Fully Robotic Retroperitoneal Lymph Node Dissection- A Fusion of Technologies

Abstract

Introduction: Retroperitoneal lymph node dissection (RPLND) is technically challenging, requiring Vascular surgical involvement. It has an overall morbidity of 17-33%, often involving the conversion of laparoscopic approaches to open. Robotic surgery lends itself to RPLND with its superior visualisation, greater degrees of motion, and precise movements. However, visualising complex relationships of tumour to aorta remains challenging. Our group has pioneered the fusion of robotic surgery and 3D modelling in preoperative planning and in intraoperative integration of these models to aid precision dissection in the world's first fully robotic malignant RPLND following curative resection of colorectal cancer. Methods: Using the medical image processing software 3D Slicer (version 4.10; Harvard, US, 2019), standard patient CT imaging was 3D reconstructed. The node and aorta to its bifurcation were further highlighted and superimposed on the 3D reconstruction. Using the Da Vinci (Intuitive Surgical, CA, USA) Xi model, the TilePro input port was accessed via HDMI output to DVI input cable. Results: Informed consent was obtained and the patient positioned in modified lithotomy. Ureteric stents were inserted for better delineation. Four robotic ports and one assistant port were inserted. The robot was docked to the patient's left. Following adhesiolysis, small bowel loops were reflected superiorly. The parietal peritoneum over the right common iliac artery (CIA) was dissected up to the aortic bifurcation using the monopolar energy device. The left CIA and both ureters were identified and preserved. True to the 3D reconstruction, this revealed the malignant node at the bifurcation which was sharply dissected, aided by live intraoperative referencing to the 3D reconstruction which could be manipulated live by wireless mouse through the Surgeon Console. This was particularly useful in establishing a plane between the node and anterior aortic wall where dense fibrosis was encountered. The specimen was removed in an endocatch. Operative time was 150 min and estimated blood loss < 50ml. Conclusion: This innovative case highlights cutting-edge 3D modelling as an invaluable preoperative planning tool and intraoperative reference in technically challenging robotic RPLND. [3D reconstruction of retroperitoneal lymph node] Disclosure: Nothing to disclose