Robotic pelvic lymphadenectomy

Since 2000, the Da Vinci surgical system has allowed the development of new minimal invasive surgical techniques in cardiac, urological, general and gynaecological surgery. In 2005, the Food and Drug Administration of the USA approved the da Vinci Surgical system for gynecological surgery. The da Vinci Surgical system has some advantages, such as three dimensional vision, better ergonomics, a higher degree of freedom of the robotic instruments, and reduction of tremor interference, when compared to conventional laparoscopic surgery [118]. The development of robotic technology has facilitated the application of minimally invasive techniques for complex operations in gynecologic oncology, and the data of gynecologic cancer show comparable results for robotic surgery when compared with laparoscopy or laparotomy in terms of blood loss, length of hospital stay, and complications [119].

• In 2008, Lambaudie et al [120], tried to evaluate the feasibility and the outcome of gynaecological cancer surgery with the Da Vinci Surgical system. From February 2007 to September 2007, 28 patients underwent 32 gynecologic surgeries for various indications with the Da Vinci surgical system (four-arm model). Surgical procedures consisted of total hysterectomy, bilateral oophorectomy, and pelvic and/or lombo-aortic lymphadenectomy. All patients were placed in low lithotomy position with arms padded and tucked to the side. The position of the Da Vinci surgical system was modified according to the surgical procedure. The Da Vinci patient unit was positioned between the legs for all pelvic procedure with or without lomboaortic exploration. Five ports were placed: four for the Da Vinci surgical system’s arms (one camera port, three instrument ports) and the fifth as a classical laparoscopic port for the assistant. The first port was placed after opening the abdominal cavity with a small abdominal incision to introduce the camera; its position depended on the anatomical site of the intended procedure. For pelvic surgery, the camera port was placed 1–2 cm above the umbilicus and the four additional ports were placed in a curved line, keeping a 7- or 8-cm distance between the ports. A similar position was chosen when a concomitant lombo-aortic lymph node dissection was indicated, but ports were placed more cranially in the abdomen. After routine exploration of the peritoneal cavity the Da Vinci patient unit was docked.
Picture 70. Port placement. O: the 12-mm camera port was placed 1 or 2 cm above the umbilicus or very high on the abdomen as shown, depending on the necessity or not to realize lombo-aortic lymph node staging. 1, 2 and 3: 8-mm ports for robotic instruments. A: 10-mm port for the assistant (suction, clips, endobag). Green: pelvic, lombo-aortic procedure. Red: pelvic procedure. Blue: isolated lombo-aortic procedure. ( [120] )

Picture 71. Definitive position after docking time. ( [120] )
• The set-up and technique of robotic surgery have been well introduced by Madhuri et al [121], in 2012. They described the initial docking between the patient’s legs ( tail docking). This was followed by docking on the patient’ s left lateral side at a angle of 30º (side docking). Left side docking is preferable for a left-handed surgeon. Also, this technique improves vaginal access for tissue removal or if vaginal repair of a prolapse is required. Subsequently, the surgeons moved to right side docking, which enables two different intruments to be switched between arms 1 and 3 on the right side of the patient.

• In 2014, Escobar et al [125], described the technique as follow : Equipment and robotic column Two monitors are located at each side of the operative table at the level of the patient’s knees. The robotic tower and the tower containing electrosurgical generators and active smoke evacuators are positioned to the right or left of the patient’s feet, depending on the operating room organization.

Trocar placement and docking As it has been described, an open Hasson transumbilical entry technique with a 12mm trocar is prefered. A CO2 pneumoperitoneum is created once intraperitoneal entrance is confirmed. The robotics laparoscope is used to perform a survey of the upper abdomen and the pelvis. Two 8mm robotic trocars are placed bilaterally, 10cm distal to and at the level of the umbilicus. An accessory 10mm trocar is placed 3 cm cranial and equidistant between the umbilical and the left lateral ports. An additional 8mm robotic trocar is placed in the right lower quadrant at the level of the cecum.The patient is placed in Trendelemburg position to shift the small bowel and sigmoid of the pelvis.


Picture 72. Trocar placement. ( [125] )

The robotic column is side-docked to the patient’s right. A EndoWrist monopolar spatula or scissors,depending on the surgeon’s preference, is inserted through the right lateral trocar and a EndoWrist bipolar grasper is inserted through the left lateral trocar. EndoWrist ProGrasp forceps is inserted through the right lower quadrant trocar, as the fourth arm and is used for retraction. A Thermoflator and a high-flow insufflator at 30 L/min are used. Reusable insufflation tubes are attached to the trocar valves for passive smoke evacuation and dropped by gravity into a bottle containing saline solution.

Pelvic Lymphadenectomy Technique A pelvic lymphadenectomy is performed by dissecting the paravesical space and occasionally the pararectal space.

Picture 73. (a,b) Pelvic lymphadenectomy is perfomed by dissecting the paravesical space. ( [125] )

Picture 74. Pelvic lymphadenectomy occasionally involves the pararectal space. ( [125] ) The anatomic borders of the paravesical space are medially, the superior vesical artery; laterally, the external iliac artery; anteriorly, the pubic ramus; posteriorly, the parametrium. The dissection is carried down to the levator ani, being careful to identify the obturator nerve. The margins of the pararectal space are medially, the ureter; laterally, the inernal iliac artery; anteriorly, the parametrium; inferiorly, the levator muscle. The superior margin of the pelvic lymphadenectomy is the bifurcation of the common iliac arteries and the distal margin is the inguinal ligament.
Picture 75. Lateral common iliac arteries. The bifurcation of the arteries is the superior margin of the lymphadenectomy. ( [125] ) The external iliac nodes overlying and lateral to the external iliac vessels are removed, followed by the superficial lateral common iliacs and the internal iliac and obturator nodes.
Picture 76. The external iliac nodes overlying and lateral to the external iliac vessels are removed. ( [125] )
The common iliac artery and vein, the external iliac and the internal iliac arteries, the anterior bifurcation vessels of the internal iliac artery and the obturator nerve, should be clearly visible at the completion of pelvic lymphadenectomy.