nhãn hiệu được dây chằng rốn xóa sạch, tàu tuyến sinh dục, và vòng bẹn nội bộ (Hình 9-15), với các giới hạn của bóc tách nút là phân nhánh chậu, pubis, dây thần kinh bịt, các bức tường bên khung chậu, và các dây chằng rốn trung gian . Các hệ bạch huyết gần xa và thường được cắt bớt để giảm rò rỉ bạch huyết. | LAPAROSCOPIC SURGERY 143 Figure 9-14. Port placements for laparoscopic pelvic lymph node dissection. A Diamond configuration typically used. B Fan configuration for use in obese patients. marks are the obliterated umbilical ligament gonadal vessels and internal inguinal ring Figure 9-15 with the limits of the nodal dissection being the iliac bifurcation the pubis the obturator nerve the pelvic side wall and the medial umbilical ligament. The distal and proximal lymphatics are typically clipped to decrease lymphatic leakage. Dissection for bladder penile or urethral cancer usually involves a more extended field bounded by the common iliac artery the genitofemoral nerve and the bladder. Complications are similar with laparoscopic and open PLND. Specifically injuries to the obturator nerve iliac and epigastric vessels and ureter have been reported but are uncommon. Other potential complications include lymphocele bowel or bladder injury subcutaneous emphysema and scrotal swelling. Comparison studies of open versus laparoscopic PLND reveal a similar number of nodes retrieved. Patients treated with laparoscopic PLND enjoy an earlier time to oral intake less postoperative pain a shorter length of stay and decreased recovery time. The disadvantages include prolonged operative time and higher complication rates in some series especially early in one s experience. Varicocelectomy As many as 15 of adolescent males will have clinically evident varicoceles. Most of these however do not need treatment. Varicocelectomy is reserved for those with asymmetrical testicular growth infertility or pain. The laparoscopic technique typically involves 3 ports. The initial camera port is placed at the umbilicus and additional ports are placed lateral to the rectus muscle. The gonadal veins are flattened by the pneumoperitoneum and therefore the artery appears more tubular than surrounding structures. After incising through the posterior peritoneum Figure 9-16 gonadal veins are clipped and
