no randomised trials comparing SSM and NSM with mastectomy, but several articles have addressed the oncological safety.4 The introduction of anatomically shaped cohesive silicon gel has improved the cosmetic outcome for the patient.
TECHNIQUE The following description refers to NSM. There are roughly three types of breast shapes to consider, namely 0–2 cm ptosis, 2–4 cm ptosis and over-4-cm ptosis, demanding different kinds of skin incisions and different locations of the implant. In breasts with 0–2 or 2–4 cm ptosis, either a lazy-S incision from the upper border of the areola and laterally, or an incision 1.5 cm above and parallel to the submammary fold is used (see Table 1). The advantage of the lazy-S incision is that it permits good exposure of the whole breast (Fig. 1). The dissection is at the level of Scarpa’s fascia and the breast glandular tissue is first mobilised medially and laterally from the nipple–areola complex before a biopsy sample for frozen section is taken under the base of the nipple. If a frozen biopsy sample is negative for tumour cells, the Table 1
Incision and Implant Location in Relation to the Ptosis of the Breast
Breast Shape
0–2 cm Ptosis
2–4 cm Ptosis
>4 cm Ptosis
Incision
Lazy-S submammary fold
Lazy-S submammary fold
Subcutaneous reduction mammaplasty Cranial pedicle
Implant location
Submuscular
Cranially submuscular Caudally subcutaneous
Submuscular
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FIGURE 1 The lazy-S incision.
nipple–areola complex is preserved. The thickness of the breast glandular tissue that is left beneath the nipple is 3 mm and its diameter is 10 mm. After the breast glandular tissue has been mobilised from the subcutaneous tissue, it is removed from the pectoralis major muscle, leaving the fascia behind. Any tissue around the earlier resection cavity area is properly removed to avoid future local recurrence. The incision 1.5 cm above and parallel to the submammary fold has the advantage that the scar is hidden behind the ptotic breast, but the dissection of the breast glandular tissue is more difficult. With this incision the breast glandular tissue is first mobilised from the pectoralis major muscle, making the breast more mobile when the skin flaps are dissected in the subcutaneous layer. The dissection is performed under direct vision. A pocket for the implant is dissected between the pectoralis major and minor muscles, and in cases where the implant is placed submuscularly the pocket is dissected 1.5 cm below the submammary fold and laterally behind the serratus anterior muscle. In patients with ptosis of 2–4 cm the intention is to preserve the submammary fold and try to create a natural ptosis. The pectoralis major muscle is divided caudally as low as possible and the muscle is then sutured to the overlying subcutaneous tissue without skin tension. An anatomical cohesive gel implant is placed under the pectoralis major muscle cranially and subcutaneously caudally, thereby creating a natural ptosis. The use of a test implant, with the patient in a sitting position, facilitates an optimal choice of size of the permanent implant.
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In a patient with >4 cm ptosis a subcutaneous reduction mammaplasty (SRM) is needed. In SRM it is safer to use a cranial pedicle, because of its shorter distance to the nipple–areola complex, than a caudally located pedicle, in which the circulation has been shown to be only 13% of the normal circulation (Figs. 2 and 3).6 The implant
FIGURE 2 The construction of the vertical pedicle of the skin and fat.
FIGURE 3 The final result of subcutaneous reduction of mammaplasty.
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is placed submuscularly in SRM and usually a cohesive gel is used, but an expander implant can be considered if a volume of >225 cc is desired.
DISCUSSION The advantage of NSM is that the whole breast reconstruction is performed in one operation and results in the appearance of a natural breast with the patient’s own nipple–areola complex. It is possible to spare the submammary fold. Usually no contralateral operation is needed except for SRM. Historically, submuscular placement of the implant is preferred because of the high frequency of capsular contracture when a silicon implant is located subcutaneously. The use of a saline-filled implant located subcutaneously results in a capsular contracture frequency after 5 years of 14%, and if radiotherapy is given, of 41%, but after one re-operation with capsulotomy or capsulectomy of the ventral surface of the capsule, no further capsulectomy is required.7 With the introduction of an anatomically shaped cohesive gel breast implant and with the use of a test implant, an adequate permanent implant can be chosen which does not lose volume with time as do saline-filled implants. Future studies are needed to determine whether there are any differences between different implants in relation to their textured surfaces with different pore sizes.
REFERENCES 1. Carlson GW, Bostwick J III, Styblo TM, et al. (1997) Skin-sparing mastectomy: oncologic and reconstructive considerations. Ann Surg 223: 570–575. 2. Meretoja TJ, Rasia S, Von Smitten KAJ, et al. (2007) Late results of skinsparing mastectomy followed by immediate breast reconstruction. Br J Surg 94: 1220–1225. 3. Hultman CS, Daiza S. (2003) Skin-sparing mastectomy flap complications after breast reconstruction: review of incidence, management, and outcome. Ann Plast Surg 50: 249–255.
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4. Benediktsson KP, Perbeck L. (2007) Survival in breast cancer after nipple-sparing subcutaneous mastectomy and immediate reconstruction with implants: a prospective trial with 13 year median follow-up in 216 patients. Eur J Surg Oncol 1–6. E-pub. 5. Cense HA, Rutgers Th EJ, Lopes Cardozo M, Van Lanschot JJB. (2001) Nipple-sparing mastectomy in breast cancer: a viable option? Review article. Eur J Surg Oncol 27: 521–526. 6. Perbeck L, Proano E, Westerberg L. (1992) Circulation in the nipple– areola complex following subcutaneous mastectomy in breast cancer. Scand J Plastic Reconstr Hand Surg 26: 217–221. 7. Benediktsson K, Perbeck L. (2006) Capsular contracture around salinefilled and textured subcutaneously-placed implants in irradiated and non-irradiated breast cancer patients: five years of monitoring of a prospective trial. J Plast Reconst Aesthet Surg 59(1): 27–34.
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Radio-Guided Occult Lesion Localisation of Subclinical Breast Lesions Hodigere S. J. Ramesh† , Matilde M. Audisio‡ and Riccardo A. Audisio∗,†
INTRODUCTION With the introduction of screening mammography, the incidence of sub-clinical lesions has doubled in the past decade. One out of three breast cancer operations are aimed at removing non-palpable lesions. These lesions need to be removed with precision, satisfying the oncological criteria (safe margin) as well as patient expectations (cosmesis). Several localisation techniques have been described. The most popular one is wire-guided lumpectomy (WGL), although this may be associated with several drawbacks, such as difficult placement of the wire in a dense breast, displacement, traumatic injury to patient and surgeon, long needle tract, interference in the processing of the specimen, and inflexibility in the approach to the lesion due to the entry point of the wire. New methods of localisation are now being developed; examples are ultrasound-guided skin ∗ Corresponding
author. Hospital, Warrington Road, Prescot L35 5DR, UK. E-mail: raudisio@ doctors.org.uk ‡ Carmel College, St Helens, UK. † Whiston
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marking, intra-operative ultrasound-guided excision, carbon tracer, haematoma-directed ultrasound-guided excision and radio-guided occult lesion localisation (ROLL).
EVOLUTION OF ROLL The use of radio-pharmaceutical compounds to localise breast lesions was pioneered in the 1990s at the European Institute of Oncology, Milan.1–3 It immediately gained popularity because of its precision in localising non-palpable lesions while allowing the use of sentinel node biopsy. The technique described below is our modification of the original one to reduce radioactive dosage and an extra day of hospital stay,6–8 as well as to eliminate pre-operative scintigraphy.
GENERAL PRINCIPLES (t/2 = 6 hours) is suspended in a macro-aggregate of albumin (LyoMAA). It contains approximately 90,000 particles and has a particle size of 10–90 µm. The radioactivity administered is 1 MBq, equal to 0.02 msv (i.e. the same dosage as for a chest X-ray). This radio-pharmaceutical is delivered in a pre-loaded, sterile-packed syringe within a protective lead case. It is important to shake the syringe gently to mix the macro-aggregates before injection. Within the core of the lesion, 0.2 ml of LyoMAA is injected under ultrasound guidance 1–4 hours before surgery, as 75% of lesions are ultrasoundvisible. Alternatively, stereotactic localisation can be employed. ROLL localisation is used for diagnostic excision biopsy of suspicious lesions and therapeutic excision of a proven cancer. The aim is to localise precisely the target and to excise it within the smallest amount of glandular tissue in order to achieve excellent cosmetic results. The procedure is performed under general anaesthesia and as a day case. Initial diagnostic imaging (i.e. mammogram and/or US) should be available at the time of localisation, in order to plan the
99m Tc-labelled
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surgical approach and to compare the specimen X-ray for the presence of the lesion.
PRE-OPERATIVE CONSIDERATIONS Indications • • • • •
Micro-calcifications Parenchymal distortions, i.e. radial scars, atypical hyperplasia Suspicious soft tissue masses Impalpable cancers following neo-adjuvant chemotherapy Foreign bodies within soft tissue
Contraindication • Allergy to albumin
BEFORE ANAESTHESIA It is important to check for radioactive signals with the patient in a sitting and a supine position. This will not only ensure the functionality of equipment (gamma camera and radioisotope) but also provide a final opportunity to plan, discuss and mark the most appropriate approach to the lesion.
PATIENT POSITION The patient should rest in a supine position, with the arm well abducted to expose the outer quadrants and axilla. The extended elbow should rest on a well-padded arm board.
INCISIONS The skin incision should allow lesion removal in accordance with the oncological principles while giving the best cosmetic results. ROLL
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offers flexibility in the approach to the lesion, bearing in mind that the incision line should fall within the boundaries of the subsequent mastectomy or lumpectomy. When possible we make an infra-mammary incision for lesions at the lower quadrants (Fig. 1), a peri-areolar incision for lesions at the central quadrant (Fig. 2), or an axillary incision for lesions at the upper-outer quadrant (Fig. 3), which offer excellent cosmetic results. Skin incisions paralleling Langer’s lines which result
FIGURE 1 Sub-mammary approach.
FIGURE 2 Peri-areolar approach.
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FIGURE 3 Preferred incisions: axillary approach, peri-areolar approach, submammary approach.
in thin, cosmetically acceptable scars may also be considered for all peripheral lesions when a direct approach is preferred.
HANDLING OF THE GAMMA CAMERA The gamma camera with a mounted collimator is wrapped in a sterile polythene cover. After the skin is incised, checks for gamma signals facilitate choosing the most direct approach to the lesion. A radioguided excision biopsy is carried out following audible signals and tissue palpation. We aim to achieve 1 cm of healthy margins encasing the neoplasm surgery. The complete excision of the target is confirmed by the presence of signals in the specimen and the absence of residual signals in the excision cavity. The specimen is marked with standard orientation stitches, as per agreed laboratory practice.
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SPECIMEN X-RAY The specimen X-ray ensures the presence of the target within the excised tissue, although it must be appreciated that this does not measure the adequacy of the excision margin for neoplasm.
WOUND CLOSURE The best cosmetic result is obtained by approximating the breast plates of the excision cavity with an absorbable running suture. The skin edge is approximated with a continuous sub-cuticle absorbable 000 suture. The wound edges are reinforced with 1/4” steri-strips. The use of breathable dressing or pressure dressing is avoided and we do not routinely drain the surgical cavity.
POST-OPERATIVE CARE Resume normal activities on the evening of the surgery.
ADVANTAGES6–10 • • • • • • • •
Accurate localisation and surgical removal Improved margin clearance Reduced size of the excised specimen Better cosmetic results Reduced localisation time Cost-effectiveness Patient satisfaction (reduced pain) Reduced local recurrence rate
Finally, the simultaneous use of two radioisotopes to localise both primary cancer and the sentinel lymph node known as SNOLL is feasible.4,5,11
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RADIATION SAFETY The radiation dose absorbed by hospital personnel is low and requires neither radiation protection control nor separation of exposed workers into class A and class B. Special containers for radioactive waste are necessary in the administration room but not in the operating room, where possible contamination is negligible.12 In the case of a surgeon performing 100 procedures per annum, an FD dose of approximately 1 mSv is received, well within the annual dose limit of 150 mSv. The annual WBD (whole body dosage) to assisting staff may reach 0.04 mSv, compared to an annual limit of 6 mSv. These low doses and the lack of contamination of radioactive waste indicate that no additional radiation protection measures are required.11
REFERENCES 1. Luini A, Zurrida S, Galimberti V, Paganelli G. (1998) Radioguided surgery of occult breast lesions. Eur J Cancer 34(1): 204–205. 2. Gennari R, Galimberti V, De Cicco C, et al. (2000) Use of technetium-99mlabeled colloid albumin for preoperative and intraoperative localization of nonpalpable breast lesions. J Am Coll Surg 190(6): 692–698. 3. De Cicco C, Pizzamiglio M, Trifiro G, et al. (2002) Radioguided occult lesion localisation (ROLL) and surgical biopsy in breast cancer: technical aspects. Q J Nucl Med 46(2): 145–151. 4. Feggi L, Basaglia E, Corcione S, et al. (2001) An original approach in the diagnosis of early breast cancer: use of the same radiopharmaceutical for both non-palpable lesions and sentinel node localisation. Eur J Nucl Med 28(11): 1589–1596. 5. Ronka R, Krogerus L, Leppanen E, et al. (2004) Radio-guided occult lesion localization in patients undergoing breast-conserving surgery and sentinel node biopsy. Am J Surg 187(4): 491–196. 6. Audisio RA, Nadeem R, Harris O, et al. (2005) Radioguided occult lesion localisation (ROLL) is available in the UK for impalpable breast lesions. Ann Roy Coll Surg 87(2): 92–95. 7. Nadeem R, Chagla LS, Harris O, et al. (2005) Occult breast lesions: a comparison between radioguided occult lesion localisation (ROLL) vs. wire-guided lumpectomy (WGL). The Breast 14(4):283–289.
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8. Thind CR, Desmond S, Harris O, et al. (2005) Radio-guided localization of clinically occult breast lesions (ROLL): a DGH experience. Clin Radiol 60(6): 681–686. 9. Ramesh HSJ, Anguille S, Chagla LS, et al. Recurrence after ROLL lumpectomy for invasive breast cancer. Submitted. 10. Rampaul RS, Dudley NJ, Thompson JZ, et al. (2003) Radioisotope for occult lesion localisation (ROLL) of the breast does not require extra radiation protection procedures. The Breast 12(2): 150–182. 11. Ramesh H, Chagla LS, Ray A, et al. (2007) SNOLL is up and running in UK — an early experience. EJSO 33: 1121. 12. Ferrari M, Cremonesi M, Sacco E, et al. (1998) Radiation protection in the use of tracers in radioguided breast surgery. Radiol Med (Torino) 96(6): 607–611.
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Technical Note on Total Parotidectomy Eberhard Stennert∗,† and Orlando Guntinas-Lichius‡
DEFINITION OF AND INDICATIONS FOR TOTAL PAROTIDECTOMY In the literature, the definition of total parotidectomy is inconsistent. Often, total parotidectomy is declared although only subtotal parotidectomy has been performed. Therefore, it is important to differentiate between the two techniques: subtotal parotidectomy includes a lateral parotidectomy, i.e. the resection of all parotid tissue lateral to the facial plexus, and partially medial to the facial plexus, but not necessarily including the deep portion, under preservation of the facial nerve. To fulfil the criteria for total parotidectomy, an additional complete resection of the deep portion is mandatory. Absolute indications for total parotidectomy are malignant parotid tumours independent of the subtype, metastasis to the parotid gland and chronic parotitis.
∗ Corresponding
author.
† Jean-Uhrmacher-Institute,
University of Cologne, Geibelstrasse 29-31, D-50931 Koeln, Germany. E-mail: eberhard.stennert@ uni-koeln.de ‡ Department of Otorhinolaryngology, Friedrich-Schiller-University Jena, Lessingstrasse 2, D-07740 Jena, Germany. E-mail:
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STEP 1: BEDDING OF THE PATIENT The patient is rested in a supine position in order to minimise intraoperative bleeding, with his hyperextended head rotated to the opposite side. The bed is tilted head up–feet down as far as is defensible.
