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Robot Assisted Video Endoscopic Inguinal Lymph Node Dissection for Carcinoma Penis
Description:
Robot Assisted Video Endoscopic Inguinal Lymph Node Dissection for Carcinoma Penis
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https://cadmoremediastorage.blob.core.windows.net/a5bf6d28-878a-4578-baa0-e6aeb8fdc25b/videoscrubberimages/Scrubber_1.jpg?sv=2019-02-02&sr=c&sig=oUZo6CSyNLBMkqX2teRW%2FmR3kmmpfCCNiXImHAq6abo%3D&st=2024-11-22T18%3A02%3A09Z&se=2024-11-22T22%3A07%3A09Z&sp=r
Duration:
T00H11M57S
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https://cadmoreoriginalmedia.blob.core.windows.net/a5bf6d28-878a-4578-baa0-e6aeb8fdc25b/Atlas VEIL .mp4?sv=2019-02-02&sr=c&sig=naAruFDcuJ7ANeD09aVh4fYMRbpDpCnMZL6lH4NVoAU%3D&st=2024-11-22T18%3A02%3A09Z&se=2024-11-22T20%3A07%3A09Z&sp=r
Upload Date:
2023-12-06T00:00:00.0000000
Transcript:
Language: EN.
Segment:1 Introduction.
SPEAKER 1: Greetings from the Rajiv Gandhi Cancer Institute and Research Center, India. In this video, we will demonstrate our technique of robot-assisted video endoscopic inguinal lymph node dissection for carcinoma penis patients. The fascia lata-first approach highlight our technical modifications of the conventionally described technique.
Segment:2 Patient Positioning.
SPEAKER 2: With the legs supported by Allen stirrups, the patient is placed in modified lithotomy position with extension and bilateral hips and a 10-degree Trendelenburg tilt. Such positioning allows us to perform bilateral node dissections without repositioning the robot and provides adequate space for assistance. The thigh is abducted and externally rotated, distorts the tendon of the adductor longus muscle, and aids in the surface marking of the femoral triangle.
SPEAKER 2:
Segment:3 Port Placement.
SPEAKER 2: A cut section of the soft tissue of thigh looks something like this. From outside in, we have the skin, the fatty Camper's fascia, which is followed by a membraneous Scarpa's fascia. The superficial inguinal lymph nodal packet lies beneath the Scarpa's fascia and over the fascia lata. The fascia lata is the deep fascia of the thigh that covers the thigh musculature as well as the deep inguinal lymph nodes.
SPEAKER 2: Conventionally, the plane of initial entry is described just below the Scarpa's fascia, which in our experience is difficult to create and maintain during port placement. In addition, the thickness of the skin flap around the port side may be less, with subsequent epidermal necrolysis around this side in the post-operative period.
SPEAKER 3: We create the initial plane just superficial to the fascia lata, which is a tough structure, and allows to easily lift off the superficial nodal packet off it. We can appreciate the difference at entry between both these techniques.
SPEAKER 2: A 5-centimeter transverse incision is made approximately 5 centimeters caudal to the apex of the femoral triangle. The incision is deepened to first identify the Scarpa's fascia and then continued till we reach the glistening fascia lata.
SPEAKER 1: Gentle finger dissection is used to separate the superficial lymph nodal packet from the fascia lata. A single gloved finger attached to a sphygmomanometer cuff makes a very effective balloon dilator. Balloon dilatation is performed to create the space just superficial to the fascia lata, and the ports are placed under finger guidance.
SPEAKER 1: The ports are placed as shown in the figure.
SPEAKER 3: Inter-arm clashing is avoided by the use of XL ports.
SPEAKER 2: The da Vinci Xi robot is side-docked, and docking is done as can be seen in the picture.
SPEAKER 3: Carbon dioxide is insufflated at a pressure of 8 to 10 millimeters of mercury.
Segment:4 Defining Surgical Landmarks And Dissection Boundaries.
SPEAKER 2: With the monopolar scissors in the right hand and a fenestrated bipolar in the left hand, the aim of dissection here is to lift off the superficial inguinal lymph nodal packet of the fascia lata within the dimensions of the Dressler's quadrangle. We can appreciate that the fascia lata is easily identifiable. Short and blunt dissection is used for this step of the procedure.
SPEAKER 2: Digital indentations by the assistant can guide the operating surgeon. Unlike the conventional technique where the great saphenous vein lies on the floor, in this technique, the great saphenous is seen on the roof of the dissection field and can guide dissection towards the saphenofemoral junction. As the dissection proceeds cranially, the saphenofemoral junction becomes apparent.
