Laparoscopic or Open Pelvic and Para-Aortic Lymphadenectomy

What is a lymphadenectomy?

A lymphadenectomy is an operation to remove lymph nodes so that they can be examined by a specialist pathologist.

The lymph nodes are sent to the laboratory, where they are carefully examined for evidence of cancer cells.

The results can help establish:

• Whether cancer has spread to the lymph nodes
• Which lymph nodes are affected
• How extensive the cancer is
• The stage of the cancer
• Whether additional treatment may be recommended

Lymph node surgery is therefore often an important part of surgical staging for selected gynaecological cancers.

It is not necessary for every patient with every type or stage of cancer. Modern cancer treatment increasingly uses tailored approaches, including sentinel lymph node assessment for some patients, to avoid unnecessary removal of lymph nodes where appropriate.

Where are the pelvic and para-aortic lymph nodes?

Lymph nodes are located throughout the body.

In gynaecological cancer surgery, the two main groups that may be assessed are:

Pelvic lymph nodes

Pelvic lymph nodes are located around the major blood vessels and structures within the pelvis.

They include lymph nodes around areas such as the:

• External iliac vessels
• Internal iliac vessels
• Common iliac vessels
• Obturator region
• Presacral area

The exact areas assessed depend on the cancer and the planned operation.

Para-aortic lymph nodes

Para-aortic lymph nodes are located higher in the abdomen, alongside the aorta and inferior vena cava, the major blood vessels carrying blood to and from the lower body.

Para-aortic lymph node surgery may therefore involve operating higher within the abdomen than pelvic lymphadenectomy.

The extent of lymph node surgery is tailored to the type and stage of cancer and the information required from the operation.

Why might I need lymph node surgery?

Lymph node assessment may form part of the treatment or staging of several gynaecological cancers, including selected cases of:

• Cervical cancer
• Endometrial (womb) cancer
• Ovarian cancer
• Fallopian tube cancer
• Primary peritoneal cancer

Whether lymph nodes need to be removed depends on your individual diagnosis.

Your consultant may consider:

• The type of cancer
• The stage of the cancer
• The size and location of the tumour
• Results from your biopsy
• Findings on ultrasound, MRI, CT or PET-CT
• Whether lymph nodes look abnormal on imaging
• Your individual risk of lymph node involvement
• Whether the results are likely to change your treatment

Your case may also be discussed by a specialist multidisciplinary team (MDT) before surgery.

Lymphadenectomy and ovarian cancer

Lymph node assessment can form part of the surgical staging of selected ovarian cancers.

For women whose ovarian cancer appears to be confined to the ovaries, NICE recommends retroperitoneal lymph node assessment as part of optimal surgical staging, with assessment of the pelvic and para-aortic areas. However, systematic removal of all retroperitoneal lymph nodes is not recommended routinely for every woman with apparently stage 1 disease.

For more advanced ovarian cancer, the focus of surgery is different. Where surgery is undertaken, the objective is generally to remove all visible cancer that can safely be removed, with lymph node surgery considered according to the individual circumstances.

Lymphadenectomy and endometrial cancer

Lymph node assessment may be recommended for women with higher-risk endometrial cancer because the presence or absence of cancer in the lymph nodes can influence staging and subsequent treatment.

For some women with lower-risk disease, a full lymphadenectomy may not be necessary.

Sentinel lymph node biopsy is now an accepted alternative for lymph node staging in selected stage I and II endometrial cancers, while systematic lymphadenectomy may be considered when the risk of lymph node involvement is higher or sentinel nodes cannot adequately be assessed.

Your treatment will therefore be based on the specific characteristics of your cancer rather than a one-size-fits-all approach.

Lymphadenectomy and cervical cancer

Lymph node assessment is an important part of surgical staging for selected women with early-stage cervical cancer.

Depending on the stage and circumstances, this may involve:

• Sentinel lymph node assessment
• Pelvic lymphadenectomy
• Para-aortic lymph node assessment in selected cases

For some locally advanced cervical cancers, para-aortic lymph node assessment may be considered to help determine the most appropriate treatment, particularly when imaging does not show para-aortic involvement.

Importantly, lymph node surgery is not appropriate for every cervical cancer patient. In some situations, chemoradiotherapy rather than surgery is the preferred treatment.

Your specialist team will explain why a particular approach has been recommended for you.

What is sentinel lymph node surgery?

A sentinel lymph node is the first lymph node, or group of nodes, that cancer cells are most likely to reach if they spread through the lymphatic system.

Instead of removing many lymph nodes, a surgeon may be able to identify and remove the sentinel nodes for detailed examination.

If the sentinel nodes are clear, this can sometimes avoid the need for a full lymphadenectomy.

Sentinel lymph node techniques are used for selected patients and are particularly established in the surgical staging of certain early-stage gynaecological cancers.

Whether sentinel lymph node assessment is suitable depends on the type and stage of your cancer and the operation being planned.

What is laparoscopic lymphadenectomy?