STEP 2: FACIAL NERVE MONITORING In addition to standard surgical coverage, the ipsilateral face is covered with a transparent sheath to guarantee optical monitoring of the face by the assistant surgeon (Fig. 1). By this, even slight movements of the face become obvious when anaesthesia is performed without relaxation. In addition, electric monitoring can be performed optionally.
FIGURE 1 Tumour in the infra-auricular region of the left parotid gland. Ipsilateral face is covered with transparent sheath for optical facial nerve monitoring. Tumour localisation, incision line, angle of the mandibule and course of the zygomatic arch are plotted on the face.
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STEP 3: SKIN INCISION AND SKIN FLAP PREPARATION A preauricular and submandibular lazy S incision (modified Blairs incision) is performed (Fig. 1). It is oriented along the preauricular crease and inferior in the neck along natural skin lines. A distance of at least 2 cm from the mandibule is important, to avoid damage to the marginal mandibular branch of the facial nerve. If a neck dissection is planned, the submandibular incision can be modified easily. If the tumour is lying lateral to the main trunk of the facial nerve or if an exposure of its intramastoidal segment is necessary, the incision can also be extended retroauricularily. By blunt dissection, the parotid gland is separated from the ear cartilage in the preauricular region and from the sternocleidomastoid muscle until the exposure of the digastric muscle. It is often necessary to ligate the greater auricular nerve. Ligation is mandatory in order to prevent neuroma formation. However, preservation of its posterior branch should be intended. The preparation of the buccal skin flap is most important. The flap is lifted in the layer between the parotid pseudocapsule and the deep buccal fascia, combined with a short platysmal dissection in the neck. The fascia has to be protected as a barrier in order to decrease Frey’s syndrome.
STEP 4: ANATOMICAL LANDMARKS FOR IDENTIFICATION OF THE FACIAL NERVE The primary approach to identifying the facial nerve depends on the site and extension of the lesion. The preparation of the entire plexus, i.e. the nerve trunk and all peripheral branches, is performed under microscopic control to minimise their trauma. There are three surgical approaches: (1) Anterograde approach: identification of the facial nerve at its exit at the stylomastoid foramen. Then, the bifurcation and the different branches are prepared in the proximal-to-distal direction.
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Three landmarks help to identify the main trunk: (a) Conley’s pointer is a conchal cartilage extension of the ear canal at the medial end of its anterior–inferior edge; the nerve lies 5–6 mm inferior to this pointer (see Video-clip); (b) the tympanomastoid fissure is better palpable than visible; the facial nerve lies 6–8 mm medial to the anterior end of the fissure; (c) the lateral surface of the digastric muscle lies in the same plane as the facial nerve. (2) Retrograde approach: the best landmark to start with this preparation is the middle third of the zygomatic arch, where the frontal branch crosses its periosteum. A zygomatic branch is found about 1 cm inferior to the arch. Alternatively, identification of Stenson’s duct might be helpful, which is crossed by a buccal branch. (3) In many cases, a combination of the anterograde and the retrograde approach is necessary. Anyway, the parotid surgeon has to be trained in all these techniques.
STEP 5: LATERAL PAROTIDECTOMY The anterograde and the retrograde preparation, or a combination of the two procedures, lead step by step to exposure of the whole peripheral nerve plexus, including the trunk and bifurcation. Hereby, the parotid tissue lateral to these nerve structures is progressively dissected free and finally delivered. Touching of the tumour has to be avoided. If the tumour is lying in the lateral lobe, the lateral parotid is removed with the associated tumour en bloc (Fig. 2).
STEP 6: COMPLETION OF TOTAL PAROTIDECTOMY The main trunk and the facial nerve branches are dissected from the underlying tissue in an atraumatic fashion. Step by step, every branch is gently lifted by using rubber slings to dissect the underlying parotid tissue. Stretch and compression trauma to the nerve has to be avoided. Finally, the underlying masseter muscle is visible in the whole area. To clear the retromandibular space, it is mandatory
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FIGURE 2 Situs after lateral parotidectomy as the first step of total parotidectomy. The complete facial nerve fan is explored. Upper right inlay: Resected specimen corresponds to the lateral lobe of the parotid gland including the tumour.
to resect the retromandibular vein by ligation distally in the submandibular fossa and proximally next to the zygomatic arch. Finally, the parotid tissue of the deep lobe has to be resected completely along the skull base up to the stylomastoid process (Fig. 3).
STEP 7: DEFECT FILLING Its accomplishment depends on the underlying disease, the size of the defect and the patient’s will. There are two options: (1) Preparation of a muscle flap from the craniolateral aspect of the sternocleidomastoid muscle lateral to the spinal accessory nerve, which is rotated anteriorly into the defect. The mastoid attachment has to be preserved, to ensure occipital blood supply to the flap. (2) For large defects, primarily abdominal fat is used. The fat is harvested via a periumbilical incision. Meticulous bleeding control is necessary, to avoid abdominal haematoma formation. Some overcorrection is necessary because of postoperative shrinkage. The fat is fixed with several sutures, avoiding any contact with nerve branches.
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FIGURE 3 Final situs after total parotidectomy. For the resection of the medial “lobe” and the deep portion it is mandatory to mobilise the complete facial nerve plexus.
STEP 8: WOUND CLOSURE A Redon drainage is placed without contact with nerve structures. The wound is closed in two layers by subcutaneous and cutaneous sutures. A circular head–neck bandage is recommended. The drainage is removed within 24–72 h.
REFERENCES 1. Guntinas-Lichius O, Kick C, Klussmann JP, et al. (2004) Pleomorphic adenoma of the parotid gland: a 13-year experience of consequent management by lateral or total parotidectomy. Eur Arch Otorhinolaryngol 261(3): 143–146. 2. Guntinas-Lichius O, Klussmann JP, Wittekindt C, Stennert E. (2006) Parotidectomy for benign parotid disease at a university teaching hospital: outcome of 963 operations. Laryngoscope 116(4): 534–540. 3. O’Brien CJ. (2005) The parotid gland as a metastatic basin for cutaneous cancer. Arch Otolaryngol Head Neck Surg 131(7): 551–555. 4. Patel RS, Low TH, Gao K, O’Brien CJ. (2007) Clinical outcome after surgery for 75 patients with parotid sialadenitis. Laryngoscope 117(4): 644–647.
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5. Stennert E, Kisner D, Jungehuelsing M, et al. (2003) High incidence of lymph node metastasis in major salivary gland cancer. Arch Otolaryngol Head Neck Surg 129(7): 720–723. 6. Stennert E, Wittekindt C, Klussmann JP, et al. (2004) Recurrent pleomorphic adenoma of the parotid gland: a prospective histopathological and immunohistochemical study. Laryngoscope 114(1): 158–163. 7. Wittekindt C, Streubel K, Arnold G, et al. (2007) Recurrent pleomorphic adenoma of the parotid gland: analysis of 108 consecutive patients. Head Neck 29(9): 822–828.
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Total Thyroidectomy Niall O’Higgins∗
(1) The operation is usually carried out under general anaesthesia with the patient in the supine position with the neck slightly extended and the table top tilted so that the head is raised. (2) The incision is planned in a transverse skin crease approximately half way between the suprasternal notch and the thyroid cartilage. The incision line is mainly horizontal, with a slight upward concavity depending on skin creases. It is rarely necessary to extend the incision further than the anterior borders of the sternocleidomastoid muscle. For large multinodular goitres extending behind the sternum, the incision is placed somewhat higher in the neck to facilitate access to the upper pedicles of the thyroid, as these are likely to be situated higher in the neck than is the case with a normal thyroid. (3) The skin incision is deepened in the same line through the platysma. The flap of skin and platysma is dissected upwards as far as the thyroid cartilage and downwards to the suprasternal notch. This dissection is facilitated by staying close to the deep surface of the platysma rather than the superficial surface of the underlying deep fascia.
∗ Department
of Surgery, RCSI Medical University of Bahrain, Kingdom of Bahrain. E-mail:
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(4) Once the flaps have been developed and retracted, the deep fascia is divided in the midline between the strenohyoid muscles and incised upwards and downwards to the extent of the elevated skin/muscle flaps. The midline is easy to identify lower in the neck where the space between the sternohyoid muscles is readily seen as they separate before insertion to the sternum. The underlying sternothyroid muscles are then identified and elevated with the sternohyoids on each side. If the thyroid is big, the sternothyroids may become attenuated and stretched and may lie lateral to the midline. Elevation of the sternohyoid and sternothyroid (strap) muscles exposes the plane of the thyroid. Retraction of these muscles provides good access to the thyroid and it is rarely necessary to divide them. (Clip 1: Exposure and retraction of the strap muscles.) (5) Retraction of the upper part of the strap muscles allows the superior pole of the thyroid to be displayed. A useful instrument here is the Dunhill double-angled retractor. The main lobe of the thyroid is retracted downwards medially, a manoeuvre sometimes facilitated by a transfixing suture into the belly of the lobe. The superior thyroid vessels can thereby be exposed. (Clip 2: Display of the superior thyroid vessels.) (6) The external branch of the superior laryngeal nerve, running downwards and medially along the cricothyroid muscle, can often be seen. (Clip 3: Demonstration of the external laryngeal nerve.) The superior thyroid are ligated or clipped and divided separately, care being taken to ensure that there is a substantial cuff of the artery and vein artery distal to the clip or ligature in order to minimise the risk of slippage. In a small percentage of cases, the superior laryngeal nerve runs between the superior artery and vein and could then be damaged if the vessels are not separately ligated. (7) Once the superior pedicle has been divided, the lobe of the thyroid is rolled medially and held in this position with the aid of a dry swab. Lateral retraction of the strap and sternocleidomastoid muscles together with the carotid sheath brings the middle
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(9)
(10)
(11)
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thyroid veins and the border of the gland into view. Once the middle thyroid vein or veins have been divided, the inferior thyroid artery, the parathyroids and the recurrent laryngeal nerve are sought. (Clip 4: Exposure of the superior and inferior parathyroid glands.) The nerve, usually behind but sometimes anterior to the artery, has a distinctive serpiginous blood vessel on its surface and should be traced throughout its cervical course to the point where it dips into the larynx. The small branches of the artery are followed to the surface of the gland, where they are divided. This capsular dissection technique has the advantages of (i) preserving the blood supply to the parathyroid glands, which receive the blood supply from the inferior thyroid artery before its branches enter the thyroid, and (ii) protecting the recurrent laryngeal nerve and the parathyroid glands from inadvertent damage. At this stage the full cervical extent of the recurrent laryngeal nerve can be traced. (Clip 5: The recurrent laryngeal nerve exposed throughout its cervical extent to its entry to the larynx.) The remaining attachment of the upper pole by the ligament of Berry can be safely divided with a pointed blade, the nerve being displaced laterally. Attention is then turned to the inferior thyroid veins as they run vertically from the lower part of the gland. (Clip 6: Demonstration of the inferior thyroid veins before they are divided). After these have been divided, the lobe is almost completely free. Steps 5–8 are repeated on the contralateral lobe. (Clip 7: Dissection of the contralateral recurrent laryngeal nerve from metastatic lymph nodes.) The entire gland, which is now fully mobilised, is dissected off the trachea from inferior to superior by sharp dissection. The gland is now attached only by the pyramidal lobe. (Clip 8: Display of the total thyroidectomy specimen attached only by the pyramidal lobe.) Holding the thyroid away from the trachea allows the pyramidal lobe to be traced upwards and removed completely and en bloc with the rest of the thyroid. Care is taken to ensure complete haemostasis. A small ooze of venous blood sometimes occurs near where the recurrent
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laryngeal nerve enters the larynx. This can readily be stopped with a pledget of gauze. Use of diathermy near the nerve should be avoided. (12) Prospective studies have demonstrated that the use of vacuum drains following thyroidectomy is of no particular benefit, yet the practice remains common as a small amount of blood is almost always collected in vacuum drains during the first few hours after the operation. (13) The strap muscles are reunited with absorbable interrupted sutures, the platysma is similarly sutured and a subcuticular 4/0 or 5/0 suture is inserted. A loose dressing is applied.
REFERENCES 1. Harness JK, Fung L, Thompson NW, et al. (1986) Total thyroidectomy: complications and technique. World J Surg 10(5): 781–786. 2. Delbridge L, Reeve TS, Khadra M, Poole AG. (1992) Total thyroidectomy: the technique of capsular dissection. Aust N Z J Surg 62(2): 96–99. 3. Reeve TS, Thompson NW. (2000) Complications of thyroid surgery: how to avoid them, how to manage them, and observations on their possible effect on the whole patient. World J Surg 24(8): 971–975. 4. Wheeler MH. (1998) The technique of thyroidectomy. JR Soc Med 91(Suppl) 33: 12–16.
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Neck Dissection for Thyroid Cancer † and Jaroslav Betka† ˇ Jan Betka∗,† , Petr Lukeš† , Zdenˇek Cada
The importance of treating lymph node metastasis of thyroid papillary and follicular carcinoma is still controversial. The extent of treatment of lymph node metastasis of papillary and follicular carcinoma is still being discussed and many different points of view on this subject still exist. The first problem to discuss is: Is it beneficial to treat lymph-nodemetastatic involvement? There is not even a general consensus about the importance of lymph-node-metastasic involvement in the currently used classification and staging system for differentiated thyroid carcinoma. Lymph-node-metastatic involvement is not even included in some of the prognostic criteria. For example, the criteria being used at the Mayo Clinic, called MACIS, include as prognostic criteria distant metastasis, patient age, completion of resection, local invasion and tumour size. So lymph nodes are not included. Another prognostic schema, called GAMES, is used by the Memorial Sloan-Kettering Cancer Center. In their GAMES scoring system, G is for Grade, A for Age of the patient when the tumour is discovered, M for Metastase of the tumour (other than neck LN), E for Extent of the primary tumour ∗ Corresponding
author. of Otorhinolaryngology and Head and Neck Surgery, 1st Faculty of Medicine, Faculty Hospital Motol, Postgraduate Medical School, Charles University in Prague. E-mail:
[email protected]. † Department
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and S for Size of the tumour. So, again, lymph node metastases are missing. In the sixth edition of the American Joint Committee on Cancer (AJCC), 2002, it is already seen that authors started to imagine the importance of metastasic spread into the regional lymph nodes for treatment of differentiated thyroid carcinoma. They divide the N status more accurately than for previous classifications: N No: metastatic nodes N1: regional lymph node metastasis N1a: metastases in ipsilateral cervical lymph node(s) N1b: metastases in bilateral, midline or contralateral cervical or mediastinal lymph node(s); unifocal T1 (≤ 1 cm) N0M0 and no extension beyond the thyroid capsule In accordance with this system, the panel on European consensus for the management of patients with differentiated thyroid carcinoma agreed to group patients into three risk categories at the time of initial treatment. The lymph nodes play an important role in this division. These groups are: Very low risk: unifocal T1 (−1 cm) N0M0 and no extension beyond the thyroid capsule or T2N0M0 or multifocal T1N0M0 Low risk: T1 (> 1 cm) N0M0 or T2N0M0 or multifocal T1N0M0 High risk: any T3 and T4 or any T, N1 or any M1 Not all authors believe that lymph node involvement in differentiated thyroid carcinoma has little or no importance for the final result on treatment of thyroid carcinoma. Massaferi.1,2 states that radical surgery can positively influence overall survival and that current tumour staging systems are too inaccurate to guide surgery. He believes, on the basis of his long-time observations and similar studies, that an aggressive approach to initial management and follow-up may render nearly 90% of the patients permanently tumour-free. Lin3 analysed patients with lymph node involvement and postulated, that it did not influence the survival rate, but that patients with poor prognostic factors needed more aggressive treatment to avoid progression
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of the cancer. Lymph node metastases can develop even in early stages of thyroid carcinoma.4 Patients with positive lymph nodes have a higher recurrence risk, but no significant increase in death. Surgical radicalness and technique can positively influence the survival of patients with papillary thyroid cancer.5 Even European consensus placed all patients with positive lymph nodes in the high risk group.8 In conclusion, we currently feel that radical surgery can positively influence recurrence risk and maybe even survival of patients. The next problem is: Who is indicated for lymph node surgery? Wada6 writes in his article that patients with differentiated carcinoma who had lymphonodopathy, which is palpable, should have therapeutic node dissection. Palpable disease in the lateral neck is widely accepted as an indication for neck treatment by many others. The problem starts when positive nodes are not palpable. Currently, ultrasonography is the most accurate imaging technique for the detection of suspicious cervical lymph nodes as small as a few millimetres in diameter. Ultrasonographic features suggestive of malignant lymph nodes depend on typical appearance, size, shape, hypervascularity and internal architecture. A rounded lymph node or one causing a mass effect is also at elevated risk of being malignant. Lymph nodes with short axis measuring more than 7 mm should be considered suspicious. Yasuhiro7 advocated that neck treatment is not indicated in a group of patients without lateral node metastasis detected by ultrasonography preoperatively. Many other papers support this experience and neck dissection is not indicated as elective surgery. Prophylactic node dissection is not beneficial to those without palpable or ultrasonographically suspicious neck lymphonodopathy. Ultrasonography is ideally connected with fine needle aspiration biopsy. This technique in the experienced hands of a trained cytologist can give an accuracy of about 95%. The next indication for neck intervention can be preoperatively proven and by frozen section verified positive metastatic lymph node. In conclusion, compartment-oriented dissection of lymph nodes should be performed in cases of preoperatively suspected and/or
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intraoperatively proven lymph node metastases. The rationale for this surgical approach is based on evidence that radical primary surgery has a favourable impact on survival in high-risk patients, and on the recurrence rate in low-risk patients. On the other hand, there is little benefit from prophylactic (elective) surgical nodal treatment in the absence of pre or intraoperative evidence for nodal disease. There is no evidence that it improves recurrence or mortality rates, but it may be better and an accurate staging of the disease that may guide subsequent treatment and follow-up.
