Robotic Technology Overcomes Previous Limitations

The retroperitoneal space is developed and the ureter is identified medially, and if the ovary is to be removed, which is the case in most patients, the infundibular ligament is isolated, desiccated, and divided using the bipolar forceps and scissors.

The paravesical and pararectal spaces are then developed by retracting the umbilical ligament (the superior vesicle artery) medially and performing blunt dissection between this artery and the pelvic side wall.

The obturator nerve can usually be identified at this point, and the obturator fossa nodes and hypogastric lymph nodes can be removed. Occasionally, when the obturator nerve cannot be identified initially, the obturator fossa nodes must be dissected and retracted medially, under the external iliac vein. Then, when the nerve is identified under these lymph nodes using blunt dissection, all nodes from the obturator fossa all the way up to the hypogastric vessels can be resected (

After removing the lymphatic nodes from the obturator fossa and the hypogastric vessels, we remove all nodes along the external iliac vessels from the external common iliac artery down to the deep circumflex vein.

Blunt and sharp dissection performed with the scissors, forceps, and suction irrigator is used for resection of all these nodes, and bipolar and unipolar forceps are used to achieve hemostasis and to clear the lymphatic channels (

This is the same process we follow during conventional laparoscopic lymphadenectomy, except that the conventional laparoscopic approach can be done using ultrasonic shears, which are multifunctional and may lower the risk for tissue damage. With the current da Vinci system, we are limited to using electrosurgery instrumentation for coagulation and cutting, but we have found that these instruments are more than adequate.

Para-Aortic Lymphadenectomy

For para-aortic lymphadenectomies in which node dissection will extend up to the inferior mesenteric artery, the trocar positioning is the same as for pelvic lymphadenectomy.

If node dissection above the inferior mesenteric artery is planned, however, trocar placement must be modified, with the camera port placed approximately 5–8 cm above the umbilicus and the other trocars adjusted accordingly, based on the different camera port placement (

The peritoneum is incised over the right common iliac artery, and the incision is extended cephalad over the inferior vena cava and lower abdominal aorta to the level of the duodenum, above the inferior mesenteric artery. The right ureter should be identified first, with the retroperitoneal space gradually developed toward the left side, and the left ureter then identified (

The assistant port or the fourth arm of the robot is used to retract the ureter or the bowel laterally. The lymph adenectomy starts from below and gradually extends upward toward the insertion of the ovarian vein to the vena cava on the right side and the renal vein on the left side.

The nodes are removed using the same technique as for pelvic lymphadenectomy, with bipolar forceps used as a grasping forceps and for coagulation of the small blood vessels and unipolar forceps used for cutting and achieving hemostasis for these vessels (

Final Steps, Outcomes

In patients also undergoing a hysterectomy, lymphadenectomy can be performed before or after the hysterectomy, depending on the indication.

Lymph nodes dissected with the robotic approach can be stored and removed in a laparoscopic bag that is introduced through the assistant's port. In patients undergoing a hysterectomy, the bag can be stored in the abdomen during the procedure and then removed through the vagina afterward.

After we complete lymphadenectomy, the pelvic cavity is thoroughly irrigated, Seprafilm slurry is applied to prevent adhesions, and all trocar sites are routinely closed. Closing all ports, even the 8-mm sites, is important since a small bowel trocar-site herniation has been reported. We also inject Marcaine in all trocar sites. Depending on the patient's condition, she can be discharged on the same day or after 1 or 2 days.

Gynecologic surgeons have developed various techniques for robotic-assisted laparoscopic lymphadenectomy that include different placement of the trocar sites. We have been performing robotic lymphadenectomy and radical hysterectomy since 2003 and have modified our technique to be as feasible and reproducible as possible.

We recently compared the experiences of 43 women with early cervical cancer who were treated with either robotic radical hysterectomy with pelvic lymphadenectomy or laparoscopic radical hysterectomy with pelvic lymphadenectomy.

The treatments—using either conventional laparoscopy or robotic-assisted laparoscopy—were equivalent with respect to operative time, blood loss, hospital stay, and oncologic outcome. The mean pelvic lymph node count was similar in the two groups (JSLS 2008;12:227–37).