Robotic Single Port Retroperitoneal Para-aortic Lymphadenectomy, Staging for Advanced Squamous Cell Carcinoma of the...

The aim of this video is to show the feasibility and added value of using a single-port robot-assisted approach for para-aortic lymphadenectomy.

Stepwise demonstration of the technique with narrated video footage.

This intervention was realised in Gynecology and Obstetrics Department, Saint-Etienne University Hospital Center. We received institutional review board approval under the number #2024-GYN-0703.

A 47-year-old female patient with advanced squamous cell carcinoma of the cervix, dimension of the lesion 6 × 4.5 × 4.5 cm, International Federation of Gynecology and Obstetrics stage IIIC1 disease, based on pelvic lymph node fixation on positron emission tomography-computed tomography. Large loop excision of the transformation zone. Body mass index: 20 INTERVENTIONS: According to current guidelines, the multidisciplinary tumor board approved lymph node staging via infra-mesenteric para-aortic lymphadenectomy. A diagnostic laparoscopy was not required by the multidisciplinary tumor board given the recent positron emission tomography-computed tomography and pelvic magnetic resonance imaging, which showed no evidence of peritoneal carcinomatosis or upper abdominal metastasis. The procedure was performed with the Da Vinci SP system. 1. We first describe the patient positioning followed by the robotic system setup [1]. 2. We then detail the access to the retroperitoneal space. 3. Finally, we demonstrate the dissection of the preaortic node, lateroaortic node, interaorticocave node, precave node. From a technical standpoint, the complete dissection was performed in 58 minutes.

The technical challenges of para-aortic lymphadenectomy, particularly the risk of bleeding in case of difficult dissection, have been previously described [2]. The single-port robotic system might help overcome these issues by enhancing precision and access compared to conventional laparoscopy. The space is created by a flexible balloon, which limits traction on the abdominal wall. It differs from a rigid trocar. In this case, an accessory trocar was introduced to assist with peritoneal retraction and smoke evacuation. This was our first case, and the accessory trocar was barely used. It has not been needed in subsequent procedures and does not seem essential. From the patient's perspective, this approach allowed for same-day discharge in this case, with limited visible scarring and low levels of postoperative pain. However, further studies are needed to confirm the benefits of a single-site access across a larger population. By facilitating accurate staging while aiming to reduce surgical morbidity, this technique may help support early recovery and timely initiation of adjuvant radiotherapy. VIDEO ABSTRACT.