This is a surgical video demonstrating minimally invasive staging for ovarian cancer using the robotic surgical platform, highlighting supermesenteric periaortic lymph node dissection. In cases of high-grade serous ovarian, fallopian tube, and primary peritoneal cancer, standard care for staging entails full periaortic lymph node dissection to the renal veins via laparotomy. However, given the benefit of minimally invasive surgery over laparotomy with regards to recovery time and rate of complications, the minimally invasive approach has been used increasingly for ovarian cancer staging. Minimally invasive periaortic lymph node dissection has been reported both using conventional laparoscopy and robotic-assisted laparoscopy. Dissection via conventional laparoscopy can be limited by visualization and range of motion of laparoscopic instruments. And while the robotic platform provides enhanced visualization and greater dexterity of movement, previous generations of robotic platforms required the movement of the patient or robotic patient cart for access to multiple abdominal quadrants. This is seen here as the robot is undocked from its position for upper abdominal surgery, and the patient is rotated into position for lower abdominal surgery. In this video, we will demonstrate multi-quadrant surgical staging for high-grade serous carcinoma utilizing the newest robotic platform. Specifically, this video will focus on the removal of a large pelvic mass as well as supra-mesenteric periaortic lymph node dissection. We highlight the case of a 65-year-old who presented with pelvic pressure, elevated CA125, and imaging, which demonstrated a 13-centimeter cystic mass with solid components. The patient elected for surgical management. A minimally invasive approach was discussed, and the surgical team elected to utilize the robotic platform. Once the patient is prepped and draped, robotic and assistant ports were inserted as shown. A semilunar pattern was utilized with one trocar inserted near the patient's umbilicus, two robotic trocars inserted 6 to 8 centimeters apart on the patient's right side. An assistant port and a robotic trocar are on the patient's left, also 6 to 8 centimeters apart. The robot was subsequently docked for pelvic surgery. The mass is shown here freed of its vascular attachments to the uterus. The infundibulopelvic ligament has also been ligated and divided. The mass was subsequently removed in an endoscopic bag and drained in the bag at the abdominal wall. In this case, frozen section of this mass demonstrated serous carcinoma. Staging was subsequently performed, including paraortic lymph node dissection. Once the pelvic portion of the staging procedure was completed, the robotic instruments were removed and robotic arms were undocked from the trocars. The robotic arms are repositioned to allow access to the upper abdomen. Specifically, the da Vinci XI platform is utilized here. The platform allows for the robotic arms to be rotated without altering the position of the robotic patient cart. Additionally, the XI platform allows for the camera to be inserted in any of the robotic trocars, depending on the target anatomy. In this case, the surgical team felt that the right paraortic anatomy could be best visualized by inserting the camera into the port lateral and to the right of the umbilical port. Choice of location for camera and robotic instruments can be altered to suit the surgeon's preference and target anatomy. The right paraortic lymphadenectomy is begun by incising the peritoneum lateral to the right common iliac artery. In this case, the maryland bipolar forceps are in the left arm and the monopolar scissors are in the right arm. The third arm utilizes the prograsp forceps and is being used for retraction. The peritoneal incision is extended caudad and it is extended cephalad. As the dissection is carried further cephalad, the duodenum comes into view. To carry the dissection further cephalad, the duodenum is lifted by an assistant. Here, the aorta, duodenum, and inferior vena cava could be clearly visualized. At this point, the surgeon felt that the left-sided dissection could be best visualized by switching the camera to the peri-umbilical port. The left gonadal artery is seen at its insertion to the aorta. As the mesentery is retracted, the left gonadal vessel appears to be reflected cephalad as it enters the infundibulopelvic ligament. A lumbar vein can also be seen here. The nodal tissue is dissected around this vessel. As the dissection is continued, the anterior longitudinal ligament of the spine is visualized. With the left paraortic nodal dissection nearly completed, it was noted that this patient had a retroaortic left renal vein, as can be seen here. The left nodal tissue is now removed. The left gonadal vein can be seen at its insertion to the left renal vein. Attention is turned again to the right-sided nodal tissue. The nodal tissue is taken over the IVC and lateral to the edge of the aorta. The dissection is carried caudate. As the dissection is carried laterally, the right ureter can clearly be visualized. The psoas can be seen here. An anterior perforating vein, commonly referred to as the fellow's vein, is seen here. It is ligated and divided. The remaining nodal tissue is removed. The insertion of the right gonadal vein into the IVC can be seen. The resection bed is checked for hemostasis and to be sure lymphatic tissue is removed. In this video we have demonstrated the use of the newest robotic platform for minimally invasive ovarian cancer staging. We have highlighted the removal of a large pelvic mast as well as paraortic lymphadenectomy.

minimally invasive staging

ovarian cancer

robotic platform

periaortic lymph node dissection

high-grade serous cancers