Abstract
Objective: To present our surgical technique for Robotic-Assisted Supine Retroperitoneal Lymph Node Dissection (RAS-RPLND) using the da Vinci robotic system. We emphasize a nerve-sparing approach and the mandatory preservation of the inferior mesenteric artery (IMA) in a high-risk patient with active Crohn's disease. Introduction: Post-chemotherapy RPLND is critical for managing Non-Seminomatous Germ Cell Tumors (NSGCTs) with residual masses >1 cm, as imaging cannot reliably differentiate teratoma from necrosis or viable tumor. While open RPLND carries significant morbidity and laparoscopic approaches present technical challenges, robotic assistance offers precision and reduced invasiveness. Preserving the IMA is typically elective; however, in patients with inflammatory bowel disease, it becomes critical. Clinical case and surgical procedure: A 26-year-old male with active Crohn's disease and Stage IIB NSGCT (post-BEP chemotherapy) underwent RAS-RPLND due to contraindications for additional chemotherapy. The procedure employed a supine position with the DaVinci Si system, using a port configuration adaptable to X/Xi systems. A bilateral template dissection was performed. Initial key steps included reflecting the bowel to expose the retroperitoneum, identifying the duodenum, and fixing the peritoneum with V-Loc sutures. The IMA was preserved to ensure collateral blood supply to the bowel, and sympathetic nerves were spared for ejaculatory function. The right spermatic cord was resected laparoscopically. The 38 mm paracaval mass was resected en bloc. Operative time was 210 min, with 150 mL blood loss and no complications. Pathology confirmed teratoma in 9/27 nodes. Discussion: RAS-RPLND addresses the limitations of open and laparoscopic techniques. This case is distinct as it demonstrates the feasibility of IMA sparing not just as a technical exercise, but as a mandatory maneuver for a patient with Crohn's disease. While the learning curve is steep, the robotic platform facilitates complex vascular and neural preservation. Conclusion: RAS-RPLND is a promising approach for post-chemotherapy NSGCT. This case highlights its role in balancing oncologic control with functional preservation in patients with significant comorbidities.
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