SPEAKER 2: When the dissection proceeds to the medial side, we can appreciate a whitish structure with horizontal orientation, which is nothing else but the inguinal ligament. Dissection proceeds cranially to the inguinal ligament to expose two critical structures, which are the spermatic cord medially and the medial half of the external oblique aponeurosis that can be appreciated.
SPEAKER 2: We then proceed dissection lateral to the saphenofemoral junction. The aim here is to identify the lateral aspect of the inguinal ligament and to dissect the lateral half of the external oblique aponeurosis. Once this part of the dissection is complete, we can appreciate the superficial inguinal lymph node packet on the roof.
SPEAKER 2: The fascia lata can be appreciated on the floor covering the sartorius muscle laterally, the femoral vessels in the middle, and the adductor longus medially. The great saphenous can be seen draining into the femoral vein. The external oblique aponeurosis and the inguinal ligament form the cranial dissection limits.
Segment:5 Superficial Inguinal Lymph Node Dissection.
SPEAKER 2: For this part of the dissection, we move from a 0-degree telescope to a 30-up telescope.
SPEAKER 2: This helps in easier visualization of the saphenous vein as well as the superficial inguinal lymph nodal packet. The great saphenous vein is dissected free from the superficial inguinal lymph nodal packet, starting from the saphenofemoral junction till the apex of the femoral triangle. The downward traction by the fenestrated bipolar is countered by the upward retraction by the insufflated carbon dioxide.
SPEAKER 2: Blunt and sharp dissection is utilized to separate the lymph nodal packet from the glistening Scarpa's fascia. We can observe that it is possible to preserve the Scarpa's fascia uniformly throughout the dimensions of the flap. This ensures uniform flap thickness, and thereby, its vascularity, which translates into better flap-related outcomes postoperatively.
SPEAKER 2: The assistant observes the intensity of the transillumination in order to guide the surgeon about the thickness of the flap as the medial and lateral bounds of dissection have been already accurately defined. The superficial inguinal lymph nodal packet is dropped within these boundaries, preserving the main saphenous trunk. Venous tributaries draining into the great saphenous vein or at the saphenofemoral junction can be easily clipped and divided to release the superficial inguinal lymph nodal packet from the great saphenous vein.
SPEAKER 2: Finally, the superficial inguinal lymph node packet is released from the cranial-most boundaries that are formed by the inguinal ligament, the external oblique aponeurosis, and the spermatic cord. This packet is then bagged and retrieved from the camera port incision and sent for frozen section analysis.
SPEAKER 2: If the frozen section confirms inguinal metastasis,
Segment:6 Deep Inguinal Lymph Node Dissection.
SPEAKER 2: the deep inguinal lymph node dissection is then pursued for which the robot is redocked. Incision of the deep fascia over the femoral triangle gives access to the deep lymph nodal packet, which are clipped at the apex and then divided. Small branches of the femoral vessels are likewise clipped and divided.
SPEAKER 2: One can note that the dissection lateral to the femoral artery should be avoided to prevent injury to the femoral nerve and the profunda femoris vessels. Dissection continues along the medial aspect of the femoral vein. We excised the deep lymph nodes of Cloquet. At the end of the deep inguinal lymph node dissection, the floor of the dissection field looks something like this.
Segment:7 Technical Modifications.
SPEAKER 2: Patients in whom preoperative evaluation confirms inguinal lymph nodal metastases, small technical modifications can make combined superficial and deep inguinal lymph nodal dissection easier to perform. After initial dissection, once the femoral triangle is defined, with the adductor longus being medially, the sartorius being laterally, and the great saphenous vein on the roof with the superficial inguinal lymph nodal packet, two options exist.
SPEAKER 2: Conventionally, when the superficial inguinal dissection is done prior to the deep dissection, this bulky packet tends to fall to the floor of the dissection field. The surgeon then requires constant retraction of this nodal packet by the assistant, making the dissection around the vessels a little cumbersome. In node-positive patients, we prefer to do the deep inguinal lymph node dissection first as this provides direct access to the nodal packet and allows for safe dissection around the major vessels with minimal assistance.
SPEAKER 2: Once the deep inguinal lymph nodal packet is dissected free from the femoral vessels, the combined superficial and deep inguinal lymph nodal packet is then separated off of the Scarpa's fascia in the manner that has been described earlier in this video. The wounds are closed over suction drains. Our technique has distinct advantages. We believe that our technique is easier to replicate starting from the plane of initial entry, superficial to the fascia lata, which is easier to identify and develop as compared to the conventionally described subscarpal plane.
SPEAKER 2: As the anatomical landmarks of the femoral triangle and the lateral boundaries of the Dressler's quadrangle are defined early on in this procedure, we are able to limit our dissection within the field. We believe our technique makes the superficial inguinal lymph node dissection easier to accomplish with minimal assistance. When the superficial inguinal packet is being lifted off the fascia lata, its natural attachment to the Scarpa's fascia is maintained, which in addition to the insufflated carbon dioxide, prevent the packet from falling into the field.
