V09-02: Robot Assisted Salvage Retroperitoneal Lymph Node Dissection of Retrocrural Teratoma
Robot assisted retroperitoneal lymph node dissection (RARPLND) for testicular cancer is emerging as a minimally invasive approach to residual retroperitoneal mass following chemotherapy. This operation is associated with high operative risk due to the intimate involvement of these masses to the great vessels. In particular, dissection superior to the renal vessels can be associated with a higher risk of injury to the thoracic duct and arterial supply to the intestines. Although template dissection robotically has been demonstrated to be feasible and safe, resection of masses outside of a standard template can be difficult due to accessibility and exposure. This unique video demonstrates dissection of retrocrural masses superior to the standard template RARPLND.
A 37 year old male with a history of metastatic testicular cancer underwent salvage RARPLD for residual retrocrural masses. This complex patient had previously undergone open RPLND at an outside center followed by chemotherapy after initial diagnosis. Subsequently he underwent thoracotomy with mediastinal lymph node dissection with T4/5 laminectomy and vertebral fixation and finally a sternotomy for further mediastinal lymph node dissection. The retrocrural masses were his only remaining disease. This was done with a transabdominal approach and the patient positioned in a left side up modified flank position. This video demonstrates retrocrural dissection posterior to the aorta with division of the crus of the diaphragm.
The operation was conducted successfully with no immediate surgical complications. Key structures include the superior mesenteric and celiac arteries were identified and preserved. The left crus of the diaphragm was split in order to expose the retrocrual mass. The second retrocrural mass behind the right crus of the diaphragm was able to be dissected from behind the aorta without repositioning the patient. Total operative time was 4 hours with an estimated blood loss of 25mL. There was no need to reposition the patient and they were discharged the same day of surgery. Pathology confirmed mature teratoma with clear surgical margins.
This video demonstrated feasibility of robot assisted dissection of bilateral retrocrural residual mass with demonstration of important suprarenal anatomical structures.