In the operating room, general anesthesia was established and an orogastric tube was placed. The patient was placed supine, pressure points were padded, and secured to the table. Prior to this positioning, the patient was placed in steep Trendelenburg to facilitate mobilization of the small bowel out of the pelvis. Once this was achieved, the patient was taken slowly back down to 15° to keep the bowel from settling back into the pelvis. Pneumoperitoneum was obtained with a Veress needle. A total of 6 ports were placed across the lower abdomen: a 8-mm midline camera port placed infraumbilically in the midline approximately 3 cm above the pubic symphysis; 3 robotic trocars; and one 12-mm & 15mm access ports for the assistant, placed in a gentle U-shaped arc across the lower abdomen.
The Robot was docked, we dissected out the left spermatic cord remnant. In left-sided cases, this dissection was taken cephalad from the internal ring, up to and underneath the sigmoid colonic reflection for later completion of spermatic cord removal after located the silk suture from the left orchiectomy. Dissection then commenced in an inferior to superior direction. An incision was made in the posterior peritoneum medial to the cecum overlying the right common iliac artery and carried up to the ligament of Treitz, after placing the bowel in the right upper quadrant. Gentle dissection then proceeded underneath the mesentery and along the retroperitoneum until the crossing duodenum was encountered. The laterally placed robotic arm #3 (Prograsp) was used to sweep the bowel including the duodenum anteriorly. This was done after the plane between the preperitoneal and retroperitoneal fat was separated. This plane allowed for a working space between the peritoneal structures and the retroperitoneum. A 2– 0 V-loc Hammock sutures was placed to suture the peritonenum up to the abdominal wall, away from the retroperitoneum in a hammocklike fashion. This maneuvers afforded an excellent view of the great vessels and retroperitoneum and provided adequate working space throughout the procedure, with minimal retraction of the bowel.
Once the bowel was appropriately retracted and access to the retroperitoneum was secured with the hammock sutures, the lymphadenectomy could be started. On the right side, the lymphatic tissue was split along the midline surface of the IVC and dissected both medially and laterally, in a split-and-roll technique. On the left side of the interaortocaval packet, the renal vein was then traced to the IVC, and the tissue was rolled medially off the IVC to help create the interaortocaval package. Hem-O-Lok polymer clips secured the superior aspect of the interaortocaval lymph node packet. Once the left renal vein and the renal artery were identified, the dissection proceeded from cephalad to caudad, rolling the lymph node packet off the anterior longitudinal spinal ligament. We took care to preserve most lumbar vessels; however, when necessary, they were divided between Hem-O-Lok clips or with the assistance of the Vessel Sealer electrocautery device. On the left side, the left ureter was readily identified usually at the medial portion of the suspended retroperitoneum. While dissecting the para-aortic packet, we mimicked the open technique and take care to preserve the inferior mesenteric vein. In addition, when proceeding caudally within the para-aortic packet, the inferior mesenteric artery should be readily identified and preserved. On the right side, the right ureter was easily identified in the dependent portion of the swath of tissue contained within the suspended retroperitoneal tissue. The paracaval lymph node packet should be dissected cephalad until the renal hilum is identified. Care was taken to visualize and preserve, when possible, the lumbar vessels and all nerves of the post ganglionic fibers. All lymph node packets can be removed by the assistant using a reusable endocatch bag.
The 3-dimensional visualization and flexibility of the robot facilitated the dissection posterior to the IVC and aorta, with complete removal of nodal tissue over the anterior longitudinal ligament. Prospectively, sympathetic nerve roots and ganglia are identified and preserved to prevent ejaculatory dysfunction. These nerve roots can be prospectively identified over the anterior aspect of the aorta and tracked back to the sympathetic ganglia. Alternatively, they can be tracked from the ganglia, along their course, to the anterior aspect of the aorta and beyond. At the conclusion of the dissection, the abdomen was carefully inspected for bleeding or injury to the surrounding viscera. The posterior peritoneum was returned to its proper anatomical position with removal of the hammock sutures. All trocars were removed under direct vision, and the fascia of the 12 & 15-mm assistant ports were closed using a 0-Vicryl UR6 . Skin was closed using absorbable suture and adhesive glue. No nasogastric tube or Jackson Pratt drains were left at the conclusion of the case