Red Out: Bleeding During Robotic Retroperitoneal Lymph Node Dissection and Strategies To Manage It

Robotic retroperitoneal lymph node dissection is emerging as an attractive minimally invasive technique to remove residual and recurrent retroperitoneal masses in patients with germ cell malignancies. It has huge potential benefits for patients in terms of lower rates of blood loss, ileus, postoperative pain, and scarring, and faster return to full activity. Inadvertent injury to the great vessels, lumbar tributaries, and other vessels is not uncommon and requires a calm but strategic management response. A thorough knowledge of the standard anatomy, specific pathology, and anatomic variations will help robotic surgeons in managing intraoperative haemorrhage. We describe the anatomy of the retroperitoneal vessels, surgical case selection, and the technical and nontechnical skills essential for success in this complex and high-risk procedure. PATIENT SUMMARY: Robot-assisted surgical removal of lymph nodes from the area behind the abdominal cavity is a complex operation that has minimal bleeding if all goes well. However, as it involves operating on the major abdominal blood vessels, there is a risk of life-threatening bleeding that the operating team must be able to rapidly control. Effective teamwork and a range of advanced technical skills are required to respond to any serious bleeding.