Transperitoneal para-aortic lymphadenectomy by robot assisted laparoscopy in 10 steps

Objective: Para-aortic lymphadenectomy was the cornerstone of gynecologic oncology surgery. In endometrial cancer, the quality of para-aortic lymphadenectomy had direct impact on survival of patient. The launch of robot assisted laparoscopy started in 2005 in France, and in 2008 a transperitoneal para-aortic lymphadenectomy was described [ 1]. With the increase of robots, the robot assisted laparoscopy became more and more popular, hence the need of video tutorial to help less experienced surgeon in this surgical procedure [ 2]. Methods: We proposed a description in 10 key steps, of a transperitoneal para-aortic lymphadenectomy by robot assisted laparoscopy (Da Vinci (R) Si or Xi Robot Surgical System; Intuitive Surgical Inc., Sunnyvale, CA, USA), without other surgical procedure. Results: The 10 steps are: Step 1: port placement and Da Vinci robot positioning Step 2: identification of the right ureter Step 3: identification of the left renal vein Step 4: latero-caval and aorto-caval lymph nodes dissection Step 5: identification of the left ureter Step 6: creation of peritoneal tent Step 7: identification of the inferior mesenteric artery Step 8: latero-aortal lymph nodes dissection Step 9: pre-sacral lymph nodes dissection Step 10: extraction of bags with specimen and surgical textile Conclusion: A standardization of transperitoneal para-aortic lymphadenectomy by robot-assisted laparoscopy is the basis of teaching and learning process. Also it increases the quality of surgery, and consequently decreases the risk of complications.