A Case of Robot-Assisted Repair of Lymphatic Fistula with Chylous Ascites Following Robotic Retroperitoneal Lymph Node Dissection

Abstract

Clinical History: A 47-year-old patient, with a history of testicular tumor treated with chemotherapy and robotic retroperitoneal lymph node dissection, experienced recurrent postoperative chylous ascites despite conservative management. Therefore, decision was made to perform robot-assisted exploration to find the source of chyle leakage and to repair it. Physical Examination: Shifting dullness refers to a sign elicited on abdominal examination for ascites, see: https://en.wikipedia.org/wiki/Shifting_dullness. The patient had this sign on abdominal examination at the time of the intervention, as explained in the video. Diagnosis: Inguinal intranodal lymphography was performed, showing an effusion at the level of the third lumbar vertebral body that was embolized. Intervention: On robot-assisted abdominal exploration, intraperitoneal lymphatic effusion was noted from the left para-aortic region, close to the left renal artery. The lymphatic vessels of greater caliber were then closed with metal clips, until all the major sources of lymph effusion were under control. Next, a continuous suture running over the remaining para-aortic lymphatic tissue was applied. Once the suture was completed, methylene blue was then introduced through the nasogastric tube, with no effusion resulting from the lymphatic tissue at any level in the abdomen. A layer of hemostatic matrix was then added and a tubular drain was placed in the retroperitoneum, with its tip laying on the effusion site. The peritoneum was closed and after a final check of the hemostasis, the robotic trocars were removed and the port sites closed. Follow-Up Outcomes: The drain was removed after 72 hours. Since the intervention, the patient did not experience any further recurrence. In this first description, robotic approach was feasible and efficient in management of postoperative chylous ascites not responding to conservative treatment. The authors have received and archived patient consent for video recording/publication in advance of video recording of procedure. The authors declare that they have not had any commercial associations during the past 3 years that might create a conflict of interest in connection with the video. This study is derived from the “IRCCS Azienda Ospedaliero-Universitaria di Bologna,” and there are no conflicts of interest or obligations resulting from it. Runtime of video: 4 mins 22 secs