Introduction

A 65 year old female with BMI of 35 kg/m² presented with postmenopausal bleeding for 3 months. An endometrial biopsy revealed endometrial sarcoma. Her staging CT scan showed a 6.6cm endometrial mass distending the cavity. There was no lymphadenopathy or distant metastasis. She had a history of open umbilical hernia repair with a large mesh in 2019. In view of sarcoma on the histology, she was counselled for full surgical staging including total hysterectomy, bilateral salpingo-oophorectomy, pelvic lymphadenectomy and omentectomy.

Description

We needed to avoid disruption of the large mesh across the umbilicus during surgical staging of this patient, as well as avoid potential bowel adhesions in the central region. We wanted to perform this using a minimally invasive approach. Therefore, we decided to adopt an “outside-in” approach whereby we performed an extraperitoneal pelvic lymph node dissection first followed by completion hysterectomy bilateral salpingo-oophorectomy and omentectomy via the VNOTES route. The surgery took a total of 206 minutes with an estimated blood loss of 200 mls. The patient recovered well post-operatively with minimal pain and no complications. She was discharged on post-operative Day 3. Final histology revealed Stage 1B low grade adenosarcoma. 14 lymph nodes were harvested with no metastasis. She was recommended for close observation and surveillance.

Conclusion/Implications

This “outside-in” approach is a safe and novel minimally invasive method of surgical staging for gynaecological cancers. It confers an advantage for technically difficult cases, such as multiple previous midline abdominal surgeries and morbid obesity.

Introduction

Sentinel lymph node dissection is widely used in the staging of endometrial cancer. Moloney et al [1] published the paper on identifying mandatory and prohibited steps of sentinel lymph node (SLN) dissection in endometrial cancer. This video is incooperating the quality assessment tool used in this paper to develop a systematic approach to SLN dissection.

References

Moloney K, Janda M, Frumovitz M, et al. Development of a surgical competency assessment tool for sentinel lymph node dissection by minimally invasive surgery for endometrial cancer. International Journal of Gynecologic Cancer 2021;31:647-655.

Description

This video is an attempt at trying to fulfil the surgical steps of the sentinel LN tool but also an approach that can be useful in training fellows to continue to develop the avascular spaces and identify the anatomy prior to resecting the sentinel lymph nodes.

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. USing the 10 steps that has been taken from the surgical assessment tool is used to demonstrate a systematic approach to SLN dissection.

Conclusion/Implications

A systematic approach to SLN dissection is paramont. The use of this systematic approach is important in teaching of our fellows but also to maintain surgical competency in SLN dissection.

Introduction

Frozen section is a common tool used in cases of suspected but unconfirmed endometrial cancer. Indocyanine green allows identification of pelvic and para-aortic sentinel lymph nodes prior to hysterectomy, but the mapped nodes are removed before the hysterectomy per usual protocol. If sentinel nodes are mapped but not removed prior to the hysterectomy, the dye can spread and identification of the original sentinel node is not possible. Additionally, the dye cannot be injected after the hysterectomy is performed.

Description

We demonstrate mapping and tagging of the sentinel lymph nodes to allow for removal in the event of a positive frozen section or to avoid unnecessary lymph node dissection in the event of a negative frozen section.

Conclusion/Implications

Mapped sentinel nodes can be tagged with a clip for removal after hysterectomy. This allows the operator to perform sentinel lymph node biopsy after frozen section confirms malignancy, improving operating time and morbidity. In cases of benign pathology on frozen section, the risks associated with node biopsy or dissection can be avoided.

Introduction

A novel approach to use of the ICG lymphatic channels to identify uterine artery at every dissection of the SLN in endometrial cancer surgery.

Description

The surgical steps of the sentinel LN dissection are an useful approach to training fellows to continue to develop the avascular spaces and identify the anatomy prior to resecting the sentinel lymph nodes. It also allows them to always identify the uterine artery and ligate it at its origin hysterectomies for endometrial cancers.

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. This demonstrates a systematic approach to the development of the pelvic avascular spaces and using the ICG to isolate the uterine artery prior to ligation.

Conclusion/Implications

The use of ICG tracts during dissection of SLN in endometrial cancer allows for clear identification of the uterine artery. Using this systematic approach to dissecting the uterine artery and ligating it during hysterectomies is a useful tool in teaching fellows and trainees.