Table 3

Operation guide

Surgical step	Descriptor	Consensus recommendation
Tracer	ICG	Mandatory
	Blue dye	Optional
	Radio-labeled technetium	Optional
Injection location	Ectocervix in two or four positions	Mandatory
Injection technique	Superficial injection into the ectocervix Transperitoneal injection into the uterus Hysteroscopic injection into the uterus Surgeon appreciation of resistance at tracer injection	Mandatory Prohibited Prohibited Mandatory
Injection needle	Gauge between 20G and 25G Length sufficient to ensure easy and accurate access to the cervix	Mandatory Mandatory
Uterine manipulator	If being used, insert uterine manipulator after tracer injection	Mandatory
White light inspection	Prior to SLN mapping, conduct an inspection of the pelvic areas	Mandatory
Round ligament & Infundibulopelvic ligament	Preserve	Optional
Round ligament & Infundibulopelvic ligament	Divide	Optional
External vessels	Identify the external iliac vessels	Mandatory
Internal iliac artery	Identify the internal iliac artery	Mandatory
Ureter	Identify the ureter	Mandatory
Obliterated umbilical ligament	Identify the obliterated umbilical ligament	Mandatory
Uterine artery	Identify the uterine artery (medial to the ureter)	Optional
Paravesical space	Open the paravesical space	Mandatory
Direction of dissection	Start sentinel lymph node mapping at the level of the uterine artery and continue dissection LATERALLY away from the uterus	Mandatory
	Start sentinel lymph node mapping at the level of the uterine artery and and continue MEDIALLY toward the uterus	Optional
	Start sentinel lymph node mapping at the level of the uterine artery and and continue toward the pre-sacral area	Optional
	Start sentinel lymph node mapping at the most highlighted node and dissect proximally (TOWARD cervix)	Optional
	Start sentinel lymph node mapping at the most highlighted node and dissect cephalad (AWAY from cervix)	Optional
Dissection technique	Use blunt or electrosurgical technique Avoid disrupting lymphatic channels during dissection Ensure isolation of node from local anatomy	Mandatory Mandatory Mandatory
Definition of the sentinel node	A sentinel node is defined as … The most proximal node [The most proximal node is defined as the node closest to the uterus, regardless of location.], irrespective of the nodal station in which the node is found A single mapped node or a single node plus its next station echelon node(s).	Mandatory Mandatory
SLN dissection	SLN dissection should be completed in one hemi-pelvis before proceeding to the contralateral side	Mandatory
Troubleshooting	Troubleshooting when no nodes are mapping includes any one, or combination of, the following options: Wait, undertake dissection on the contralateral side before returning to original side Extend retroperitoneal dissection to encompass common, pre-sacral and/or paraaortic areas Re-inject ICG Undertake a side-specific lymphadenectomy	Mandatory
Specimen extraction	Removal of nodes without using a containment device	Prohibited
Proof of sentinel node	Use ex-vivo green fluorescence to prove the sentinel node	Mandatory
Specimen labeling	Label specimens according to laterality (right/left) AND nodal station (obturator/external iliac/internal iliac/presacral/common iliac/aortic/caval)	Mandatory
Ultrastaging	Use enhanced pathology techniques, such as immunohistochemistry, for ultrastaging of sentinel nodes	Mandatory

Final consensus on mandatory and prohibited steps of sentinel lymph node dissection (SLND) by minimally invasive surgery in endometrial cancer.
ICG, indocyanine green.