Retroperitoneal Dissection Research Articles

Cervical Fibroid Myomectomy

Study Objective This video reviews various techniques to reduce risk of blood loss and injury when performing a laparoscopic cervical myomectomy. Design N/A. Setting The techniques and surgery demonstrated in this video were performed on a patient who underwent laparoscopic cervical myomectomy in an academic tertiary care center. This patient had a large (8 × 8 cm) symptomatic cervical fibroid and desired future fertility, so she opted to have a myomectomy. The size and location of this fibroid increased the risk of blood loss and damage to the ureters or bladder. Various techniques were employed during surgery to reduce these risks, and the techniques shown in this video may be helpful in similar cases. Patients or Participants N/A. Interventions Three techniques were used in this video to reduce risk of blood loss and injury to nearby structures. First, the ureters and uterine artery are identified. Retroperitoneal dissection is performed and the ureter is isolated on its course beneath the uterine artery. Additionally, the obliterated umbilical artery is pulled which confirms the identification of the internal iliac artery and the uterine artery. By clearly identifying these structures, one can avoid injury during operation. Second, vascular clips are temporarily applied to the uterine arteries bilaterally. This reduces blood flow to the uterus while performing the myomectomy and afterwards the clips are removed once hemostasis is ensured. Third, vasopressin is injected below the uterine serosa to cause vasoconstriction and temporary reduction in blood flow while performing the myomectomy. Measurements and Main Results N/A. Conclusion Laparoscopic cervical myomectomy can be performed using various techniques to reduce the risk of bleeding and injury to nearby structures. This video reviews various techniques to reduce risk of blood loss and injury when performing a laparoscopic cervical myomectomy. N/A. The techniques and surgery demonstrated in this video were performed on a patient who underwent laparoscopic cervical myomectomy in an academic tertiary care center. This patient had a large (8 × 8 cm) symptomatic cervical fibroid and desired future fertility, so she opted to have a myomectomy. The size and location of this fibroid increased the risk of blood loss and damage to the ureters or bladder. Various techniques were employed during surgery to reduce these risks, and the techniques shown in this video may be helpful in similar cases. N/A. Three techniques were used in this video to reduce risk of blood loss and injury to nearby structures. First, the ureters and uterine artery are identified. Retroperitoneal dissection is performed and the ureter is isolated on its course beneath the uterine artery. Additionally, the obliterated umbilical artery is pulled which confirms the identification of the internal iliac artery and the uterine artery. By clearly identifying these structures, one can avoid injury during operation. Second, vascular clips are temporarily applied to the uterine arteries bilaterally. This reduces blood flow to the uterus while performing the myomectomy and afterwards the clips are removed once hemostasis is ensured. Third, vasopressin is injected below the uterine serosa to cause vasoconstriction and temporary reduction in blood flow while performing the myomectomy. N/A. Laparoscopic cervical myomectomy can be performed using various techniques to reduce the risk of bleeding and injury to nearby structures.

Novel Articulated Laparoscopy in Gynecologic Surgery

<h3>Study Objective</h3> To discuss the advantages and disadvantages of articulated laparoscopy versus conventional laparoscopy. To demonstrate the benefits of a novel articulated laparoscopic device in a cadaveric model. <h3>Design</h3> Educational video. <h3>Setting</h3> Cadaver Laboratory and Simulation Center- Laparoscopic surgery performed in a cadaveric model. <h3>Patients or Participants</h3> We present a novel articulated laparoscopic instrument and our experience with the implementation of this device in a cadaveric model. <h3>Interventions</h3> Cadaveric laparoscopic wristed dissection including adhesiolysis, retroperitoneal dissection, salpingo-oophorectomy, and hysterectomy. <h3>Measurements and Main Results</h3> The advantages of robotic surgery include that it represents a less morbid alternative to laparotomy, it gives a minimally invasive surgery option for a broader patient population, and it improves precision with wristed instruments. On the other hand, Limitations of robotic surgery include the absence of haptic or tactile feedback and a higher cost. Additionally, depending on the practice setting, availability may be a problem. We present a novel hand-held articulated laparoscopic device that provides haptic feedback, short set up time, lower cost while improving precision and dexterity with wristed instruments. <h3>Conclusion</h3> This novel articulated laparoscopic instrument may be an option to offer MIS surgery with potential increased dexterity at a lower cost compared with robotic surgery. This option potentially combines the benefits of conventional laparoscopy and robotic surgery. Future research is needed to determine the learning curve and operative cost of this device.

