Knacks and pitfalls of retroperitoneal sarcoma surgery, part 1: preparation for tumor resection

Although retroperitoneal sarcoma (RPS) is a rare malignancy, it is unlikely that a general surgeon would go through their career without encountering at least one case. Surgical resection remains the only potentially curative treatment and is performed in many institutions worldwide. However, given its low incidence, most centers manage only one or two cases annually, resulting in limited operative experience among surgeons. The clinical presentation of RPS varies widely depending on the tumor location and extent of invasion into adjacent organs and major vessels. This heterogeneity poses a challenge in standardizing surgical techniques and demands a high level of intraoperative adaptability. RPS is commonly found as large tumors, precluding the use of minimally invasive approaches, such as laparoscopy or robotic surgery. The retroperitoneal space also contains critical vascular structures, and inappropriate surgical approaches may lead to life-threatening hemorrhage. At Nagoya University Rare Cancer Center, numerous RPS surgeries have been performed. Through this experience, various technical considerations essential for safe and effective surgery were identified. This article introduces key operative strategies for RPS, including technical "knacks and pitfalls," derived from extensive clinical experience with RPS surgery. Part 1 discusses general preparations that are specifically required for RPS surgery. Part 2 focuses on the details of the practical techniques of the RPS surgery. Finally, part 3 discusses resection of the tumor involving large retroperitoneal vessels, which need special preparations.