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Cisterna chyli: An important landmark in laparoscopic paraaortic lymphadenectomy

Published:December 29, 2019DOI:https://doi.org/10.1016/j.ygyno.2019.12.004

      Highlights

      • The location and appearance of cisterna chyli (CC) is highly variable
      • Identification and preservation of CC is critical during laparoscopic paraaortic lymphadenectomy
      • Inadvertent injury to CC during laparoscopic paraaaortic lymphadenectomy could lead to chylous ascites

      Abstract

      Objective

      Cisterna chyli is a pearl-shaped elongated lymphatic structure located at the level of L1-L2 vertebra just beneath the aorta (Hsu and Itkin, 2016 [
      • Hsu M.C.
      • Itkin M.
      Lymphatic anatomy.
      ]). It receives lymphatic drainage of intestines and lower body structures (Loukas et al., 2007 [
      • Loukas M.
      • Wartmann C.T.
      • Louis R.G.
      • Tubbs R.S.
      • Salter E.G.
      • Gupta A.A.
      • Curry B.
      Cisterna chyli: a detailed anatomic investigation.
      ]). Size, shape and location are all highly variable and in some autopsy series CC was identified in only half of the cases (Song, 2016 [
      • Song Y.B.
      Thoracic duct, cisterna chyli, and right lymphatic duct.
      ]). During the laparoscopic paraaortic lymphadenectomy inadvertent injury to otherwise unidentified CC could lead to refractory chylous ascites (Favero et al., 2010 [
      • Favero G.
      • Lanowska M.
      • Schneider A.
      • Marnitz S.
      • Köhler C.
      Laparoscopic approach for correction of chylous fistula after pelvic and paraaortic lymphadenectomy.
      ]). The objective of this video is to demonstrate the anatomic localization and consequences of inadvertent injury to CC in laparoscopic paraaortic lymphadenectomy.

      Methods

      Two different patients undergoing laparoscopic paraaortic lymphadenectomy were presented.

      Results

      The first case is a 51 year old woman with grade III endometrioid adenocarcinoma of uterus who was subjected to laparoscopic staging (laparoscopic hysterectomy + BSO + pelvic and paraaortic lymphadenectomy). Intraoperatively an injury to cisterna chyli occurred which was sealed and repaired immediately. The second case is a woman with stage IIB clear cell cervical cancer undergoing laparoscopic staging (pelvic and paraaortic lymphadenectomy). In this case cisterna chyli could be recognized and preserved.

      Conclusion

      Cisterna chyli is an important anatomic structure which should be identified and preserved during laparoscopic paraaortic lymphadenectomy. Any iatrogenic injury to cisterna chyli could lead to chylous ascites and indeed in minority of these cases surgical intervention is required.

      Keywords

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