Patients are placed on a clear liquid diet beginning at noon the day prior to their procedure and are also instructed to drink a bottle of magnesium citrate in an effort to cleanse the bowel. Decompression of the bowel aids in visualization during the operation and improves the speed of bowel recovery. On call to the operating room, the patient is administered a single dose of an appropriate intravenous broad-spectrum antibiotic. Patients on long-term steroid immunosuppressive therapy may require supplemental stress dosing per the anesthesia team. Compressive knee or thigh-high stockings (T.E.D.) and sequential compression devices are applied to the lower extremities to reduce the risk of deep venous thrombosis formation. Hair is removed from the area of the operative field, including the pubic region and lower abdomen, using electric clippers.

The operating table should be equipped with a kidney rest and allow flexion/deflection and full Trendelenburg positioning. A 3-inch foam pad mattress is placed on the operating table, followed by a full-size gel pad to aid in securing the patient. Prior to transferring the patient from the transport bed to the operating table, 70% isopropyl alcohol can be used to cleanse the back to remove body oils and debris to establish secure traction between the patient and the gel pad without the use of shoulder bars, chest tape, or straps. Alternatively, any of the other aforementioned securing methods can be utilized. Following intubation of the patient, an orogastric tube is inserted to decompress the stomach, and nitrous oxide should be avoided to prevent bowel distention and to reduce the risk of creating a combustible environment when electrocautery is being utilized. The patient should be positioned with the umbilicus at the region of the kidney rest to allow flexion of the table with slight kidney rest elevation to increase the distance between the umbilicus and the pubic symphysis, assisting in spacing of the trocars.

The Foley catheter should be inserted on the operative field after preparing and draping to allow access for filling and decompressing the bladder, which may assist in localization of the lymphocele. Male patients are placed supine on the operating table. Female patients should be positioned in low lithotomy using Allen stirrups to allow adequate access to the urethral meatus. Alternatively, slight frog-leg positioning can be utilized in nonobese female patients. If the legs are not secured in stirrups, tape can be placed across the upper thighs and a strap across the lower legs to secure them in position.

The arms are protected in eggcrate foam and tucked at the sides. When arm sleds are utilized, care must be taken to avoid disruption of the securing Velcro on their insertion, as this holds the 3-inch foam mattress in place and can lead to its dislodgement and inadvertent patient movement on deep Trendelenburg positioning. Although it is rarely required, the security of the patient’s position should be tested in full Trendelenburg tilt prior to preparation and draping. A wide surgical skin preparation should be performed to include the genitals for sterile Foley catheter insertion and adequate exposure to allow adequate trocar spacing and conversion to an open operation if necessary. A standard wide-aperture laparoscopic drape can be utilized when patients are not placed in stirrups; otherwise, standard cystoscopy legging and aperture drapes are utilized after four-towel draping of the abdominoperineal region. The aperture can be enlarged to give adequate exposure to the lower abdomen.

Access to the peritoneum can be obtained utilizing a closed needle (Veress) puncture technique or an open direct vision (i.e., Hasson cannula) method. If the lymphocele is extremely large, extending to or above the level of the umbilicus, this centrally located port can be moved in a cephalad direction
to ensure that the port enters approximately a handsbreadth above the upper extent of the lymphocele. Transabdominal ultrasound can be used to assist in port placement or the extent of the lymphocele estimated by counting CT scan slices above and below the umbilicus to predict its location. The underlying soft tissues are bluntly dissected down to fascia using a sharp clamp.

Pneumoperitoneum is established using standard technique. The insufflation pressure set point should be placed at 15 mm Hg, and once this pressure level is obtained, a visual introducing trocar (e.g., Optiview, Ethicon Endo-Surgery, Cincinnati, Ohio) is used to insert a 10/12-mm port via the previously made periumbilical incision. The 0-degree 10-mm laparoscope is inserted into the Optiview and can be used to visualize each layer of the abdominal wall as it is traversed using a back-and-forth twisting motion until full entry into the peritoneal cavity is confirmed. Once the visual introducing port has been inserted, the 0-degree lens is exchanged for a 30-degree lens to allow a greater range of visualization angles.

