Objective: In comparison with laparoscopic transperitoneal para-aortic lymphadenectomy, the advantages of laparoscopic extraperitoneal para-aortic lymphadenectomy (ePAL) are that the operative field is not obstructed by bowel and the Trendelenburg position is not required [1]. The ePAL technique has been adopted to the robotic surgery with the da Vinci Xi. There are only a few reports demonstrating the technical feasibility of robot-assisted ePAL (RAePAL) [2,3]. This report describes the new surgical technique of RAePAL with the bipolar cutting method. Methods: The patient was a 53-year-old woman diagnosed as ovarian clear cell carcinoma (CCC) after left salpingo-oophorectomy. As the re-staging surgery, robot-assisted right salpingo-oophorectomy, hysterectomy, omentectomy, and pelvic lymphadenectomy were planned following ePAL. The patient was placed in the supine position and tilted 5 degrees to the right. Three da Vinci arms were docked at the patient's left side (Fig. 1). The bipolar cutting method was performed by with the surgeon's right hand. An AirSeal® port (ConMed, Utica, NY, USA) was placed on the side near the assistant. After the para-aortic space was expanded, lymphadenectomy was performed up to the renal veins with the bipolar cutting method. Results: The PAL operative time was 155 minutes, estimated blood loss was 25 mL. The patient developed no perioperative complications, and the postoperative diagnosis was stage IC1 ovarian CCC with no pelvic (n=0/42) and para-aortic lymph nodes (n=0/59) metastasis. Conclusion RAePAL with the bipolar cutting method was technically feasible. Performing lymphadenectomy between the aorta and the vena cava was facilitated by the articulated robotic arm.

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Carcinosarcoma*