By Jihad Kaouk, MD; Maria Carmen Mir, MD, PhD; Riccardo Autorino, MD, PhD; and Andrew Stephenson, MD
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Laparoscopic retroperitoneal lymph node dissection (RPLND) requires substantial technical experience and has failed to gain widespread acceptance. Robot-assisted laparoscopic RPLND seems to be the next logical step due to the improved quality of vision and range of motion.
Only a few small case series on this robotic procedure have been reported to date. Here, we describe the features of a specific port placement and discuss the nuances of the surgical technique of robotic RPLND for left-side stage I nonseminomatous germ cell tumor (NSGCT).
A 37-year-old male presented with a left intermediate-risk (95 percent embryonal carcinoma and 5 percent yolk sac tumor, negative lymphovascular invasion) NSGCT. The patient’s body mass index was 31 kg/m2. Tumor markers were within normal limits at preoperative RPLND workup, whereas abdominopelvic CT showed a small (5 to 8 mm) interaortocaval lymph node.
We advised the patient of the natural history of the disease as well as the treatment options, including observation, RPLND or chemotherapy. He elected to undergo a robot-assisted laparoscopic RPLND. This was a preventive RPLND for stage I NSGCT, and the dissection of the interaortocaval lymph nodes was an extra procedure due to suspected lesion.
The patient was positioned in 60-degree right-flank position with his left side up and the bed flexed. A 10-degree Trendelenburg was applied to the whole bed. We established pneumoperitoneum using a Veress needle. We placed a 12 mm camera port about 10 cm cephalad to the umbilicus, halfway between the midline and the left pararectal line at the level of the tip of the twelfth rib.
We placed three 8 mm robotic trocars on the same line, parallel to the midline. Space between them was about 10 cm (Figure 1). Two 12 mm assistant ports were located over the midline, one on the right umbilical edge and the other halfway between the two lower robotic trocars. The periumbilical assistant port was used for suction and instrument introduction. The lower assistant port was used to introduce a fan retractor to obtain an atraumatic retraction of the bowel medially. The robot was docked perpendicularly to the operative table (Figure 2).
Figure 1. Port placement (R: robotic ports, C: camera port, U: umbilicus, A: assistant ports). Camera port and assistant ports were all 12 mm diameter.
Figure 2. Operating room robotic docking and assistant’s positioning.
The operation started with mobilizing medially the left colon by incising along the avascular line of Toldt. We identified the left ureter and spermatic cord and isolated both with vessel loops. We performed a left modified bilateral template dissection with removal of the para-aortic nodes from the left renal hilum to the crossing of the left ureter over the common iliac vessels.
We removed the interaortocaval lymph nodes above the inferior mesenteric artery. Since the patient did not desire future paternity, we made no attempt to preserve the postganglionic sympathetic fibers. We dissected the para-aortic lymph nodes and left common iliac lymph nodes laterally off the anterior surface of the psoas muscle. We dissected the lymph nodes anterior and lateral to the aorta and left common iliac arteries off the vessels using a split-and-roll technique up to the root of the left renal artery.
We clipped the lumbar arteries proximally and distally with Hem-o-lok® clips before division. At the cephalad extent of the dissection, we placed Hem-o-lok clips across the lymphatic tissue at the inferior border of the left renal artery. We divided the left gonadal vein at its insertion in the left renal vein after placing Weck clips proximally and distally. We then dissected the lymph nodes off the anterior surface of the spine and anterior psoas, applying Hem-o-lok clips to control the lumbar veins.
Next, we dissected the lymph nodes off the inferior edge of the left renal vein to its insertion into the inferior vena cava. We dissected the interaortocaval lymph nodes medially off the interior vena cava and aorta using a split-and-roll technique up to the root of the right renal artery and inferiorly to the inferior mesenteric artery. We clipped the lumbar arteries and veins proximally and distally with Hem-o-lok clips before division. At the cephalad extent of the dissection, we placed Hem-o-lok clips across the lymphatic tissue at the inferior border of the right renal artery (Figure 3). We dissected the left spermatic cord to the internal inguinal ring. We placed the lymph nodes and spermatic cord in an Endo Catch™ bag for removal at the end of the procedure through one of the assistant ports.
Figure 3. Vision of the left retroperitoneal space after dissection, interaortocaval dissection completed. A: left renal vein, B: aorta, C: inferior mesenteric artery, D: inferior vena cava. The limits of dissection were left ureter on the lateral side, mid aorta, renal hilum, and IMA-inguinal canal in the distal portion.
Benefits of Robotic Approach
Operative time was 200 minutes, and there were no perioperative complications. We did not place a drain, and the Foley catheter was removed on postoperative day one. The postoperative course was uneventful, and the patient was discharged to home after 48 hours. Pathology revealed a count of 20 lymph nodes, all negative.
In conclusion, an efficient port configuration for left robotic RPLND seems to guarantee maximal range of motion for the robotic instruments, ultimately facilitating a meticulous and safe dissection. As a result, a robot-assisted unilateral left RPLND can be safely performed in minimally invasive fashion and according to accepted oncological principles.
Dr. Kaouk is Director of Cleveland Clinic Glickman Urological & Kidney Institute’s Center for Robotic and Laparoscopic Surgery and is the Urological & Kidney Institute’s Vice Chair for Surgical Innovations. He is a Professor of Surgery at Cleveland Clinic Lerner College of Medicine.
At the time this article was written, Drs. Mir and Autorino were Clinical Fellows at the Urological & Kidney Institute.
Dr. Stephenson is Director of the Urological & Kidney Institute’s Center for Urologic Oncology and is a staff member of the Taussig Cancer Institute.