Two additional working ports are then placed, adjusting their position depending on the location of the lymphocele. In general, a 5-mm working port is inserted a handsbreadth down from the supraumbilical port just lateral to the midline on the side contralateral to the lymphocele. If the distance between the umbilicus and the pubic symphysis is sufficient to allow placement of two ports separated by a handsbreadth without entry into the bladder, the third port (5 mm) can be placed below the second port in the midline. This also requires that the lymphocele is not exceptionally large and that the patient is not morbidly obese (body mass index <35). In general, placement of this port a handsbreadth lateral to the midline just below the level of the umbilicus on the side ipsilateral to the lymphocele is preferred. In the standard trocar arrangement, a 10-mm port can be utilized to allow lateral camera positioning if desired during the case (Fig. 16.3). Alternatively, a 5-mm port can be utilized if a 5-mm laparoscope is available.

The surgeon stands on the side opposite the lymphocele and the assistant and scrub personnel stand on the ipsilateral side across from the primary surgeon. The monitor and tower or boom arm containing the insufflation unit, light, and camera source are positioned at the foot of the patient. The patient is placed in Trendelenburg positioning to the extent necessary to liberate the bowel off the area of dissection, and the table is airplaned slightly toward the operating surgeon.

After release of any overlying bowel or omental adhesions to the lower quadrant of interest, the lymphocele can be identified as a bluish-black pelvic structure if thin-walled. The overall appearance can vary significantly, and when the wall is thickened, differentiation from the bladder can be difficult (Fig. 16.4A). Depending upon its location, other surrounding vital structures, such as the transplant or native ureter or iliac vessels, can also be incorporated into one or more of the walls of the lymphocele. Methods to assist in identification and differentiation from the bladder have been described, including distention followed by decompression of the bladder with sterile saline. The bladder can also be filled with indigo carmine or methylene blue-stained saline and a laparoscopic aspirating needle can be inserted into the identified structure presumed to be the lymphocele (Fig. 16.4B). This is confirmed to be the lymphocele if the aspirated fluid does not contain blue-tinged fluid (17).

Alternatively, outlining the lymphocele using transabdominal ultrasound and percutaneous needle puncture with aspiration followed by injection of the lymphocele with dilute methylene blue-tinged saline results in staining of the walls of the lymphocele, allowing confirmation of the structure prior to unroofing by laparoscopic needle aspiration with return of blue-tinged fluid (2,17). Once the lymphocele is entered, the blue staining of the chamber assists in identification of its extent and the amount of unroofing required.

Laparoscopic shears (Fig. 16.4C) or a harmonic scalpel can be used to unroof the lymphocele, incising through the area of the wall that appears to be the thinnest portion of the structure in a direction parallel to the presumed course of the transplant ureter. After the initial incision, care should be taken to inspect the wall to make sure that structures such as the renal allograft ureter or pelvis, native ureter, or bladder are not injured in the process. In general, only the portion of the wall in contact with the peritoneum is excised, and any of the contained loculations are disrupted bluntly and the walls excised. Although stenting of the transplant ureter can be performed to help in its identification, this can be technically challenging. In a large multi-institutional retrospective study, 81 patients underwent laparoscopic marsupialization, and none of the ureters were stented prior to the laparoscopic surgery, yet no ureteral injuries occurred (3). The wall of the lymphocele can then be excised from the central incision to the edge of the thin region of the wall using the laparoscopic instruments to ballot the area to help judge its thickness and the likely involvement of surrounding structures. The excision is then carried out circumferentially until the entire exposed region of the lymphocele is excised (Fig. 16.4D). Once the segments are excised, they can be removed via the 10/12-mm port or cut into strips prior to removal if they are too large to fit through the port. The specimen is visually inspected, and if any concerning elements are identified, such as portions of ureter, these can be confirmed via frozen
section analysis, allowing intraoperative management. If the excised region of the lymphocele is small (<4 cm) and this results in a deep-chambered cavity with a narrow aperture, consideration should be given for placement of an omental wick.