SPEAKER 2: Subsequently, when the lymph nodal packet is being released off the Scarpa's fascia, the insufflated carbon dioxide provides the necessary countertraction that aids in the uniform preservation of the Scarpa's fascia throughout the dimensions of the flap, helps maintain uniform flap thickness and vascularity that translates into better flap-related outcomes postoperatively.
SPEAKER 2: [MUSIC PLAYING]
Segment:1 Introduction.
SPEAKER 1: Greetings from the Rajiv Gandhi Cancer Institute and Research Center, India. In this video, we will demonstrate our technique of robot-assisted video endoscopic inguinal lymph node dissection for carcinoma penis patients. The fascia lata-first approach highlight our technical modifications of the conventionally described technique.
Segment:2 Patient Positioning.
SPEAKER 2: With the legs supported by Allen stirrups, the patient is placed in modified lithotomy position with extension and bilateral hips and a 10-degree Trendelenburg tilt. Such positioning allows us to perform bilateral node dissections without repositioning the robot and provides adequate space for assistance. The thigh is abducted and externally rotated, distorts the tendon of the adductor longus muscle, and aids in the surface marking of the femoral triangle.
SPEAKER 2:
Segment:3 Port Placement.
SPEAKER 2: A cut section of the soft tissue of thigh looks something like this. From outside in, we have the skin, the fatty Camper's fascia, which is followed by a membraneous Scarpa's fascia. The superficial inguinal lymph nodal packet lies beneath the Scarpa's fascia and over the fascia lata. The fascia lata is the deep fascia of the thigh that covers the thigh musculature as well as the deep inguinal lymph nodes.
SPEAKER 2: Conventionally, the plane of initial entry is described just below the Scarpa's fascia, which in our experience is difficult to create and maintain during port placement. In addition, the thickness of the skin flap around the port side may be less, with subsequent epidermal necrolysis around this side in the post-operative period.
SPEAKER 3: We create the initial plane just superficial to the fascia lata, which is a tough structure, and allows to easily lift off the superficial nodal packet off it. We can appreciate the difference at entry between both these techniques.
SPEAKER 2: A 5-centimeter transverse incision is made approximately 5 centimeters caudal to the apex of the femoral triangle. The incision is deepened to first identify the Scarpa's fascia and then continued till we reach the glistening fascia lata.
SPEAKER 1: Gentle finger dissection is used to separate the superficial lymph nodal packet from the fascia lata. A single gloved finger attached to a sphygmomanometer cuff makes a very effective balloon dilator. Balloon dilatation is performed to create the space just superficial to the fascia lata, and the ports are placed under finger guidance.
SPEAKER 1: The ports are placed as shown in the figure.
SPEAKER 3: Inter-arm clashing is avoided by the use of XL ports.
SPEAKER 2: The da Vinci Xi robot is side-docked, and docking is done as can be seen in the picture.
SPEAKER 3: Carbon dioxide is insufflated at a pressure of 8 to 10 millimeters of mercury.
Segment:4 Defining Surgical Landmarks And Dissection Boundaries.
SPEAKER 2: With the monopolar scissors in the right hand and a fenestrated bipolar in the left hand, the aim of dissection here is to lift off the superficial inguinal lymph nodal packet of the fascia lata within the dimensions of the Dressler's quadrangle. We can appreciate that the fascia lata is easily identifiable. Short and blunt dissection is used for this step of the procedure.
SPEAKER 2: Digital indentations by the assistant can guide the operating surgeon. Unlike the conventional technique where the great saphenous vein lies on the floor, in this technique, the great saphenous is seen on the roof of the dissection field and can guide dissection towards the saphenofemoral junction. As the dissection proceeds cranially, the saphenofemoral junction becomes apparent.
SPEAKER 2: When the dissection proceeds to the medial side, we can appreciate a whitish structure with horizontal orientation, which is nothing else but the inguinal ligament. Dissection proceeds cranially to the inguinal ligament to expose two critical structures, which are the spermatic cord medially and the medial half of the external oblique aponeurosis that can be appreciated.
SPEAKER 2: We then proceed dissection lateral to the saphenofemoral junction. The aim here is to identify the lateral aspect of the inguinal ligament and to dissect the lateral half of the external oblique aponeurosis. Once this part of the dissection is complete, we can appreciate the superficial inguinal lymph node packet on the roof.
