Strategic Planning

Postchemotherapy surgery should be planned strategically in the case of multiple-site residual masses. At the very beginning of the cisplatin era, Merrin31 proposed a heroic operation: contemporary median laparotomy and sternal split to remove, in a single operation, the abdominal, thoracic, and (eventually) supraclavicular metastases. This very heavy surgery had too many complications and has been practically abandoned.

Usually, RPLND is performed first, with the contemporaneous removal of the testis that harbors the initial tumor if the patient has not previously undergone orchiectomy.32 Figure 11-11 shows an en bloc specimen of fibrous necrotic para-aortic tissue that was adherent to the left renal vein (see Figure 11-10, A), with spermatic vessels, spermatic cord, and the left testis, which contained residual cancer. Hepatic and supraclavicular metastases33 can also be resected at the same time as the RPLND is performed. Figure 11-12 shows the resection of a fifth-segment liver metastasis with the argon beam; Figure 11-13 shows the intraoperative ultrasonographically guided high intensity focused ultrasound (HIFU) destruction

Images Rplnd Thorac Abdominal
Figure 11-6. For upper bilateral retroperitoneal metastases, it is possible to do a complete bilateral retroperitoneal lymph node dissection with prospective sparing of both L3 nerves and the superior hypogastric plexus.
Retroperitoneal Resection
Figure 11-7. A, Prospective nerve sparing of L3 can be performed during a unilateral retroperitoneal lymph node dissection for a solitary upper residual metastasis. B, The resected residual metastasis.

of a small deep lesion. The special needle is also shown in the closed and open position. Figure 11-14 shows large left supraclavicular metastases, the operative field following supraclavicular node dissection, the teratomatous specimen, and the supraclavicular incision, along with the position of the patient's neck. Solitary ileo-pelvic metastases are easily removed with an extraperitoneal iliac incision (Figure 11-15).

Nerve Controls What
Figure 11-8. A, Computed tomography scan shows residual tumor compressing the inferior vena cava (IVC). B and C, The tumor appears to be extensively attached to the IVC (B); however, it can be dissected carefully (C). D, The operative field at the end of the dissection.
Aortocaval Lymph Node Anatomy

Figure 11-9. A, Computed tomography scan shows a small residual tumor entering the inferior vena cava (IVC). B, During retroperitoneal lymph node dissection, the IVC is opened, following distal and proximal control, and a partial resection of the vein is performed. C, The defect is repaired with a Goretex patch. D, The pre-aortocaval and interaortocaval specimen, with the resected IVC and the protruding tumor thrombus.

Figure 11-9. A, Computed tomography scan shows a small residual tumor entering the inferior vena cava (IVC). B, During retroperitoneal lymph node dissection, the IVC is opened, following distal and proximal control, and a partial resection of the vein is performed. C, The defect is repaired with a Goretex patch. D, The pre-aortocaval and interaortocaval specimen, with the resected IVC and the protruding tumor thrombus.

Aortocaval Lymph Node
Figure 11-10. The left renal vein is often adherent to scar or residual tumor close to the confluence of the spermatic vein (A). In this case, a wedge resection can easily be done (B).

Intrathoracic masses are usually removed at a subsequent operation.34 In particular, intrathoracic access may vary in relation to disease localization. Lower mediastinal metastases, which are posterolateral to the descending aorta, are easily removed through a posterolateral approach, just dividing only the dorsal and intercostal muscles (Figure 11-16, A and B); the sympathetic chain is separated from the teratomatous mass, which is detached from the cos-tovertebral angle and descending aorta (see Figure 11-16, C and D). Anterior mediastinal or bilateral lung metastases are best removed through a median sternal split (Figure 11-17). Large solitary upper-lobe (Figure 11-18) or para-tracheal metastases (Figure 11-19) are best approached through an anterolateral thoracotomy (Figure 11-20). Unilateral lung metastases can be approached through an axillary thoracotomy, separating the anterior serratus muscle and dividing only the intercostal muscles (Figure 11-21). Nevertheless, relatively small retrocrural masses can be removed at laparotomy during a RPLND, vertically dividing the diaphragmatic crus laterally to the aorta35 (Figure 11-22), and large upper retroperitoneal and lower thoracic metastases can be contemporaneously resected with a thora-coabdominal approach36 (Figure 11-23). It is clear that different clinical situations may require different surgical strategies. For instance, a basal-segment right pulmonary metastasis and an upper-eighth-segment liver metastasis could be removed through a low posterolateral thoracotomy combined with a limited phrenotomy (Figure 11-24). So far, complex situations will need a multidisciplinary surgical approach, discussed and organized by the team

Posterolateral Complex

Figure 11-11. En bloc specimen of fibrotic para-aortic nodes, left spermatic vessels and cord, and left testis with residual cancer.

leader. In particular, when dealing with mediastinal and supraclavicular metastases, it is important to remember that para-aortic lymphatics at the level of the renal arteries drain into the posterior medi-

Liver Resection

Figure 11-12. A, Liver metastasis in the fifth segment. B, Argon beam resection. C, The liver is sutured, following resection of the metastasis.

Figure 11-11. En bloc specimen of fibrotic para-aortic nodes, left spermatic vessels and cord, and left testis with residual cancer.

Figure 11-12. A, Liver metastasis in the fifth segment. B, Argon beam resection. C, The liver is sutured, following resection of the metastasis.

Cancer Internal Jugular Vein
Figure 11-13. A, Ultrasonographically guided HIFU of a small deep hepatic metastasis. B,The HIFU needle, closed. C, The HIFU needle, opened.

astinum, passing behind the diaphragmatic crura on both sides of the aorta (Figure 11-25). They then course laterally and posterior to the descending thoracic aorta to reach the subcarinal nodes and then the anterosuperior mediastinum (Figure 11-26), ending in the left supraclavicular nodes, where the thoracic duct enters the left supraclavicular vein at the confluence with the internal jugular vein (Figure 11-27).

Supraclavicular Lymphadenectomy

Figure 11-14. A, Computed tomography scan of the neck, showing two large left supraclavicular nodes. B, The operative field following supraclavicular lymphadenectomy, showing (from left to right) the internal jugular vein, the phrenic nerve, the scalene muscle, and the digastric muscle. C, The specimen with two large teratomatous masses. D, The supraclavicular incision and the position of the head and neck.

Figure 11-14. A, Computed tomography scan of the neck, showing two large left supraclavicular nodes. B, The operative field following supraclavicular lymphadenectomy, showing (from left to right) the internal jugular vein, the phrenic nerve, the scalene muscle, and the digastric muscle. C, The specimen with two large teratomatous masses. D, The supraclavicular incision and the position of the head and neck.

Incisions Supraclavicular MassSupraclavicular Fossa Mass

Figure 11-15. A, Computed tomography scan showing a residual right ileo-pelvic teratomatous mass. B, From bottom to top, the iliac vessels, the obturator nerve, the ureter, and the vesical artery can be seen in this photograph. C, The skin suture after resection. D, The specimen, with the extension into the obturator fossa.

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