Robot-Assisted Transumbilical Single-Site Resection of Bulky Para-Aortic Lymph Nodes in Endometrial Cancer

To demonstrate the surgical technique of robot-assisted transumbilical single-site resection of bulky para-aortic lymph nodes in a patient with endometrial cancer.

Surgical video article demonstrating stepwise robotic single-site retroperitoneal dissection.

Single tertiary academic referral center.

A 64-year-old woman with a body mass index (BMI) of 19.2 kg/m² and suspected stage IIIC2 endometrioid adenocarcinoma was found on preoperative magnetic resonance imaging to have a bulky left para-aortic nodal mass measuring 1.8 × 1.5 cm, located between the inferior mesenteric artery, abdominal aorta, left ureter, and left common iliac artery bifurcation. Her relatively low BMI was considered technically favorable for transumbilical single-site access and the planned robotic arm configuration.

The patient was placed in the dorsal lithotomy position with steep Trendelenburg positioning. A customized port with four independent 10-mm trocars was inserted through a 3.5-cm transumbilical incision. The da Vinci Xi surgical system was docked with caudal camera placement, bipolar fenestrated forceps on the left, monopolar curved scissors on the right, and a cranial assistant channel for laparoscopic countertraction and suction, creating separate triangular working zones. Key operative steps included: 1. Retroperitoneal entry, 2. Identification of the IMA and aortic surface, 3. Ureterolysis and lateralization of the left ureter, 4. Inframesenteric para-aortic nodal dissection along the aortic adventitial plane, 5. En bloc specimen retrieval through the umbilical incision. Particular attention was directed toward continuous identification of vascular landmarks and protection of the left ureter using gauze-assisted displacement during dissection. Assistant-assisted countertraction facilitated stable exposure of the retroperitoneal corridor while minimizing instrument collision within the confined operative workspace.

Intraoperative frozen section analysis confirmed lymph node metastasis, prompting completion of hysterectomy, bilateral salpingo-oophorectomy, and resection of suspiciously enlarged bilateral obturator lymph nodes. The total operative time was 187 minutes, and the estimated blood loss was 30 mL. The patient was discharged on postoperative day 3 without perioperative complications. Final histopathology confirmed metastasis in 4 of 4 para-aortic lymph nodes, whereas all 19 pelvic lymph nodes were negative.

Robot-assisted transumbilical single-site para-aortic lymphadenectomy is feasible in selected patients and may offer ergonomic and minimally invasive advantages for inframesenteric retroperitoneal surgery [1,2]. Strategic robotic arm configuration and assistant-assisted countertraction enable precise dissection near major vessels without an accessory port. Our experience supports the feasibility of this approach [3]. A relatively low BMI may facilitate access, while reproducibility requires surgical experience and coordinated assistance.