Introduction/Background This video presents the key surgical steps of the laparoscopic removal of bulky pelvic lymph nodes in two different cases of high-grade serous ovarian cancer recurrences.

Methodology Two patients underwent laparoscopic cytoreduction due to bulky pelvic lymph nodes.

The first case refers to a tertiary recurrence of HGSOC, the second one to a secondary relapse.

Both patients underwent Interval Debunking Surgery and chemotherapy as first treatment.

Results Laparoscopic cytoreduction, performed after previous chemotherapy and prior surgery, presents several significant challenges. Tissues appear scarred and fibrotic due to the insults from prior surgeries, making them more adherent and less mobile. Additionally, the anatomical planes can be disrupted due to adhesions or changes in tissue morphology.

In the first case we initially attempt a medial approach to the obturator fossa, dissecting the spaces between the external iliac vessels and isolating the pelvic portion of the ureter. The medial approach resulted unfeasible due to the increased tissue consistency and fibrosis. Eventually we attempted a lateral approach between the psoas muscle laterally and the external iliac artery medially.

There is also an increased risk of intraoperative complications such as bleeding or damage to nervous structures, as we can see in the second case: the bleeding from external iliac vein injured was stopped by the traction of a silicon strip previously positioned, which surrounded the vessel. Two bulldog hemostatic forceps are positioned upstream and downstream of the lesion in order to allowed the surgeon to suture the vessel.

Conclusion Secondary cytoreduction, which is technically more complex compared to upfront surgery, is characterized by the difficulty in opening anatomical spaces, often altered by the outcomes of previous treatments. Tissues appear edematous, fibrotic, and easily prone to bleeding, which may necessitate the use of alternative surgical approaches.

Disclosures The authors declare that they have no conflict of interest.