Left Sided Testicular Primary

After the administration of the anesthetic, a Foley catheter is anchored and the abdomen is prepared. The midline incision is made, and a self-retaining Bookwalter retractor is used. Inspection of the abdomen and retroperitoneum is carried out; if a higher-volume retroperitoneal tumor is identified, a full bilateral dissection is performed, as in the case of right-sided disease. If minimal or no retroperi-toneal tumor is identified, an incision is made in the posterior peritoneum lateral to the left colon. The left colon is then mobilized medially, exposing the

Testicle Inspection

Figure 10-9. In this same dissection, as seen in Figure 10-8, this figure is the dissection from the patient's left side. The vena cava is being retracted anteriorly, and the arrows indicate lumbar veins that pass from the vena cava to the lumbar foramina in the posterior body wall. These lumbar veins must be dissected and divided to allow complete mobilization of the vena cava.

Figure 10-9. In this same dissection, as seen in Figure 10-8, this figure is the dissection from the patient's left side. The vena cava is being retracted anteriorly, and the arrows indicate lumbar veins that pass from the vena cava to the lumbar foramina in the posterior body wall. These lumbar veins must be dissected and divided to allow complete mobilization of the vena cava.

Retroperitoneum Vessels And Ligaments
Figure 10-10. As viewed from the patient's left side, the vena cava is retracted anteriorly, thus exposing the right-sided sympathetic chain. Efferent sympathetic fibers are held in vessel loops, and the anterior spinous ligament is seen posteriorly at the completion of the lymphatic dissection.

left side of the retroperitoneum. The identification of the efferent sympathetic fibers on the left side is somewhat more difficult than on the right side. With experience, the efferent fibers can be identified as they pass anterior to the left common iliac artery and can be encircled with a vessel loop (Figure 10-13). They can then be dissected proximally and identified as they enter the left-sided sympathetic trunk. Alternatively, the efferent sympathetic fibers can be identified by dissecting on the psoas laterally and mobilizing the lymphatic tissue anteriorly until the

Figure 10-11. Also as viewed from the patient's left side, retractors hold the vena cava laterally and retract the origin of the left renal vein to the vena cava superiorly. The leftward-facing arrow indicates the right renal artery, which has been dissected from lymphatic tissue; the rightward-facing arrow indicates the insertion of the crus of the diaphragm to the posterior body wall at the anterior spinous ligament.

Aortocaval Lymph Node Picture

Figure 10-12. A completed right modified nerve-sparing retroperitoneal lymph node dissection as seen from the patient's left side. The lymphatic tissue has been completely removed, as indicated by the lack of lymphatic tissue in the right paracaval, precaval, and inter-aortocaval areas. The vessel loops hold efferent sympathetic fibers, and the anterior spinous ligament is seen posteriorly between the aorta and the vena cava.

Figure 10-12. A completed right modified nerve-sparing retroperitoneal lymph node dissection as seen from the patient's left side. The lymphatic tissue has been completely removed, as indicated by the lack of lymphatic tissue in the right paracaval, precaval, and inter-aortocaval areas. The vessel loops hold efferent sympathetic fibers, and the anterior spinous ligament is seen posteriorly between the aorta and the vena cava.

sympathetic chain is identified. The chain is fully exposed, which allows the identification of the efferent fibers. They are then dissected distally as they pass over the left common iliac artery. Since the anatomy of the efferent sympathetic fibers on the left side is more variable than that of those on the right side, it is very important to determine this neu-roanatomy early in the procedure in order to avoid

Figure 10-13. In this full bilateral dissection, the surgical anatomy of left-sided efferent sympathetic fibers is shown. The upward-pointing arrows show the left-sided sympathetic chain, and the downward-pointing arrow indicates the left-sided sympathetic efferent fibers as they pass anterior to the left common iliac artery. In this particular patient, right-sided sympathetic fibers were also preserved, and the confluence of right- and left-sided fibers is seen at the bifurcation of the aorta.

Figure 10-13. In this full bilateral dissection, the surgical anatomy of left-sided efferent sympathetic fibers is shown. The upward-pointing arrows show the left-sided sympathetic chain, and the downward-pointing arrow indicates the left-sided sympathetic efferent fibers as they pass anterior to the left common iliac artery. In this particular patient, right-sided sympathetic fibers were also preserved, and the confluence of right- and left-sided fibers is seen at the bifurcation of the aorta.

Figure 10-11. Also as viewed from the patient's left side, retractors hold the vena cava laterally and retract the origin of the left renal vein to the vena cava superiorly. The leftward-facing arrow indicates the right renal artery, which has been dissected from lymphatic tissue; the rightward-facing arrow indicates the insertion of the crus of the diaphragm to the posterior body wall at the anterior spinous ligament.

injury to the fibers. The preferred technique is to initially identify the fibers as they pass anterior to the left common iliac artery.

After the nerves have been identified, the lymphatic tissue overlying the left renal vein is divided and is rolled inferiorly. The origin of the left gonadal vein is identified and dissected (Figure 10-14). The left gonadal vein is divided from the left renal vein and dissected distally to the internal ring. At this point, the vas deferens is seen passing from the pelvis to the internal ring. The vas deferens is dissected and divided. The cord stump is mobilized from the internal ring, and this specimen, the left gonadal vein, is sent to pathology for permanent section (Figure 10-15).

The next step is to dissect the aorta. The anterior aspect of the aorta is identified as it passes posterior to the left renal vein. The lymphatic tissue on the aorta is split at the twelve-o'clock position, from the crossing of the left renal vein distally to the bifurcation of the left common iliac artery. Lymphatic tissue is dissected laterally away from the aortic wall into the left para-aortic area, with special care taken to identify lower-pole renal arteries to the left kidney (Figure 10-16). Since the sympathetic fibers have been previously identified and placed in vessel loops, injury to them is prevented. The left-sided lumbar arteries are then identified, dissected, and divided between ties (Figure 10-17). This allows the aorta to be retracted anteriorly and allows the sur-

Figure 10-14. In this postchemotherapy dissection as seen from the patient's left side, the left gonadal vein is seen at its origin at the left renal vein. It has been encircled with a silk tie.The arrow indicates the divided inferior mesenteric artery as this was a full bilateral postchemotherapy dissection.

Gonadal Vein
Figure 10-15. The resected left gonadal vein. On the right, the resected stump of the cord is seen; on the left, a silk tie has been placed to divide the left gonadal vein from its origin at the renal vein. The arrow illustrates metastatic tumor along the lymphatics of the left gonadal vein.

geon to perform a complete removal of lymphatic tissue. Next, the left ureter is dissected laterally from left periaortic lymphatic tissue. Finally, the left renal artery is sharply mobilized from lymphatic tissue to expose the crus of the diaphragm on the left (Figure 10-18). At this point, the "subtraction" technique has been performed, and the only remaining attachment of lymphatic tissue is to the posterior body wall. This lymphatic tissue is then harvested off the psoas muscle and anterior spinous ligament, with special care being taken to preserve the sympathetic chain and efferent fibers on the left side. The lumbar arteries and veins that typically enter the posterior

Testicular Artery
Figure 10-16. Viewed from the pelvis, a left lower-pole renal artery is indicated by the arrow. Vessel loops encircle sympathetic fibers in the initial stages of the dissection.

Figure 10-14. In this postchemotherapy dissection as seen from the patient's left side, the left gonadal vein is seen at its origin at the left renal vein. It has been encircled with a silk tie.The arrow indicates the divided inferior mesenteric artery as this was a full bilateral postchemotherapy dissection.

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