Left paraaortic, inframesenteric lymphadenectomy preserving the superior hypogastric plexus supported by indocyanine green (ICG) labeling of the lymphatic compartment in cervical cancer.
Superior hypogastric plexus (SHG) contains mainly sympathetic and most probably also postganglionic parasympathetic fibers. Thus, surgical damage of SHG may cause autonomic pelvic organ dysfunction (Kraima et al., 2015). As already shown for rectal cancer, preservation of the autonomic nerves is facilitated by robotic surgery and may avoid sexual dysfunctions and voiding disorders (Kim et al., 2015). In this educational video, we demonstrate left lower paraaortic lymph node dissection preserving the SHG using ICG fluorescence to label the lymphatic compartment. Prior to total mesometrial resection (TMMR) with therapeutic lymphadenectomy for cervical cancer (Höckel et al., 2009, Kimmig et al., 2013) 4 × 0.5 ml of a 1.66 mg/ml Indocyanine green solution (ICG Pulsion®, PMS SE, Feldkirchen, Germany) was injected into the uterine cervix at all four quadrants, 0.5 cm in depth (Kimmig et al., 2016). The lymphatic network of the downstream common iliac and inferior paraaortic lymph compartments of the uterine cervix is visualized (ICG fluorescence) including the individual connecting vessels between the different compartments. As can be demonstrated, the medial upper common iliac (subaortic) compartment drains preferentially into the anterior (mesenteric) compartment, whereas lateral common iliac lymphatic vessels mainly drain to the posterior (lumbar) paraaortic compartment. The autonomic nerve fibers of the SHP may easily be identified and preserved due to the excellent image resolution and the discrimination from fluorescent lymphatic structures. The video shows the preparation of left lower paraaortic nodes in cervical cancer following ICG labeling using a da Vinci Xi system®. This technique seems not only advantageous for preserving SHP, but even more highly educational to learn surgical anatomy for trainees.
West German Cancer Center, Department of Gynecology and Obstetrics, University of Duisburg-Essen, Klinik für Frauenheilkunde und Geburtshilfe, Hufelandstraße 55, 45122 Essen, Germany.
Rainer
R
Kimmig
West German Cancer Center, Department of Gynecology and Obstetrics, University of Duisburg-Essen, Klinik für Frauenheilkunde und Geburtshilfe, Hufelandstraße 55, 45122 Essen, Germany.
Peter
P
Rusch
West German Cancer Center, Department of Gynecology and Obstetrics, University of Duisburg-Essen, Klinik für Frauenheilkunde und Geburtshilfe, Hufelandstraße 55, 45122 Essen, Germany.
Paul
P
Buderath
West German Cancer Center, Department of Gynecology and Obstetrics, University of Duisburg-Essen, Klinik für Frauenheilkunde und Geburtshilfe, Hufelandstraße 55, 45122 Essen, Germany.
Bahriye
B
Aktas
Educational video; Indocyanine green; Paraaortic lymphadenectomy; Preservation of superior hypogastric plexus; Robotic surgery; Uterine cancer
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26792025
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23589777
Surg Oncol. 2015 Sep;24(3):172-80
26141555
Auton Neurosci. 2015 May;189:60-7
25704391
Lancet Oncol. 2009 Jul;10(7):683-92
19482513