Deep Pelvic Side Wall Anatomy; A Case of Laparoscopic Management of Vaginal Vault Fistula to the Presacral Area

<h3>Study Objective</h3> Video presentation showing retroperitoneal dissection and deep pelvic side wall anatomy. <h3>Design</h3> Case presentation. <h3>Setting</h3> Tertiary medical center. <h3>Patients or Participants</h3> 74-year-old female with history of type 2 diabetes, hypertension, and a vaginal hysterectomy with left sacrospinous ligament suspension nine years ago, presented with fever and found to have bacteremia. Abdominal and pelvic MRI showed a presacral and precoccygeal loculated collections, sacral osteomyelitis, and fistula from the left superior vaginal vault to one of the presacral collections. <h3>Interventions</h3> Laparoscopic resection of sacrospinous fistula tract. <h3>Measurements and Main Results</h3> The patient showed significant improvement in her symptoms with resolution of low back pain, vaginal discharge and bleeding. <h3>Conclusion</h3> Gentle dissection with maintained hemostasis, creating windows, and starting from less distorted anatomy are key points in retroperitoneal dissection.

Training Inadequacies Among Accreditation Council for Graduate Medical Education (ACGME) Surgical Specialties

<h3>Study Objective</h3> To compare general trends in residency training operative experience between Obstetrics & Gynecology (OBGYN), Urology, and General Surgery as determined by ACGME, the governing body that sets the standards for US graduate medical education training programs. <h3>Design</h3> All available ACGME residency case log data was collected. OBGYN data was available from 2002-2019, Urology from 2015-2019, and General Surgery from 1999-2019. Operative experience was assessed, with particular attention to retroperitoneal dissection/ureterolysis and small bowel repair. The mean case numbers reported per resident were compared between the 2 groups using unpaired 2-tailed t tests, with P values < .05 considered significant. <h3>Setting</h3> N/A. <h3>Patients or Participants</h3> We reviewed data from approximately 865 ACGME-accredited institutions. Case log data was self-reported by residents as cases were performed each year of their training program. <h3>Interventions</h3> N/A. <h3>Measurements and Main Results</h3> The mean number of total gynecologic cases logged by OBGYN residents was 315.48 (SD 46.09). The mean number of cases logged by urology residents was as follows: intestinal diversion 5.25 (SD 1.02); ureteral exposure 207.23 (SD 3.44); gynecologic cases 35.9 (SD 1.22). The mean number of cases logged by general surgery residents was as follows: small bowel repair 14.13 (2.78); ureteral exposure 11.08 (2.54); gynecologic cases 4.19 (1.33). <h3>Conclusion</h3> Notably, both urology and general surgery training programs require cross-specialty exposure and familiarity with retroperitoneal dissection, ureterolysis, bladder and bowel repairs, whereas OBGYN training does not. We propose multiple potential solutions for addressing these inadequacies in surgical training among OBGYN residents, including amending the base ACGME requirements for graduation to include some exposure to retroperitoneal dissection and bowel surgery in order to increase comfort level with operating in these spaces frequently encountered by gynecologic surgeons.

Stepwises Technique in Robotic Assisted Notes Sacrocolpopexy

<h3>Study Objective</h3> To demonstrate stepwise techniques for the successful utilization of the single-site technique for safely performing transvaginal sacrocolpopexy for pelvic organ prolapse. <h3>Design</h3> Stepwise demonstration with narrated video footage. <h3>Setting</h3> An academic tertiary care hospital. <h3>Patients or Participants</h3> The patient is a 69-year-old G2P2002 with a history of SVD x2 who presented with symptomatic stage II anterior vaginal prolapse (Aa +1) and stage II posterior vaginal prolapse (Ap -1). The preoperative vaginal length was measured at 9 cm. <h3>Interventions</h3> Laparoscopic transvaginal single-site sacrocolpopexy has been demonstrated to be feasible and safe in the surgical management of pelvic organ prolapse. However, retroperitoneal dissection or suturing/knot tying can be technically challenging to perform, especially in the event of an anatomical variation of a deeply angled S1 vertebra. Wristed robotic instrumentation may overcome some of these obstacles and result in easier suturing and knot tying. Integration of a robotic platform for sacrocolpopexy is a novel alternative minimally invasive approach that is more cosmetic, safer and effective. <h3>Measurements and Main Results</h3> The procedure was successfully performed in approximately 227 minutes with a measured postoperative vaginal length of 7 cm. The patient's postoperative pelvic organ prolapse quantification was stage 0. <h3>Conclusion</h3> Robotic-assisted transvaginal single-site sacrocolpopexy for pelvic organ prolapse is feasible, effective, and safe in patients with pelvic organ prolapse.

