Introduction/Background To describe our technique for excision of the para-aortic, pre-aortic, pre-caval and laterocaval nodes using an extraperitoneal approach. This technique was developed to make the dissection and excision of the less accessible nodes in an easier and safer way by minimizing the risk of great vessels injury and bleeding.

Methodology Step-by-step description of the surgical procedure using video.

A 50-year-old woman with a body mass index of 36 underwent endoscopic extraperitoneal para-aortic lymphadenectomy for advanced high grade cervical adenocarcinoma FIGO IIIC1r.

The patient underwent an endoscopic extraperitoneal para-aortic lymphadenectomy. An anatomical dissection is being performed being the upper limit of the dissection the left renal vein.

Results Firstly we complete a dissection of all the anatomical aortic limits until the renal vein and exeresis of aortic nodes. A plane just above the cava vein is carefully developed by pushing all the lymph nodes to the roof of the dissection.

Nodes are excised in four blocks, supramesenteric and inframesenteric aortic and precaval nodes.

Conclusion A complete para-aortic retroperitoneal dissection can be achieved with this extraperitoneal approach. Benefits of this technique are based on the absence of the bowel or other intraperitoneal structures invading the operative field given the barrier-free nature of the retroperitoneal space. Despite the challenge of the access to the right nodes in a retroperitoneal paraaortic lymphadenectomy they can be successfully excised reaching the renal vein including obese patients.

Extraperitoneal paraaortic lymph node dissection is a minimally invasive procedure that is an excellent and safe approach to the paraaortic area, with a low complication rate, sufficient number of lymph nodes, and short hospital stay. It seems to be a good alternative to the classic transperitoneal approach.

This new technique deserves to be used as a tool to identify lymph node positive patients who require extended-field radiation and/or chemotherapy.