A laparoscopic lymphadenectomy is performed using keyhole surgery.

Rather than making a large abdominal incision, your surgeon makes several small incisions through which a camera and specialist surgical instruments are inserted.

The camera provides a magnified view of the pelvic and abdominal structures on a monitor, allowing the surgeon to identify and carefully remove the relevant lymphatic tissue.

Laparoscopic lymphadenectomy may be performed as part of another laparoscopic cancer operation, such as a hysterectomy, where this is appropriate.

Minimally invasive surgery can offer benefits such as smaller incisions, less postoperative pain and a shorter recovery compared with open surgery in appropriately selected patients.

What is open lymphadenectomy?

An open lymphadenectomy is performed through an abdominal incision, usually called a laparotomy.

An open approach may be recommended when:

• The cancer is extensive
• A large pelvic or abdominal mass is present
• A tumour needs to be removed intact
• Extensive abdominal surgery is required
• The surgeon needs wider access to the abdomen
• Keyhole surgery would not provide the safest or most effective approach

For example, when an ovarian mass is large and there is concern that it could be cancerous, an open operation may allow the mass to be removed intact and reduce the risk of rupture during surgery.

Choosing open surgery does not mean that the cancer is necessarily more advanced. It may simply be the safest surgical approach for the particular circumstances.

Laparoscopic or open surgery, which is better?

There is no single surgical approach that is right for everyone.

Where cancer surgery can safely be performed using a minimally invasive technique, keyhole surgery may offer advantages including:

• Smaller incisions
• Less visible scarring
• Reduced postoperative discomfort
• Shorter hospital stay
• Faster recovery

However, cancer surgery must always prioritise safe and effective removal and accurate staging of the cancer.

If an open operation provides better access or allows the cancer or mass to be removed more safely, this may be the preferred option.

Your surgeon will discuss the recommended approach with you and explain why it is appropriate.

What happens before lymphadenectomy?

Before surgery, your consultant will review your diagnosis and all relevant investigations.

These may include:

• Biopsy or histology results
• Ultrasound
• MRI
• CT
• PET-CT
• Blood tests
• Previous surgical or treatment history

The purpose of these investigations is to establish the extent of the disease and plan the safest and most effective operation.

Your case may then be discussed at a specialist gynaecological oncology MDT.

You will have the opportunity to discuss:

• Why lymph node surgery is recommended
• Which lymph nodes may be removed
• Whether the procedure will be laparoscopic or open
• The possible benefits and risks
• How the operation may affect your treatment afterwards
• Your expected recovery

What happens during lymphadenectomy?

The operation is performed under a general anaesthetic, so you will be asleep.

If you are having laparoscopic surgery, several small abdominal incisions are made. The abdomen is gently inflated with carbon dioxide to create space for the surgeon to work.

The surgeon identifies the relevant lymphatic tissue and carefully separates it from surrounding structures, including major blood vessels, nerves and the ureters.

The lymph nodes are removed and sent to the laboratory for detailed pathological examination.

If the procedure is being performed as part of a larger cancer operation, the lymphadenectomy may be carried out at the same time as your hysterectomy, ovarian cancer surgery or another procedure.

Could my operation be changed from keyhole to open surgery?

Occasionally, yes.

Although your operation will be carefully planned beforehand, your surgeon may find that open surgery is safer once the operation begins.

This may happen because:

• The cancer is more extensive than expected
• There are significant adhesions or scar tissue
• There is unexpected bleeding
• A mass cannot be safely removed using the planned technique
• Additional surgery is required

Your consent discussion before surgery will include the possibility of converting from laparoscopic to open surgery if this is necessary to protect your safety and provide appropriate cancer treatment.

What happens to the lymph nodes after surgery?

The removed lymph nodes are sent to a specialist pathology laboratory.

A pathologist examines the tissue under a microscope to determine whether cancer cells are present.

The report may establish:

• Whether the lymph nodes are negative or positive for cancer
• How many lymph nodes were examined
• How many contain cancer
• The size and characteristics of any deposits
• Other features relevant to your cancer diagnosis

These findings are combined with the other information from your operation and investigations to determine the final stage of your cancer.

How can the results affect my treatment?

The results of lymph node surgery can be very important when planning treatment after surgery.

If no cancer is found in the lymph nodes, your overall stage and risk profile may be different from someone whose cancer has spread to the lymphatic system.

If cancer is found in the lymph nodes, your specialist team may recommend additional treatment such as chemotherapy, radiotherapy, hormone treatment or another systemic treatment, depending on the type of cancer.

However, lymph node results are only one part of the overall picture.

Your treatment recommendation will also take into account the type and grade of your cancer, the extent of disease elsewhere, molecular or pathological findings and how completely the tumour has been removed.

What are the risks of lymphadenectomy?

Lymphadenectomy is a specialist operation and, like any major surgery, carries potential risks.