Laparoscopic Management of Tubo-Ovarian Abscess Refractory to Percutaneous Drainage

<h3>Study Objective</h3> To demonstrate the feasibility and safety of a laparoscopic approach to a case of tubo-ovarian abscess (TOA) refractory to percutaneous drainage and antibiotic therapy. <h3>Design</h3> Case report. <h3>Setting</h3> Operating room with traditional laparoscopy. <h3>Patients or Participants</h3> 30-year-old female patient with refractory TOA. <h3>Interventions</h3> Laparoscopic lysis of adhesions, bilateral salpingectomy, right oophorectomy, wash out and drain placement. <h3>Measurements and Main Results</h3> The patient is a 30-year-old female who presented with a 16cm TOA, initially managed with parenteral antibiotics and percutaneous drainage. However, despite initial improvement, the abscess continued to re-accumulate, refractory to a total of three percutaneous drain placements over the course of 8 weeks. She was taken to the operating room for laparoscopic resection of the TOA. Four port sites were utilized, three 5mm ports and one 10mm port. Survey of the pelvis revealed dense adhesions, bilateral pyosalpinx, and residual large abscess encompassing the right ovary. Given the patient's prolonged pre-operative course and her consent for loss of future fertility, the decision was made to proceed with bilateral salpingectomy and right oophorectomy. The right adnexal structures were densely adherent to the pelvic side wall and cul de sac; therefore, retroperitoneal dissection was utilized to identify important landmarks including the medial umbilical ligament, uterine artery and ureter in order to safely remove the diseased tissue without injuring the surrounding vital structures. The pelvis was irrigated and a JP drain was placed. She was discharged home on the same day. She had an uncomplicated post-operative course. Final surgical pathology revealed chronic and active salpingitis as well as focal endometriosis. <h3>Conclusion</h3> Laparoscopy is a safe and feasible surgical approach to the management of tubo-ovarian abscess refractory to percutaneous drain placement. The surgeon should be adept and familiar with retroperitoneal dissection to ensure safety of surrounding structures in the setting of dense adhesive disease and inflammation.

Uterine Artery Clipping at the Level of the Ureteric Tunnel for Reduction of Blood Flow

Study Objective Though cervical myomas comprise only 5% of total uterine myomas, they present unique surgical challenge due to proximity to the uterine vessels and ureters. We aim to highlight an approach to robotic-assisted hysterectomy with a large cervical fibroid, with minimal blood loss and clear visualization of the displaced anatomy. Design Video Case Presentation. Setting A robotic-assisted hysterectomy (RAH) was performed under general anesthesia in dorsal lithotomy position at a university-affiliated hospital. Patients or Participants 41-year-old G0 with abnormal uterine bleeding in the setting of 5 × 4 × 5 cm subserosal fibroid of the left posterior cervix. The patient was pretreated with leuprolide acetate injections then letrozole to reduce the fibroid volume, however, no change in size was observed. The patient desired definitive management of the fibroid. Interventions Once in the operating room, a uterine manipulator could not be placed due to displacement of the cervix by the fibroid. Careful retroperitoneal dissection was performed to identify the uterine artery coursing over the ureter at the ureteric tunnel of Wertheim. Laparoscopic clips were applied to the uterine artery to decrease blood supply to the fibroid. After completion of the hysterectomy, the fibroid capsule was entered and myomectomy was completed, resulting in separation of the fibroid from the vagina. Measurements and Main Results Estimated blood loss was 50 cc. Final specimen were uterus, fallopian tubes, and cervix weighing 54 g and cervical fibroid weighing 99 g. The patient had an uncomplicated postoperative course and was discharged home on postoperative day 1. Conclusion This case demonstrates the use of minimally-invasive surgical approach to safely complete a hysterectomy in the context of a large, cervical myoma. Our video demonstrates improved hemostasis and visualization of the ureters throughout the case due to placement of vessel clips at the level of the ureteric tunnel. Though cervical myomas comprise only 5% of total uterine myomas, they present unique surgical challenge due to proximity to the uterine vessels and ureters. We aim to highlight an approach to robotic-assisted hysterectomy with a large cervical fibroid, with minimal blood loss and clear visualization of the displaced anatomy. Video Case Presentation. A robotic-assisted hysterectomy (RAH) was performed under general anesthesia in dorsal lithotomy position at a university-affiliated hospital. 41-year-old G0 with abnormal uterine bleeding in the setting of 5 × 4 × 5 cm subserosal fibroid of the left posterior cervix. The patient was pretreated with leuprolide acetate injections then letrozole to reduce the fibroid volume, however, no change in size was observed. The patient desired definitive management of the fibroid. Once in the operating room, a uterine manipulator could not be placed due to displacement of the cervix by the fibroid. Careful retroperitoneal dissection was performed to identify the uterine artery coursing over the ureter at the ureteric tunnel of Wertheim. Laparoscopic clips were applied to the uterine artery to decrease blood supply to the fibroid. After completion of the hysterectomy, the fibroid capsule was entered and myomectomy was completed, resulting in separation of the fibroid from the vagina. Estimated blood loss was 50 cc. Final specimen were uterus, fallopian tubes, and cervix weighing 54 g and cervical fibroid weighing 99 g. The patient had an uncomplicated postoperative course and was discharged home on postoperative day 1. This case demonstrates the use of minimally-invasive surgical approach to safely complete a hysterectomy in the context of a large, cervical myoma. Our video demonstrates improved hemostasis and visualization of the ureters throughout the case due to placement of vessel clips at the level of the ureteric tunnel.

