Introduction/Background Lymphadenectomy is part of surgical staging in gynecologic oncology practice. Occasionally, the size of these lymph nodes dictates the resectability and surgical approach.

Minimally invasive surgery has been known to be as safe and feasible as traditional open surgery. However, both laparoscopic lymphadenectomy and removal of isolated bulky lymph nodes are more difficult to perform due to limited surgical space and associated technical problems, especially in the para-aortic lymphadenectomy procedure.

Methodology This video describes step-by-step the surgical technique and strategy for the complete removal of two bulky para-aortic and precaval lymph nodes, from two different clinical cases, using a laparoscopic extraperitoneal approach.

Results The first case involves a 54-year-old woman diagnosed with locally advanced squamous cell carcinoma of the cervix, presenting bilateral iliac lymph node infiltration and a 30x14mm precaval node. The second case involves an 86-year-old woman with a multilocular-solid cyst in the left ovary, and a suspicious node situated below the left renal vein observed in the imaging tests. It presents the anatomical peculiarity of a circumaortic left renal vein and a polar artery, with a bulky node described in between.

In both cases, para-aortic lymphadenectomy and resection of the bulky nodes were performed, highlighting the particularities of dissection in these cases, which represent a surgical challenge.

This video explains the technique of para-aortic limfadenectomy in complex situations, emphasizing the importance of knowing the anatomy perfectly and the possible anatomical variations, as well as the relevance of tissue manipulation to avoid complications.

Conclusion Despite surgical removal of large pathological para-aortic nodes before definitive CTRT is not routinely recommended, laparoscopic approach is feasible and safe in cases of bulky nodes in gynecological oncology. In order to perform a proper surgery and avoid complications, a deep knowledge of the anatomy is necessary, as well as a previous review of the complementary imaging tests.