SURGICAL MANAGEMENT AND TECHNIQUE The standard procedure for treatment of lymph node metastases is posterolateral and central compartment neck dissection.9 Posterolateral neck dissection refers to the removal of lymph nodes at levels II–V — basically all nodal groups except levels IA and IB (Fig. 1). The standard procedure is selective modified posterolateral neck dissection with preservation of the non-lymphatic structures: the spinal accessory nerve, internal jugular vein and sternocleidomastoid muscle.10 The procedure is carried out under general anaesthesia. The surgical field must not be sterilised with iodine solution, as this would compromise radioiodine uptake. The skin incision is a combination of classical horizontal (for thyroidectomy) continuing to mastoid on the operated side. It is possible to also make a single horizontal long incision. This incision is cosmetically more favourable, but there is difficulty in making it reach all parts of the surgical field. Next is elevation of the skin flaps together with platysma muscle, and the deep neck fascia is exposed. The fascia is separated from sternocleidomastoid muscle and included in the dissection. The dissection usually starts cranially. The great auricular nerve is identified and the spinal accessory nerve is separated, and both are saved. Compartments IIA and IIB are dissected, and the cervical/brachial plexus is exposed and the lateral cervical triangle cleared. The transverse cervical artery and
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FIGURE 1 Lateral view of neck compartments.
vein can usually be spared. The space above the clavicle is very important (compartment VB), as metastatic lymph nodes can be hidden in fatty tissue here. The anterocranial border of the dissection is the submandibular salivary gland and we identify the hypoglossal nerve and lymph nodes with fatty tissue from the carotid and jugular sheet. The vagus nerve comes into view and all structures are isolated gently and followed caudally (Fig. 2). If the en-bloc dissection is connected with thyroidectomy, it is the time to identify the superior thyroid vascular pedicle and ligate it, preferably just above the lateral lobe of the thyroid gland. This secures the superior laryngeal nerve. Dissecting the anterior border of compartments III and VI, we open up space around the laryngeal recurrent nerve, which must be identified and spared. Also, both parathyroid glands are visible and must be separated from the thyroid gland and neck dissection tissue from the anterior aspect, as both have blood supply from the inferior thyroid artery, which
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FIGURE 2 Posterolateral neck dissection.
gives them a connection from the inferior aspect. In this area there is no strict anatomical borderline between compartment IV and compartment VI. Sternocleidomastoid muscle is elevated and tissue from the lateral triangle is removed together with the specimen, taking the subclavian vessels as the caudal border. If the surgery continues with thyroidectomy, the specimen can be left with a connection to the thyroid gland (Fig. 3). It is recommended that there be negative suction for two days after surgery. Central compartment neck dissection refers to the bilateral removal of lymph nodes surrounding the midline visceral structures of the anterior neck — level VI. The lymph nodes include the preand paratracheal, the precricoid (Delphian) and the perithyroidal. The superior limit of the dissection is the hyoid bone, the inferior limit is the suprasternal notch, and the lateral limits are the carotid artery sheets. This surgery is preferably performed together with thyroidectomy. If the primary thyroid tumour is having a rupture through
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FIGURE 3 Drain position.
the thyroid capsule, it is indicated to dissect prelaryngeal muscles as sternohyoid, sternothyroid and thyreoglossus. Dissection below the hyoid bone lateral borders are carotid arteries and compartment IV. We have to the pay meticulous attention to the recurrent laryngeal nerve and especially the inferior parathyroid gland, where blood supply can be in danger. The next important structure is the thoracic duct, and it is usually ligated to prevent postoperative lymphorrhoea. The dissection runs caudally, following as the lateral border both carotid arteries, and ends below the suprasternal notch following the tracheal rings (Fig. 4). In young patients we meet the apex of the thymus
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FIGURE 4 Frontal view of central neck dissection.
gland, and it can be dissected. After finishing dissection we should ask the anaesthesiologist to perform positive thorax pressure to make sure that there is no bleeding from mediastinal vessels. Before suture, negative suction is inserted.
COMPLICATIONS Permanent hypocalcaemia can be seen in 3–5% of operative cases. It is more likely to develop after bilateral posterolateral and central neck dissection with total thyroidectomy. It can be due to revascularisation of parathyroid glands or their accidental removal. It is more likely to remove or injure the inferior parathyroid glands. If a parathyroid gland is removed, it must be implanted back into the muscle. Before implantation, the parathyroid gland is divided by a sharp instrument into small cubes not larger than 1 mm. The implanted parathyroid
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tissues are integrated and have blood supply from the surrounding muscle bed. The second-most-common complication is recurrent laryngeal nerve injury. It is reported to be about 1–2% and is more likely with more excessive surgery. To prevent nerve injury the recurrent nerves must be identified, and the vascular bed of the nerves must be respected. Routine use of a neurostimulator to identify the recurrent nerves is recommended. If bilateral vocal cord palsy occurs, it is an indication for immediate surgical revision under the guidance of a thyroid surgical expert. Future development will probably focus on minimising surgical complications. It can be predicted that there will be routine use of magnifying loops or microscopes for a better understanding of the operative field. The nerve neurostimulator will be a routine tool in every operating theatre. Endoscopically assisted surgery can avoid the necessity for large incisions, and a well-illuminated and magnified surgical field can be beneficial in avoiding surgical complications.
REFERENCES 1. Mazzaferri EL. (1999) An overview of the management of papillary and follicular thyroid carcinoma. Thyroid 9(5): 421–427. 2. Mazzaferri EL. (2007) Management of low-risk differentiated thyroid cancer. Endocr. Pract. 13(5): 498–512. 3. Lin JD, Liou MJ, Chao TC, et al. (1999) Prognostic variables of papillary and follicular thyroid carcinoma patients with lymph node metastases and without distant metastases. Endocr Relat Cancer 6(1): 109–115. 4. Reddy RM, Grigsby PM, Moley JF, Hall BL. (2006) Lymph node metastases in differentiated thyroid cancer under 2 cm. Surgery 140(6): 1050– 1054. 5. Roh J-L, Park J-Y, Park CI. (2007) Total thyroidectomy plus neck dissection in differentiated papillary thyroid carcinoma patients. Ann Surg 245(4): 604–610.
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6. Wada N, Duh QY, Sugino K, et al. (2003) Lymph node metastasis from 259 papillary thyroid microcarcinomas: frequency, pattern of occurrence and recurrence, and optimal strategy for neck dissection. Ann Surg 237(3): 399–407. 7. Yasuhiro I, Chisato T, Takashi U, et al. (2004) Preoperative ultrasonographic examination for lymph node metastasis: usefulness when designing lymph node dissection for papillary microcarcinoma of the thyroid. World J Surg 28(5): 498–501. 8. Pacini F, et al. (2006) European consensus for the management of patients with differentiated carcinoma of follicular epithelium. Eur J Endocrinol 154: 787–803. 9. Astl J. (2007) Surgical Treatment of Thyroid Gland Diseases, Maxdorf, Ed. Jessenius, Prague, p. 208 (in Czech). 10. Betka J, Mrzena L, Astl J, et al. (1997) Surgical treatment strategy for thyroid gland carcinoma nodal metastases. Eur Arch Otorhinolaryngol 254(Suppl 1): S169–S174.
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Total Laryngectomy Mohssen Ansarin† , Augusto Cattaneo† and Fausto Chiesa∗,†
INTRODUCTION The first total laryngectomy (TL) was performed by Billroth, in 1873,1 while Bottini2,3 was the first surgeon to carry out a laryngectomy for cancer, in 1875. The separation of the trachea from the larynx to create an end stoma and the primary closure of the pharynx was performed by Gluck in the early 1900.4 Between 1920 and 1950, radiotherapy was the treatment of choice.5 From 1950, TL was the gold standard for the treatment of advanced or recurrent laryngeal carcinomas.6 Between the end of the last century and the beginning of the third millennium TL played a restricted role in the management of untreated advanced laryngeal cancer owing to the progressive increase of non-surgical therapies, the so-called organ preservation schedules: neoadjuvant chemotherapy followed by radiotherapy or concomitant chemoradiation treatment.7 Hoffman in 2006 reported a decreasing survival rate among patients with laryngeal cancer during the last two decades in the US.8 In his opinion these poor results could be explained by the increasing use of conservative treatment modalities (i.e. selective neck dissection, conservative surgical techniques such as laser resection and organ preservation schedules). ∗ Corresponding
author. and Neck Department, European Institute of Oncology, Milan, Italy. E-mail:
[email protected] † Head
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Today TL remains the gold standard therapy for laryngohypopharyngeal cancers in the following cases: (a) advanced squamous cell carcinoma (SCC) or other non-epithelial tumours of the larynx with massive invasion of the cartilage framework; (b) recurrences after chemo-radiotherapy; (c) recurrence after conservative laryngectomy; (d) as an emergency procedure in massive airway obstructive tumours or in rare complications of previous treatments such as chondro-radionecrosis. Before performing a TL, we must also consider the potential metastatic spread of laryngeal carcinoma to the cervical lymph nodes. The supraglottic area has a rich lymphatic network and about 50% of T1–T4 tumours of this area develop metastases into the cervical nodes. However, glottic carcinoma has a low rate (50% in selected patients.1 Due to significant improvements in liver surgery techniques, the possibility of curative hepatectomy is determined only by the extent of the resection in relation to the remnant liver volume. Resection of up to 75% of normal parenchyma can be performed without the risk of postoperative liver failure.2 Clearly, the most important indication for extended hepatectomy is the presence of extensive intrahepatic tumour, caused by either multinodular bilobar disease or large tumour size. Additionally, lesions
∗ Corresponding
author. Hôpital Paul Brousse, Centre Hépato-Biliaire, 12 Avenue Paul Vaillant Couturier, F-94804 Villejuif, France. E-mail:
[email protected] ‡ Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands. § Inserm, Unité 785, F-94804 Villejuif, France. Université Paris-Sud, UMR-S 785, F-94804 Villejuif, France. ¶ Liver Transplant Unit, Saint Vincent’s University Hospital, Dublin 4, Ireland. †AP-HP
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closely related to vascular or biliary structures may require larger resections. Extended hepatectomies can currently be performed with low mortality and acceptable morbidity, not so different from those reported overall for liver resections.3 The classification of extended hepatectomies is based on the segmental liver anatomy described by Couinaud.4 Extended hepatic resections are defined as resections exceeding the boundaries of a normal right (segments V–VIII) or left (segments II–IV) hepatectomy and are divided into six different types. Right hepatectomies can be extended to segment IV, segment I, or both [Figs. 1A–1C]. Similarly, extended left hepatectomies may include segment I, segments V and VIII, or segments I,V and VIII [Figs. 2A–2C].
FIGURE 1(A)–1(C) Right hepatectomy extended to segment IV (A), segment I (B), and segments I and IV (C).
FIGURE 2(A)–2(C) Left hepatectomy extended to segment I (A), segments V and VIII (B), and segments I, V and VIII (C).
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TECHNIQUE Preoperative Evaluation and Patient Selection Computed tomography and magnetic resonance imaging of the liver are the preferred investigative modalities. Determining the intrahepatic extent of the disease and its relation to important vascular and biliary structures is essential for planning the extensiveness of the resection. The functional capacity of the liver is measured by the indocyanine green (ICG) test, to determine the necessary volume of the remaining liver after hepatectomy. Portal vein embolisation (PVE) may be considered when the remnant liver is too small in relation to the planned resection and the functional capacity. By compensatory hypertrophy of the nonembolised lobe, the future liver remnant may increase to a sufficient volume enabling resection.5 In general, to perform a safe resection, the remnant liver should have >30% of functional parenchyma in the absence of prolonged chemotherapy and normal ICG clearance. On the other hand, for patients who have had prolonged chemotherapy or abnormal ICG clearance, the functional parenchyma volume should be >40%.
Surgical Procedure A bilateral subcostal incision with a vertical extension is widely employed for extended liver resections. Once the abdomen is entered, thorough exploration is performed to identify all hepatic and extrahepatic disease, and if there are no contraindications to resection, liver mobilisation should start. At this point, it is important to use intraoperative ultrasound to define the resection plane correctly, which is a crucial step of the procedure.
Extended Right Hepatectomy The initial steps of this procedure are identical to those of a right hepatectomy. In addition, supplying vessels to segment IV should be
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divided. This is done by transecting the parenchymal bridge between segments III and IV, followed by dissection on the right side of the ligamentum teres, identifying and suture-ligating all the portal branches with the accompanying arteries and ducts. In resections where segment I has to be included, its mobilisation is achieved by rotating the right lobe medially. The exposed hepatic veins can be divided and ligated from below upwards. The dissection is then continued on the lateral side of the inferior vena cava (IVC) dividing the draining veins of segment I under direct vision. This manoeuvre leaves the liver attached only on the main hepatic veins. The operation continues with the hilar dissection in order to divide the feeding vessels to segment I which arise from the left hepatic artery and vein.6 Another described approach involves anterolateral dissection; however, this is technically more difficult and surgeons often adopt a combination of approaches.7 The parenchyma is divided progressing posteriorly towards the junction of the right hepatic vein with the IVC. Transection is usually done by using an ultrasonic dissector. Hemostasis of the cut liver surface is secured by suture-ligation combined with a bipolar or argon beam. During this stage, using a tape along the retrohepatic surface can be useful in controlling the direction of the transection.
Extended Left Hepatectomy The initial steps are the same as for a left hepatectomy. Before defining the plane of parenchymal transection, it is important to complete two manoeuvres involving the portal triad and the common trunk of the middle and left hepatic vein. The structures of the portal triad are dissected above the origin of the feeding vessels to segment I, to secure and preserve them intact. However, if segment I has to be included in the resection, both bile duct and portal vein are ligated and divided close to the hilum. Further dissection continues to control the right anterior and posterior sectorial pedicle. Once this step is completed, the hepatic veins are dealt with. Their control, which is usually done
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in their extrahepatic portion, is very important as it facilitates the later parenchymal transection and reduces blood loss. After a complete left lobe mobilisation and medial retraction, further dissection between the left hepatic vein (top of the caudate lobe) and the IVC opens a window which allows complete control of the middle and left hepatic vein. The parenchymal resection is done in an upward direction. Defining the resection plane is important, as it allows the preservation of the posterior sectorial pedicle which supplies segments VI and VII. Usually, this plane runs anterior to the right hepatic vein extending horizontally to the right of the gallbladder fossa. Early clamping of the anterior sectorial pedicle can be useful, as it better defines the line of resection by producing a clear parenchyma demarcation.