Laparoscopic Extraperitoneal Total Retroperitoneal Dissection- the Right Approach.

<h3>Study Objective</h3> To demonstrate our minimally invasive para-aortic and pelvic lymphadenectomy via the retroperitoneal approach. This technique is performed entirely from the renal vein to the circumflex iliac vein extraperitoneally for cases with mainly endometrial cancer, selected cases of ovarian cancer and in rarer situations for advanced cervical cancer cases as a staging procedure. <h3>Design</h3> Analysis of a technique via video. <h3>Setting</h3> Urban general hospital in Japan. <h3>Patients or Participants</h3> More than 900 cases have undergone laparoscopic or robotic extraperitoneal para-aortic dissection and around 19 of these cases have also undergone extraperitoneal pelvic lymphadenectomy. <h3>Interventions</h3> The extraperitoneal approach is performed using a 5mm EndoTIP cannula. We place all 4 retroperitoneal ports along the left flank. For dissection we use a monopolar hook equipped with an aspiration device and advanced bipolar for retroperitoneal dissection. <h3>Measurements and Main Results</h3> The estimated blood loss for para-aortic dissection was only 30ml and 160ml in the pelvic procedure. Only 3 cases of the total 900 cases required a conversion to open laparotomy. We experienced 23 cases of peritoneal tent perforation, but did not abandon the original procedure, rather suture-repaired the hole and continued. <h3>Conclusion</h3> The advantage of this approach is that the operative filed is bowel-free as the peritoneum acts as a natural retractor. This means that there is minimally impact to the bowel. Patients are not required to be placed in a deep Trendelenburg position. Even extensive intraperitoneal adhesion cases have been successfully managed with this procedure making it a patient friendly option.

Complicated Laparoscopic Trachelectomy Following Supracervical Hysterectomy

<h3>Study Objective</h3> To review the most common indications and risk factors for trachelectomy after supracervical hysterectomy and demonstrate technique for a complicated laparoscopic trachelectomy. <h3>Design</h3> Narrated video tutorial for a safe and reproducible laparoscopic trachelectomy complicated by extensive adhesive disease after supracervical hysterectomy. <h3>Setting</h3> Although trachelectomy is a relatively uncommon procedure, it may be indicated for a variety of benign pathologies women who have undergone supracervical hysterectomy. The potential complications of this procedure may be elevated from baseline surgical risks due to the presence of adhesive disease from prior surgeries or concurrent pelvic pathologies. This patient underwent her surgery at a tertiary academic center. She was positioned in dorsal lithotomy with arms tucked for surgical ergonomics. <h3>Patients or Participants</h3> This is a 43-year-old para 1 who presented for surgical management of cyclic heavy vaginal bleeding after a supracervical hysterectomy for adenomyosis and fibroids in 2014. <h3>Interventions</h3> This educational video demonstrates a complicated laparoscopic trachelectomy with an opportunistic bilateral salpingectomy, left ureterolysis, excision of endometriosis, and cystoscopy. <h3>Measurements and Main Results</h3> Not applicable. <h3>Conclusion</h3> Laparoscopic trachelectomy after supracervical hysterectomy may be significantly complicated by adhesive disease. The following strategies are key in the approach to a complicated laparoscopic trachelectomy: 1. Restoration of normal pelvic anatomy 2. Retroperitoneal dissection to safely identify the ureters, as well as the gonadal and uterine vessels and 3. Use of a uterine manipulator with a colpotomy ring to delineate target tissues, allow for multidirectional movement and facilitate safe entry into key planes.

