Robot assisted laparoscopic retroperitoneal lymph node dissection in testicular tumor
A 23 year old male presented to us with right testicular swelling for 4 months. There was no significant past history or family history of testicular tumors. On examination, the right testis was enlarged and hard while the rest of the clinical examination was unremarkable. Tumor markers were found to be marginally raised. The levels of α-foetoprotein and β-HCG were 370 ng/ml and 650 U/L respectively. A computed tomography (CT) scan abdomen, however, revealed only subcentrimetric lymhnodes (clinically insignificant) in the retroperitoneum []. A right high inguinal orchidectomy was performed and the histopathology showed mixed NSGCT with predominnent embryonal component with vascular and lymphatic invasion. The tumor markers after 6 weeks were normalized. The patient was staged as clinical stage Ib American Joint Committee on -T2N0M0. He was given the option of RPLND or chemotherapy, and after explaining about the implications of both forms of treatment, he opted for RPLND. The patient was subsequently taken up for right modified template robot assisted laparoscopic transperitoneal RPLND.\nThe patient was placed in right lateral oblique position (60°) and pneumoperitoneum was created using Verres’ needle. A total of 6 ports were used []. The camera port (12 mm) was placed just lateral to umbilicus on the left. Two 8 mm robotic metallic ports were placed just lateral to umbilicus on the right at a distance of 8 cm from the camera port. A third robotic port was placed for the 4th robotic arm just medial to the anterior superior iliac spine. One 5 mm port was placed for liver retraction at the subxiphoid area. An assistant port (12 mm) for retraction, suture transfer and specimen retrieval was placed below the camera port towards the pelvis. The robot was docked with the cart being kept behind the back of the patient. On the right robotic arm, a monopolar curved scissors and needle holder were used. On the left, a bipolar Maryland forceps, needle holder and prograsp forceps were used. The prograsp forceps was very useful in holding and retracting tissues. However, the third robotic arm was not helpful because of crossing over and collision of the robotic instruments.\nThe dissection was started with mobilisation of hepatic flexure, ascending colon and caecum followed by kocherisation of the duodenum. The right gonadal vessels were identified and dissected from the inferior vena cava (IVC) till the right deep inguinal ring. The silk suture, which was used to ligate the vessels and cord during orchidectomy was identified and the right gonadal vessels along with a part of spermatic cord were excised. The right ureter, which was the right lateral limit of dissection, was identified, and carefully dissected from the paracaval tissue. Paracaval lymphatic tissue was dissected from the right renal hilum (proximal limit) to the right common iliac artery bifurcation [distal limit, ]. Excised tissues were retrieved through the 12 mm assistant port using home made plastic bag at the end of the procedure. The retrocaval tissue behind the IVC and the interaortocaval tissue between aorta and IVC were carefully dissected, and divided between clips (liga, weck). We didn’t use any hemostatic agent. During this dissection, the aorta and IVC were gently retracted by the assistant and the lumbar vessels were identified and preserved. With the help of 3D view and magnification, postganglionic sympathetic fibres and sympathetic ganglia were also identified and preserved. Pre-aortic dissection was done from the left renal vein (proximal limit) to the inferior mesenteric artery (distal limit). While dissecting, the wall of the aorta was injured, which was easily repaired with the 5-0 prolene suture. At the end of the dissection, we could see the skeletonised IVC, exposed aorta, right ureter and right and left renal hilum []. Hemostasis was ensured at the end of the procedure and the mobilised colon was repositioned.