complete hysterectomy, bilateral adnexectomy, sentinel node biopsy pelvic bilateral laparoscopic, robot-assisted laparoscopy (DaVinci)

• Positioning is done in lithotomy position (or more safely on abductable straight leg supports), ideally on a large vacuum cushion or non-slip mat
• It is recommended to position both arms (caution: cotton wrapping when positioning with a cloth sling), or to position one arm on the side of the robot
• For leg positioning, padded "boots" are recommended so that the legs can be moved separately and covered sterilely if needed. Alternatively, the legs can be positioned in leg holders with fixation of the legs in them (Caution: compartment syndrome).
• The legs should be adjustable via the OR table control during the procedure
• Shoulder supports bilaterally to prevent the patient from slipping on the OR table
• For longer procedures, application of pneumatic compression cuffs for the legs for thrombosis prophylaxis
• Attachment of a cervical adapter

Note: It is important to consider the risk of injury to the patient from the instruments if the patient slips. With coupled tables in the Xi system, intraoperative position changes are possible without uncoupling. If the "Table-Motion" technique is not available, the surgical robot must always be undocked and removed from the OR table before any position change

Creation of a pneumoperitoneum by inserting a Veress needle approximately 20 cm away from the target anatomy (usually periumbilical). The three to four 8 mm robotic trocars are positioned in a straight, horizontal line (Xi) or a slightly curved line towards the surgical site (X, SI). Ideally, there is a distance of 8 cm between each trocar (minimum 7 cm to maximum 10 cm). The 10 or 12 mm assistant trocar can be placed in the lower abdomen, cranial to the trocars, or as an additional trocar along the straight line, depending on the assistant's position at the operating table and the surgeon's preference (see illustration).

During laparoscopy, the abdomen is inspected, including the upper abdominal area, the diaphragmatic domes, the liver, the gallbladder, the stomach, and the omentum. Additionally, an inspection of the intestines and peritoneum is performed.

The patient is positioned at the end of the operating table and then placed in a head-down position (approximately 30°). The table tilt is adjusted as necessary for anesthetic or surgical requirements. The laser marking is aligned so that the crosshair points directly at the camera trocar (Xi). The Da Vinci system is then aligned. The arms are connected (docked) with the three to four 8 mm robotic trocars. Subsequently, the instruments are introduced under visual control and parked under the ventral abdominal wall.

Caution: The trocars must be positioned with the wide black ring at the level of the muscular abdominal wall (so-called remote center) to avoid injury during movement.

Note: Depending on the operating room and the surgeon's preference, the positioning of the Da Vinci patient cart and the trocars may vary.

Inspection of the small pelvis, considering the uterus, both adnexa, the Douglas pouch, as well as the transperitoneal visualization of both ureters.

If possible, transperitoneal visualization of the lymphatic pathways using the fluorescence camera.

Localization of sentinel nodes bilaterally in the paracervical lymphatic drainage area using a fluorescence camera. Lateral opening of the peritoneum and exposure of the iliac lymph node region while preserving the surrounding vascular nerve structures and the previously exposed ureters bilaterally. Excision of two sentinel nodes on the right and one on the left after secure color identification. Checking for bleeding and collateral injuries, which are absent, ensuring a bloodless field. Forwarding of specimens for rapid histological examination.

After identifying the infundibulopelvic ligament (also known as the suspensory ligament of the ovary), bipolar coagulation and transection are performed here. The ovarian artery, ovarian vein, ovarian plexus, and lymphatic vessels run here. Stepwise detachment of the adnexa from the pelvic wall. The adnexa remains attached to the uterus.