Surgical Principles for Management of Major Vessel Injury during Laparoscopic Gynecologic Surgery

<h3>Study Objective</h3> Vascular injury of the major pelvic vessels is one of the most dreaded complications in gynecologic laparoscopy. Risk factors include distorted anatomy, fibrosis secondary to pathology or previous surgery, and procedures involving retroperitoneal dissection. We aim to outline fundamental principles for management of major vessel injury during gynecologic laparoscopy. <h3>Design</h3> Case report. <h3>Setting</h3> Tertiary academic medical center. <h3>Patients or Participants</h3> We present the case of 32-year-old patient who sustained an injury to the left external iliac artery during surgical excision of deeply infiltrating endometriosis. <h3>Interventions</h3> Critical steps demonstrated in this video include rapid identification, application of direct pressure, and communication with the operating room team regarding the need for additional resources. Once bleeding has slowed, mobilization of surrounding structures including the ureter and bowel can be performed to improve visualization and minimize risk of secondary injury. Atraumatic self-retaining vascular clamps such as laparoscopic Satinsky clamps can be used to occlude without traumatizing vessel walls. If bleeding is unable to be controlled with laparoscopic pressure or additional visualization is required for primary repair, laparotomy must be performed expeditiously. <h3>Measurements and Main Results</h3> This patient received definitive primary repair of a 5mm external iliac artery defect with Vascular Surgery and was discharged home in stable condition on postoperative day two. <h3>Conclusion</h3> This case demonstrates fundamental principles for initial management of acute major vessel injury during gynecologic laparoscopy, including application of direct pressure, communication, identification and mobilization of surrounding anatomy, and application of vascular clamps to temporize bleeding when definitive repair is not possible through a minimally invasive approach.

Management of Lymphatic Leaks After Retroperitoneal Lymph-Node Dissections in Gynecologic Cancers

Objective: Lymphatic-channel leakage after retroperitoneal lymph-node dissection (RPLND) includes lymphatic ascites or chylous ascites. Given that the presentation is rare and that only limited literature is available, no guidelines or treatment guides are available for its management. This study aimed to help develop a management strategy for this rare condition. Materials and Methods: This retrospective study took place from January 2014 to January 2020. Case records of 255 patients were reviewed from a prospectively maintained computerized database of patients who underwent RPLND as a part of surgical management for ovarian and endometrial carcinomas and who had postoperative lymphatic-channel leaks. Demographic profile, disease incidence, clinical details, diagnoses, stages, and treatment modalities were analyzed. Results: A total of 11 patients had lymphatic leaks postoperatively. Four patients had chylous ascites, and 7 patients had lymphatic ascites. All patients were managed conservatively; none of them required surgery. There was no perioperative mortality in these patients. Conclusions: Lymphatic leak is a known, but uncommon, complication after RPLND, leading to a prolonged hospital stay and increased risk of infection. The majority of these leaks can be managed conservatively. A backup surgical plan should be in place if the leak persists. (J GYNECOL SURG 38:133)

ISOlation Procedure vs. conventional procedure during Distal Pancreatectomy (ISOP-DP trial): study protocol for a randomized controlled trial

BackgroundRadical antegrade modular pancreatosplenectomy (RAMPS) is an isolation procedure in pancreatosplenectomy for pancreatic body/tail cancer. Connective tissues around the bifurcation of the celiac axis are dissected, followed by median-to-left retroperitoneal dissection. This procedure has the potential to isolate blood and lymphatic flow to the area of the pancreatic body/tail and the spleen to be excised. This is achieved by division of the inflow artery, transection of the pancreas, and then division of the outflow vein in the early phases of surgery. In cases of pancreatic ductal adenocarcinoma (PDAC), the procedure has been shown to decrease intraoperative blood loss and increase R0 resection rate by complete clearance of the lymph nodes. This trial investigates whether the isolation procedure can prolong the survival of patients with pancreatic ductal adenocarcinoma who undergo distal pancreatosplenectomy (DPS) compared with those that undergo the conventional approach.Methods/designPatients with PDAC scheduled to undergo DPS are randomized before surgery to undergo either a conventional procedure (arm A) or to undergo the isolation procedure (arm B). In arm A, the pancreatic body, tail, and spleen are mobilized, followed by removal of the regional lymph nodes. The splenic vein is transected at the end of the procedure. The timing of division of the splenic artery (SA) is not restricted. In arm B, regional lymph nodes are dissected, then we transect the root of the SA, the pancreas, then the splenic vein. At the end of the procedure, the pancreatic body/tail and spleen are mobilized and removed. In total, 100 patients from multiple Japanese high-volume centers will be randomized. The primary endpoint is 2-year recurrence-free survival by intention-to-treat analysis. Secondary endpoints include intraoperative blood loss, R0 resection rate, and overall survival.DiscussionIf this trial shows that the isolation procedures can improve survival with a similar R0 rate and with a similar number of lymph node dissections to the conventional procedure, the isolation procedure is expected to become a standard procedure during DPS for PDAC. Conversely, if there were no significant differences in endpoints between the groups, it would demonstrate justification of either procedure from surgical and oncological points of view.Trial registrationUMIN Clinical Trials Registry UMIN000041381. Registered on 10 August 2020. ClinicalTrials.gov NCT04600063. Registered on 22 October 2020.

