RU2831093C1 - Method of arranging ports for laparoscopic approach to posterior group of pancreatoduodenal lymph nodes in lymphadenectomy in patients with cholangiocarcinoma - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to hepatobiliary surgery. Optical port is placed in the right mesogastrium at distance of 10–12 cm from the midline. Right working port is placed under the right costal arch along the middle axillary line. On the left, the working ports are placed under the left costal arch along the midclavicular line and in the left mesogastrium along the anterior axillary line.

EFFECT: method provides reduction of traumatism in lymph node dissection of posterior pancreatoduodenal group of lymph nodes of thirteenth group, reduced intraoperative and postoperative complications due to improved visualization and ergonomics of laparoscopic instruments.

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Description

The invention relates to hepatobiliary surgery and can be used in laparoscopic liver resections in patients with cholangiocarcinoma.

One of the key stages of surgery for cholangiocarcinoma is regional lymphadenectomy. To date, the possibility of complete lymphadenectomy during laparoscopic resection in patients with cholangiocarcinomas remains a subject of discussion. AJCC recommendations (8th edition) for intrahepatic cholangiocarcinoma include removal of at least 6 lymph nodes for adequate staging [1 - Bagante F., Spolverato G., Weiss M., Alexandrescu S., Marques H.P., Aldrighetti L. et al. Assessment of the Lymph Node Status in Patients Undergoing Liver Resection for Intrahepatic Cholangiocarcinoma: the New Eighth Edition AJCC Staging System. J Gastrointest Surg. 2018 Jan;22(l):52-59. doi: 10.1007/sl 1605-017-3426-x. Epub 2017 Apr 19. PMID: 28424987].

A method of port placement during laparoscopic resections of anterolateral segments of the liver is known, in which the surgeon's working instruments are in the most advantageous position of 90° relative to each other with the placement of an optical port between them [2 - Starkov Yu.G., Vishnevsky V.A., Shishin K.V. Laparoscopic operations for focal liver lesions // Annals of surgical hepatology. - 2008. - T.N., - No. 1. - P. 34-41]. This method is accepted as an analogue.

There is also a known method of port placement during laparoscopic resections of the posterosuperior segments, proposed by Lee W. et al. in 2014 [3 - Lee W, Han HS, Yoon YS, Cho JY, Choi Y, Shin HK. Role of intercostal trocars on laparoscopic liver resection for tumors in segments 7 and 8. J Hepatobiliary Pancreat Sci. 2014 Aug; 21(8):E65-8. doi: 10.1002/jhbp.l23. Epub 2014 May 19. PMID: 24841194], which differs from the standard port placement by the use of 2 additional transthoracic (intercostal) ports in the 7th and 9th intercostal spaces on the right. Moreover, a laparoscope is subsequently installed in one of the trocars, which allows for clear visualization of the posterior-upper segments of the liver. This method is adopted as a prototype. The disadvantage of all transthoracic approaches is the inevitable entry into the pleural cavity and the need to use special trocars with sealing inflatable cuffs to prevent pneumothorax during the operation.

The aim of the invention is to reduce trauma during lymphadenectomy of the posterior group of pancreatoduodenal lymph nodes and to reduce intraoperative and postoperative complications.

The technical result consists in the fact that the optical port is installed in the right mesogastrium at a distance of 10-12 cm from the midline, the right working port is placed under the right costal arch along the midaxillary line, on the left the working ports are located under the left costal arch along the midclavicular line and in the left mesogastrium along the anterior axillary line.

The method is carried out as follows

Regional lymphadenectomy during laparoscopic liver resections, including the posterior group of pancreaticoduodenal lymph nodes, for the purpose of adequate staging of cholangiocarcinoma is one of the most complex lymphadenectomy options [4. Lendoire JC, Gil L, Imventarza O. Intrahepatic cholangiocarcinoma surgery: the impact of lymphadenectomy. Chin Clin Oncol. 2018 Oct; 7(5):53. doi: 10.21037/cco.2018.07.02. Epub 2018 Jul 17. PMID: 30180752. 5. Wu J, Han J, Zhang Y, Liang L, Zhao J, Han F, Dou C, Zhang Y, Liu J, Wu W, Hu Z, Zhang C. Safety and feasibility of laparoscopic versus open liver resection with associated lymphadenectomy for intrahepatic cholangiocarcinoma. Biosci Trends. 2020 Nov 4; 14(5):376-383. doi: 10.5582/bst.2020.03293. Epub 2020 Sep 11. PMID: 32921695. 6. Chen C, Su J, Wu H, Qiu Y, Song T, Mao X, He Y, Cheng Z, Zhai W, Li J, Geng Z, Tang Z. Prognostic value of lymphadenectomy in node-negative intrahepatic cholangiocarcinoma: A multicenter, retrospectively study. Eur J Surg Oncol. 2023 Apr; 49(4):780-787. doi: 10.1016/j.ejso.2022.11.008. Epub 2022 Nov 8. PMID: 36404249]. According to the generally accepted worldwide classification of the Japanese Society of Hepatopancreatobiliary Surgeons [6. Chen C, Su J, Wu H, Qiu Y, Song T, Mao X, He Y, Cheng Z, Zhai W, Li J, Geng Z, Tang Z. Prognostic value of lymphadenectomy in node-negative intrahepatic cholangiocarcinoma: A multicenter, retrospectively study. Eur J Surg Oncol. 2023 Apr;49(4):780-787. doi: 10.1016/j.ejso.2022.11.008. Epub 2022 Nov 8. PMID: 36404249.], the posterior group of lymph nodes includes the lymph nodes of the posterior surface of the head of the pancreas (posterior pancreaticoduodenal group).

