Explain：Cervical cancer with
retroperitoneal lymph node metastasis
Clinical Information:
The patient had {{ abnormal vaginal bleeding, abnormal Pap smear, ASCUS,
LSIL, HSIL, Cancer on Pap}}.
Patient underwent a
cervical biopsy and microscopic histological showed malignant cervical cancer.
Clinical staging is
stage {Ib2, IIa, IIb}}.
Pelvic and abdominal
CT shows retroperitoneal lymph node {{enlarged, not
enlarged}}.
The biochemical data
are: SCC:_______, CEA:________.
Menopause {{ +, -}}.
Neoadjuvant
chemotherapy {{+, -}}.
Radiation history {{+, -}}.
Operative Procedures:
Type of operation: Staging
laparotomy: [[BSO,
RSO, LSO, BS, BPLD, para-aortic lymph node dissection, appendectomy, enterolysis,
cytology ]].
The
uterus was anteverted in position. Bilateral
adnexae were grossly normal in appearance. Soft retroperitoneal lymph nodes
were palpable over the common iliac and pelvic lymph nodes. Bilateral ureters
and urinary bladder were not remarkable. However, dilated blood vessels around
the cervical and upper vaginal areas were noted. Endometrium and corpus were normal in grossly. Moderate
pelvic adhesion was noted over bilateral pelvic adnexa area and culdesac.
Bilateral parametrium were free. There was not ascites. Liver, spleen and
omentum, peritoneum all were free from cancer invasion. Retroperitoneal nodes
were enlarged.
Frozen section of retroperitoneal lymph nodes were
malignancy.
The pelvic cavity was accessed through
a midline/left-lateral longitudinal abdominal incision. A self-retaining
retractor was applied to expose the retroperitoneal space. Left/right round ligaments were severed
and double ligated with silk sutures, The left paravesical and pararectal
spaces were developed by blunt dissection. The space between left psoas muscle
and external iliac vein was also developed. Then the left ureter was gently
pushed medially to expose left iliac vessels. Dissection of the lymphatic
tissue began from the bifurcation of left common iliac artery and extended
upward to the bifurcation of the aorta and downward to the lateral and medial
inguinal regions. The lymphatic tissue above the common iliac bifurcation was
removed en bloc and sent for histologic investigation as upper pelvic nodes.
That below the point of bifurcation, which including the external iliac nodes,
internal iliac nodes, obturator, medial and lateral inguinal nodes, were also
dissected en bloc as lower pelvic nodes. Particular care was taken to avoid
trauma to the obturator nerve and vessels. Lymph node dissection over the right
upper and lower pelvis, dissection of the right uterine artery, separation of
the right lower ureter. Special care was put to prevent damage to the
adventitia and muscular wall of the ureter, and also the bladder wall. This procedure
was performed [or not] over the contralateral side thereafter. Meticulous
normal saline irrigation to wash the blood clot and hemostasis was then
performed. Two J-P draining tubes were placed over bilateral pelvic floors.
□ Salpingo-oophorectomy
The infundibulopelvic ligament was clamped, cut and ligated
with 1-0 silk. The ovarian ligament mesosalpinx and tube were clamped, cut and
ligated with 1-0 silk. The ovary and adnexa were removed. The pritoneum was
repaired with 1-0 chromic suture materials.
□ Wedge resection of ovarian
tumor / enucleation of ovarian tumor.
An elliptical incision was made over the wall of the ovarian
tumor through the cortex. A plane is developed and the tumor was mobilized by
sharp and blunt dissection. Once the tumor is removed, the inner ovarian stroma
was approximated with a purse-string of 2-0 chromic, and hemostasis completed.
The cortex is closed with a running suture of 1-0 chromic.
□ Lysis of adhesion.
The adhesion tissues were removed, and the intestine,
omentum, ovary. tube, uterus, and
peritoneum were separated into original location. Wound is accomplished with
special attention to hemostasis.
□ Incidental appendectomy.
The mesoappendix and appendix artery were clamped, cut and ligated with 2-0 catgut. The appendix
was removed. The appendix cut surface was clean with betaiodine and normal
saline.
The
abdominal wall was closed layer by layer. The peritoneum below the umbilicus was approximated by 1-0
chromic catgut, the abdominal fascia was closed by 1-0 PDS continuous suture,
the sub-cutaneous fat was approximated by 1-0 vicryl, and the skin was
approximately by 3-0 vicryl subcutaneously. Scrupulous normal saline irrigation before closure of
abdominal wall and between layers of closure was done to wash out the possible
floating tumor cells. The patient was sent to POR intensive care unit for
recovery and respiratory support. The patient stood the procedure well
and in stable condition.
Operative Findings:
Cervix tumor size:
_________CM.
Hydroureter: {{not, yes}}
Lymph node status: [[node not enlarged, R’t pelvic nodes enlarged, L’t node
enlarged, paraaortic node not enlarged, Paraaortic node metastasis]]
Complication: [[massive
bleeding, ureter injury, bladder injury, intestine injury, _______________]].
Pathology:
Cell type: {{SQUAMOUS CELL CARCINOMA, ADENOCARCINOMA, SMALL CELL
CARCINOMA, LELC}}.
Grade: {{1, 2, 3}}
R’t pelvic nodes: {{ negative, positive _______}}.
L’t pelvic nodes: {{ negative, positive _______}}.
R’t paraaortic nodes: {{ negative, positive _______}}.
R’t paraaortic nodes:
{{ negative, positive _______}}.
Dr:________________. Date: _______________.