Difference between revisions of "Open Retroperitoneal Lymph Node Dissection"

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Oncologic procedure done for management of metastatic disease, typically from testicular cancer. Many surgical teams are often involved because many retroperitoneal organ systems can be involved: typically Urology +/- GI +/- Vascular. Most notably, metastases requiring dissection often directly involve the SVC and/or Aorta, creating a serious high-volume bleed risk to this procedure.


== Overview ==
=== Indications<!-- List and/or describe the indications for this surgical procedure. --> ===
Metastatic disease
=== Surgical procedure<!-- Briefly describe the major steps of this surgical procedure. --> ===
Large ventral incision followed by exposure to retroperitoneal space. Dissection then follows in whichever organs are affected: duodenum, IVC, aorta, kidney, etc.
== Preoperative management ==
=== Patient evaluation<!-- Describe the unique and important aspects of preoperative evaluation. Add or remove rows from the systems table as needed. --> ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|
|-
|Neurologic
|
|-
|Cardiovascular
|Expect intraoperative and postoperative tachycardia.
|-
|Pulmonary
|
|-
|Gastrointestinal
|
|-
|Hematologic
|
|-
|Renal
|
|-
|Endocrine
|
|-
|Other
|
|}
=== Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> ===
=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> ===
=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> ===
=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> ===
== Intraoperative management ==
=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> ===
At least 2x large bore PIV, arterial line.
=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> ===
GA w/ ETT, maintain complete paralysis.
=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> ===
Arched back, supine, arms out.
=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> ===
=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> ===
== Postoperative management ==
=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> ===
ICU. Due to manipulation of the hypogastric plexus, fairly significant tachycardia is expected in the post-operative period. It is typically advised to resuscitate to the blood pressure and UOP with lesser regard to the HR because it is not their actual circulatory status that is elevating the HR, so inappropriate volume resuscitation would not be helpful. Esmolol can be useful, though.
=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> ===
Epidural > Truncal block but both are valid.
=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> ===
Significant bleeding.
== Procedure variants<!-- This section should only be used for cases with multiple approaches (e.g. Laparoscopic vs. open appendectomy). Otherwise, remove this section. Use this table to very briefly compare and contrast various aspects between approaches. Add or remove rows as needed to maximize relevance. Consider using symbols rather than words when possible (e.g. +, –, additional symbols such as ↑ and ↓ are available using the "Ω" tool in the editor). --> ==
{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Variant 1
!Variant 2
|-
|Unique considerations
|
|
|-
|Indications
|
|
|-
|Position
|
|
|-
|Surgical time
|
|
|-
|EBL
|
|
|-
|Postoperative disposition
|
|
|-
|Pain management
|
|
|-
|Potential complications
|
|
|}
== References ==
[[Category:Surgical procedures]]

Latest revision as of 07:56, 17 August 2023

Oncologic procedure done for management of metastatic disease, typically from testicular cancer. Many surgical teams are often involved because many retroperitoneal organ systems can be involved: typically Urology +/- GI +/- Vascular. Most notably, metastases requiring dissection often directly involve the SVC and/or Aorta, creating a serious high-volume bleed risk to this procedure.

Overview

Indications

Metastatic disease

Surgical procedure

Large ventral incision followed by exposure to retroperitoneal space. Dissection then follows in whichever organs are affected: duodenum, IVC, aorta, kidney, etc.

Preoperative management

Patient evaluation

System Considerations
Airway
Neurologic
Cardiovascular Expect intraoperative and postoperative tachycardia.
Pulmonary
Gastrointestinal
Hematologic
Renal
Endocrine
Other

Labs and studies

Operating room setup

Patient preparation and premedication

Regional and neuraxial techniques

Intraoperative management

Monitoring and access

At least 2x large bore PIV, arterial line.

Induction and airway management

GA w/ ETT, maintain complete paralysis.

Positioning

Arched back, supine, arms out.

Maintenance and surgical considerations

Emergence

Postoperative management

Disposition

ICU. Due to manipulation of the hypogastric plexus, fairly significant tachycardia is expected in the post-operative period. It is typically advised to resuscitate to the blood pressure and UOP with lesser regard to the HR because it is not their actual circulatory status that is elevating the HR, so inappropriate volume resuscitation would not be helpful. Esmolol can be useful, though.

Pain management

Epidural > Truncal block but both are valid.

Potential complications

Significant bleeding.

Procedure variants

Variant 1 Variant 2
Unique considerations
Indications
Position
Surgical time
EBL
Postoperative disposition
Pain management
Potential complications

References

Top contributors: Matthew Abadir and Jeremy Sieker

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