SPEAKER 2: The fascia lata can be appreciated on the floor covering the sartorius muscle laterally, the femoral vessels in the middle, and the adductor longus medially. The great saphenous can be seen draining into the femoral vein. The external oblique aponeurosis and the inguinal ligament form the cranial dissection limits.
Segment:5 Superficial Inguinal Lymph Node Dissection.
SPEAKER 2: For this part of the dissection, we move from a 0-degree telescope to a 30-up telescope.
SPEAKER 2: This helps in easier visualization of the saphenous vein as well as the superficial inguinal lymph nodal packet. The great saphenous vein is dissected free from the superficial inguinal lymph nodal packet, starting from the saphenofemoral junction till the apex of the femoral triangle. The downward traction by the fenestrated bipolar is countered by the upward retraction by the insufflated carbon dioxide.
SPEAKER 2: Blunt and sharp dissection is utilized to separate the lymph nodal packet from the glistening Scarpa's fascia. We can observe that it is possible to preserve the Scarpa's fascia uniformly throughout the dimensions of the flap. This ensures uniform flap thickness, and thereby, its vascularity, which translates into better flap-related outcomes postoperatively.
SPEAKER 2: The assistant observes the intensity of the transillumination in order to guide the surgeon about the thickness of the flap as the medial and lateral bounds of dissection have been already accurately defined. The superficial inguinal lymph nodal packet is dropped within these boundaries, preserving the main saphenous trunk. Venous tributaries draining into the great saphenous vein or at the saphenofemoral junction can be easily clipped and divided to release the superficial inguinal lymph nodal packet from the great saphenous vein.
SPEAKER 2: Finally, the superficial inguinal lymph node packet is released from the cranial-most boundaries that are formed by the inguinal ligament, the external oblique aponeurosis, and the spermatic cord. This packet is then bagged and retrieved from the camera port incision and sent for frozen section analysis.
SPEAKER 2: If the frozen section confirms inguinal metastasis,
Segment:6 Deep Inguinal Lymph Node Dissection.
SPEAKER 2: the deep inguinal lymph node dissection is then pursued for which the robot is redocked. Incision of the deep fascia over the femoral triangle gives access to the deep lymph nodal packet, which are clipped at the apex and then divided. Small branches of the femoral vessels are likewise clipped and divided.
SPEAKER 2: One can note that the dissection lateral to the femoral artery should be avoided to prevent injury to the femoral nerve and the profunda femoris vessels. Dissection continues along the medial aspect of the femoral vein. We excised the deep lymph nodes of Cloquet. At the end of the deep inguinal lymph node dissection, the floor of the dissection field looks something like this.
Segment:7 Technical Modifications.
SPEAKER 2: Patients in whom preoperative evaluation confirms inguinal lymph nodal metastases, small technical modifications can make combined superficial and deep inguinal lymph nodal dissection easier to perform. After initial dissection, once the femoral triangle is defined, with the adductor longus being medially, the sartorius being laterally, and the great saphenous vein on the roof with the superficial inguinal lymph nodal packet, two options exist.
SPEAKER 2: Conventionally, when the superficial inguinal dissection is done prior to the deep dissection, this bulky packet tends to fall to the floor of the dissection field. The surgeon then requires constant retraction of this nodal packet by the assistant, making the dissection around the vessels a little cumbersome. In node-positive patients, we prefer to do the deep inguinal lymph node dissection first as this provides direct access to the nodal packet and allows for safe dissection around the major vessels with minimal assistance.
SPEAKER 2: Once the deep inguinal lymph nodal packet is dissected free from the femoral vessels, the combined superficial and deep inguinal lymph nodal packet is then separated off of the Scarpa's fascia in the manner that has been described earlier in this video. The wounds are closed over suction drains. Our technique has distinct advantages. We believe that our technique is easier to replicate starting from the plane of initial entry, superficial to the fascia lata, which is easier to identify and develop as compared to the conventionally described subscarpal plane.
SPEAKER 2: As the anatomical landmarks of the femoral triangle and the lateral boundaries of the Dressler's quadrangle are defined early on in this procedure, we are able to limit our dissection within the field. We believe our technique makes the superficial inguinal lymph node dissection easier to accomplish with minimal assistance. When the superficial inguinal packet is being lifted off the fascia lata, its natural attachment to the Scarpa's fascia is maintained, which in addition to the insufflated carbon dioxide, prevent the packet from falling into the field.
SPEAKER 2: Subsequently, when the lymph nodal packet is being released off the Scarpa's fascia, the insufflated carbon dioxide provides the necessary countertraction that aids in the uniform preservation of the Scarpa's fascia throughout the dimensions of the flap, helps maintain uniform flap thickness and vascularity that translates into better flap-related outcomes postoperatively.
SPEAKER 2: [MUSIC PLAYING]
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