Haemorrhage Control Despite technical refinements, operative bleeding still remains a concern, clearly being an independent risk factor in the postoperative outcome.8 Inflow clamping is the most used technique to reduce blood loss. Vascular pedicles can be divided either during the preliminary portal dissection or during the division of the parenchyma. For complex hepatic resections where bleeding is anticipated, total vascular exclusion with or without IVC clamping and venovenous bypass can be useful.9,10 This approach has the advantage of eliminating bleeding as well as enabling vascular reconstruction. Obviously, vascular exclusion without clamping the IVC is the preferred approach as it avoids the negative consequences of IVC clamping [Fig. 3A]. When such a step is not feasible, for example in case of proximity of the tumour to the hepatic vein confluence, a true lobe ischaemia with IVC clamping should be performed [Fig. 3B]. A test clamp lasting 5 minutes should be done to see if the haemodynamic changes are tolerated by the patient. If IVC clamping is not tolerated, venovenous bypass remains the only available option through which resection can be done [Fig. 3C].
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FIGURE 3(A)–3(C) Selective total vascular exclusion of the liver (A). Total vascular exclusion with clamping of interior vene cava (B). Total vascular exclusion combined with venous bypass (C).
DISCUSSION Resection of primary and metastatic liver lesions depends solely on the technical ability to resect the total number of lesions, while leaving a sufficient volume of remnant parenchyma. Accordingly, preoperative PVE can be used to facilitate such resections. For extended right and left hepatectomies, the control of supplying vessels to segments I and/or IV, and segments I and/or V and VIII, respectively, is a very important step to consider. Measures aimed at reducing blood loss, such as intermittent selective portal clamping and total vascular exclusion with or without bypass, should always be considered when performing extended hepatectomies.
REFERENCES 1. Simmonds PC, Primrose JN, Colquitt JL, et al. (2006) Surgical resection of hepatic metastases from colorectal cancer: a systematic review of published studies. Br J Cancer 94: 982–999.
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2. Vauthey JN, Chaoui A, Do KA, et al. (2000) Standardized measurement of the future liver remnant prior to extended liver resection: methodology and clinical associations. Surgery 127: 512–519. 3. Vauthey JN, Pawlik TM, Abdalla EK, et al. (2004) Is extended hepatectomy for hepatobiliary malignancy justified? Ann Surg 239: 722–732. 4. Couinaud C. (1957) Le foie: études anatomiques et chirurgicales. Masson et Cie, Paris. 5. Azoulay D, Castaing D, Smail A, et al. (2000) Resection of nonresectable liver metastases from colorectal cancer after percutaneous portal vein embolization. Ann Surg 231: 480–486. 6. Yamamoto J, Takayama T, Kosuge T, et al. (1992) An isolated caudate lobectomy by the transhepatic approach for hepatocellular carcinoma in cirrhotic liver. Surgery 111: 699–702. 7. Elias D, Lasser PH, Desruennes E, et al. (1992) Surgical approach to segment I for malignant tumors of the liver. Surg Gynecol Obstet 175: 17–24. 8. Jarnagin WR, Gonen M, Fong Y, et al. (2002) Improvement in perioperative outcome after hepatic resection: analysis of 1803 consecutive cases over the past decade. Ann Surg 236: 397–407. 9. Cherqui D, Malassagne B, Colau PI, et al. (1999) Hepatic vascular exclusion with preservation of the caval flow for liver resections. Ann Surg 230: 24–30. 10. Shaw Jr BW, Martin DJ, Marquez JM, et al. (1984) Venous bypass in clinical liver transplantation. Ann Surg 200: 524–534.
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Isolated Hepatic Perfusion: How It Should Be Done Alexander L. Vahrmeijer† , Liselot B. J. van Iersel‡ , Peter J. K. Kuppen† and Cornelis J. H. van de Velde∗,†
INTRODUCTION Isolated hepatic perfusion (IHP) is based on the expectation that tumour cells confined to the liver can be killed by drug doses that would kill a patient if delivered systemically but will not cause fatal hepatotoxicity. Based on pre-operative CT scans, and when necessary MRI or PET scans in difficult cases, patients with irresectable metastases confined to the liver are considered for IHP treatment. Most experience is obtained in patients with irresectable colorectal cancer hepatic metastases.1–5 An obvious limitation of IHP is that its effect totally depends on a high peak concentration during a relatively short exposure time: the duration of IHP is usually limited to one hour. Alkylating compounds like the most frequently used drug, Melphalan ∗ Corresponding
author. of Surgery, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands. E-mail:
[email protected] ‡ Medical Oncology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands. † Department
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(L-PAM), are effective after a relatively short exposure time and show a steep dose–response relationship, and are therefore a logical choice for testing in an IHP setting. Throughout the perfusion period, systemic leakage should be avoided and an accurate leakage detection system is absolutely necessary.
TECHNIQUE OF IHP The liver is mobilised from the diaphragm through a hockey-stickshaped abdominal incision. Ultrasonography should be performed in order to prove irresectable disease and to exclude extrahepatic pathology. Moreover, one should estimate the amount of normal liver tissue, which should be at least 40% to prevent post-operative liver failure. Adequate mobilisation of the liver is mandatory. The round ligament is divided and the falciform ligament is dissected over its full length, just anterior to the inferior vena cava (IVC). The superior ligamentous attachments and the triangular ligaments are divided. The right adrenal gland should be separated from the liver and the adrenal veins are ligated. Mobilisation of the liver continues until the IVC is fully exposed (Fig. 1). Lumbar veins are ligated
FIGURE 1 Dissected inferior vena cava prior to cannulation.
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FIGURE 2 Dissected hepatoduodenal ligament prior to cannulation.
to prevent systemic leakage of perfusate. The gastrohepatic ligament should be dissected and inspected for a replaced left hepatic artery. The latter is extremely important, because in eight patients treated via the portal vein only at our institution, no tumour response was observed. Therefore, infusion of chemotherapy via the hepatic artery is absolutely necessary. At present, aberrant arterial anatomy is a contraindication for IHP. The common bile duct, the portal vein and the common hepatic artery are dissected over an adequate length in the hepatoduodenal ligament (Fig. 2). After heparinisation, the common hepatic artery is cannulated via the gastroduodenal artery (8-Fr 77008 one-piece pediatric arterial cannula; Medtronic, Minneapolis, Minnesota, USA). Subsequently, the portal vein is cannulated (12Fr perfex perfusion catheter). Both inflow limbs are connected to a heart–lung machine which consists of two independent roller pumps (model 10-30-00; Cobe/Stöckert, Munich, Germany). The inflow in the hepatic artery and portal vein is usually about 360 and 330 ml/min respectively.1 The IVC is cross-clamped above the hepatic veins, just
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below the diaphragm, and cannulated proximal of the renal veins (Polystan 36-Fr, straight, A/S; Värlöse, Denmark) to allow undisturbed blood flow from the hepatic veins through the IVC towards the heart–lung machine. The perfusion medium consists of intrahepatically trapped blood and 1250 mL Gelofusine (Vifor Medical, Sempach, Switzerland) plus 2500 units heparin (Leo Pharma, Breda, The Netherlands) to yield a final volume of approximately 2 litres. Throughout the 1 h perfusion period, the perfusate is kept at a temperature of 39.5◦ C by a heat exchanger and oxygenated using an oxygenator (Cobe VPCML; Cobe Cardiovascular, Arvada, Colorado, USA, or Dideco D901; SORIN group Italia, Mirandola, Italy). To isolate the hepatic circuit, tourniquets are secured around the hepatic artery, portal vein and IVC above the right renal vein. Blood from the IVC below the tourniquet and from the mesentery is shunted by applying a venovenous bypass. For the extracorporeal venovenous bypass, the right femoral vein (22-Fr cannula DIITF022L; Edwards Lifesciences, Irvine, California, USA) and the portal vein (17-Fr perfex perfusion catheter CH17; B. Braun) (proximal to the tourniquet) are cannulated and connected to the right axillary vein (18-Fr 7326 perfusion cannula; Lifestream International, The Woodlands, Texas, USA). The venovenous bypass is supported by a centrifugal pump (Medtronic BIO-Medicus, Eden Prairie, Minnesota, USA) and primed with 700 mL 0.9% saline.
SAFETY Leakage of perfusate into the systemic circulation is monitored using a 99m Technetium-pertechnetate (99m Tc)-based method that is adapted from a method described by Runia et al.6 Before isolation of the liver, tin pyrophosphate (1 mg in 2 ml of PBS) (Technescan Pyp, Mallinckrodt Medical) is intravenously injected. This will bind 99m Tc to red blood cells: detection of leakage is based on measurement of leakage
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FIGURE 3 bypass.
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of erythrocytes from the isolated circuit to the systemic circulation. After 15–30 min, the liver is isolated from the systemic circulation as described above. Next, 10 MBq 99m Tc is added to the isolated circuit. The level of radioactivity is measured continuously by two detectors (NaI scintillation counters, model 51S51, efficiency 15.5%; Canberra, Cedex, France) — one placed above the tube of the venovenous bypass and the other above the tubing that directs blood flow from the liver (vena cava) to the heart–lung machine (Fig. 3). The detectors are shielded from the background using a cover of lead 1 cm thick. Tubing under the detector is winded to increase the detection volume in order to increase sensitivity. The volume under the systemic detector is 10.4 ml and under the isolated circuit detector 5.5 ml. Special
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software, based on the algorithms described by Runia et al.6 has been developed (Canberra Eurisys Benelux, Zellik, Belgium) for real time monitoring of leakage with a sensitivity of 4 mm) primary melanoma. Ann Surg Oncol 5: 322–328. 4. Ng AKT, Jones WO, Shaw JHF. (2001) Analysis of local recurrence and optimizing excision margins for cutaneous melanoma. Br J Surg 88: 137–142. 5. Lens MB, Dawes M, Goodacre T, et al. (2002) Excision margins in the treatment of primary cutaneous melanoma: a systematic review of randomized controlled trials comparing narrow vs wide excision. Arch Surg 137: 1101–1105. 6. Haigh PI, DiFronzo LA, McCready DR. (2003) Optimal excision margins for primary cutaneous melanoma: a systematic review and meta-analysis. Can J Surg 46: 419–426.
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7. Tsao H, Atkins MB, Sober AJ. (2004) Management of cutaneous melanoma. N Engl J Med 351: 998–1012. 8. Farshad A, Burg G, Panizzon R, et al. (2002) A retrospective study of 150 patients with lentigo maligna and lentigo maligna melanoma and the efficacy of radiotherapy using Grenz or soft X-rays. Br J Dermatol 146: 1042–1046.
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Ilioinguinal Dissection for Melanoma Alessandro Testori∗,† and Mark Zonta†
INTRODUCTION Ilioinguinal dissection for melanoma is indicated for positive sentinel nodes following selective lymphadenectomy or for palpable, histologically positive groin nodes. The procedure provides important staging information, helps with decision-making regarding adjuvant treatment, affords regional disease control and may be curative in patients without distant metastases. Several retrospective studies have demonstrated the importance of deep inguinal and pelvic lymphadenectomy in patients with superficial nodal involvement only.1–5
TECHNIQUE Under general anaesthesia and antibiotic prophylaxis, a urinary catheter is inserted and the patient is positioned supine, with the ipsilateral lower limb slightly abducted to flex the knee. ∗ Corresponding † Division
author. of Melanoma and Soft Tissue Sarcoma, European Institute of Oncology,
Italy. † European Institute of Oncology, via Ripamonti 435, 20141 Milano, Italy. E-mail:
[email protected] 223
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The operative field is prepared with a small drape to exclude the genitals from the sterile field and to shift the genitals (male) contralaterally. The remaining drapes are positioned to expose an area from just superior of the iliac crest to just inferior of the apex of the femoral triangle. Various skin incisions have been described. We employ either a curvilinear elliptical incision from just medial of the iliac crest to the apex of the femoral triangle, or separate incisions including a curvilinear elliptical infrainguinal incision and an oblique iliac fossa incision (Fig. 1). The incisions incorporate the previous biopsy site and skin overlying palpable nodes. A lateral subcutaneous flap is mobilised until the medial border of the sartorius is exposed after incising the overlying fascia and sparing the lateral femoral cutaneous nerve. This flap is at least 0.5–1 cm thick, to avoid rendering it ischaemic. The superficial epigastric and superficial circumflex iliac vessels, the anterior saphenous vein and
FIGURE 1 Preoperative photo showing an iliac fossa incision to approach the deep pelvic nodes and an elliptical infrainguinal incision incorporating the previous sentinel node biopsy site.
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the intermediate femoral cutaneous nerve are encountered as this flap is mobilised along its full length. A medial flap of similar thickness is mobilised to the medial border of the adductor longus. In males it is necessary to identify and retract the spermatic cord medial to the dissection. Below the pubic tubercle, the fascia over the medial border of the adductor longus is incised and dissected off this muscle and the pectineus after securing the external pudendal vessels, the accessory saphenous vein and the long saphenous vein. The suprainguinal lymph nodes are then dissected from the underlying external oblique to the level of the inguinal ligament. The femoral sheath is incised below the ligament and the femoral vein is identified just deep to the lateral border of the adductor longus. The vein is skeletonised of its adventitia and nodal tissue and the saphenofemoral junction is suture-ligated and divided. Unless there is gross disease involving the long saphenous vein, some surgeons preserve it to facilitate subsequent drainage of the limb. The femoral artery is identified immediately lateral to the femoral vein and is similarly skeletonised. The leash of motor branches of the femoral nerve are in a deeper plane and not usually exposed. The specimen is divided at the femoral canal, as there is no proven benefit in maintaining its continuity with the deep pelvic nodes. Various approaches to these nodes have been proposed. We employ a pararectus approach without dividing the inguinal ligament. The inguinal ligament is retracted to allow dissection between it and the femoral vessels, and to secure the inferior epigastric vessels. This will facilitate blunt separation of the peritoneum from the abdominal wall and external iliac nodes once the ligament is suspended and the abdominal wall divided along the lateral border of the rectus abdominis muscle. The retroperitoneal iliac fossa is exposed until the bifurcation of the common iliac artery and the ureter are identified. Retractors are positioned into the pelvic wound to maintain adequate exposure.
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The nodal dissection then continues from the common femoral vessels to the bifurcation of the common iliac artery. This involves incising the adventitia of the anterior surface of the external iliac artery and vein, and dissecting the nodal tissue from them and towards the obturator fossa until both vessels have been circumferentially skeletonised. Proceeding cephalad, the vessels encountered during this phase of the dissection include the deep circumflex iliac vessels coursing laterally, the inferior epigastric vessels medially, and a variable communicating vein between the external iliac and obturator veins. Only the deep circumflex vessels can be preserved, as they do not impede the dissection. Care is needed in identifying and dividing the communicating vein, because its inadvertent laceration can cause troublesome bleeding. Once the common iliac bifurcation has been reached, an orientation suture is secured to the most proximal lymph nodes. The cephalad retroperitoneal lymphatics are ligated to reduce postoperative lymphorrhoea. Dissection of the obturator nodes is then initially performed to safely identify and preserve the obturator nerve posteriorly, and to dissect the lymphatic structures immediately cephalad to the pelvic wall. The bladder is dissected off the medial aspect of the obturator nodes and sponge-holding forceps are used to remove the remaining nodal tissue from deep within the pelvis whilst always visualising the nerve (Fig. 2). The obturator dissection is considered adequate when the branches of the internal iliac artery have been exposed. Following haemostasis a retroperitoneal pelvic drain is positioned via the groin. The peritoneal sac is re-positioned and the abdominal wall is closed in two layers including the transversalis fascia and external oblique aponeurosis. To prevent a femoral hernia, non-absorbable monofilament interrupted sutures are placed between Cooper’s ligament and the inguinal ligament. Some surgeons, including ourselves, recommend dividing the sartorius at its origin and rotating the muscle to cover the femoral vessels (Fig. 3), as this wound may be complicated
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FIGURE 2 Operative photo after deep pelvic lymphadenectomy with the external iliac artery (broad arrow) and vein (narrow white arrow) and obturator nerve (black arrow) exposed.
