Laparoscopic para-uterine lymphovascular tissue sentinel lymph node biopsy with indocyanine green in cervical cancer

Up to 10% of patients with positive lymph nodes in apparent early stage cervical cancer harbor lymph node metastasis in the para-uterine lymphovascular tissue (PULT), defined as the tissue surrounding the uterine vessels.1-3 The sentinel lymph node (SLN) is reported to be found at the level of the PULT in 4% to 35% of patients.3,4 The present video aims to show a technique to identify, dissect, and remove the PULT SLN using indocyanine green (ICG) through a laparoscopic approach. We report the case of a woman in her late 50s who was diagnosed with grade 3 squamous cell carcinoma of the cervix International Federation of Gynecology and Obstetrics 2018 stage IB2 (25 mm diameter), who underwent laparoscopic bilateral SLN biopsy with ICG sent for frozen section and converted to open type C1 radical hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymphadenectomy (after negative frozen section results). The SLNs were in the left PULT and right obturator fossa. First, 0.5 mL of ICG (1.25 mg/mL) was injected superficially at the 3 o’ clock and 9 o’ clock positions in the cervical stroma. The procedure was initiated by a laparoscopic transperitoneal assess- ment of ICG migration. Once this was confirmed, the pelvic peri- toneum was opened, and the left pelvic sidewall was inspected for SLN using a neareinfra-red camera. The ICG mapping was iden- tified medially to the obliterated umbilical artery in the PULT area. Two SLNs were identified on the uterine artery, dissected, and removed separately (Fig.), thanks to the use of color-segmented fluorescence mode, which allowed the identification of higher tracer concentrations. The SLNs were removed using an endobag and sent for frozen section, followed by an ultra-staging protocol. No intra- or post-operative complications were recorded. SLNs were reported to be negative in pathological analyses. SLN is defined as the first node receiving tracer closest to the uterus. For this reason, PULT must be investigated either in the absence or even in the presence of pelvic sidewall SLN.