Robotic Radical Antegrade Modular Pancreatosplenectomy Using the Supracolic Anterior Superior Mesenteric Artery Approach

BackgroundRadical antegrade modular pancreatosplenectomy (RAMPS) is the standardized approach in open pancreatic resection for pancreatic body and tail cancer. However, few studies have described regarding robotic RAMPS for pancreatic cancer. We herein present our techniques of robotic RAMPS using the supracolic anterior superior mesenteric artery (SMA) approach with the ventral view. MethodsThe patient was a 75-year-old female with a diagnosis of pancreatic body cancer. Following neoadjuvant chemotherapy with gemcitabine plus nab-paclitaxel, robotic RAMPS was performed. Our techniques of robotic RAMPS include four steps: (1) gastrocolic ligament division, (2) dissection of superior and inferior border of the pancreas, (3) division of the pancreas, and (4) retroperitoneal dissection. ResultsThe operative time was 251 min with an estimated blood loss of 10 mL. The uneventful postoperative course was observed. The final pathology confirmed R0 surgical resection. ConclusionsRobotic RAMPS using the supracolic anterior SMA approach is safe and feasible for pancreatic body and tail cancer. Standardization and precise anatomical knowledge are key elements of performing robotic RAMPS.

Internal iliac artery ligation—a contemporary simplified approach

Bilateral ligation of the anterior division of the internal iliac arteries can be a lifesaving intervention for severe pelvic hemorrhage. The procedure results in decreased pelvic perfusion and promotes coagulation. The classical method of internal iliac artery ligation involved extensive retroperitoneal dissection with complete circumferential isolation of the vessel to allow the passage of a suture around the artery. This can be surgically challenging and fraught with risks of inadvertent injury to the surrounding iliac veins. We propose a contemporary technique that requires limited dissection of the anterior division of the internal iliac artery. A few millimeters of space is created on either side of the artery by spreading right-angle forceps parallel to the vessel. The artery is occluded by 2 large vascular clips. Because circumferential vessel dissection is not necessary with this technique, there is limited disruption of the delicate underlying internal iliac vein. In addition, this approach may decrease the risk of inadvertent injury to the adjacent external iliac vein. By showcasing the ease of our approach to internal iliac artery ligation, we hope to empower surgeons with an alternative approach to this lifesaving procedure.

Complete Resection of the Inferior Vena Cava Using a Robot

Isolated intrainferior vena cava (IVC) recurrence of renal cell carcinoma (RCC) is a rare presentation. In this investigator-initiated intervention, we present our novel experience, with first of kind—a robotic suprarenal cavectomy without reconstruction for an isolated RCC recurrence, occurring 3 years postright radical nephrectomy. The patient's procedure was undertaken with a Da Vinci Xi Surgical System®. As step 1, the patient was positioned right lateral side up and routine right nephrectomy port placement was undertaken, followed by side docking. As step 2, the right colon and duodenum were medialized. During step 3, the IVC was identified and en bloc retroperitoneal dissection was performed to fully expose all aspects of the IVC. A significant pericaval fibrotic rind was excised to allow exposure of the true IVC surface. Step 4 involved identification of the left renal vein, with preservation. For step 5, the suprarenal IVC was dissected circumferentially with lumbar veins clipped as necessary. The position and superior margin of the tumor thrombus were constantly confirmed with both transesophageal and robotic intraoperative sonography. Step 6 consisted of further intrahepatic caval dissection, performed to completely expose the suprarenal IVC. For step 7, a rummel-style tourniquet was placed below the level of the thrombus, and the superior margin of the IVC was secured using a Vicryl tie. Step 8 involved caval dissection, with adequate margin of IVC taken proximal to the superior border of the tumor (~2 cm). Once the mass was isolated, step 9 utilized a robotic 60 mm vascular stapler to divide the intrahepatic IVC above the mass and similarly below the mass. This wedge of IVC was collected with thrombus in situ and sent for histopathology. Hemostasis was achieved and port sites were closed in the usual manner. Tumor was confirmed as clear cell RCC (ISUP nucleolar grade 2), in keeping with the man's prior diagnosis. The tumor mass was clear of margins, and a lymph node isolated as part of the specimen demonstrated no evidence of malignancy. Patient progress since discharge has been unremarkable, with no evidence of lower limb edema, clinical or radiologic recurrence of malignancy 3 months since operation. A robot-assisted caval resection for isolated renal carcinoma recurrence within the IVC is a minimally invasive option that can facilitate complete resection with negative surgical margins and minimization of morbidity. Patient Consent Statement: Informed consent was obtained from the patient for publication of this case and accompanying images and video. The authors have received and archived patient consent for video recording/publication in advance of video recording of the procedure in accordance with the ethical standards of the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. No competing financial interests exist. Runtime of video: 5 mins 59 mins

50 Vascular bulldog clamps for robotic myomectomy

The objective of this video is to illustrate how to incorporate the use of vascular bulldog clamps for reducing blood loss during robotic-assisted laparoscopic myomectomy. This video provides technical details on the use of robotic bulldog clamps and shows their placement and removal during a robotic myomectomy case. For experienced surgeons comfortable with retroperitoneal dissection, the use of vascular bulldog clamps may be easily incorporated into surgical technique for robotic myomectomy.