FIGURE 3 The sartorius is mobilised on its preserved blood supply to be rotated over the femoral vessels.
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by flap necrosis. The viability of each flap is assessed before closing the subcutaneous tissue with a continuous absorbable suture and the skin with interrupted sutures.
DISCUSSION The difference in morbidity by the addition of a pelvic dissection to an inguinal dissection is slight.6 In patients with microscopically positive superficial sentinel nodes, the incidence of deep nodal involvement may be substantial,7 and the incidence is even higher in the presence of palpable inguinal nodal metastases.8 Therefore, ilioinguinal dissection is justified for these patients and is vitally important for those with positive deep nodes and no distant metastases.
REFERENCES 1. Mack LA, McKinnon JG. (2004) Controversies in the management of metastatic melanoma to regional lymphatic basins. J Surg Oncol 86: 189–199. 2. Tonouchi H, Ohmori Y, Kobayashi M, et al. (2004) Operative morbidity associated with groin dissections. Surg Today 34: 413–418. 3. Mann GB, Coit DG. (1999) Does the extent of operation influence the prognosis in patients with melanoma metastatic to inguinal nodes? Ann Surg Oncol 6: 263–271. 4. Hughes TM, Thomas JM. (1999) Combined inguinal and pelvic lymph node dissection for stage III melanoma. Br J Surg 86: 1493–1498. 5. Strobbe LJ, Jonk A, Hart AA, et al. (2001) The value of Cloquet’s node in predicting melanoma nodal metastases in the pelvic lymph node basin. Ann Surg Oncol 8: 209–214. 6. Karakousis CP, Thompson JF. (2004) Groin and pelvic dissection for melanoma. In: JF Thompson, DL Morton and BB Kroon (eds.), Textbook of Melanoma, pp. 285–295. London, Martin Dunitz. 7. Karakousis CP, Emrich LJ, Driscoll DL, et al. (1991) Survival after groin dissection for malignant melanoma. Surgery 109: 119–126. 8. Karakousis CP, Emrich LJ, Rao U. (1986) Groin dissection in malignant melanoma. Am J Surg 152: 491–495.
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Surgical Treatment of Peritoneal Carcinomatosis Marcello Deraco∗,† , Dario Baratti‡ , Barbara Laterza,‡ Domenico Sabia‡ and Shigeki Kusamura‡
INTRODUCTION About three decades have passed since hyperthermic intraperitoneal chemotherapy (HIPEC) was first conducted by Dr. Spratt.1 In this period the treatment of peritoneal surface malignancy (PSM) with cytoreductive surgery (CRS) and HIPEC has gained enormous popularity, changing positively the expectations for a clinical condition that in former times was considered incurable. Results of phase II studies testing the efficacy of the combination in the treatment of pseudomyxoma peritonei, peritoneal mesothelioma and ovarian cancer have been somewhat encouraging.2−4 Results of a phase III trial have confirmed the superiority of CRS + HIPEC in the treatment of patients with carcinomatosis from colon cancer over other standard surgical and/or systemic chemotherapy modalities.5 The purpose of this article is to provide a short technical description of the local regional therapy of PSM. ∗ Corresponding
author.
† Istituto Nazionale Tumori Milano, Via Venezian 1, 20133 Milano, Itally. E-mail: mar-
[email protected] of Surgery, National Cancer Institute of Milan, Italy.
‡ Department
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TECHNIQUE The eligibility requirements for treatment are as follows: histologically confirmed diagnosis of peritoneal carcinomatosis or sarcomatosis; age < 75 years; no distant metastasis; adequate renal, haematopoietic and liver functions; and performance status (ECOG) 0, 1 or 2. The CRS is performed according to the Sugarbaker technique.6 Patients are put in the supine position with gluteal folds advanced to the break in the operating table. The surgical procedure starts with a xyphopubic, midline incision, and the successive layers of the abdominal wall are dissected until the parietal peritoneum is visualised. The dissection of the parietal peritoneum from the abdominal wall is begun without opening the peritoneal cavity and is continuous until the identification of the vena cava, aorta, iliac vessels and ureters. Then, the parietal peritoneum is incised and full access to the abdominal cavity is achieved. Peritoneal carcinomatosis is quantified according to the Peritoneal Cancer Index.7 The surgical procedure is carried out with one or more of the following steps, depending on disease extension, in order to achieve a residual disease of less than 2.5 mm: (1) greater omentectomy, right parietal peritonectomy ± right colon resection; (2) pelvic peritonectomy ± sigmoid colon resection ± hysteroadnexectomy; (3) lesser omentectomy and dissection of the duodenal–hepatic ligament ± antrectomy ± cholecystectomy; (4) right upper quadrant peritonectomy ± Glisson’s capsule; (5) left upper quadrant peritonectomy ± splenectomy; (6) other intestinal resection and/or abdominal mass resection. The stripping of the right upper quadrant continues until the bare area of the liver. At this point, tumour on the superior surface of the liver is electroevaporated until the liver surface is cleared. In the case of massive tumour implantation on the liver (Fig. 1), the Glisson capsule from the superior surface of the liver can be removed. Dissection continues down to the right subhepatic space. The right
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FIGURE 1 Intraoperative view of extensive peritoneal neoplastic dissemination in the upper abdomen of a pseudomyxoma peritonei patient.
diaphragmatic peritoneum is resected together with the peritoneum layering Morrison’s pouch. The gall bladder is removed from its fundus toward the cystic artery and cystic duct. The triangular ligament of the left lobe of the liver is resected in performing the left subphrenic peritonectomy. This completed, the left lateral segment of the liver is retracted left to right to expose the hepatogastric ligament. A circumferential release of this ligament from the fissure between liver segments 2, 3 and 1, and from the arcade of the right gastric artery to the left gastric artery along the lesser curvature of the stomach, is required. To resect the peritoneum from the anterior aspect of the hepatoduodenal ligament, its reflection to the liver surface is released and the peritoneum peeled away from the common bile duct and hepatic artery. Resection of the lesser omentum is always indicated, even in the absence of metastatic disease in this structure.
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After stripping the left upper quadrant peritoneum from the diaphragmatic muscle, we begin the greater omentectomy ± splenectomy. The greater omentum is elevated, and separated from the transverse colon. This dissection continues beneath the peritoneum that covers the transverse mesocolon, so as to expose the pancreas. The gastroepiploic and the short gastric vessels on the greater curvature of the stomach are clamped, ligated and divided. The peritoneum anterior to the pancreas is stripped. The splenic vessels at the tail of the pancreas are ligated in continuity and proximally suture-ligated. When the upper quadrant peritonectomy is completed, the stomach is reflected medially. Branches of the gastroepiploic arteries are ligated. The left adrenal gland, the pancreas, the left perirenal fatty tissue and the anterior peritoneal surface of the transverse mesocolon are totally exposed. A distal pancreatectomy is performed when required and the transection done using a GIA stapler with reinforcing handsewn separate Vycril 2-0 stitches. Whether a partial or total gastrectomy is performed, a Roux-en-Y reconstruction is indicated. Small bowel and colic anastomoses are hand-sewn in an end-to-end fashion using single-layer extramucosal continuous Maxon 4-0 or 3-0 stitches (Fig. 2). Most of the time the cul-de-sac area is filled with coalescing tumour implants that also include much of the sigmoid colon. A complete pelvic peritonectomy with a low anterior resection is frequently needed to completely remove these tumour implants. The low colorectal anastomosis is performed with an intraluminal stapler of 29–33 mm diameter.
HIPEC Generally speaking, there are two types of HIPEC modalities: the closed and open abdomen techniques. At the National Cancer Institute of Milan the closed technique is used. After cytoreduction, four silicone catheters are placed in the abdominal cavity: one in the right subphrenic cavity: one in the deep pelvis, one in the left
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FIGURE 2 Aspect of the upper abdomen after a radical cytoreduction with partial gastrectomy.
subphrenic cavity and one in the superficial pelvic site cavity. Two thermocouples are placed in the abdominal cavity. Using the closed abdomen technique, the skin is closed with a running suture. The catheters are then connected to the extracorporeal circuit Performer LRT®, RAND, Medolla (MO), Italy. The intraperitoneal chemotherapy regimens used are as follows: Cisplatin (CDDP-25 mg/m2 /L) and Mitomycin C (MMC-3.3 mg/m2 /L), or cisplatin (CDDP-43 mg/L of perfusate) and doxorubicin (Dx-15.25 mg/L of perfusate). A heat exchanger keeps the intracavitary perfusate temperature at 42◦ C to 43◦ C. The HIPEC lasts 60 to 90 minutes, depending on the drug schedule (Fig. 3).
DISCUSSION The local–regional therapy (CRS + HIPEC) has already been standardised and described in detail by its introducer.6 However, the increasing number of surgeons and centres interested in setting up a local–regional therapy unit in the world renders the procedure subject to several modifications.
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FIGURE 3 Extracorporeal circuit in hyperthermic intraperitoneal chemotherapy. This schema represents the extracorporeal circuit in the closed abdomen technique.The perfusate containing the drugs is mobilised by the pump and prepared by the heater up to the temperature of 42.5◦ C. Then, it is infused in the abdominal cavity through two inflow catheters of Tenkhoff (5 and 6). After the circulation inside the abdominal cavity, the perfusate is recovered by the outflow catheters (7 and 8), to be instilled again in the abdomen. The thermostat controls the temperature through four probes located respectively in the upper abdomen (1), lower abdomen (2), outflow (3) and inflow (4) of the circuit.
In December 2006 the National Cancer Institute of Milan organised a consensus statement on the management of PSM. This conference brought together experts in the field of local–regional therapy to discuss current approaches to PSM. The consensus was achieved with several conflicting points regarding the technical variations of CRS.8 The main conflicting points discussed were the radicalness of the peritonectomy procedure, the cytoreduction of neoplastic nodules < 2.5 mm, and indications of protective ostomies.
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A partial parietal peritonectomy restricted to the macroscopically involved regions could be indicated in all listed clinical conditions with the exception of peritoneal mesothelioma. According to the experts, a radical parietal peritonectomy is not advisable irrespective of the disease being treated. The electrovaporisation of small non-infiltrating metastatic nodules (< 2.5 mm) in the mesentery, after the completion of CRS, would be indicated, even if theoretically HIPEC could exert a microscopic cytoreductive effect. Regarding the policy for protective stomas, it could be flexible and the procedure could be done at the surgeon’s discretion. As to the modalities of HIPEC (open vs closed), it was concluded that the evidence in the literature is not sufficient to confirm the superiority of one modality over the others in terms of outcome, morbidity, and safety of the personnel in the operating theatre. Each option has its own experimental evidence and operational advantages and disadvantages.9 The continuous application of the local–regional treatment in different diseases and new clinical circumstances will require the adaptation of the original technique with further modifications. The validation of the current and future variations of the technique requires prospective randomised studies to be conducted.
REFERENCES 1. Spratt JS, Adcock RA, Muskovin M, et al. (1980) Clinical delivery system for intraperitoneal hyperthermic chemotherapy. Cancer Res 40(2): 256–260. 2. Baratti D, Kusamura S, Nonaka D, et al. (2008) Pseudomyxoma peritonei: clinical pathological and biological prognostic factors in patients treated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC). Ann Surg Oncol 15(2): 526–534. Epub 2007 Nov 28. 3. Deraco M, Nonaka D, Baratti D, et al. (2006) Prognostic analysis of clinicopathologic factors in 49 patients with diffuse malignant peritoneal mesothelioma treated with cytoreductive surgery and intraperitoneal hyperthermic perfusion. Ann Surg Oncol 13(2): 229–237. Epub 2006 Jan 18.
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4. Ryu KS, Kim JH, Ko HS, et al. (2004) Effects of intraperitoneal hyperthermic chemotherapy in ovarian cancer. Gynecol Oncol 94: 325–332. 5. Verwaal VJ, van Ruth S, de Bree E, et al. (2003) Randomized trial of cytoreduction and hyperthermic intraperitoneal chemotherapy versus systemic chemotherapy and palliative surgery in patients with peritoneal carcinomatosis of colorectal cancer. J Clin Oncol 21: 3737–3743. 6. Sugarbaker PH. (1995) Peritonectomy procedures. Ann Surg 221: 29–42. 7. Jacquet P, Sugarbaker PH. (1996) Current methodologies for clinical assessment of patients with peritoneal carcinomatosis. J Exp Clin Cancer Res 15: 49–58. 8. Kusamura S, O’Dwyer S, Baratti D, et al. (2008) Technical aspects of the cytoreductive surgery: results of consensus statement. J Surg Oncol, special issue, in press. 9. Kusamura S, Dominique E, Baratti D, et al. (2008) Drugs, carrier solutions and temperature in hyperthermic intraperitoneal chemotherapy. J Surg Oncol, special issue, in press.
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Laparoscopic Management of Adnexal Tumours Liselotte Mettler∗,† , Ivo Meinhold-Heerlein† and Andreas G. Schmutzler†
The adnexa provide a direct connection from the intraabdominal cavity to the outside through the Fallopian tubes across the uterus, cervix and vagina (Fig. 1). Bacteria can migrate to the genital tract and kidney region ascending across the cervix, the uterus and the tubes. On the other hand, a descending infection from the kidney region and the tubes can reach the ureters and the bladder or the uterus and the cervix. In the lower pelvis of a female the bladder is connected to the outside through the urethra and the uterus through the cervix so that the tubes have a natural predilection for infections and consecutive tubal occlusions. Till now no ovarian or tubal transplants have been available, so the organs should be carefully diagnosed and treated. A resection seems generally only indicated in the case of a malignant disease or in old age. In addition, removal of a damaged Fallopian tube may increase the success rate of in vitro fertilisation and embryo transfer. Even ovaries beyond the reproductive age carry a certain function and should only be removed if indicated. Nearly all adnexal tumours ∗ Corresponding
author. of Obstetrics and Gynecology, Christian-Albrechts-University of Kiel, Klinikum Schleswig-Holstein, Campus Kiel, Michaelisstr. 16, 24105 Kiel, Germany. E-mail:
[email protected] † Department
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FIGURE 1 Anatomy of the right half of the uterus and the right adnexa.
