pelvic lymphadenectomy on both sides, laparoscopic, robot-assisted laparoscopy (DaVinci)

• Positioning is done in lithotomy position (or more safely on spreadable 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 necessary. Alternatively, the legs can be positioned in leg holders with fixation in these (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, caution tumor cell dissemination in cervical cancer.

Note: It is important to be aware of the risk of patient injury from 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 steep Trendelenburg position (approximately 30°). The table tilt is adjusted as needed 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 can be varied.

A cytology lavage is performed. Inspection of the pelvis, considering the uterus, both adnexa, the Douglas pouch, and the transperitoneal visualization of both ureters.

Incision with the monopolar scissors. The cut is initiated above the external iliac artery, starting at the round ligament and extending cranially to the bifurcation of the iliac vessels.

During the preparation, tissue separation is performed with simultaneous coagulation using the monopolar scissors. Vessels and tissue are grasped with the bipolar fenestrated clamp to ensure a safe and bloodless preparation.

Identification of important anatomical structures

• External iliac artery and vein → Run directly below the preparation line
• Ureter → Runs medially to the external iliac artery, is identified early and preserved to avoid injury.
• Genitofemoral nerve → Runs along the psoas major muscle and is displayed for preservation.
• Medial umbilical ligament → Contains the obliterated umbilical artery (pars occlusa) and forms the medial boundary of the dissection field.
• Bifurcation of the iliac vessels → Defines the cranial limit of the peritoneal opening.
• Ovarian artery and vein → Are explicitly preserved in this premenopausal patient to maintain ovarian perfusion.

First, the peritoneum is lifted with the ProGrasp instrument to expose the retroperitoneal space. Subsequently, a stepwise mobilization of the tissue is performed with the monopolar scissors, while the fenestrated bipolar clamp is used for fixation and coagulation of the tissue structures.

The first landmark in this section is the psoas major muscle, which serves as the lateral boundary. Along its course, the genitofemoral nerve is identified, lying superficially on the muscle. The nerve is carefully exposed and preserved to avoid neurological complications.

The dissection is carried out from caudal to cranial along the external iliac artery and vein. The lymphatic tissue is mobilized from lateral to medial while simultaneously being transected with the monopolar scissors. Targeted coagulation with the bipolar clamp enables a blood-sparing dissection.

Cranially, the dissection is limited by the deep circumflex iliac vein, which is identified as an important vascular trunk and preserved. It runs in the region of the inguinal ligament and drains into the external iliac vein. Special care is required here to avoid venous bleeding.

During the lymphadenectomy, special attention is paid to the ovarian artery and vein, which run cranially to the dissection field. In this premenopausal patient, care is taken to preserve these vessels completely to avoid compromising ovarian perfusion.

The lymph node tissue is mobilized towards the bifurcation of the iliac vessels. In this area, particularly careful dissection is performed to avoid injury to the common iliac artery or its branching vessels. The lymph nodes are exposed and resected along the external iliac artery and vein up to the inguinal ligament.