Robot-Assisted Laparoscopic Bilateral Nerve Sparing Retroperitoneal Lymph Node Dissection for Testicular Cancer: Supine Position with Lower Abdominal Trochar Placement

Abstract

Introduction: Testicular cancer is the most common malignancy in young men.1 For clinical stage 1 and 2, nonseminomatous germ cell tumor robot-assisted laparoscopic retroperitoneal lymph node dissection (r-RPLND) has recently been accepted as a therapeutic option.2,3 We have developed a technique employing an infraumbilical approach with transabdominal hammock sutures, which suspend the posterior peritoneum allowing the bowel to hover anterior to the operative field.3 This approach allows unparalleled visibility and access to the key structures of the retroperitoneum, while minimizing bowel manipulation. Materials and Methods: We present a video describing our technique. The key elements of the approach are: (1) Supine position. (2) Over the left shoulder robotic docking. (3) Infraumbilical trochar placement. (4) Hammock sutures suspending the posterior peritoneum. (5) Third robotic arm suspending the duodenum anteriorly. (5) Adherence to standard oncologic and nerve sparing concepts. Initial results of a series of the first five patients are also presented. All patients are given magnesium citrate and simethicone preoperatively for bowel preparation and to reduce intraoperative bowel distension. The robot is docked over the left shoulder and the patient is placed in gentle Trendelenburg to allow the bowel to fall cephalad. A camera port, 3 8-mm robotic ports, and two assistant ports are place below the umbilicus. After access to the retroperitoneum is established, posterior peritoneal traction sutures were placed transabdominally using a Grice needle. The third robotic is placed on the patient's left side and used, primarily to retract the duodenum ventrally. Results: Our first five patients had a median age of 22 with a body mass index of 30.1. There were no complications with a median skin-to-skin operative time of 360 minutes (range 336–420 minutes) and median estimated blood loss of 250 mL (range 75–700 mL). The average hospital stay was 2.3 days (range 1–4 days). The median morphine equivalents during their hospital stay was 17 mg (range 15–90.8 mg). The median number of nodes collected was 29 (range 17–35). Conclusion: The described technique improves visibility and access to both sides of the retroperitoneum during an r-RPLND without position changes and with promising early results. Minimized bowel manipulation appears to offer significant advantages in terms of early postoperative recovery. Access to all pertinent structures is readily facilitated with straight forward assisting techniques. Further evaluation is warranted and is currently underway. J. L'Esperance, Ethicon Endo-Surgery Consultant; E. Castle, Intuitive Surgical Consultant; I. Derweesh, Ethicon Endo-Surgery Consultant; S. Stroup, Intuitive Surgical Consultant. Runtime of video: 5 mins The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government.