can be managed laparoscopically. Procedures include excision of ovarian or paraovarian cysts, partial oophorectomy, total (salpingo-) oophorectomy, enucleation of ovarian cysts with borderline malignancy and the treatment of tubal pregnancy. Tubectomy, fimbroplasty, salpingostomy, end-to-end anastomosis and adnexectomy are possible. In the case of ovarian cancer with an indication for radical surgery, the resection of the uterus, tubes and ovaries, as well as an extensive pelvic and parotic lymphadenectomy together with omentum resection, is generally possible. However, the surgical treatment of ovarian cancer by laparoscopy is still not widely accepted and the key general surgical options remain to be performed via laparotomy.6 The most common surgical procedures in the management of benign adnexal tumours are still the enucleation of ovarian cysts and adnexectomies. These two surgical procedures are performed as follows: (1) Ovarian cyst enucleation An endoscopic ovarian cyst enucleation must be carried out in toto in the correct anatomical plane. Any remnant, as sometimes in
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cases of endometriosis, is destroyed by electrocoagulation or other energy sources. As an example, six steps of enucleation of a 5cm-in-diameter ovarian cyst in a 23-year-old with a hyperechoic zone in ultrasonography with suspicion of borderline lesion are demonstrated in Fig. 2. Step 5 is controversial, as most surgeons prefer not to suture. (2) Adnexectomy Ovarectomy, tubectomy or adnexectomy is an easy laparoscopic procedure if the adnexa are not pathologically attached to the pelvic sidewall. Figure 3 details schematically a right adnexectomy using a stapler in six individual steps. Under traction the adnexa are pulled away from the ovarian and infundibulopelvic ligament, and separated from the uterus and infundibulopelvic ligament using a stapling gun. Other energy sources to be used are ultrasound, bipolar coagulation and thermofusion. Adnexa can only be reached intraperitoneally. Alternatively, sutures and the two- or three-loop ligation technique can be applied.6 Laparoscopic adnexal surgery has widely replaced laparotomy Every ovarian cyst without any suspicion of malignancy in the reproductive age range should be enucleated laparoscopically conserving the organ. Any functional cyst in this age range, however, should first be treated by estrogen suppressants and excised only if it persists. Each adnexal tumour with an ovarian cyst should be carefully evaluated preoperatively, by imaging techniques, tumour marker measurement and palpation. During endoscopic surgery the most modern oncological criteria must be observed. At most gynaecological–oncological surgical centres, in suspected ovarian cancer a primary laparotomy with the aim of an RO resection with hysterectomy, adnexectomy, lymph node resection and omentectomy is carried out. Only a few laparoscopic oncological centres have the know-how and the infrastructure to laparoscopically treat ovarian cancer. If
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FIGURE 2 Ovarian cyst enucleation (with suspicion of borderline lesion) (A) Ultrasound of the hyperechoic zone in a double-chambered ovarian cyst, tumour marker negative; (B) ovarian cyst, double the size of the normal ovary, between the ovary and the uterus, near the normal-looking ovary; (C) dissection of a cyst capsule; (D) coagulation of the cyst pedicle; the cyst is enucleated out of its bed; (E) putting the ovarian cyst in an endobag; (F) extraction of the cyst, tapping and adaption of wound edges with endosuture, and extracorporeal knotting.
malignancy is diagnosed during laparoscopy, the patient must be either treated adequately laparoscopically or subjected to laparotomy in the same session or within the next 5–8 days.3,8 In the case of borderline ovarian tumours, laparoscopic restaging should be regularly performed.1 After incomplete initial ovarian cancer
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FIGURE 3 Right adnexectomy using a stapling device and abdominal extraction in an endobag (A) Resection of the stretched adnexa from the uterus; (B) resection of adnexa from the pelvic sidewall above the infundibulopelvic ligament; (C) putting the adnexa in an endobag; (D) closing the endobag; (E) pulling the endobag in a 10 to 15 mm trocar; (F) widening the abdomen with two retractors and extraction of the endobag out of the abdomen.
surgery, laparoscopic restaging with pelvic and parotic lymphadenectomy, LAVH and/or salpingo-oophorectomy was found to essentially improve the prognosis of such patients.4 Every effort is made to avoid intraoperative capsule rupture during primary surgery. If this does happen, irrigation is carried out
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carefully with copious normal saline even though it has not been proved that rupture worsens the prognosis of ovarian carcinoma. In five-year survival studies of stage I (FIGO) ovarian carcinoma, capsule rupture and “spilling” has appeared to play no role. The grade of histological differentiation and ascitis seem to play a greater role in the case of stage I cancers.2,7 Vergote et al.9 proved in a multi-variate analysis of surgery on 1545 patients with ovarian cancer that the degree of differentiation is the most powerful prognostic indicator of diseasefree survival — followed, however, by rupture before surgery, rupture during surgery, and age. The specimen obtained by laparoscopy should be removed from the abdominal cavity in an endobag, so as to avoid port site metastases. An aggressive operative regimen in the field of endoscopic surgery for genital carcinomas can be discussed on a broad basis only if randomised double blind studies show better success with endoscopic surgery as compared to conventional surgery. In advanced ovarian carcinoma, we employ endoscopic methods merely for obtaining specimens, to avoid exploratory laparotomy. In benign ovarian and adnexal tumours, endoscopic surgery has already replaced conventional laparotomy.
REFERENCES 1. Darai E, Tulpin L, Prugnolle H, et al. (2007) Laparoscopic restaging of borderline ovarian tumors. Surg Endoscopy 21(11): 2039–2043. 2. Dembo AJ, Davy M, Stenwick, AE. (1990) Prognostic factors in patients with stage I epithelial ovarian cancer. Obstet Gynecol 74: 263–273. 3. Kindermann G, Jung EM, Maassen V, Bise K. (1996) Incidence of primary malignant lesions in clinically benign teratoma: on the problem of adequate surgical procedure. Geburtshilfe und Frauenheilkunde 56: 438–440. 4. Leblanc E, Querleu D, Narducci F, et al. (2005) Laparoscopic restaging of early-stage adnexal tumors: a 10-year experience. Obstet Gynecol Survey 60(1): 31–32. 5. Medeiros LR, Stein AT, Fachel J, et al. (2007) Laparoscopy versus laparotomy for benign ovarian tumor: a systematic review and
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9.
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meta-analysis. Int J Gynecol Cancer, Online-Article, publ. 10 Aug. 2007 (http://www.blackwell-synergy.com). Mettler L, Semm K, Gebhardt JH, et al. (2006) Manual for Laparoscopic and Hysteroscopic Gynecological Surgery. Jaypee Brothers, New Delhi. Sevelda P, Varra N, Schemper M, Salzer H. (1990) Prognostic factors for survival in stage I epithelial ovarian cancer. Cancer 65: 10. Salfelder A, Nugent A, Lueken RP, et al. (2002) Laparoscopic treatment of malignant ovarian tumors — late results. Geburtshilfe und Frauenheilkunde 62: 452–457. Vergote I, de Brabanter J, Fyles A, et al. (2001) Prognostic importance of degree of differentiation and cyst rupture in stage I invasive epithelial ovarian carcinoma. Lancet 357(9251): 176–182.
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Excision of Intra-Abdominal Sarcomas: Technical Notes on Surgical Procedures Beate Rau∗ and Peter M. Schlag
INTRODUCTION Nonepithelial cancers derive from the various connective tissues and a variety of mesenchymal cell types (fibroblasts, adipocytes, osteoblasts and myocytes) throughout the body. These tumours, the sarcomas, constitute nearly 1% of the malignancies. Soft tissue sarcomas are slightly increased in patients with a variety of genetically transmitted diseases, and patients with soft tissue sarcoma very often have a recent history of a trauma or previous exposure to radiation. Approximately 60% of sarcomas occur in the extremities, 9% in the head and neck regions and 31% in the intra-abdominal cavity. Intra-abdominal soft tissue sarcomas (IASTS) are usually located in the retroperitoneal space in 40%. The remaining tumours are located in the abdominal or chest wall, the mediastinum and the breast. Most retroperitoneal soft tissue sarcomas are liposarcomas, leiomyosarcomas or malignant fibrous histiocytomas.1 ∗ Corresponding
author. Department of Surgery and Surgical Oncology, University of Berlin, Charité Campus Milte, Charite platz 1, 10 M7 Berlin, Germany. E-mail:
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The tendency of soft tissue sarcomas to metastasise depends on the grade of the tumour. Low grade sarcomas are characterised mainly by local invasive growth, but do not tend to metastasise. High grade tumours are more likely to disseminate. Therefore in these tumours surgery is usually covered by a pre- and/or post-operative treatment strategy. However, complete resection and the grade of the tumour are the most important prognostic factors. Surgery plays an important role in the treatment of soft tissue sarcomas and is a challenging procedure especially in retroperitoneal tumours, because these are usually very large when detected. However, the anatomical location of most retroperitoneal sarcomas precludes complete surgical excision with tumour-free circumferential margin. Surgical excision should be aimed at removing all gross tumours with as much marginal tissue in the expected areas of local spread as is compatible with reasonable morbidity. Usually the retroperitoneal tumours are adjacent to, covered by or close to the big vessels of the aorta and cava vein, kidney, adrenal gland, diaphragm, pancreatic head, corpus or tail, spleen, liver, colon, rectum, stomach, etc. In the case of marginal excision of the tumour, additional radiotherapy should be considered, especially in high grade sarcomas, and the surgeon should outline the margins of resection with clips. However, any potential enhancement of local control by radiotherapy must be weighed against functional deficits and impairments in quality of life induced by radiotherapy.
OPERATIVE TECHNIQUE In retroperitoneal sarcomas, it is of major importance to resect the tumour within gross tumour-free circumferential margins. The average mean diameter of retroperitoneal tumours is often very impressive, so median laparotomy extends from the xiphoid process to pubic symphysis. Sometimes even lateral extension of the scar is
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necessary (be aware of the right angle of the incisions to each other, to avoid necrosis of the abdominal wall). Retroperitoneal sarcomas are covered ventrally by the bowel (see Fig. 1) and the peritoneum, and dorsally by the retroperitoneal plane adjacent to the autochthonous muscles and the vertebra as well as the lateral abdominal wall. Usually, to achieve complete resection, multivisceral en bloc resection has to be planned. Therefore the first step of the procedure should be dissection of the big vessels and a truncular cut through the mesenteric inferior and renal artery, if the kidney is involved. The same procedure has to be performed with the vein. The second step is dissection of the tumour within the retroperitoneal fascia and the ventral part of the adjacent autochthonous muscles of the back. Sometimes the complete muscles have to be resected including the femoral nerve. Preparation of the retroperitoneal space dorsal of the tumour could be very difficult, because of the bad view. To reduce the blood loss during the operation, especially in this part, sealing equipment could help. If nephrectomy is necessary for achieving complete resection, retransplantation of the kidney could be an option for organ-saving surgery. Then the cortex of the kidney has to be dissected outside the body and retransplantation of the kidney can be performed easily.
DISCUSSION The incidence of retroperitoneal sarcoma (RPS), a rare disease, appears stable. Most patients who undergo surgery do not receive any adjuvant radiotherapy, and very few receive preoperative radiotherapy. The Swedish Council of Technology Assessment in Health Care analysed the literature on radiation therapy for soft tissue sarcomas (STS).2 The review was based on data from 5 randomised trials, 6 prospective studies, 25 retrospective studies and 3 other articles involving 4579 patients. Again, prognostic factors for tumour-related death from STS re-confirmed the histological grade, tumour size and age. There
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FIGURE 1 (a) A 54-year-old man was detected to have an incidental Grade 1 liposarcoma at the abdominal US. There was no evidence of metastatic spread. Radical surgical excision was undertaken. (b) Specimen of en bloc excision of the large liposarcoma with the left colon.
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is strong evidence that adjuvant radiotherapy improves the local control rate in combination with conservative surgery in the treatment of STS of extremities and the trunk in patients with negative, marginal or minimal microscopic positive surgical margins.2 For RPS no convincing studies exist which demonstrate the beneficial influence of adjuvant or neoadjuvant radiotherapy in these patients, mostly due to the radio-therapeutically induced toxicity. On the other hand, this leads to more sophisticated delivery methods that deliver high dose rates while sparing surrounding normal tissues. Preoperative radiotherapy for RPS demonstrated less local recurrence and a low rate of induced toxicity. However, even for large retroperitoneal tumours the data are still discussed to establish preoperative radiotherapy for RPS.2 There is no randomised study comparing external beam radiotherapy and brachytherapy. The data suggest that external beam radiotherapy and low-dose-rate brachytherapy result in comparable local control for high-grade tumours. Some patients with low-grade soft tissue sarcomas benefit from external beam radiotherapy in terms of local control. The available data are inconclusive concerning the effect of intraoperative high-dose-rate radiotherapy for RPS. Differences in adjuvant radiotherapy that are related to demographic and geographic factors suggest that at least some treatment variations reflect differences in individual and institutional practice patterns.2 However, there remains no definitive prospective, randomised trial that establishes the role of adjuvant or neoadjuvant radiation versus no radiation. Owing to significant radiation morbidity with adjacent organs, especially the small bowel, there exists no consensus on radiation timing, delivery method or dosing.3,4 The weighting of surgery in the multimodal treatment setting is widely accepted: complete resection of the sarcoma is the number one prognostic factor. But complete resection of RPS is difficult and is possible only in 50% of cases.1,5 Usually, incomplete resections over no resection have not shown a survival benefit. However, in selected patients with unresectable retroperitoneal liposarcoma, incomplete
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surgical resection can provide prolongation of survival and successful symptom palliation. Most likely to benefit are those patients presenting with primary tumours, which suggests that surgical resection should be attempted in the majority of patients.6 The use of intraoperative radiation therapy has also been examined as a means of improving local recurrence rates, but may be associated with more radiation-related morbidity.7 To summarise the treatment strategies in RPS: surgery with complete resection is the most important factor for long term survival and recurrence rate. However, every effort should be made to minimise local recurrence, but recurrence alone does not define the long term outcome. The biology of the tumour seems to be the most important prognostic factor; therefore our challenge remains to find effective multimodal treatment strategies for ameliorating the result. Further studies are needed.
REFERENCES 1. Weiss SW, Goldblum J. (2001) Sarcomas in the retroperitoneum. In: Enzinger F, Weiss SW, editors, Soft Tissue Tumours, 4th ed. St. Louis, Mosby, pp. 37–44. 2. Strander H, Turesson I, Cavallin-Stahl E. (2003) A systematic overview of radiation therapy effects in soft tissue sarcomas. Acta Oncol 42(5–6): 516–531. 3. Tzeng CW, Fiveash JB, Heslin MJ. (2006) Radiation therapy for retroperitoneal sarcoma. Expert Rev Anticancer Ther 6(8): 1251–1260. 4. Tzeng CW, Fiveash JB, Popple RA, et al. (2006) Preoperative radiation therapy with selective dose escalation to the margin at risk for retroperitoneal sarcoma. Chirurg 107(2): 371–379. 5. Erzen D, Novak J, Spiler M, Sencar M. (2007) Aggressive surgical treatment of retroperitoneal sarcoma: long-term experience of a single institution. Surg Technol Int 16: 97–106. 6. Glass A, Wieand HS, Fisher B, et al. (1981) Acute toxicity during adjuvant chemotherapy for breast cancer: the National Surgical Adjuvant
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Breast and Bowel Project (NSABP) experience from 1717 patients receiving single and multiple agents [prior annotation incorrect]. Cancer Treat Rep 65: 363–376. 7. Pawlik TM, Ahuja N, Herman JM. (2007) The role of radiation in retroperitoneal sarcomas: a surgical perspective. Curr Opin Oncol 19(4): 359–366.
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Laparoscopic Adrenalectomy for Tumours in the Adrenal Glands Bergþór Björnsson∗,† , Guðjón Birgisson† and Margrét Oddsdóttir††
INTRODUCTION Laparoscopic adrenalectomy became the method of choice in the early 1990s for the removal of adrenal glands with presumed benign tumours.1 The laparoscopic approach, with its magnification and delicate instruments, was found to be ideal for the removal of these small organs deep in the retroperitoneum and in close proximity with the caval vein, the renal vessels as well as the spleen. Several studies have shown excellent outcomes with short hospital stays and low morbidity in comparison with the conventional open method.1 Malignant lesions of the adrenals are relatively rare. The laparoscopic approach is not feasible for invasive adrenal malignancy. However, for suspected malignancy without apparent local invasion, laparoscopic adrenalectomy is considered appropriate.2,3
∗ Corresponding
author. of Iceland Medical School and Landspitali-University Hospital, Reykjavik, Iceland. †† Landspitali-University Hospital, Reykjavik, Iceland. † University
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TECHNIQUE The adrenal glands can be removed using the laparoscope by either the transperitoneal or the retroperitoneal approach. We prefer the transperitoneal route, and it is the technique more commonly used. The patient is placed in a lateral decubitus position. The braking point of the table should be at or just above the pelvic rim of the patient. The table is flexed to provide as much space as possible between the costal margin and the iliac crest (Fig. 1). The whole table is then adjusted so that the upper part is almost horizontal, but with the lower part sloping downwards. The legs are slightly bent, with a pillow between them. A small roll is placed in the axilla facing the table and the contralateral arm secured on an arm table. The patient is secured in this position with tape or stabilisers. It is convenient to mark the anterior and mid-axillary line while the patient is supine. The first trocar is placed at the anterior axillary line, 2–5 cm below the costal margin. We usually place the first trocar by the open technique and use a 30◦ laparoscope. This incision can later be enlarged if necessary to deliver the specimen out of the abdomen. Once the intra-abdominal pressure is 15 mmHg, a 5 mm trocar is placed below the costal margin
FIGURE 1 Patient position for laparoscopic left adrenalectomy.
