Vascular complication during staging lymphadenectomy in early-stage ovarian cancer
Surgical Technique

早期卵巢癌分期淋巴结切除术中的血管并发症

Vito Andrea Capozzi1, Giulia Armano1, Valentina Ceni1, Matteo Riccò2, Nicola Volpe1, Roberto Berretta1

1Department of Gynecology and Obstetrics, University Hospital of Parma, Parma, Italy; 2Servizio di Prevenzione e Sicurezza negli Ambienti di Lavoro, Dipartimento di Prevenzione, Azienda USL di Reggio Emilia, Reggio Emilia, Italy

Correspondence to: Vito Andrea Capozzi, MD, Department of Gynecology and Obstetrics, University Hospital of Parma, via Gramsci, 14, 43125 Parma, Italy. Email: vitoandrea.capozzi@studenti.unipr.it.

摘要：卵巢癌（OC）是欧洲第五大常见的癌症，也是目前妇科肿瘤患者最主要的死因。大约70％的病例都是在无特异性症状的晚期阶段诊断出来。在早期阶段，我们需要行分期手术来评估病情的进展程度。根据美国国立综合癌症网络（NCCN），手术分期包括全子宫切除术、双侧输卵管卵巢切除术、大网膜切除术、腹膜活检术、盆腔和腰椎淋巴结切除术。经典的手术入路为沿腹正中线纵行切口。然而，在专业医疗中心，可以对经过筛选的患者经腹腔镜进行分期手术。相对于开腹手术，腹腔镜手术可以减少术中及术后并发症、缩短住院时间，让患者可以更快回归工作，并且切口更加美观。尽管如此，即便是微创手术也不是完全没有并发症。在腹腔镜手术中发生重大并发症时，需要迅速进行抢救。我们展示了一个63岁的病例，该病例具有55毫米大的左附件多房实性包块，色彩评分2分、CA 125异常，需要进行全面的分期手术。该研究旨在展示在对早期卵巢癌进行分期淋巴结清扫术期间可能发生的一种危险的血管并发症。在这种情况下，需要快速中转开腹以达到快速止血的目的。

关键词：卵巢癌（OC）；血管并发症；分期淋巴结切除术

Received: 27 March 2020; Accepted: 23 June 2020; Published: 25 September 2020.

doi: 10.21037/gpm-20-26

视频1 External iliac artery injury during staging lymphadenectomy in early-stage ovarian cancer patient.

介绍

卵巢癌是女性第五大常见癌症，也是目前妇科肿瘤患者最主要的死因[1]。大约70％的病例都是在无特异性症状的晚期阶段被诊断出来[2]。在早期阶段，有必要对其进行分期手术。根据美国国立综合癌症网络（NCCN），手术分期包括全子宫切除术、双侧输卵管卵巢切除术、大网膜切除术、腹膜活检术、盆腔和腰椎淋巴结切除术[3]。

应通过沿腹正中线纵行切口进行分期手术。然而，在专业医疗中心，可以对经过筛选的患者经腹腔镜进行分期手术[3]。相对于开腹手术，腹腔镜手术可以减少出血量、缩短住院时间，生活质量更高、并发症更少[4-7]。

尽管如此，在腹腔镜手术中，当发生重大并发症时，除了需要医生具备及更好的手术技能以外，还需要迅速采取抢救措施。

我们展示了一个63岁的病例，该病例具有55毫米大的左附件多房实性包块，色彩评分2分、CA 125异常，附件表现提示为恶性病灶[8]。计算机断层扫描没有提示有远处转移病灶。左附件的冰冻冰冻病理切片提示左卵巢高级别浆液性癌，因此我们对其进行全面分期手术。

本文旨在展示在对早期卵巢癌进行分期淋巴结清扫术期间可能发生的一种危险的血管并发症。

手术技巧

  • 开发膀胱旁和直肠旁的空间以充分暴露手术野（图1-图3）。
  • 此外，确认主要解剖结构：输尿管、闭孔神经、子宫血管、脐动脉（图4,图5）。
  • 分离血管及淋巴周围组织，以便于完整切除盆腔淋巴结，注意不要损伤生殖股神经（图6,图7）。盆腔淋巴结切除术的范围下限为深髂腰静脉（图8）。
  • 当意外损伤血管时，必须迅速夹闭血管（图9,图10）。助手必须将视频镜移开并保持完整手术野的正确视图，防止血液弄脏视频镜。
  • 一旦出血止住，在缝扎血管断端前需充分暴露血管走形。血管的修复可以在腹腔镜下进行，也可以开腹进行[9]。在次病例中，我们采取脐旁正中切口，并用3-0缝线进行动脉血管缝扎。由于快速干预，患者总失血量预计1200毫升（视频1）。
图1
图1 膀胱旁间隙
图2
图2 直肠旁间隙
图3
图3 闭孔间隙
图4
图4 主要解剖结构
图5
图5 输尿管和子宫血管
图6
图6 生殖股神经
图7
图7 淋巴管
图8
图8 深髂腰静脉
图9
图9 受损的髂外静脉
图10
图10 钳夹髂外动脉

