Linfadenectomía paraórtica laparoscópicatécnica transperitoneal vs. retroperitoneal

Abstract

Introduction: Laparoscopic paraortic lymphadenectomy is a surgical procedure which consists of the removal of the lymph nodes in the aortic zone for their pathological study. It is performed primary in the staging of gynecological cancers such as endometrial, cervical and ovarian cancer; being able to determine the administration of adyuvants treatments. There are two approaches: extraperitoneal and tranperitoneal. Materials and methods: A retrospective, comparative, observational descriptive study was conducted in a serie of 77 patients who had laparoscopic paraortic lymphadenectomy at Prince of Asturias University Hospital from June 2009 to December 2018. 50 of them was realized by route retroperitoneal and to 27 by means of a collision transperitoneal. Possible factors analyzed include: age of the patient, perssonal history, I.M.C., parity, type of cancer for which she was intervened, histological type, route of approach, state of the paraortic ganglia pre-surgery, imaging technique for evaluation of them, concordance of the imaging tests (Kappa index), number of aortic ganglia extracted, number of aortic ganglia affections, quantification of blood loss, percentage of intraoperative and postoperative complications, type of intraoperative and postoperative complications, treatment of complications intraoperative and postoperative, duration of surgery, days of admission, percentage of readmission and percentage of recurrence. Results: A univariate analysis of the factors mentioned above is performed. The mean age of the patients treated by extraperitoneal approach was 55.14 (13.18) years and of those operated by transperitoneal route was 54.26 (11.84 years). A percentage of previous abdominal surgery and I.M.C. similar between both groups. For the preoperative evaluation of aortic nodes, it was found that the imaging tests (CT and MRI) used obtained a moderate kappa index. More aortic nodes were obtained in those women operated by extraperitoneal approach (9.84 +/-4.64) than transperitoneal approach (7.11 +/- 5.08). The quantification of hematic loss, which was performed through the determination of preoperative and postoperative hemoglobin, was similar in both groups. The percentage of intraoperative and postoperative complications was similar in both approaches. Patients operated through an extraperitoneal approach had a shorter duration of surgery than those who were operated on through transperitoneal approach. The days of hospitalization of the operated patients was greater in women who underwent transperitoneal approach. Conclusions: 1. There were no statistically significant differences between the two groups in the percentage of intraoperative and postoperative complications. However, the number of aortic nodes removed was higher in the extraperitoneal approach. 2. The patients included in both groups had epidemiological characteristics that could be extrapolated. 3. The imaging tests used for the assessment of the aortic nodes were of moderate reliability, with a Kappa index between 0.4 and 0.8. 4. The retroperitoneal approach is the approach of choice for patients where: a. The only surgical procedure to be performed is para-aortic lymphadenectomy. b. High C.M.I. (greater than 30). c. Previous abdominal surgery. 5. Patients with cervical cancer had greater lymph node involvement, mainly due to a greater number of patients included in this group. 6. Both techniques are safe although, after the results obtained, the retroperitoneal approach is technically less complex and offers advantages over the transperitoneal approach in the aforementioned patients.