Laparoscopic Management of Hypogastric Vein Injury during Pelvic Lymphadenectomy

Article Information: Publication Date:: 04/18/2004    Update Date:: 04/21/2004

Introduction

The first laparoscopic lymphadenectomy was reported in the late 1980’s and safety of this procedure has been largely proved. Familiarity with instrumentation and management of  complication is a prerequisite to perform this procedure.  

In this case report we describe the successful management of a hypogastric vein injury during a pelvic laparoscopic lymphadenectomy. 

Case History

A 41 years old, 5 gravid, 2 Para patient with a 1A₂ squamous  cell carcinoma of the cervix.   The patient underwent a Laparoscopic Assisted Radical Hysterectomy and Pelvic Lymphadenectomy.

Technique of Laparoscopic Pelvic Lymphadenectomy

After the introduction of the trocars and the visualization of the retroperitoneal vessels, the peritoneum of the right side wall is lifted with a grasper and incised with harmonic scalpel.

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The incision is then extended cephalically  parallel to the infundibulo-pelvic ligament to expose the retroperitoneal structures. Lymphadenectomy is began by scheletonizing the external iliac artery.

The proximal group of external iliac nodes is excised by entering the adventitious sheet of the vessels using the harmonic scalpel.   Care is taken to avoid injury to the genitor-femoral nerve along its course on the psoas muscle when it is  lateral to the external iliac vessels.

The lymphnodes are removed in small groups one at the time.

The distal group of the external iliac artery nodes is removed up  to the vessels exit under the inguinal ligament.

Next, the paravescical  space is developed between the obliterated umbilical artery medially and the external iliac vessels laterally.

Blunt and sharp dissection in this space enables the visualization of the obturator nerve. This is an vascular plane,  therefore only a minimal bleeding is encountered.

The lymphnode  bundle  between the obturator nerve and the external iliac vein is the obturator fossa nodule   packet,  witch is removed using the harmonic scalpel used for coagulation and dissection.

Lastly the nodes along the hypogastric artery are removed.

If some bleeding has been noted, the harmonic scalpel consents to achieve haemostasis.

Many groups of nodes are removed and placed in the anterior cul de sac for later retrieval.

Once the vessels and the nodes have been cleaned of the lymphatic tissue they are clearly visualized and identified: the hypogastric vein and the lymphnode chain along the hypogastric vein is also excised.

Case Report

As an enlarged and adherent lymphatic tissue of the hypogastric vein was removed,  a hypogastric vein injury occurred with the tip of the harmonic scalpel.

The bleeding was controlled partially by applying the suction irrigator device.

After the complete removal of the lymph node the vessel was clasped with an atraumatic grasping forceps.

Three endoscopic haemostatic clips were applied on both end of the bleeding site.

The bleeding was successfully controlled with the above measures.

The site was thereafter evaluated under low pressure pneumoperitoneum for security. No further bleeding was noted.

The patient subsequently underwent radical hysterectomy and left pelvic lymphadenectomy procedure uneventfully.   The estimated blood loss of the procedure was 150 ml. In all 32, all negative, lymph nodes were removed.   The post operative hospital stay  was 3 days. No post operative complications and no long term sequelae were reported.

References:

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