评论

国际指南推荐具备妇科肿瘤学专业知识的妇科医生的医学中心进行卵巢癌的治疗[3]。意外的髂内动脉损伤需要迅速采取抢救措施。当微创手术发生并发症时，主刀医生的手术技巧对于快速和正确处理并发症是必不可少的。

目前，应对可能发生的并发症的最佳手术方式尚未达成共识[10]。手术医生应当采取他/她最舒服或最自信的手术方式[11]。

考虑到这一情景，我们强烈认为，这类手术应当在癌症中心开展，并由操作熟练的专科医生进行。

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Gynecology and Pelvic Medicine for the series “Laparoscopic Surgery for Ovarian Cancer”. The article has undergone external peer review.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://gpm.amegroups.org/article/view/10.21037/gpm-20-26/coif). The series “Laparoscopic Surgery for Ovarian Cancer” was commissioned by the editorial office without any funding or sponsorship. VAC served as the unpaid Guest Editor of the series. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for publication of this study and any accompanying images.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

  1. Torre LA, Trabert B, DeSantis CE, et al. Ovarian cancer statistics, 2018. CA Cancer J Clin 2018;68:284-96. [Crossref] [PubMed]
  2. Doubeni CA, Doubeni AR, Myers AE. Diagnosis and Management of Ovarian Cancer. Am Fam Physician 2016;93:937-44. [PubMed]
  3. National Comprehensive Cancer Network. Ovarian cancer. (Version 32019). Available online: http//www.nccn.org/professionals/physician_gls/pdf/ovarian.pdf
  4. Gueli Alletti S, Capozzi VA, Rosati A, et al. Laparoscopy vs. laparotomy for advanced ovarian cancer: a systematic review of the literature. Minerva Med 2019;110:341-57. [Crossref] [PubMed]
  5. Capozzi VA, Sozzi G, Gambino G, et al. Laparoscopy versus laparotomy for surgical treatment of obese women with endometrial cancer: A cost-benefit comparative analysis. Mol Clin Oncol 2019;11:335-42. [PubMed]
  6. Cianci S, Tarascio M, Rosati A, et al. Sexual function and quality of life of patients affected by ovarian cancer. Minerva Med 2019;110:320-9. [Crossref] [PubMed]
  7. Uccella S, Zorzato PC, Lanzo G, et al. The role of sentinel node in early ovarian cancer: a systematic review. Minerva Med 2019;110:358-66. [Crossref] [PubMed]
  8. Van Calster B, Van Hoorde K, Froyman W, et al. Practical guidance for applying the ADNEX model from the IOTA group to discriminate between different subtypes of adnexal tumors. Facts Views Vis Obgyn 2015;7:32-41. [PubMed]
  9. Krishnakumar S, Tambe P. Entry complications in laparoscopic surgery. J Gynecol Endosc Surg 2009;1:4-11. [Crossref] [PubMed]
  10. Samsonov VT, Ermolov AS, Gulyaev AA, et al. Laparoscopy in emergency abdominal surgery. Khirurgiia (Mosk) 2019;32-7. [Crossref] [PubMed]
  11. Capozzi VA, Rosati A, Turco LC, et al. Surgery vs. chemotherapy for ovarian cancer recurrence: what is the best treatment option. Gland Surg 2020; [Crossref]
译者介绍
雷曾静
四川大学华西临床医学院妇产科硕士，研究方向为早期宫颈癌手术方式的相关研究。（更新时间：2022-03-18）

（本译文仅供学术交流，实际内容请以英文原文为准。）

doi: 10.21037/gpm-20-26
Cite this article as: Capozzi VA, Armano G, Ceni V, Riccò M, Volpe N, Berretta R. Vascular complication during staging lymphadenectomy in early-stage ovarian cancer. Gynecol Pelvic Med 2020;3:23.

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