Possible complications include:

• Bleeding
• Infection
• Blood clots
• Damage to blood vessels
• Injury to the bowel
• Injury to the bladder
• Injury to the ureters
• Temporary or longer-term changes in bladder or bowel function
• Nerve injury
• Lymphocyst formation
• Lymphoedema
• Wound complications
• Anaesthetic complications
• The need for further surgery

The risk depends on the extent of the lymphadenectomy, the type of cancer surgery being performed at the same time and your individual health.

Your surgeon will discuss your specific risks before you consent to treatment.

What is lymphoedema?

One of the longer-term risks of lymph node surgery is lymphoedema.

Lymphoedema occurs when lymph fluid is unable to drain normally through the lymphatic system, resulting in swelling.

Following pelvic lymphadenectomy, this most commonly affects one or both legs, although swelling can also occur around the genital or pelvic area.

Lymphoedema may develop soon after surgery or at a later stage.

Not everyone who has lymph nodes removed develops lymphoedema, but your risk is higher following a full lymphadenectomy than after a sentinel lymph node procedure.

If you notice persistent swelling, heaviness or tightness in your legs following surgery, you should tell your medical team.

Early assessment and specialist management can help control symptoms.

What is a lymphocyst?

A lymphocyst is a collection of lymphatic fluid that can sometimes develop in the area where lymph nodes have been removed.

Small lymphocysts often resolve without treatment.

Larger collections can occasionally cause discomfort, pressure or urinary symptoms and may need to be drained.

Your surgical team will monitor you for complications following surgery and advise you if further treatment is required.

What is recovery like?

Your recovery will depend on whether you have had laparoscopic or open surgery and whether lymphadenectomy was performed alongside another major cancer operation.

Following laparoscopic surgery, you may be able to return home relatively quickly if your recovery is uncomplicated.

Open surgery generally requires a longer hospital stay and recovery period because of the larger abdominal incision.

During your recovery, you will be encouraged to:

• Get out of bed and walk as soon as it is safe
• Drink and eat as your bowel function returns
• Take prescribed pain relief
• Wear compression stockings where advised
• Have blood-thinning medication where appropriate
• Gradually increase your activity
• Attend your follow-up appointments

Your specialist team will give you individual advice about driving, work, exercise, lifting and returning to normal activities.

When should I seek medical advice after surgery?

You will receive specific information about what to look out for following your operation.

You should seek medical advice if you develop symptoms such as:

• A high temperature or fever
• Increasing abdominal pain
• Heavy bleeding
• Redness, swelling or discharge from the wound
• Persistent vomiting
• Difficulty passing urine
• Significant swelling of one or both legs
• Shortness of breath or chest pain
• A painful or swollen leg

These symptoms can sometimes indicate infection, bleeding, a blood clot or another postoperative complication and should be assessed promptly.

Does lymphadenectomy affect fertility?

The effect on fertility depends largely on the wider cancer operation rather than lymph node removal itself.

For example, some women undergoing treatment for early cervical cancer may be candidates for fertility-sparing surgery in carefully selected circumstances. In these cases, lymph node assessment can form an important part of determining whether fertility-preserving treatment is appropriate.

For women undergoing treatment for endometrial or ovarian cancer, the overall surgical and cancer treatment plan will determine whether fertility can be preserved.

If having children in the future is important to you, this should be discussed with your cancer team before surgery wherever possible.

Specialist laparoscopic and open lymphadenectomy at Gynae Solution

Lymph node surgery can be an important part of the diagnosis, staging and treatment planning for gynaecological cancer.

Because lymph nodes sit close to major blood vessels, nerves, the bowel, bladder and ureters, lymphadenectomy requires careful surgical planning and specialist expertise.

At Gynae Solution, Mr Jafaru Abu has a specialist interest in gynaecological oncology and minimally invasive cancer surgery. His areas of expertise include laparoscopic hysterectomy and lymphadenectomy for selected early-stage gynaecological cancers.

Where keyhole surgery is appropriate, the aim is to provide accurate cancer staging while reducing the physical impact of surgery.

Where an open operation is safer or more appropriate, the priority remains complete and safe cancer treatment.

Every patient's situation is different, and the recommended approach will be based on your individual diagnosis, investigations and treatment plan.

We are here to help

Being told that you may need lymph node surgery can raise many questions.

You may be wondering why the lymph nodes need to be removed, whether you can have keyhole surgery, how the operation will affect your recovery or what the results could mean for your further treatment.

A specialist consultation gives you the opportunity to understand your diagnosis and discuss your options in detail.

Book a consultation with Mr Abu to discuss your gynaecological cancer diagnosis and whether laparoscopic or open lymphadenectomy may form part of your treatment.

Related services

• Ovarian cancer
• Endometrial cancer
• Cervical cancer
• Vulval cancer
• Debulking, advanced ovarian cancer
• Fertility sparing key-hole procedures
• Robot assisted gynaecological procedures
• Total laparoscopic radical trachelectomy
• ICRS and HIPEC
• Ultra-radical surgery for ovarian cancer

See all conditions and treatments

Common questions