Article Text

Laparoscopic ovarian sentinel lymph node mapping using indocyanine green for ovarian restaging purpose
  1. Jessica Mauro,
  2. Chiara Borghi,
  3. Alessandro Surace and
  4. Alessandro Buda
    1. Department of Gynecologic Oncology, Ospedale Michele e Pietro Ferrero, Verduno, Italy
    1. Correspondence to Dr Alessandro Buda, Department of Obstetrics and Gynecology, Azienda Ospedaliera San Gerardo, Monza, Italy; alebuda1972{at}

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    In stage I ovarian cancer, comprehensive surgical staging, including systematic pelvic and aortic lymphadenectomy, is mandatory, even in the absence of clear evidence regarding the survival benefits associated with lymphadenectomy.1 Sentinel lymph node biopsy in early-stage ovarian cancer showed a high detection rate and negative predictive value.2 3 Furthermore, considering the complexity of the procedure, particularly during the minimally invasive approach, it seems critical that the injection of the tracer should be performed preferably with the adnexa still in situ, before removing the ovary. Three pathways of drainage of the ovary are known: the infundibulopelvic route, the pelvic route, and the third minor inguinal route drain via the round ligament to the groin.4 In the presence of a high suspicion of an ovarian mass limited to the ovary, the injection should be made into both the suspensory and the infundibulopelvic ligament of the ovary, thus allowing a significantly higher rate of sentinel node identification.3

    In this educational Video 1 we present use of the technique in a young woman with occult serous high-grade ovarian cancer after simple left ovarian cystectomy. The sentinel node mapping was performed with the PinPoint HD S1 SPY camera (PinPoint Endoscopic Fluorescence Imaging System; NOVADAQ, Mississauga, Ontario, Canada). After induction of the pneumoperitoneum, the fluorescent tracer indocyanine green was injected at a concentration of 1.25 mg/mL with two separate injections just below the peritoneum in the suspensory ligament of the ovary and in the proper ovarian ligament. Overall, 0.4 mL of indocyanine green solution was injected using a 12 cm long 22 Gage spinal needle. A percutaneous abdominal approach was used to better guide laparoscopic forceps in the retroperitoneum to reduce the risk of spillage of the near-infrared tracer, which can greatly reduce identification of the sentinel nodes. Thereafter, exposure of the aortic region started with the dissection on both sides along the Toldt fascia up to the left renal vein. Two nodes were identified below the inferior mesenteric artery in the para-aortic and superficial left common areas. Nodal staging was completed by removing both pelvic and aortic lymph nodes up to the renal vessels. The sentinel lymph nodes and the other lymph nodes were all negative at final pathology. The minimally invasive approach in combination with the use of indocyanine green is feasible. This approach will need to be further confirmed by ongoing studies.

    Supplemental material

    Video 1 The sentinel lymph nodes in the inferior aortic and common iliac regions as they appears using near-infrared technology.

    Data availability statement

    All data relevant to the study are included in the article.

    Ethics statements

    Patient consent for publication

    Ethics approval

    This study involves human participants but the institutional review board of Ospedale Michele e Pietro Ferrero exempted this study. Participants gave informed consent to participate in the study before taking part.


    We thank the Fondazione Ospedale Alba Bra ONLUS for the support in the activities of the Division of Gynecologic Oncology of Michele and Pietro Ferrero Hospital.


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    • Contributors Conceptualization: AB; data curation: JM, CB, AS; formal analysis: AB, JM; investigation: all authors; methodology: AB; supervision: AB, JM, CB; Writing - original draft: JM, AB; Writing - review and editing: JM, AB; guarantor: AB.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.