This is a surgical video demonstrating robotic-assisted total pelvic exoneration for recurrent vulvar carcinoma. Pelvic exoneration is a radical procedure which can be considered in women with recurrent gynecologic cancers. This video aims to demonstrate a total pelvic exoneration for recurrent vulvar cancer utilizing the robotic surgical platform. This video highlights the case of a 79-year-old with recurrent vulvar squamous cell carcinoma who had undergone two prior radical vulvectomies as well as pelvic radiation. She presented with a central recurrence involving the vulva, urethra, and anus. After appropriate counseling, the patient elected to undergo total pelvic exoneration with utilization of the robotic surgical platform. The procedure is begun by placing surgical trocars in a semi-lunar pattern across the patient's abdomen to allow for access to the pelvis. After peritoneal survey demonstrated no evidence of metastatic disease, the exoneration is started by developing the avascular spaces of the pelvis bilaterally. The paravesical space is developed by incising the peritoneum and loose areolar tissue lateral to the medial umbilical ligament. The ovarian vessels are ligated and divided. The ureter is dissected from the medial leaf of the broad ligament and the pararectal space is developed. Branches of the anterior division of the hypogastric artery are ligated and divided. The anterior division of the internal iliac may be ligated and divided at its source to minimize bleeding. The dissection is carried to the pelvic floor on the right side with attention paid to ligating and dividing terminal branches of the internal iliacs. A tension is turned anteriorly, and the round ligament is divided, and the paravesical space is further developed. The dissection is carried further anteriorly, and the space of retzius is developed. Vessels of the plexus of Santorini may be encountered, and bleeding can be minimized if the dissection is performed close to the pubic bone. Attention is again turned posteriorly. The distal rectum is placed on traction, and the rectal mesentery is dissected. The right ureter is now transected with proximal and distal clips placed. The lateral limits of the dissection are guided by a second surgeon at the patient's perineum, pressing to help delineate the margins of the dissection. This dissection is now repeated on the patient's left side. The ureter is again dissected. The left paravesical space is developed and meets the bladder dissection from the right. The branches of the anterior division of the hypogastric are divided. and the dissection is carried to the pelvic floor. The mesorectal dissection is completed in preparation for dividing the rectosigmoid. The musculature of the pelvic floor is transected. A second surgeon from below again aids in this dissection, delineating the margins of the planned resection. Additionally, the perineal phase of the operation is begun. A tension is turned to the recto-sigmoid, which is prepared for transection. The rectum is divided using the robotic stapling device. With the rectum now freed, the peroneal and abdominal dissections are joined. With the perineal and abdominal dissections joined circumferentially, the specimen is removed. The patient subsequently underwent closure of the perineal defect with myocutaneous flap and her urinary and gastrointestinal systems were diverted in a single bag with a double-barreled wet colostomy. Total operative time inclusive of reconstructive procedures was 496 minutes. Estimated blood loss was 100 milliliters. Surgical margins were free of disease.

robotic-assisted surgery

pelvic exoneration

recurrent vulvar carcinoma

ligating blood vessels

myocutaneous flap