Robotic-Assisted Inguinal Lymphadenectomy: The University of Texas M.D. Anderson Cancer Center Approach

Fig. 23.1

Patient positioning. Hips are externally rotated and relevant landmarks are kept in view

Trocar Placement

As seen in Fig. 23.2, the camera port is about three fingerbreadths inferior to the apex of the femoral triangle. The trocars for the right and left hand should have approximately one handbreadth separation from the camera port to avoid clashes between the camera and instrument arms. The assistant port is inserted between the camera and lateral trocar, slightly inferior to have enough working space below the robotic arms.

Fig. 23.2

Anatomy and port placement: anatomical landmarks and boundaries of dissection are illustrated here

Instrumentation and Equipment List

Surgeon Equipment

da Vinci^® Si HD Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA)
Endowrist^® Maryland bipolar forceps or PK dissector (Intuitive Surgical, Inc., Sunnyvale, CA)

Endowrist^® curved monopolar scissors (Intuitive Surgical, Inc., Sunnyvale, CA)
Endowrist ^® vessel sealer (Intuitive Surgical Corp, Sunnyvale, CA)
InSite^® Vision System with 0° and 30° lens (Intuitive Surgical, Inc., Sunnyvale, CA)

Trocars

12 mm balloon trocar (1)
8 mm robotic trocars (2)
12 mm trocar (1)

Recommended Sutures

Vascular Repair Rescue Stitch—4-0 Prolene on a RB needle cut to 6 in.

Assistant Equipment

Suction irrigator device

Hem-o-lok^® clip applier (Teleflex Medical, Research Triangle Park, NC)
Small and Medium-Large Hem-o-lok^® clips (Teleflex Medical, Research Triangle Park, NC)

10 mm specimen entrapment bag

Jackson Pratt/Blake closed suction Drain (2)

Step-by-Step Technique (Video 23.1)

Establishing Groin Access/Insufflation and Trochar Placement

Access is obtained through a 2 cm skin incision, three fingerbreadths below the apex of the femoral triangle, dissecting through dermis and subcutaneous tissue to just above Scarpa’s fascia. Using finger dissection in the cephalad direction, as well radially with a hemostat (Fig. 23.3) a working space is created that is large enough to accommodate a balloon dissector. This is then advanced as far cephalad as the inguinal crease and dilation proceeds from cephalad backward toward the camera port incision (Fig. 23.4). After this is completed, the dissector is deflated and the balloon port is placed and insufflation is started. Subsequently, the medial and lateral robotic trocars are placed under direct vision one handbreadth away from the camera port. The assistant port is then placed under direct vision between the lateral robotic port and the camera port (Fig. 23.5). After the robotic trocars and the assistant port are placed, the robot can be docked (Fig. 23.6).