Robotic transperitoneal infrarenal aortic lymphadenectomy

The Da Vinci and da Vinci S robotic systems do not provide access tο the entire abdomen without relocating the robotic column. This relocation is a major limitation for full staging or excision, or both, of early or disseminated gynaecologic malignancies, including removal of the infrarenal aortic nodes. Relocation of the robotic column is not recommended because of the column’s large size and weight and the lengthy time required [132]. • Magrina et al [133], in 2009, designed a study to develop a technique for robotic infrarenal aortic lymphadenectomy in cavaders and to evaluate the results in patients with gynecologic malignancies. Two unembalmed female cadavers were used to evaluate the feasibility of performing an infrarenal aortic lymphadenectomy with the da Vinci and da Vinci S robotic systems with the robotic column positioned between the patient’s lower extremities or at the patient’s head. An operating table rotation system was developed to accommodate abdominal operations and infrarenal aortic lymphadenectomy after robotic pelvic surgery. The newly developed technique of robotic transperitoneal infrarenal aortic lymphadenectomy was performed in 33 patients undergoing surgical treatment between July 2005 and June 2008 for ovarian (n = 20), endometrial (n = 6), cervical (n = 4), vaginal (n = 1), and peritoneal (n = 2) malignancies. The technique is as follow : The trocar placement for the pelvic portion of the robotic operation has been previously described. A new set of trocars was placed in the lower pelvis for the infrarenal aortic lymphadenectomy after pelvic surgery. An optical 12-mm trocar was inserted 2 or 3 fingerbreadths suprapubically and 1 or 2 fingerbreadths to the left of the midline. Two robotic trocars were inserted 10 to 12 cm to the right and the left of the optical trocar. Either a monopolar spatula or a monopolar scissors, but not both, was used on the right robotic arm, and a plasma kinetic grasper was used on the left robotic arm. Two accessory trocars were placed 2 cm caudally and equidistant to the right and left of the optical trocar.

Picture 78. Trocar placement for robotic pelvic surgery, abdominal procedures and infrarenal aortic lymphadenectomy. The robotic column is located at the patient’s head for abdominal and aortic operations. ( [133] ) The patient was placed in Trendelenburg position, and the robotic column was positioned at the patient’s head. The assistant stood between the patient’s legs and used the left hand to retract the
duodenum and pancreas ventrally with a 10-mm fan bowel retractor introduced through the left assistant trocar and the right hand for lateral retraction of the sigmoid mesentery, insertion of a vessel-sealing-cutting device, and suction and irrigation using the right assistant trocar.

Picture 79. Assistant’s position for abdominal and aortic operations. ( [133] )

A small (3-4 cm) incision was made on the peritoneum overlying the midportion of the right common iliac artery and extended to the aortic bifurcation. The subperitoneal loose areolar tissue was dissected over the main vessels until the left renal vein was identified. A small tent was then created by gently elevating the peritoneum ventrally with the fan bowel retractor, preventing the small bowel from sliding into the aortic field. The right aortic nodes over the vena cava and aorta were excised first, as well as the interaortic nodes if a separating space existed between these 2 vessels. The dissection was extended cranially until no nodal tissue was present, usually at or above the level of the insertion of the right ovarian vein to the vena cava. To access the inframesenteric left aortic nodes, the surgeon extended the peritoneal incision from the aortic bifurcation caudally and over the left common iliac artery for approximately 4 to 5 cm. The sigmoid mesentery was retracted laterally by the assistant surgeon, exposing the psoas muscle and the left ureter. The right aortic nodes were removed first, followed by removal of the left inframesenteric nodes. The inferior mesenteric artery was transected with the EnSeal tissue-sealing device or the LigaSure V vessel-sealing instrument to increase exposure by allowing additional lateral mobilization of the left colon mesentery and to facilitate removal of the left infrarenal nodes. Temporary clamping of the inferior mesenteric artery before its division was performed when needed to check for sigmoid viability. The left ovarian vein and the cranial border of the left renal vein were the lateral and upper limits of left aortic dissection, respectively. Lumbar veins or arteries, or both, were transected by the assistant when needed. The mean console time was 42 minutes (range, 19-64 minutes). The mean number of nodes was 12.9 (range, 2-27); the mean number of positive nodes was 2.6 (range, 0-8). There was 1 conversion to laparotomy. Magrina et al, concluded that the robotic transperitoneal infrarenal lymphadenectomy is feasible,
adequate and safe when performed with the robotic column at the patient’s head. Operating table rotation (180°) and additional trocar sites are needed when used in conjunction with robotic pelvic surgery. • Jacob et al [135], in 2011, described a left lateral approach for robotic transperitoneal infrarenal aortic lymphadenectomy using a right lateral decubitis position. Minimal patient repositioning (60°) provides access for pelvic surgery using the same abdominal trocar placement. The technique is as follow : Patients were positioned on the operating table as described by Martin et al. [136] with a slight modification. The patient rested supine atop an underlying antiskid material withn a 10-pound sandn bag bump placed under the left flank. Then left arm was supported, padded, and tucked to the left side. The right arm was secured and extended outward on an arm board. The legs were slightly flexed at the knees with pillow support and a pillow between the knees. The torso, hips, and knees were secured with padding and tape, allowing for extreme rotation of the table to the right exposing the patient’s left flank. Allen stirrups were secured and rotated beneath the table so that they could be rotated outward for placement of the patient’s legs when the pelvic portion of the procedure ensued. The security of the patient was verified by carefully rotating the patient into extreme right tilt before surgical preparation and draping.

