Robotic-Assisted Total Laparoscopic Supralevator Pelvic Exenteration: Steps in Excising the Pelvic Viscera

Study Objective: To illustrate the key steps involved in performing a supralevator pelvic exenteration robotically. Design: Presentation of the steps involved in excising the pelvic viscera during robotic-assisted supralevator pelvic exenteration. Setting: Tertiary care academic center. Patients: A patient undergoing pelvic exenteration for uterine leiomyosarcoma. Interventions: Robotic total supralevator pelvic exenteration. Measurements and Main Results: In this woman undergoing pelvic exenteration for uterine leiomyosarcoma, the paravesical and pararectal spaces are shown, along with important pelvic landmarks, such as the major vessels and the ureters. Once the pararectal and paravesical spaces are identified, the parametrium in between is resected. The posterior dissection is then performed along the filmy presacral space to the level of the coccyx and levator muscles. Anteriorly, the bladder is dissected along the space of Retzius, and the urethra is transected. Once the pelvic organs are separated, the specimen is removed, and reconstruction of the pelvic floor is performed. The ileal conduit is created from a segment of small bowel approximately 20 cm from the terminal ileum measuring 15 cm long. The 2 ureters are spatulated and attached to the ileal conduit, and a stoma is created. The descending segment of colon is brought up through a separate stoma site on the other side of the abdomen to create the colostomy. The total operating time, including reconstruction with the ileal conduit, was 480 minutes, and the estimated blood loss was 250 mL. Conclusion: Total pelvic exenteration can be safely performed robotically with appropriate understanding of the key steps and anatomic landmarks.