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at the mid-clavicular line. Another 5 mm trocar is then placed just below the costal margin, just lateral to the mid-axillary line. On the right, the third 5 mm trocar is placed in the epigastrium for the liver retractor. Sometimes, the third 5 mm trocar is needed on the left side for additional retraction. On the left side, it may be necessary to take down the lateral attachments of the left colon flexure to accommodate this trocar. On the right, an additional trocar (5 mm) is placed in the epigastrium for a liver retractor. Sometimes, yet another 5 mm trocar is needed on the left side for retraction. The placement may either be in the epigastrium or posterolateral to the lateral 5 mm trocar, depending on the operative field. In general, we use a combination of electrocautery and ultrasonic scissors for dissection. The adrenal veins are controlled with titanium clips, but if they are large we prefer vascular staplers. It is important to handle the adrenal glands with care, so as to keep their fragile capsule intact.
Left Adrenalectomy The lienocolic ligament is divided and the left colon flexure is mobilised away from the spleen. The proximal part of the left colon may need to be mobilised from the lateral abdominal wall to give a good view of the area behind the spleen. The lateral attachments of the spleen are divided, starting below the inferior pole and continuing up to the diaphragm, where the attachments of the superior pole are divided. If the tip of the pancreas is noted, the dissection is continued dorsal to it. When fully mobilised the spleen falls medially without retraction and the area behind it is now visualised as “an open book”. The dissection is adequate when the medial edge of the adrenal gland is exposed. The inferior and medial border of the gland is mobilised, and as one dissects the medial-dorso-inferior part of the gland, the left adrenal vein comes into view (Fig. 2). Once around the vein it is secured with clips and divided. As one carries out the dissection superiorly, an additional branch may be found that needs attention.
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FIGURE 2 Exposure of the right adrenal gland and the right adrenal vein.
The gland is now mobilised by freeing all its edges and then from the underlying retroperitoneum.
Right Adrenalectomy The lateral liver attachments and the triangular ligament are divided. With a retractor the liver is retracted. The dorsal peritoneal attachments to the liver are divided until the upper edge of the adrenal gland comes into view. The lateral edge of the caval vein and the medial side of the adrenal gland are carefully separated. Once the right adrenal vein is seen and isolated with a right angle dissector, it is secured with clips and divided (Fig. 3). The gland is fully mobilised by freeing its edges circumferentially and dividing the retroperitoneal attachments.
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FIGURE 3 Exposure of the left adrenal gland and the left adreanal vein.
An impermeable plastic bag is used for retrieval of the gland. It is taken out through the initial incision, which may need to be enlarged to deliver the specimen intact.
DISCUSSION Laparoscopic adrenalectomy is the standard of care for the removal of adrenal tumours confined to the adrenal gland.4,5 For a suspected malignant lesion of the adrenal gland, it is generally considered safe to use the laparoscopic approach.6,7 However, very large tumours and obvious signs of invasive tumour growth are indications for open surgery.
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REFERENCES 1. Lee J, El-Tamer M, Schiffner T, et al. (2008) Open and laparoscopic adrenalectomy: analysis of the National Surgical Quality Improvement Program. J Am Coll Surg 206: 953–959. 2. Cobb WS, Kercher KW, Sing RF, Heniford BT. (2005) Laparoscopic adrenalectomy for malignancy. Am J Surg 189: 405–411. 3. Sturgeon C, Kebebew E. (2004) Laparoscopic adrenalectomy for malignancy. Surg Clin North Am 84: 755–774. 4. Bjornsson B, Birgisson G, Oddsdottir M. (2008) Laparoscopic adrenalectomies: a nationwide single-surgeon experience. Surg Endosc 22: 622–626. 5. Parnaby CN, Chong PS, Chisholm L, et al. (2008) The role of laparoscopic adrenalectomy for adrenal tumours of 6 cm or greater. Surg Endosc 22: 617–621. 6. McCauley LR, Nguygen MM. (2008) Laparoscopic radical adrenalectomy for cancer: long-term outcomes. Curr Opin Urol 18: 134–138. 7. Adler JT, Mack E, Chen H. (2007) Equal oncologic results for laparoscopic and open resection of adrenal metastases. J Surg Res 140: 159–164.
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Isolated Limb Perfusion Harald J. Hoekstra∗
INTRODUCTION Isolated limb perfusion (ILP) is performed in the limb salvage treatment of locally advanced melanoma or sarcoma.1,2 The theory behind regional chemotherapy is that a high drug uptake may be achieved without systemic toxicity. The delivery of chemotherapy within the ILP setting has three major advantages: the “first pass” effect, which results in an increased drug uptake; hyperthermia, which facilitates drug uptake through increased blood flow and permeability of the cell membrane; and the use of cytostatic agents, which cannot be used outside the ILP setting due to the high systemic toxicity.3
PERFUSION LEVEL Upper limb perfusions may be performed at two levels — axillary or brachial — and lower limb perfusions at three levels — iliac, femoral or popliteal (Fig. 1). The level of perfusion is determined by the involved ∗ Division
of Surgical Oncology, Department of Surgery, Groningen University Hospital, University of Groningen, PO Box 30.001, 9700 RB Groningen, The Netherlands. E-mail:
[email protected] 259
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FIGURE 1 Five different perfusion levels for regional perfusion of the extremities.
part of the limb and the kind of disease, e.g. skin malignancies versus sarcomas. For skin malignancies the most proximal site of cannulation is the best choice, since the whole limb is at risk. In sarcomas the level of perfusion is determined by the distinct part of the limb containing the tumour.
PERFUSION TECHNIQUE After dissection of the appropriate artery and vein and ligation of the collateral vessels, to control collateral flow and prevent leakage, the patient is heparinised systemically (heparin 3.3 mg/kg BW). The limb is isolated from the systemic circulation by an esmarch bandage twisted around the root of the limb and fixed around a pin inserted into the head of the humerus (axillary perfusion) or iliac crest (iliac perfusion). An inflating tourniquet (300–400 mm Hg) is used for brachial or popliteal perfusions. The artery and vein are exposed, cannulated with 14–16 F catheters and connected to an extracorporeal circulation system. Thermister probes are placed in the subcutaneous tissue and muscle for continuous temperature monitoring. The limb is wrapped in a thermal blanket (Fig. 2).
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FIGURE 2 Schematic drawing of a regional perfusion circuit for an iliac perfusion of the lower extremity: an esmarch bandage around the hip with a Steinman pin inserted in the iliac crest, arterial and venous perfusion catheters connected to the arterial and venous line, membrane oxygenator, heat exchanger, roller pomp, continuous leakage monitoring with a scintillation detector placed over the heart, a warm water mattress and thermoprobes for skin and muscle temperature.
The extracorporeal circulation perfusion system consists of a roller pump, a membrane oxygenator, a heat exchanger and systems for continuous data monitoring of the temperature of the perfusate, the mean arterial and venous pressure in the perfusion canules, the mean arterial pressure in the system, and the venous saturation and electronic balance of the perfusion volume. The perfusate consists of 250 ml of Isodex in 0.9% saline, 250 ml of white-cell-reduced (filtered) packed red cells and 30 ml of 8.4% NaHCO3 ; 0.5 ml of 5000 IU/ml heparin is oxygenated by a membrane oxygenator (DIDECO, Mirandola, Italy) with a gas mixture of air and oxygen. Leakage into the systemic circulation is continuously monitored with radioactive tracers. A small calibration dose of radioactive iodine-131-labeled human serum albumin (RISA 0.5 MBq) and a dose of radioactive technetium-99m-labeled human serum albumin (RtcSA 10 MBq) are administered into the systemic circulation after the isolation of the limb is accomplished. The day before surgery the
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thyroid is saturated through the oral administration of iodine. A tentimes-higher dose of RISA (5 MBq) is injected in the perfusion circuit. The 364 keV gamma rays emerging from the RISA and the 140 keV gamma rays from the RtcSA are measured with a NaI detector over the precordium. The risk of leakage is less than 3% (Fig. 2).4,5 Cytostatic agents are added into the arterial line to the limb when there is no leakage, and a limb temperature of 38◦ C is reached. Perfusions are flow- and pressure-regulated to achieve adequate tissue perfusion. Adjustments of the flow rate and pressure in the perfusion circuit by the perfusionist, as well as the blood pressure of the patient by the anaesthesiologist, together with an optimal isolation of the limb by the surgeon, ensure a stable and optimal perfusion. When there is an increase leakage to the systemic circulation (losing), the flow rate should be reduced and the systemic blood pressure increased, and eventually the tourniquet tightened, while with a loss of the systemic circulation into the perfusion circuit (gaining) the tourniquet should be tightened, the flow rate increased and the outflow “occluded.” In case of too much leakage, losing or gaining, the perfusion should be terminated for technical reasons to prevent loco-regional or systemic complications. After the perfusion the limb is washed out with 4–6 l of saline and filled with 250 ml of white-cell-reduced (filtered) packed red cells. The vessels are restored, heparin is antagonised with prothrombin, and a fasciotomy is performed. Patients perfused with TNFα are monitored during a period of 24 h in the intensive care unit, while patients perfused with melphalan are observed on the ward. No prophylactic antibiotics are prescribed. Patients receive subcutaneous low-dose molecular heparin till a full mobilisation is achieved.
CYTOSTATIC AGENTS Cytostatic agents used in ILP must have appropriate pharmacokinetic profiles, and steep dose-response curves without requiring metabolic activation (Fig. 3). A variety of cytostatic agents besides melphalan have been used: darcarbazide (DTIC), actinomycin-D,
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FIGURE 3 Appropriate pharmacokinetic profiles for cytostatic agents used in ILP.
thiotepa, mitomycine-C, doxorubicin, cisplatin and carboplatin. The majority of these agents were ineffective, the duration of response was quite limited, or local toxicity hampered further application. Melphalan (Alkeran , GlaxoSmithKline Pharmaceuticals, Research Triangle Park NC) is the most effective drug in ILP for melanoma. The dose calculation of melphalan was in the past performed on body weight (lower limb 1.0–1.5 mg/kg BW and upper limb 0.5–0.7 mg/kg BW). Today the dosage is based on the perfused limb volume (lower limb 10 mg/L, upper limb 13 mg/L). Doses greater than 150 mg per limb result in regional toxicity. Tumour necrosis factor–alpha (TNFα; Boerhinger-Ingelheim GmbH, Vienna, Austria) is used together with melphalan in the treatment of locally advanced melanoma and sarcoma of the limb.1,2 TNFα attacks the neovascular endothelial cells, in particular the tumour vasculature, causing increased vessel permeability and facilitating melphalan uptake in the tumour cells.6 The dosage of TNFα for the upper limb and popliteal perfusion is 3 mg; for the lower limb, 4 mg. “TNF priming time” of 15–30 minutes prior to the intra-arterial delivery of melphalan seems appropriate. The clinically used perfusion time for
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Grade I Grade II Grade III Grade IV
Grade V
Wieberdink’s Acute Regional Toxicity Grading System.
No reaction Slight erythema and/or oedema Considerable erythema and/or oedema with some blistering; slightly disturbed motility permissible Extensive epidermolysis and/or obvious damage to the deep tissues, causing definite functional disturbances; threatening or manifest compartmental syndrome Reaction which may necessitate amputation
melphalan alone is 45–60 minutes; for the combined TNF–melphalan perfusion, 60–90 minutes.7
TREATMENT TOXICITY The effects of the perfusate on normal tissues are recorded according to Wieberdink’s criteria and vary widely between individuals (Table 1).8 Melphalan may cause skin toxicity, erythema and blistering. This resolves in general within a month with regard to the accompanying procedures, e.g. tumour resection or radiation. A small proportion of patients undergoing ILP for melanoma will have long-term limb symptoms (5–8%), without severe impairment.9 After ILP for sarcoma impairment of limb function is not related to the ILP, but to the extent of surgery with or without adjuvant irradiation.10 Another risk factor in ILP is the vascular status of the (elderly) patient. Manipulation, cannulation and tight occlusion of sclerotic vessels might cause embolic events, arterial stricture after vessel repair, or arterial thrombosis, requiring reoperation or even amputation of the perfused limb. Deep venous thrombosis is sometimes encountered due to cannulation of the vein or the thrombogenic side effect of melphalan.
SUMMARY ILP is a technically demanding procedure that delivers safe and effective high doses of cytostatic agents in the limb-saving treatment of locally advanced melanoma or sarcoma.
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REFERENCES 1. Hoekstra HJ. (2008) The European approach to in-transit melanoma lesions. Int J Hyperthermia 24: 227–237. 2. van Ginkel RJ, Thijssens KM, Pras E, et al. (2007) Isolated limb perfusion with tumor necrosis factor alpha and melphalan for locally advanced soft tissue sarcoma: three time periods at risk for amputation. Ann Surg Oncol 14: 1499–1506. 3. Guchelaar HJ, Hoekstra HJ, de Vries EG, et al. (1992) Cisplatin and platinum pharmacokinetics during hyperthermic isolated limb perfusion for human tumours of the extremities. Br J Cancer 65: 898–902. 4. Daryanani D, Komdeur R, Ter Veen J, et al. (2001) Continuous leakage measurement during hyperthermic isolated limb perfusion. Ann Surg Oncol 8: 566–572. 5. Van Ginkel RJ, Limburg PC, Piers DA, et al. (2002) Value of continuous leakage monitoring with radioactive iodine-131-labeled human serum albumin during hyperthermic isolated limb perfusion with tumor necrosis factor–alpha and melphalan. Ann Surg Oncol 9: 355–363. 6. Nooijen PT, Manusama ER, Eggermont AM, et al. (1996) Synergistic effects of TNF-alpha and melphalan in an isolated limb perfusion model of rat sarcoma: a histopathological, immunohistochemical and electron microscopical study. Br J Cancer 74: 1908–1915. 7. de Wilt JH, Manusama ER, van Tiel ST, et al. (1999) Prerequisites for effective isolated limb perfusion using tumour necrosis factor alpha and melphalan in rats. Br J Cancer 80: 161–166. 8. Wieberdink J, Benckhuysen C, Braat RP, et al. (1982) Dosimetry in isolated perfusion of the limb by assessment of perfused tissue volume and grading of toxic tissue reactions. Eur J Cancer Clin Oncol 18: 905–910. 9. Olieman AF, Schraffordt Koops H, Geertzen JH, et al. (1994) Functional morbidity of hyperthermic isolated regional perfusion of the extremities. Ann Surg Oncol 1: 382–388. 10. Hoven-Gondrie ML, Thijssens KM, Geertzen JH, et al. (2008) Isolated limb perfusion and external beam radiotherapy for soft tissue sarcomas of the extremity: long-term effects on normal tissue according to the LENT-SOMA scoring system. Ann Surg Oncol 15: 1502–1510.
