 Hi, I am Dr. Archit and today we are going to discuss on how to perform a retroperitoneal lymph node dissection by laparoscopy method. To perform a good para-caval pre-caval interioto-caval and pre-iotic lymph node dissection, the first and most important step in performing is to create a good peritoneal curtain. This peritoneal curtain is lifted by incising the peritoneum above the sacral promontory from the cecum up to the sigmoid or the rectum. This peritoneal curtain is slowly and steadily lifted up as we go superiorly up to the level of the diodenum. As you can see the diodenum is being lifted. This peritoneal curtain helps in letting the small bubble and the momentum not coming in your view of dissection or your area of dissection. This comprises of both sharp and blunt dissection. You can see the superior most extent of our dissection is the left renal vein and the right renal vein entering the inferior vena cava as is being shown in the video right now. Now we have come to the superior most extent of our dissection that is the left renal vein. The second and the third part of the diodenum fall upon the IVC and the left and the right renal vein respectively. The dotted line shows the whole of the peritoneal curtain which is lifted up and the camera and all the instruments are beneath it whereas the small bubble and the momentum is above and behind the peritoneal curtain. The first step is to identify the peritoneum and the fatty tissue overlined the right common iliac artery. Insize the right common iliac artery peritoneum and ask the assistant surgeon to retract the ureters and the gonadal vein as being shown by the yellow arrow. Slowly and steadily do the dissection between the gerotasvesia and the IVC to identify the insertion of the gonadal vessels into the inferior vena cava. Once that is dissected you go on the right side of the inferior vena cava and you encounter the right renal vein shown by the blue arrow in the video. So this is the insertion of the right renal vein into the inferior vena cava. Now that is the superior most extent. Coming back to our dissection over the right common iliac artery perform the dissection close to the common iliac artery and the common iliac vein and enter in the pre-cable space again staying very very close to the inferior vena cava. Lot of surgeons do get worried staying close to the inferior vena cava and the iota but remember this is a relatively avascular zone and much easier to perform the dissection in this area. Now the peritoneum is lifted up on the right side of the inferior vena cava. The assistant surgeon retracts the ureter and the gonadal vessels onto the right side. The dissection is performed in a fibro fatty looseriola tissue between the gerotasvacia over the overline the kidney and the right paracavel space. This ensures that all the paracavel nodes which are on the right side of the inferior vena cava come and are lifted onto the pre-cable or the inter-iota cable area. You can see the right renal vein is completely exposed and that marks the superior most extent of our dissection on the right side of the inferior vena cava. Now the dissection is performed in the pre-cable that is anterior to the vena cava and the right common iliac artery. Coming back to the right common iliac artery it helps us to gain access in the pre-iotic area that is right overline the iota. Now you can see we have exposed the right common iliac completely and gained access in the pre-iotic. Here now we are dissecting or identifying rather the inferior mesentric artery. The next step is to identify the left ureter which lies in the triangle between the inferior mesentric artery above being retracted with the ligature and the left common iliac artery below. Within this triangle runs the ureter as is being shown in the video. Coming back to the inferior mesentric artery that is our left inferior most dissection the hole of the fibro fatty tissue and the fascia above the inferior mesentric artery is incised and the dissection is performed now at the pre-iotic or the anterior to the iota and the inter-ioto cable groove all the fibro fatty tissue and the lymphatics is taken up from the between the iota and the inferior vena cava and then we encounter the inferior mesentric artery which can be easily seen by lifting the rectum. So once you lift the rectum you know that you are lifting up the inferior mesentric artery and you can identify the inferior mesentric artery easily. This part of the dissection should be again very close to the iota and the pre-iotic and the inter-ioto cable group of lymph nodes are removed end block right up to the superior most extent of our dissection that is the left renal vein and you can see the left renal vein above now this is the inferior vena cava the right renal vein entering the inferior vena cava the left renal vein entering the inferior vena cava above the iota and the iota and the inter-ioto cable groove all completely devoid of all the fibro fatty tissue and all the lymphatic tissue completely. Apart from the pre-iotic paracavel and the inter-ioto cable groove another level of dissection of the lymph nodes is between the two common iliac artery that is at the region of the iotic bifurcation and you can see the left common iliac artery here and the right common iliac artery. The inferior mesentric artery is seen now and is being lifted the inferior mesentric artery and the iotic bifurcation is been shown the inferior vena cava by the yellow arrow the left renal vein by the yellow arrow the pre-iotic or the iota by the blue arrow the iotic bifurcation is now being shown and the inferior mesentric artery by the red arrow is being shown now all these areas comprise of complete laparoscopic retroperitoneal lymph node dissection areas. Now the most important step is to perform the dissection at the level of the iotic bifurcation and one should remember that this area is very precarious in dealing with just underneath this lymph nodal packet lies the left common iliac vein and this area is also very important to clear as it comprises of the bridge between the pelvic lymph node dissection and the para iotic or the retroperitoneal lymph node dissection. Both the common iliac arteries the left and the right and underneath underline these is the left common iliac vein this has been completely bad and all the fibro fatty tissue along with the lymphatics is completely devoid and separated. This brings us close to our end of the video of how to perform an effective and relatively avascular laparoscopic retroperitoneal lymph node dissection. I hope you could enjoy this please like and subscribe to our channel and share this video as you like thank you