Picture 80. Patient positioning: View from the patient’s right side (left); view from head of right lateral table tilt (right). ( [135] )

A 12-mm trocar was inserted at the umbilicus. Assessment of the entire abdomino-pelvic cavity was performed assessing for any evidence of gross metastatic disease. Ancillary trocars were placed with the patient in the supine position as follows : (1) A 12-mm trocar at the left mid-clavicular line
3–4 cephalad to the umbilicus. This port housed the 0 robotic camera. (2) An 8-mm robotic trocar placed 2 cm left of midline just below the costal margin. (3) A 8-mm robotic trocar 4 cm above the pubic symphysis and 2 cm left of midline. (4)A5-mm bladeless trocar placed 10 cm left lateral of the umbilicus for the assistant. The patient was then placed in extreme right lateral decubitus and the da Vinci S robotic system docked over the patients left hip at a 60 angle to the legs. Robotic EndoWrist (Intuitive Surgical) instrumentation included a fenestrated bipolar grasper on the left and monopolar scissors on the right. The assistant sat on the right side of the patient and provided tissue retraction, clip application, vessel-sealing, and suction/irrigation via the umbilical and the left lateral trocar.

Picture 81. Trocar placement for aortic dissection while in right lateral decubitus position: (A) Umbilical assistant port; (B) Left midclavicular, robotic camera; © Subcostal robotic left arm; (D) Suprapubic robotic right arm; (X) Left lateral assistant port, later used as robotic left arm for pelvic dissection. ( [135] )

Picture 82. Aortic and pelvic access: Trocar, patient, and robotic column positioning. ( [135] )

The infrarenal aortic lymphadenectomy was performed first due to complications or technical difficulties of this portion of the procedure being the most likely to require conversion to
laparotomy. The white line of Toldt was incised from the pelvic brim to the splenic flexure to mobilize the descending colon medially exposing the aortic nodes. Gravity directed the colon out of the operative field. Peritoneum overlying the psoas muscle was elevated and the left ureter isolated and mobilized laterally. The left gonadal vein was transected distally and dissected cephalad to its insertion into the renal vein. Endoscopic clips were applied at the insertion into the left renal vein that delineated the most cephalad border of the aortic lymphadenectomy. The nodal dissection was started at the mid left common iliac artery and continued cephalad removing all nodal tissue anterior and lateral to the aorta up to the left renal vein. The right aortic nodes were removed from the mid-right common iliac artery to the insertion of the right gonadal vein at the inferior vena cava, the cephalad border of the right lymphadenectomy. Division of the IMA was occasionally necessary to obtain adequate exposure and accessibility to underlying lymphatics.

Once the aortic lymphadenectomy was completed, the robotic system was undocked. The patient was positioned supine, sand bag removed, Allen stirrups rotated outward, and nthe legs positioned in the standard low dorsal lithotomy position. The operating table was rotated 45 and the patient placed in steep Trendelenburg. This was accomplished without removing the sterile drapes. One additional 8-mm trocar was inserted 10 cm to the right of the umbilical port for the right robotic arm. The left 5-mm trocar was converted to an 8-mm trocar for the left robotic arm and the robotic system docked caudally between the legs. The camera was advanced transumbilically and the left mid-clavicular port was used for the assistant. A hysterectomy, salpingo-oophorectomy, with pelvic lymphadenectomy was performed as customary. A total of six trocars were used for both the dissection of the aortic lymphadenectomy as well as the pelvic dissections.

