Step 1: Diagnostic laparoscopy was performed. A 5-mm port was placed in the upper left quadrant. A systematic review of the abdomen and pelvis revealed no gross disease.

Step 2: Four robotic trocars, 8 mm in size, were placed as the following locations. The robotic camera trocar was placed in the midline and 1 cm below the umbilicus. Two trocars were placed 6 and 12 cm from the midline trocar. A fourth robotic trocar was placed in the left flank, 10 cm from the midline trocar. All robotic trocars were at the same level (Fig. 2). The Xi robot was docked in a standard fashion (left lateral docking).

Step 3: The peritoneum was incised and dissected cephalad along the aorta. The landmarks for the dissection were the following: superiorly, peritoneal reflection of the duodenum and Gerota fascia; inferiorly, the right common iliac artery; laterally, the right ureter; and medially, the aorta. The bulky tumor was sequentially dissected with a combination of blunt and sharp dissection with monopolar and bipolar cautery. The lymphatic channels and fellow veins were isolated and sealed with cautery. The specimen was removed intact in one piece, placed and secured in a 10-mm laparoscopic endobag, and removed through the infraumbilical port. Two additional para-aortic lymph nodes and cysts were removed. At the end of the procedure, no gross residual disease (R0) was observed. A fibrin sealant (10 mL) was placed along the inferior vena cava.

Step 4: The peritoneum was reapproximated using three robotic clips (Fig. 2). The estimated blood loss was 20 mL, and the operative time was 146 minutes.