Metastasectomy in colorectal carcinoma (CRC) patients (pts) with mBRAF: Prospective database analysis.

e15549 Background: Role of metastasectomy in pts with mBRAF metastatic CRC is still controversial. We performed analysis of prospective multicentric database of pts with mBRAF mCRC to evaluate the efficacy of metastasectomy in such group of pts in the real clinical practice. Methods: We analyzed a database of pts with mCRC in 7 cancer clinics in Russia and chose pts with metastasectomy with different mutational status. The primary endpoints were disease free survival (DFS) and overall survival (OS), which were calculated from the time of metastasectomy. Analysis was performed with the SPSS v.20 software package. Results: The study included 126 pts: 26 pts with mBRAF, 57 pts with mRAS and 43 pts with wtRAS/BRAF. Pts with mBRAF more often had synchronous metastases (50%/19,3/11,6%, p&lt;0,01), N2 status (38,5%/11%/19,6%, p=0,04). In mBRAF cohort all but 1 pt had V600 mutations; peritonectomy performed in 19,2%, liver resection – in 34,6%, lung resection, ovariectomy, metastasectomy in brain and retroperitoneal lymph nodes dissection with removal of the local relapse – over 11,5%; R0 resection was achieved in 88,5%. Median DFS was 7 months in mBRAF pts, 14 months in mRAS and not achieved in wtRAS/BRAF group treated (HR 2,1, 95%CI 1,5-3.1, p&lt;0.01). Median OS was 26 months in mBRAF, 38 months in mRAS and not achieved in wtRAS/BRAF group (HR 1,5, 95%CI 1,0-2,4, p=0.06). Perioperative chemotherapy didn’t improve DFS in pts with mBRAF (HR 1,9, 95%CI 0,67-5,7, p=0,2). The best median DFS were in pts after ovariectomy – 10 months, the worst - after retroperitoneal lymph nodes dissection with removal of the local relapse – 2 months. Conclusions: Prognosis of pts with mBRAF after metastasectomy is worse than with other mutational phenotypes. However in selected cases metastasectomy might be considered in such aggressive mCRC.

Surveillance after complete response in patients with metastatic non-seminomatous germ-cell tumor (NSGCT).

5018 Background: The optimal management of patients (pts) with complete response (CR) after first-line chemotherapy remains unsettled with guidelines recommending either surveillance or retroperitoneal LN dissection (RPLND). We present long-term outcomes from a large dataset of pts managed with surveillance after achieving CR to first-line chemotherapy. Methods: The prospectively maintained Indiana University testicular cancer database was queried for pts with metastatic NSGCT treated between 1990-2017 who achieved a CR after first-line chemotherapy. CR was defined as normalization of tumor markers (AFP+hCG) and no residual mass &gt; 1cm. Kaplan-Meier methods were used to analyze progression-free survival (PFS) and overall survival (OS). Results: 388 pts met eligibility and were included in this analysis. Median age at diagnosis was 28.4 (range, 13-61.5). Primary site was testis in 385 pts (99%). Primary tumor predominant histology was embryonal ca (241), mixed (61), seminoma (31), yolk sac tumor (20), choriocarcinoma (10), and teratoma (14). 126 pts (32.5%) had teratoma in the primary tumor. Metastasis sites were retroperitoneum (295), mediastinal LN (15), pulmonary (149), liver (15), bone (7), and brain (6). IGCCCG risk was good in 325, intermediate in 25, and poor in 32 pts. Pre-chemotherapy retroperitoneal LN size was available in 232 pts: &lt; 3cm in 170 and ≥3cm in 62. Median pre-chemo AFP was 10.7 (1-31,000) and hCG was 16.5 (0-595,930). First-line chemo was BEPx3 in 274, BEPx4 in 30, other regimens in 82 pts. With a median follow-up of 3.9 yrs, 34 pts (8.8%) progressed. At most recent follow-up, 363 (93.6%) pts were alive with no evidence of disease and 10 pts (2.6%) died of their disease. The estimated 2-yr PFS was 90.1% (95% CI: 86.2-93%) and 2-yr OS was 97.8% (95% CI: 95.2-99%). The estimated 2-yr PFS by IGCCCG risk category was 90.4% for good vs 90.4% for intermediate vs 86.5% for poor risk (p = 0.23), and the estimated 2-yr OS was 98.6% for good vs 95.5% for intermediate vs 92.9% for poor risk disease respectively (p = 0.002). For the 34 pts who progressed on surveillance, 16 (4%) progressed in the retroperitoneum only. 3 pts had malignant transformation of teratoma to PNET, adenocarcinoma, or other elements. 11 of progressed pts were treated with surgery, 12 were treated with salvage chemo, and 11 were treated with surgery+chemo. At most recent follow up, 21 of progressed pts had NED, 10 had died of disease, and 3 were lost to follow up. Conclusions: Pts with metastatic NSGCT who achieve CR after first-line chemotherapy can be safely observed with surveillance. Most pts who relapse can be salvaged with surgery and/or chemotherapy.

