Secondary Cytoreduction for Isolated Infra-Renal Para-Aortic Recurrence of High-Grade Serous Ovarian Carcinoma: A Robotic Approach

Abstract

Objective

To demonstrate a step-by-step robotic approach to secondary cytoreductive surgery for an isolated infra-renal para-aortic recurrence of high-grade serous ovarian carcinoma, emphasizing key anatomical landmarks, intraoperative strategy, and management of vascular injury.

Setting

University teaching hospital.

Participants

A 60-year-old woman with a history of high-grade serous ovarian carcinoma initially diagnosed via supraclavicular lymph node biopsy. Following five cycles of neoadjuvant Carboplatin-Paclitaxel chemotherapy, interval debulking surgery with complete cytoreduction, two adjuvant cycles, and PARP inhibitor maintenance therapy, she developed an isolated infra-renal para-aortic recurrence detected on PET-CT 18 months post-diagnosis.

Interventions

Robotic secondary cytoreductive surgery [1] was performed using intraureteric indocyanine green for ureteral mapping and a standardized para-aortic robotic port configuration [2]. The small bowel was suspended cranially with Prolene anchoring sutures for optimal retroperitoneal exposure. Dissection proceeded from the aortic bifurcation cranially toward the left renal vein, identifying and preserving the inferior mesenteric artery, left ureter, and inferior vena cava.

A 4–5 cm nodal mass spanning the para-aortic and interaortocaval spaces was resected en bloc. An intraoperative 3-mm inferior vena cava injury occurred during tumor dissection and was repaired primarily with 3-0 Prolene under low-pressure conditions. Estimated blood loss was approximately 100 mL. Table 1 details the surgical equipment used at each procedural stage, and Table 2 summarizes key technical tips and precautions for robotic-assisted infra-renal cytoreduction.

Conclusion

The patient recovered uneventfully, was discharged on postoperative day one, and resumed systemic Carboplatin-Caelyx chemotherapy on day 14, completing a total of six cycles. This case highlights the technical feasibility and safety of robotic para-aortic lymphadenectomy in the setting of isolated recurrence, even in the presence of vascular injury. The video is intended as a visual guide for advanced robotic gynecologic oncologic procedures, emphasizing key anatomical landmarks, surgical strategy, and complication management (Table 1, Table 2).

Video Legend

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Robotic Secondary Cytoreduction for Isolated Infra-renal Para-aortic Recurrence of High-Grade Serous Ovarian Carcinoma: Step-by-Step Surgical Technique and Intraoperative Vascular Repair.