Introduction

Rectosigmoid resections are frequently needed to achieve complete disease clearance during surgery for ovarian cancer. A severe complication from rectosigmoid resections is anastomotic leakage. Near infrared angiography (NIR) has been introduced to assess perfusion of vascular pedicles. Given the interest in usage of NIR to evaluate perfusion during rectosigmoid anastomoses, we have put together an instructional video demonstrating the setup and usage of this technology.

Description

Intraoperative setup for NIR will require a PINPOINT endoscopic fluorescence imaging system including a 10mm laparoscope, a PINPOINT rigid scope introducer, and 25 mg of indocyanine green (ICG) dye.

After the segment of colon with disease is isolated and divided, perfusion is tested in the proximal limb by injecting 5 mL of the reconstituted ICG intravenously, allowing one minute for the dye to mobilize, and visualizing the bowel with the 10mm laparoscope. A perfusion defect is identified, and the decision is made to further resect the segment of bowel without perfusion. After this step, the trimmed proximal limb is brought down to the pelvis and anastomosed with the distal limb.

Perfusion is tested after anastomosis by bringing placing the PINPOINT rigid scope introducer over the 10mm laparoscope and introducing the scope through the anus until the anastomotic ring is identified. 5mL of ICG is reinjected. Perfusion is tested again and found to be adequate.

Conclusion/Implications

Assessment of rectosigmoid anastomoses performed for gynecologic surgery using NIR with ICG is feasible, can be performed without the need for numerous additional instruments.

Introduction

In selected cases, surgical removal of hepatic lesions should be performed in order to achieve a complete cytoreductive surgery for ovarian cancer patients. A Pringle maneuver consists in clamping temporarily the portal triad, composed by the hepatic artery, portal vein and the common bile duct. It significantly reduces bleeding with hepatic tissue preservation.

Description

In this video, we demonstrate how to easily apply a reversible Pringle maneuver with daily use resources. A xifo-pubic incision was performed for cytoreductive procedure, exposing the entire abdominal cavity. After identification of the epiploic (or Winslow) foramen, from lateral to medial, the lesser omentum was sectioned to safely access the portal triad. A Foley catheter, without the connection extremity, was inserted posteriorly to the hepatoduodenal ligament structures. A loop with the tip of the catheter passed through the lateral opening offers an adequate tourniquet for intermittent blood supply interruption, at the end of the procedure the tourniquet is relieved by pulling the loose end through the catheter opening. The second Pringle maneuver was performed with a laminar drain and a segment of a catheter, clipped with a vascular clamp. Both techniques can be applied by laparoscopy, and are detailed in another video

Conclusion/Implications

This video demonstrates the useful Pringle maneuver, performed with simple and reproducible technique.

Introduction

Although radical trachelectomy after neoadjuvant chemotherapy is considered for fertility preservation in patients with locally advanced cervical cancer (LACC), its efficacy and safety are still controversial. Since R0 resection based on ontogenetic compartment theory can control tumor effectively, laterally extended endopelvic resection (LEER) during radical trachelectomy can be considered as a treatment option for loco-regional control without adjuvant radiotherapy in LACC and fertility preservation.

Description

A 28 year-old woman with cervical cancer visited the clinic hoping for fertility preservation. She had a 5 cm sized cervical mass with left parametrial invasion (PM) and pelvic lymph node metastasis (LM), suggesting stage IIIC1 disease. After neoadjuvant chemotherapy using five cycles of weekly cisplatin, left PM remained despite LNM regression. Due to her strong desire for fertility, we conducted radical trachelectomy with LEER.

Conclusion/Implications

We performed type C1 parametrectomy with mesometrial resection while preserving uterine artery on the right side and LEER on the left side during radical trachelectomy. As surgical margin was free after R0 resection, the patient received adjuvant chemotherapy using paclitaxel and carboplatin without radiotherapy. She showed regular menstruation without recurrence after five years and received assisted reproductive technology for pregnancy.

Radical trachelectomy with LEER is a feasible treatment option for LACC patients who show tumor response after neoadjuvant chemotherapy with a strong desire for fertility.

Introduction

Since sentinel lymph node mapping in endometrial cancer is becoming more widely used, the need of standardizing surgical technique is needed. The objective of this surgical video is to describe the procedure of two-step pelvic and para-aortic sentinel lymph node mapping using indocyanine green and fluorescent camera in endometrial cancer, in three versions of surgical modality, which is laparoscopic, robotic, and open.

Description

The patients in the surgical video are diagnosed with biopsy-proven endometrial cancer, with early stage according to the preoperative MRI and PET-CT scan. After collecting washing cytology, bilateral salpinges were clamped with endo-clip to minimize tumor spillage. Gauze packing in PCDS was done in order to minimize the spillage of indocyanine green dye during paraaortic sentinel lymph node mapping, which may interrupt nodal mapping. ICG dye was injected in bilateral uterine fundus, to detect isolated paraaortic sentinel lymph node pathway. After bilateral paraaortic sentinel lymph node was sampled, cervical injection of ICG dye was done in 3 o’clock and 9 o’clock direction, both superficially and deeply, 2 mL in each side. After dissecting off the obliterated umbilical ligament, developing para-vesical and para-rectal spaces, and identifying ureter, uterine artery, and internal and external iliac vessels, bilateral pelvic sentinel lymph node was then sampled.

Conclusion/Implications

This surgical video clip provides specific steps of pelvic and para-aortic SLN mapping. By standardizing surgical technique of SLN mapping, we look forward to shorten the learning curve of surgeons and to improve the accuracy of sentinel lymph node mapping.

Introduction

The use of sentinel lymph node biopsy (SLNB) in endometrial cancer is expanding and has been incorporated into international gynaecological oncology management guidelines [1, 2]. Prospective trials and a meta-analysis have found that the SLNB with indocyanine green has a high sensitivity and low false negative rate for the detection of pathological lymph nodes, especially when undertaken with micro-sectioning and immunohistochemical staining [3, 4].

Description

We record all SLNB in our unit for quality assurance and training purposes. We review these videos for unanticipated challenges during identification of sentinel lymph nodes. We created this surgical teaching video to demonstrate a systematic approach to identify and dissect the posterior chain SLNB during laparoscopy.

Conclusion/Implications

It is vital for surgeons to completely and systematically inspect pelvic lymphatic channels to identify sentinel lymph nodes in endometrial cancer patients to ensure accurate staging.

Video footage and still photographs were gleaned from unedited surgical films recorded at our institution and from institutional artists’ illustrations. Patients with early-stage uterine cancer, undergoing laparoscopic staging surgery using intracervical dye for SLN mapping, were included.