With laparoscopic access, difficulties often arise in visualizing the posterior group of pancreatoduodenal lymph nodes, which increases the risk of intraoperative and postoperative complications with possible loss of full lymphadenectomy. Lymph node dissection of the posterior group of pancreatoduodenal lymph nodes is the most complex surgical manipulation, both with open and minimally invasive approaches. The reasons for the complexity of lymphadenectomy of the posterior group of pancreatoduodenal lymph nodes are associated with poor visualization and inevitable limitations in manipulation, as well as the proximity of large vascular structures.

As a rule, during laparoscopic liver resections, in particular anterolateral segments (2,3,4,5,6) of the liver, the trocar arrangement is usually used, in which the surgeon's working instruments are in the most advantageous position of 90°. relative to each other with the placement of an optical port between them. In this case, the optical port is often located in the umbilical region, which favors visualization and the absence of conflict with the working instruments. However, this method of trocar arrangement does not provide sufficient visualization of the surgical field for safe manipulations during lymphadenectomy of the posterior group of pancreatoduodenal lymph nodes, which leads to the need to shift the angle of "attack" of the optics of the instruments laterally from the midline.

When planning laparoscopic liver resection with lymphadenectomy for cholangiocarcinoma, the patient is positioned on the table with the lower limbs apart, the surgeon is positioned to the left of the patient, and the assistants are positioned between the legs and to the right of the patient. Great attention must be paid to the patient's position on the operating table, since the success of the operation and the patient's condition in the postoperative period depend on it. Incorrect positioning of the patient on the operating table can lead to technical difficulties due to the lack of ergonomic arrangement of instruments, as well as cause positional disorders in the postoperative period. Formation of carboxyperitoneum is carried out using a puncture of the abdominal cavity with a Veress needle; in case of adhesions in the area of insertion of the Veress needle and the first trocar, the Hasson trocar placement technique is used or a Visiport series trocar is used. To create a viewing angle from right to left and upward for visualization of the posterior surface of the pancreatic head and removal of the posterior group of pancreaticoduodenal lymph nodes up to the aortocaval space and the right semicircle of the celiac trunk, the optical port is installed in the right mesogastrium at a distance of 10-12 cm from the midline, the right working port is placed under the right costal arch along the midaxillary line, on the left the working ports are located under the left costal arch along the midclavicular line and in the left mesogastrium along the anterior axillary line. This method of trocar placement improves visualization and ergonomics of laparoscopic instruments due to the ability to change the viewing angle of the surgical field, which increases the efficiency and safety of lymphadenectomy of the posterior group of pancreaticoduodenal lymph nodes during laparoscopic liver resections in patients with cholangiocarcinoma.

The method is confirmed by the following examples.

Example 1

Patient F., 66 years old, was admitted to the A.S. Loginov Moscow Clinical Research Center of the Health Department of the City of Moscow in 2020 with the diagnosis: "Intrahepatic cholangiocarcinoma of the 5,6,7,8 segments of the liver pT4N0M0 G2". The tumor was detected by CT 2 months before admission with dimensions of 80 × 67 mm. The patient underwent laparoscopic right-sided hemihepatectomy with regional lymphadenectomy. In this surgical intervention, the proposed method of trocar placement was used for optimal access during lymphadenectomy of the posterior group of pancreatoduodenal lymph nodes: the optical port is installed in the right mesogastrium at a distance of 10 cm from the midline, the right working port is placed under the right costal arch along the midaxillary line, on the left the working ports are located under the left costal arch along the midclavicular line and in the left mesogastrium along the anterior axillary line. The operation time was 425 minutes. Blood loss was 450 ml. Hemotransfusion was not performed. The postoperative period was uneventful. The patient was discharged on the 11th day after the operation. During outpatient observation for 35 months after the operation, no data on tumor recurrence were found.

Example 2

Patient I., 53 years old, was admitted to the State Budgetary Healthcare Institution "Moscow Clinical Research Center named after A.S. Loginov" of the Health Department of the City of Moscow in 2020 with the diagnosis: "Intrahepatic cholangiocarcinoma of the 8th liver segment pT4N0M0 G2". The tumor was detected by CT 2 months before admission with dimensions of 48 × 60 mm. The patient underwent laparoscopic resection of the VIII segment 10 days later. For optimal access during laparoscopic lymphadenectomy of the posterior group of pancreatoduodenal lymph nodes during laparoscopic liver resection, the proposed method was used: the optical port was installed in the right mesogastrium at a distance of 11 cm from the midline, the right working port was placed under the right costal arch along the midaxillary line, on the left the working ports were located under the left costal arch along the midclavicular line and in the left mesogastrium along the anterior axillary line. The operation time was 405 min. The Pringle maneuver was not used. Blood loss was 720 ml. Only fresh frozen plasma was transfused. The postoperative period was uneventful. The patient was discharged on the 10th day after the operation. During outpatient observation for 38 months after the operation, no data on tumor recurrence were found.

