Open Retroperitoneal Lymph Node Dissection

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

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.

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