ABSTRACT
Figure 6.10. The lymph node dissection then proceeds in a caudad-to-cephalad direction. The goal of the operation is to isolate and mobilize the great vessels (ligate the lumbar vessels) and then remove the nodal tissue between and around the vena cava and abdominal aorta. The lateral extent of the dissection is the fat plane on the lateral border of the IVC. The fatty tissue overlying the right common iliac artery is identified and elevated. The tissue over the right common iliac artery is then incised and mobilized. The incision is extended cephalad along the anterior surface of the aorta until the origin of the IMA is reached. Sharp dissection is used to mobilize the sheath laterally. The majority of the right paraaortic lymph nodes overlie the IVC and are in the interaortocaval region. There is a fairly constant small perforating vein within the lymphatics that inserts just above the bifurcation of the IVC. If care is not taken to identify and ligate this so-called ‘fellow’s vein’, it can easily be torn, with resultant heavy bleeding. Using the ‘split and roll’ technique, all tissue within the bilateral template is divided. The vena cava is gently rolled medially and laterally. The lumbar veins (usually 3-4) are then doubly ligated and transected. Ligation of the lumbar veins allows for safe dissection behind the IVC and complete removal of the pericaval and retrocaval nodes.