· Vizza et al [137], in 2012, described a new developing strategy for robotic transperitoneal aortic lymphadenectomy without relocating the robotic column or the patient. Patients with histologically confirmed cervical cancer, early ovarian cancer, or endometrial carcinoma with suspected risk factors indicating aortic lymphadenectomy were eligible for the robotic transperitoneal aortic lymphadenectomy using the Da Vinci robotic system as part of the surgical treatment of gynecologic malignancies. The technoque was as follow : Patients were placed in the lithotomy position with their arms tucked at each side. After creation of a pneumoperitoneum to 12 mmHg with a transumbilical Veress needle, a 12-mm trocar was placed at 5–7 cm cranial to the umbilical. Three 8-mm trocars, specific for the Da Vinci robotic systems (Intuitive Surgical) were placed: one (arm 1) on the right side of the abdominal wall, medial and cranial to the right anterior upper iliac spine, and two on the left side of the abdominal wall, the first (arm 2) on the left lowest rib and the second (arm 3) medial and cranial to the left anterior upper iliac spine on the same line of the right trocar, and fastened to the robotic arms. An assistant 10-mm trocar was placed on the right side of the abdominal wall, 7–10 cm laterally, from the supraumbilical trocar. After they obtained the Trendelenburg position, the Da Vinci robotic column was positioned near the operating table between the patient’s feet and docked.

Picture 83. Port site placement. ( [137] )

The instruments were introduced: a bipolar grasper and a PK grasper on the left robotic trocars (arms 2 and 3), and a monopolar scissor on the right robotic trocar (arm 1). A 30 Surgical Intuitive endoscope was used during all operations. They divided their technique for robotic aortic lymphadenectomy into four steps. In the first step, the assistant, using a laparoscopic endotract, packed the small bowel into the upper abdomen to improve the exposure of the common iliac artery. The peritoneum over the right common iliac artery was grasped and incised with monopolar scissors, following the right side of the aorta until the ligament of Treitz was reached, thus mobilizing the duodenum. The dissection of he retroperitoneal areolar tissue was performed in the direction of the right psoas muscle, which represented the lateral limit of their dissection. The genitofemoral nerve, ovarian vessels, and ureter are visualized. The lateral peritoneum was grasped with the ProGrasp device, and the ureter was reflected laterally.

Picture 84. Peritoneum incision. RCIA right common iliac artery, A aorta, SMS submesenteric space, IMA inferior mesenteric artery. ( [137] )
In the second step, node dissection was performed from the bifurcation of the common iliac vessels just below the left renal vein (LRV). The dissection proceeded from the medial to the lateral side,
creating small pedicles of lymphatic and venous vessels that were safety coagulated. During this time, they visualized the inferior mesenteric artery (IMA) and LRV successively. To gain exposure to the surgical field, robotic arm 3 grasped the peritoneum reflection over the aorta and gently placed it laterally, carrying the ureter and the left ovarian vessels, which are coated to the lateral peritoneum (white line of Toldt). Once en-bloc dissection was completed, the nodes were placed into an endobag and removed through the assistant trocar.

Picture 85. Identification of the IMA and LRV. A aorta. ( [137] )
In the third step, the dissection plane was created by opening the retroperitoneal tissue under the IMA until they reached the left common iliac artery, in the direction of the left psoas muscle, which marked the lateral limit of their dissection. Then dissection was performed below the IMA to the left common vessels, and the nodes, which they placed into an endobag, were removed trough the assistant trocar. At this time, a wide field of dissection was essential for an optimal exposure, so they preferred a 30 endoscope camera. An assistant created a backstop for the small bowel.
Picture 86. SMS development. SMS submesenteric space, RCIA right common iliac artery, A aorta, IMA inferior mesenteric artery. ( [137] )

In the fourth step, the dissection of the left paraaortic region above the IMA insertion into the aorta until the LRV started with a change in position of the 30 camera. The camera was positioned into the assistant trocar and docked to the robotic arm while the assistant moved the instruments through
the central trocar. The change of the camera’s position improved the exposure of the left surgical aortic space up to the LRV (the upper limit of their dissection) without our having to relocate the robotic column. The retroperitoneal space was opened from IMA to the LRV in the direction of the left ovarian vessels, the lateral limit of the dissection. The lymph nodes were dissected en-bloc from IMA to the LRV, placed into an endobag, and removed via the central trocar. The lumbar vessels were not ligated, and the retrocaval and retroaortic nodes were not removed. Retroperitoneal drainage was inserted via the 8-mm right port cranial upper iliac spine.

Picture 87. IRAS development. LRV left renal vein, IRAS infrarenal aortic space, SMS submesenteric space, IMA inferior mesenteric artery, A aorta. ( [137] )

The mean operating time was 224 min (range 160–300 min), and the mean console time for aortic lymphadenectomy was 43 min (range 30–75). The median hemoglobin fall was 1.3 g/dL range (0.8–2 g/dL), the median number of removed aortic lymph nodes was 12.5 (range 7–17), and the median length of the hospital stay was 2 days (range 1–4 days).

With this initial experience Vizza et al, demonstrated tha robotic aortic lymphadenectomy to the LRV after pelvis dissection ( including lymphadenectomy) is feasible and safe, and it can also be carried out without relocating the robotic column or the patient.