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Cone and Wedge Resection in Renal Cell Carcinoma Frederik C. Roos∗,† and Joachim W. Thüroff†
INTRODUCTION Nephron sparing surgery (NSS) is the treatment of choice for patients with localised renal cell carcinoma (RCC) when preservation of renal parenchyma is mandatory, such as in bilateral RCCs, RCC in a solitary kidney and in chronic renal failure (imperative indication).1 Elective NSS is defined as treatment of a single, safely resectable RCC in a patient with a normal contralateral kidney. Several reports have shown that NSS provides equivalent oncological2 and better renal functional results than radical nephrectomy (RN) for these patients.3 Long-term renal functional outcomes are better in patients undergoing NSS than RN; Lau et al.3 reported that progression to chronic renal failure (defined as a serum creatinine level of > 2.0 mg/dL) at 10 years occurred in 22.4% of patients after RN, versus 11.6% after NSS. Recent data suggest that NSS is safe for tumours up to 7 cm, and elective NSS is a reasonable option for all patients with a clinical T1 renal tumour.4,5 ∗ Corresponding
author. of Urology, Johannes Gutenberg-University Mainz Medical School, Germany. E-mail:
[email protected] † Department
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INTRAOPERATIVE PROCEDURE We generally prefer the extraperitoneal flank incision through the 10th or 11th intercostal space. After opening Gerota’s fascia, the kidney is completely mobilised, leaving the perirenal fat only attached at the site of the tumour. The renal vessels are exposed and secured by vessel loops. Clamping of the artery may not be necessary for excising small peripheral tumours. When cold renal ischaemia is required, the kidney is placed into a bowel bag, which is loosely tied around the renal hilus and has its bottom excised to be filled with slush ice. Ten minutes before clamping the renal artery, 1.2 mg of enalapril and mannitol 20% 1 ml/kg bw are administered intravenously. The fibrous renal capsule is incised at a 2–4 mm distance from the tumour in either a circle (cone resection) or an ellipse (wedge resection), depending on the size and location of the tumour and its intraparenchymal or exophytic extension (Fig. 1). A minimum of about 2 mm of normal renal parenchyma should be removed around the tumour. The cone
FIGURE 1 Illustration of cone (white scattered) and wedge resection (black scattered line).
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resection (black dotted line) allows maximal preservation of renal parenchyma while the wedge resection (grey plotted line) allows easier re-approximation of the renal parenchyma after tumour resection, especially in the mid-portion of the kidney. Using brain spatulae, the renal parenchyma is sharply and bluntly separated in the renal cortex and only bluntly in the medulla along the parallel structures of the tubules and collecting ducts of the renal papillae (Fig. 2). Small vessels are coagulated and large vessels are oversewn with 4/0 polyglycolic acid, which does not melt during a following coagulation. Major vessels at the base of the resection are clamped and ligated. The excised tumour is sent for frozen sections for diagnosis and checking of margins of resection. If the tumour extends into the renal hilum, additional biopsies should be taken from tissue at the ground of resection to ensure complete resection. Intraoperative 7.5–12 MHz ultrasound is especially useful for identifying intraparenchymally embedded tumours and to outline central tumour extension. While obtaining negative surgical margins is imperative, the width of excised normal parenchyma around the tumour margin does not affect the likelihood of recurrence.7
FIGURE 2 Resection of the tumour by clamping the vessels at the tumour ground.
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If there is a positive margin, nephrectomy may not necessarily be required in all patients with a normal contralateral kidney.8 In patients with imperative indications (solitary kidney, chronic renal failure, bilateral RCCs), immediate extension of the resection or radical nephrectomy followed by dialysis may be elected. If renal calyces and/or renal pelvis had been opened, reconstruction is performed with 6/0 polyglycolic acid sutures. When drainage of the collecting system is required, an 8–12 F nephrostomy catheter is inserted and fixed by a 5/0 polyglytone purse-string suture.6 An argon-beam laser or an infrared sapphire coagulator may be used for coagulation. Both instruments provide the required haemostasis for parenchymal bleeding. The non-contact argon laser does so by superficial tissue carbonisation, while the infrared contact coagulator provides heat necrosis of 1–3 mm of tissue, depending on the selected exposure time (1–5 s), with little carbonisation and tissue adherence. Hence, infrared coagulation may be used not only for
FIGURE 3 Use of an argon-beam laser and/or an infrared sapphire coagulator in the coagulation of the tumour bed.
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haemostasis but also for non-surgical extension of the safety margin of resection (Fig. 3). With application of either instrument, most monofilament sutures may melt, so that braided sutures should preferably be used for ligation or oversewing. The renal fibrous capsule is closed with a running monofilament mattress suture using 5/0 poly p-dioxanone; this is an important step in providing haemostasis by compression (Fig. 4). Cone resection of small tumours may be performed with or without renal clamping. In small exophytic renal tumours, the ground of resection usually does not reach the renal sinus and collecting system, rendering a superficial shallow defect of the parenchyma. When a shallow defect cannot be closed by adaptation of the renal capsule, a free patch of adjacent peritoneum or dexon cluster may be used to cover the defect.9
FIGURE 4 Suture of the renal capsular before releasing the arterial closure in order to maintain haemostasis.
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COMPLICATION MANAGEMENT In case of haemodynamically relevant postoperative bleeding, diagnostic angiography with an option of superselective embolisation of an arterial bleeding is required. If there is no arterial bleeding, conservative management is preferable to surgical revision. A urinary fistula or a urinoma is verified by examining the creatinine concentration in the fluid from the perirenal drain. Useful imaging modalities of a leakage are nephrotogram (if a nephrostomy catheter is available), IVP, CT or retrograde pyelography, which may be combined with insertion of a ureteric catheter or double-J (JJ) stent for drainage of the collecting system. When a JJ stent is placed, a continuous bladder catheter is required to prevent reflux. Large urinomas must be drained percutaneously by ultrasonographically guided placement of a drain. In all cases of urinary extravasation, antibiotic treatment is mandatory. Acute renal failure secondary to renal tubular ischemia requires temporary haemodialysis in cases of solitary kidneys or when chronic renal failure is pre-existent. Obstruction of the upper urinary tract may be caused by blood clots in the urine. If the patient is symptomatic (fever, pain), drainage by means of a ureteric catheter or a JJ/single-J stent and antibiotic treatment are required.
REFERENCES 1. Fergany AF, Saad IR, Woo L, Novick AC. (2006) Open partial nephrectomy for tumor in a solitary kidney: experience with 400 cases. J Urol 175: 1630–1633. 2. Lerner SE, Hawkins CA, Blute ML, et al. (1996) Disease outcome in patients with low stage renal cell carcinoma treated with nephron sparing or radical surgery. J Urol 155: 1868–1873. 3. Lau WK, Blute ML, Weaver AL, et al. (2000) Matched comparison of radical nephrectomy vs nephron-sparing surgery in patients with unilateral renal cell carcinoma and a normal contralateral kidney. Mayo Clin Proc 75: 1236– 1242.
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4. Becker F, Siemer S, Hack M, et al. (2006) Excellent long term cancer control with elective nephron-sparing surgery for selected renal cell carcinomas measuring more than 4 cm. Eur Urol 49: 1058–1064. 5. Pahernik S, Roos F, Röhrig B, et al. (2008) Elective nephron sparing surgery for renal cell carcinoma of larger than 4 cm. J Urol 179: 71–74. 6. Pahernik S, Gillitzer R, Thüroff JW. (2004) Surgical atlas: cone/wedge resection of renal cell carcinoma. BJU 93: 639–654. 7. Castilla EA, Liou LS, Abrahams NA, et al. ( 2002) Prognostic importance of resection margin width after nephron-sparing surgery for renal cell carcinoma. Urology 60: 993–997. 8. Permpongkosol S, Colombo JR, Gill IS, et al. (2006) Positive surgical parenchyma margin after laparoscopic partial nephrectomy for renal cell carcinoma: oncological outcomes. J Urol 176: 2401–2404. 9. Lane BR, Novick AC. (2007) Nephron-sparing surgery. BJU 99: 1245–1250.
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Transperitoneal Laparoscopic Radical Nephrectomy Hugh F. O’Kane† , Alex MacLeod† , Christopher Hagan† and Thiagarajan Nambirajan∗,†
INTRODUCTION Since the first report in 1991,1 laparoscopic radical nephrectomy has become the mainstay of surgical treatment in the majority of patients requiring nephrectomy for malignant disease.2 Traditionally, open surgical removal of the kidney has been carried out through a midline, flank or lumbar approach. These large surgical incisions often result in significant post-operative wound pain leading to a prolonged recovery time. The majority of published series demonstrate clear advantages of laparoscopic nephrectomy over open surgery with regard to decreased post-operative pain, analgesic requirements, shorter hospital stay and reduced time to full recovery.3,4 Other advantages include fewer wound complications, improved cosmesis and reduced intraoperative blood loss. The laparoscopic approach was initially used for small T1–2 renal tumours, and as experience has grown, the indication for it has been extended to include more challenging, larger tumours. ∗ Corresponding
author. of Urology, Belfast City Hospital, Lisburn Road, Belfast, Northern Ireland. E-mail:
[email protected] † Department
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With the introduction of any new technique, initial capital costs and a longer operating time as a result of the learning curve are cited as disadvantages. However, these issues have largely been resolved with time. In order for laparoscopic nephrectomy to be accepted as a treatment comparable to open surgery, the sound oncological principles of removal of the intact kidney and surrounding Gerota’s fascia need to be maintained. The two standard laparoscopic approaches, namely transperitoneal and retroperitoneal, when carried out correctly, adhere to these principles.
TECHNIQUE Pre-Operative Workup Pre-operative staging of renal tumours is performed with computerised tomography (CT) of the chest, abdomen and pelvis. The patients are cross-matched for two units of blood and have the side of the tumour marked on the skin prior to leaving for theatre. Patients are consented for the very small risk of conversion to open surgery (∼1%) in addition to specific laparoscopic complications, including bowel injury and post-operative shoulder tip pain related to CO2 insufflation. The correct tumour side is reaffirmed in theatre with CT films and with a urethral catheter inserted.
Transperitoneal Approach The patient is positioned in the lateral decubitus position at an angle of 40◦ –50◦ , with slight elevation of the kidney bridge. Careful positioning and pressure point padding prevents neuromuscular injury. The patient is strapped to the table to allow rotation if necessary to achieve an ergonomically comfortable position for the operating surgeon. Peritoneal access allowing establishment of the pneumoperitoneum is under direct vision via the Hassan approach, which is safer than the blind or “closed” Veress needle method.5
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The primary laparoscope trocar is a 12 mm port inserted adjacent to the umbilicus. Two further 5–10 mm trocars are inserted under direct vision in the subcostal and iliac fossa positions. Port site placement follows the principle of triangulation to allow maximal access to the renal hilum, where the majority of the dissection takes place, but will also allow ureteric dissection. An additional 5 mm port may be required, particularly for right-sided nephrectomies which may need liver retraction (Fig. 1). A variety of laparoscopic instruments are available for tissue dissection and coagulation, including monopolar electric cautery, bipolar vessel electro-thermal sealers and ultrasonic shears (Harmonic scalpel, Ethicon endo-surgery). Dissection begins with an incision along the line of Toldt, allowing medial retraction of the colon. The ureter is identified and mobilised to help with retraction of the kidney and to guide the dissection cephalad towards the renal hilum. Careful dissection of the hilar vessels is achieved with the combination of a right angle dissector, suction and the harmonic scalpel. The renal artery which is usually found
FIGURE 1 Port placement for right transperitoneal laparoscopic radical nephrectomy. Note the preoperative arrow marking operative side and 4th 5 mm port to allow liver edge retraction.
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posterior to the vein is ligated first, followed by the vein with particular care to avoid any unseen lumbar veins entering the renal vein posteriorly (Fig. 2). The two most commonly used methods for securing the renal vessels are endovascular linear staplers and non-polymer ligating clips (Hem-O-Lok, Weck closure system, Telelflex medical). Both methods are widely used (see video). Occasionally a large renal vein may require the placement of a loop around the vessel to “shrink” the vein so as to facilitate placement of the Hem-O-Lok clip.6 This manoeuvre is infrequently required, after the introduction of extra-large clips (Hem-O-Lok XL). Although surgeons’ preference, experience and training strongly influence the choice of the haemostatic method, all currently available techniques risk mechanical malfunction and user misuse. Once the hilar vessels have been ligated, the kidney is dissected free of its remaining attachments. For left-sided nephrectomy, attention is paid to avoiding splenic and pancreatic injuries. On the right side, particular care is given to the short adrenal vein.
FIGURE 2 An excellent view of the hilar vessels during transperitoneal laparoscopic radical nephrectomy. The renal artery is about to be clipped with a Hem-O-Lok clip.
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FIGURE 3 Wounds following retrieval of the specimen.
After the ureter has been clipped and divided, the specimen is placed in a retrieval bag prior to removal via a muscle-splitting incision created by extending the iliac fossa trocar site (Fig. 3). The practice of specimen morcellation to allow extraction through a smaller incision is not popular, as this prevents optimal histopathological assessment and carries a small risk of tumour seeding.
DISCUSSION There is overwhelming evidence to support the use of laparoscopic nephrectomy over the open approach due to reduced post-operative analgesic requirements, a shortened hospital stay, improved cosmesis and an earlier return to normal activities. The majority of this evidence has been obtained from cohort studies, although one small, randomised study has been reported.7 Long term oncological data have also confirmed an outcome comparable to that of open radical nephrectomy.8 Laparoscopic radical nephrectomy is a standard treatment modality for T1–3a renal cell carcinoma patients. It is also
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technically feasible for treating patients with T3b disease (tumour within renal vein) or N1–2 disease, and as a cytoreductive treatment for patients with metastatic disease.9 There have been very few randomised studies comparing the transperitoneal and retroperitoneal approaches to laparoscopic nephrectomy. One prospective randomised study failed to demonstrate any difference between the transperitoneal and retroperitoneoscopic approaches in terms of operative difficulty, complications or post-operative recovery time.10
REFERENCES 1. Clayman RV, Kavoussi LR, Soper NJ, et al. (2002) Laparoscopic nephrectomy. J Urol 167(2, Pt 2): 862. 2. Fenn NJ, Gill IS. (2004) The expanding indications for laparoscopic radical nephrectomy. BJU Int 94(6): 761–765. 3. Gill IS, Meraney AM, Schweizer DK, et al. (2001) Laparoscopic radical nephrectomy in 100 patients: a single center experience from the United States. Cancer 92 (7): 1843–1855. 4. Dunn MD, Portis AJ, Shalhav AL, et al. (2000) Laparoscopic versus open radical nephrectomy: a 9-year experience. J Urol 164(4): 1153–1159. 5. Bonjer HJ, Hazebroek EJ, Kazemier G, et al. (1997) Open versus closed establishment of pneumoperitoneum in laparoscopic surgery. Br J Surg 84(5): 599–602. 6. Li SK, Hou SM, Fung B, et al. (2004) Safe control of the renal vein during laparoscopic nephrectomy using the “loop around the vein” technique. BJU Int 93(3): 420–421. 7. Burgess NA, Koo BC, Calvert RC, et al. (2007) Randomized trial of laparoscopic v open nephrectomy. J Endourol 21(6): 610–613. 8. Portis AJ, Yan Y, Landman J, et al. (2002) Long-term followup after laparoscopic radical nephrectomy. J Urol 167(3): 1257–1262. 9. Ono Y, Hattori R, Gotoh M, et al. (2005) Laparoscopic radical nephrectomy for renal cell carcinoma: the standard of care already? Curr Opin Urol 15(2): 75–8 (review). 10. Nambirajan T, Jeschke S, Al Zahrani H, et al. (2004) Prospective, randomized controlled study: transperitoneal laparoscopic versus retroperitoneoscopic radical nephrectomy. Urology 64(5): 919–924.
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Radical Prostatectomy for Locally Advanced Prostate Cancer Marc Claessens∗,† , Steven Joniau† and Hendrik Van Poppel†
INTRODUCTION Locally advanced prostate cancer (T3) is defined as cancer that has extended beyond the prostatic capsule with invasion of the pericapsular tissue or seminal vesicles, but without lymph node involvement or distant metastases.1 According to the 2002 TNM classification, T3a is an extracapsular extension either unilaterally or bilaterally and T3b involves invasion of seminal vesicles.2 According to the guidelines of the European Association of Urology, radical prostatectomy can be performed in patients with locally advanced CaP, PSA serum levels
