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 |
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 …
| 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:
| 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.