Robotic transabdominal excision of retrocrural germ cell tumor metastasis

Abstract Objective To demonstrate a minimally-invasive method for excision of retrocrural masses. The patient was a 31-year-old male with mixed germ cell testicular cancer underwent left radical orchiectomy, chemotherapy, and open extraperitoneal retroperitoneal lymph node dissection (eRPLND), presented with recurrent disease two years later. Surveillance imaging demonstrated three enlarging retrocrural masses in the setting of normal tumor markers. Methods The patient was placed in a reverse Trendelenburg position. The liver was retracted. Laparoscopic abdominal inspection demonstrated no adhesions as a benefit of his prior eRPLND. The da Vinci XI robot was docked, the gastrohepatic ligament and short gastric vessels were identified and divided. The stomach and gastro-esophageal junction were identified. The esophagus was mobilized at the level of the diaphragmatic crura before being retracted anterolaterally. The peritoneum was dissected and the diaphragmatic crura was split longitudinally. The larger mass was dissected off of the vena cava and aorta. Lumbar vessels and lymphatics were clipped. Additional inferior dissection was performed to excise the remaining two masses that were adjacent to the celiac artery. The diaphragmatic hiatus was repaired with interrupted sutures. Following closure, esophagogastroduodenoscopy identified viable esophageal mucosa without stricture or evidence of perforation. A drain was placed in the retrocrural fossa. Estimated blood loss was 50 mL. Results Expected small bilateral pneumothoraces resolved by postoperative day (POD) 2. The drain was removed and the patient was discharged home on POD 2. Final pathology demonstrated metastatic mature teratoma in 3 of 3 nodes with the largest tumor measuring 4.4 cm. The patient has since continued surveillance with no evidence of disease. Conclusions This video demonstrates the surgical benefits of eRPLND in facilitating reoperation in the abdomen. Furthermore, this video ultimately demonstrates an innovative, minimally-invasive method of removing teratomatous tumors from the retrocrural space through a robotic transabdominal approach.