Anatomical framework for pre-operative planning of laparoscopic left-sided colorectal surgery: Potential relevance of the distance between the inferior mesenteric artery and inferior mesenteric vein

BackgroundThe medial-to-lateral approach is favored by most colorectal surgeons for laparoscopic retroperitoneal dissection and mobilisation of the left colon. The peritoneal access window, i.e. the distance between the inferior mesenteric vein (IMV) and inferior mesenteric artery (IMA) must be large enough to perform the procedure safely and successfully. However, studies investigating the IMA–IMV distance and factors affecting this variable, are scarce. Therefore, we examined the IMA–IMV and D3-IMA distances to determine an anatomical framework on planning and adapting surgical therapy. Basic proceduresThe IMA–IMV and D3-IMA distances were retrospectively measured in 230 patients (127 Male/103 Female, Median Age=54.5) who had undergone pre-operative CT-scanning before laparoscopic left-sided colorectal surgery. Two observers rated the images and interrater reliability was calculated. Subgroup, simple and multiple linear regression analyses were performed in order to detect potential interaction between morphometric variables and IMA–IMV distance. Main findingsWe demonstrated a significant correlation between the inferior margin of the duodenum and the origin of IMA. Determination of the IMA–IMV distance was simple and reproducible. Approximately 45% of patients undergoing laparoscopic colorectal procedures had a narrow distance (≤50mm). There was a sexual dimorphism in IMA–IMV distance, being consistently large in males. There were no other pre-operative factors which predicted whether the peritoneal dissection window for a medial-to-lateral approach was sufficient. ConclusionsOur results provide new data for a better understanding of metric variations in abdominal vascular structures and complement previous observations. In view of our results, we recommend pre-operative measurement of the IMA–IMV before colorectal surgery where the medial-to-lateral approach is planned. Given that a narrow distance may predict a difficult dissection, this factor should be taken into account to determine the optimal surgical approach in each patient.

43. Transvaginal Resection of a Rectovaginal Mass

<h3>Background</h3> Extragonadal teratomas are histologically similar to gonadal teratomas but arise from structures outside of the ovaries and testes, typically along midline structures such as the coccyx, mediastinum, retroperitoneum, and brain. Retroperitoneal teratomas specifically make up 2-5% of pediatric teratomas. Though surgery is curative, it can be technically challenging with high rates of complications including hemorrhage requiring blood transfusion and injury to other organs including the gastrointestinal tract and urinary system. We present the case of a retroperitoneal teratoma of the pelvis that was successfully resected through a transvaginal approach. Though adult case reports have been published using this approach for rectal masses, to our knowledge it has not been used for pediatric cases of rectovaginal masses. <h3>Case</h3> 15 year old G0 female presented to the emergency room with symptoms of acute viral gastroenteritis and incidentally found to have a cystic mass in the inferior left pelvis on ultrasound during workup. Further evaluation of the mass with pelvic MRI demonstrated a 5.8 cm non-enhancing cyst in the rectovaginal space causing significant mass effect on the vagina. Pediatric surgery and pediatric gynecology were consulted for resection. Pediatric surgery initially attempted resection laparoscopically via dissection of the sigmoid colon from the abdominal sidewall to allow for retroperitoneal access. Due to deep retroperitoneal location of the mass, our pediatric gynecologic surgeon attempted a transvaginal approach. Incision of the lateral vaginal wall allowed for access to the mass, which was bluntly dissected from surrounding tissue and removed through the vagina. The cyst incidentally ruptured during removal, with sebaceous fluid noted. The operating space was irrigated and the vagina was closed in two layers. Pathology was consistent with dermoid cyst without evidence of malignancy. The patient recovered well after surgery and is scheduled for surveillance pelvic ultrasound every 6 months to evaluate for recurrence. Her initial follow up ultrasound was normal. <h3>Comments</h3> This case demonstrates a successful transvaginal approach for a rectovaginal teratoma in the pelvis, the first to our knowledge in a pediatric patient. This approach may decrease the risk of surgical complications from retroperitoneal dissection for masses that are low in the pelvis.