Retroperitoneal minimally invasive sigmoidectomy with D3 lymph node dissection in the presence of an aortic aneurysm: a novel dissection strategy

Resectable sigmoid cancer with a stable abdominal aortic aneurysm (AAA) complicates standard laparoscopy due to aortic manipulation risk. We propose a retroperitoneal approach to circumvent this. A 54-year-old male smoker with cardiac disease had sigmoid adenocarcinoma (cT3N0M0) and a 5.8 cm infrarenal AAA. We performed retroperitoneal laparoscopic sigmoidectomy with left colic artery-sparing D3 dissection, using a lateral-to-medial plane to expose the inferior mesenteric artery root without touching the AAA. The key operative steps are demonstrated in a video. This retroperitoneal technique enables central ligation and complete lymphadenectomy while avoiding the aneurysm sac, achieving negative margins and 16 negative nodes. It is a valuable alternative for high-risk patients. It represents a technically feasible adaptation of a previously described retroperitoneal approach for a complex clinical scenario in selected high-risk patients.