Example 3

Patient P., 59 years old, was admitted to the A.S. Loginov Moscow Clinical Research Center of the Health Department of the City of Moscow in 2020 with the diagnosis: "Intrahepatic cholangiocarcinoma of the 7,8th liver segments pT4N0M0 G3". The tumor was detected by CT with dimensions of 58 × 62 mm. The patient underwent laparoscopic resection of the 7,8 liver segments. For this surgical intervention, the proposed method of trocar placement was used for optimal access to the 13th group of lymph nodes. For optimal access during laparoscopic lymphadenectomy of the posterior group of pancreatoduodenal lymph nodes, the patient underwent surgery according to the proposed method:

The optical port is installed in the right mesogastrium at a distance of 12 cm from the midline, the right working port is placed under the right costal arch along the midaxillary line, on the left the working ports are located under the left costal arch along the midclavicular line and in the left mesogastrium along the anterior axillary line.

The operation time was 470 min. Pringle's maneuver was not used. Blood loss was 510 ml. No blood transfusion was performed. The postoperative period was uneventful. Discharged on the 7th day after the operation. No evidence of tumor recurrence was found during outpatient observation for 33 months after the operation.

Currently, in the State Budgetary Healthcare Institution “Moscow Clinical Research Center named after A.S. Loginov” of the Health Department of Moscow, using this method of access to the posterior group of pancreatoduodenal lymph nodes, laparoscopic liver resections have been performed in 40 patients with cholangiocarcinoma. Thus, the proposed method of trocar placement during laparoscopic liver resections in patients with cholangiocarcinoma provides improved visualization and ergonomics of laparoscopic instruments, which allows for safe lymphadenectomy of the posterior group of pancreatoduodenal lymph nodes.

Sources of information

1. Bagante R, Spolverato G., Weiss M., Alexandrescu S., Marques H.P., Aldrighetti L. et al. Assessment of the Lymph Node Status in Patients Undergoing Liver Resection for Intrahepatic Cholangiocarcinoma: the New Eighth Edition AJCC Staging System. J Gastrointest Surg. Jan 2018; 22(l):52-59. doi: 10.1007/s 11605-017-3426-x. Epub 2017 Apr 19. PMID: 28424987 1.

2. Starkov Yu.G., Vishnevsky V.A., Shishin K.V. Laparoscopic operations for focal liver lesions // Annals of surgical hepatology. - 2008. - V. 13., -№1.-P. 34-41.

3. Lee W, Han HS, Yoon YS, Cho JY, Choi Y, Shin HK. Role of intercostal trocars on laparoscopic liver resection for tumors in segments 7 and 8. J Hepatobiliary Pancreat Sci. 2014 Aug;21(8):E65-8. doi: 10.1002/jhbp.l23. Epub 2014 May 19. PMID: 24841194.

4. Lendoire JC, Gil L, Imventarza O. Intrahepatic cholangiocarcinoma surgery: the impact of lymphadenectomy. Chin Clin Oncol. 2018 Oct;7(5):53. doi: 10.21037/cco.2018.07.02. Epub 2018 Jul 17. PMID: 30180752.

5. Wu J, Han J, Zhang Y, Liang L, Zhao J, Han F, Dou C, Zhang Y, Liu J, Wu W, Hu Z, Zhang C. Safety and feasibility of laparoscopic versus open liver resection with associated lymphadenectomy for intrahepatic cholangiocarcinoma. Biosci Trends. 2020 Nov 4;14(5):376-383. doi: 10.5582/bst.2020.03293. Epub 2020 Sep 11. PMID: 32921695.

6. Chen C, Su J, Wu H, Qiu Y, Song T, Mao X, He Y, Cheng Z, Zhai W, Li J, Geng Z, Tang Z. Prognostic value of lymphadenectomy in node-negative intrahepatic cholangiocarcinoma: A multicenter, retrospective study. Eur J Surg Oncol. 2023 Apr;49(4):780-787. doi: 10.1016/j.ejso.2022.11.008. Epub 2022 Nov 8. PMID: 364.

Claims (1)

A method for placing ports for laparoscopic access to the posterior group of pancreaticoduodenal lymph nodes during lymphadenectomy in patients with cholangiocarcinoma, characterized in that the optical port is installed in the right mesogastrium at a distance of 10-12 cm from the midline, the right working port is placed under the right costal arch along the midaxillary line, on the left the working ports are located under the left costal arch along the midclavicular line and in the left mesogastrium along the anterior axillary line.