Robotic extraperitoneal aortic lymphadenectomy: Development of a technique Javier F. Magrina a, ⁎, Rosanne Kho a , Regina P. Montero a , Paul M. Magtibay a , Wojciech Pawlina b a Department of Obstetrics and Gynecology, Mayo Clinic Arizona, 5777 East Mayo Boulevard, Phoenix, Arizona 85054, USA b Department of Anatomy, Mayo Clinic Rochester, 200 First Street S.W., Rochester, MN 55905, USA abstract article info Article history: Received 21 August 2008 Available online 21 January 2009 Keywords: Robotic Extraperitoneal Aortic Lymphadenectomy Objectives. To develop a robotic technique for extraperitoneal aortic lymphadenectomy in cadavers followed by application in a patient with advanced cervical cancer. Methods. Two fresh frozen female torso cadavers were used to develop the correct placement of the robotic column and trocars, respectively, to allow for a safe and adequate performance of aortic lymphadenectomy using the da Vinci S system. The resulting technique was applied to a patient with cervical cancer Stage IB2 presenting with enlarged aortic nodes. Results. Appropriate sites for trocar and robotic column placement were identified in the female cadavers. In the patient, the operating, docking, and console times were 103, 3.5, and 49 minutes, respectively. The blood loss was 30 ml. Selective removal of 5 enlarged aortic nodes revealed no evidence of metastases. Conclusion. Robotic extraperitoneal aortic lymphadenectomy is feasible provided there is proper robotic trocar and column placement. The operating time and number of aortic nodes selectively removed by robotics in this patient are within the range of those reported with an extraperitoneal systematic aortic lymphadenectomy by laparoscopy. © 2008 Elsevier Inc. All rights reserved. Introduction Obesity, in particular the truncal and mesenteric types, short intestinal mesentery, distended bowel, intestinal adhesions, previous aortic lymphadenectomy, and intolerance to Trendelenburg are limiting factors for the performance of transperitoneal laparoscopic or robotic aortic lymphadenectomy to renal vessels. To overcome some of the limitations of the transperitoneal route and in an attempt to reduce the formation of postoperative intestinal adhesions, an extraperitoneal approach to aortic lymphadenectomy was developed and has been reported by numerous authors [1–6]. This new technique provided a similar number of aortic nodes as with the transperitoneal laparoscopic approach [7–10]. Because robotic technology provides advantages over conventional laparoscopic instrumentation [11], in particular when working on a limited surgical field, we aimed to develop an extraperitoneal approach for the performance of aortic lymphadenectomy to renal vessels using the da Vinci S robotic system (Intuitive Inc, Sunnyvale CA). Two fresh frozen female torso cadavers were used to develop correct placement of the robotic column and trocars to allow a safe and adequate performance of aortic lymphadenectomy. The resulting technique was performed in a patient and is described here. Materials and methods Two fresh frozen female cadaver torsos were used on separate occasions. On the first torso, a small incision was made 3 cm medial to the anterosuperior iliac spine. The extraperitoneal space was devel- oped by finger dissection of the peritoneum over the psoas muscle and left flank. CO 2 was insufflated and the space widened. The laparoscope (InSite Vision System; Intuitive Surgical, Sunnyvale, CA) was intro- duced through the left flank, equidistant between the iliac crest and left costal margin, and 10 cm distant from the first trocar. Under visual laparoscopic control, different robotic trocar positions were selected and tried. Peritoneal perforations occurred when the left costal margin trocars were placed too medial, requiring suturing. An optimal trocar position which would avoid arm collision and would allow adequate instrument movement was finally identified. The assistant’s trocar was inserted between the laparoscope and the caudal robotic trocar to provide ventral retraction of the peritoneum, suction and irrigation and removal of specimens without interference with the robotic arms. An additional assistant's trocar site was identified equidistant to the laparoscope and the cranial robotic trocar. The aortic nodes were removed from the aortic bifurcation to the renal vessels. The left external and common iliac nodes were also removed. Zero and 30 degree scopes were tried. Measurements, video and photographs were obtained. The robotic column, situated to the patient's right, was initially perpendicular to the torso but restriction on the arm movements Gynecologic Oncology 113 (2009) 32–35 ⁎ Corresponding author. Department of Obstetrics and Gynecology, Mayo Clinic Arizona, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA. Fax: +1 480 342 2944. E-mail address: jmagrina@mayo.edu (J.F. Magrina). 0090-8258/$ – see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.ygyno.2008.11.038 Contents lists available at ScienceDirect Gynecologic Oncology journal homepage: www.elsevier.com/locate/ygyno