Table 3

Operation guide

Surgical stepDescriptorConsensus recommendation
TracerICGMandatory
Blue dyeOptional
Radio-labeled technetiumOptional
Injection locationEctocervix in two or four positionsMandatory
Injection techniqueSuperficial 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 needleGauge between 20G and 25G
Length sufficient to ensure easy and accurate access to the cervix
Mandatory
Mandatory
Uterine manipulatorIf being used, insert uterine manipulator after tracer injectionMandatory
White light inspectionPrior to SLN mapping, conduct an inspection of the pelvic areasMandatory
Round ligament & Infundibulopelvic ligamentPreserveOptional
DivideOptional
External vesselsIdentify the external iliac vesselsMandatory
Internal iliac arteryIdentify the internal iliac arteryMandatory
UreterIdentify the ureterMandatory
Obliterated umbilical ligamentIdentify the obliterated umbilical ligamentMandatory
Uterine arteryIdentify the uterine artery (medial to the ureter)Optional
Paravesical spaceOpen the paravesical spaceMandatory
Direction of dissectionStart sentinel lymph node mapping at the level of the uterine artery and continue dissection LATERALLY away from the uterusMandatory
Start sentinel lymph node mapping at the level of the uterine artery and and continue MEDIALLY toward the uterusOptional
Start sentinel lymph node mapping at the level of the uterine artery and and continue toward the pre-sacral areaOptional
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 techniqueUse blunt or electrosurgical technique
Avoid disrupting lymphatic channels during dissection
Ensure isolation of node from local anatomy
Mandatory
Mandatory
Mandatory
Definition of the sentinel nodeA 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 dissectionSLN dissection should be completed in one hemi-pelvis before proceeding to the contralateral sideMandatory
TroubleshootingTroubleshooting 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 extractionRemoval of nodes without using a containment deviceProhibited
Proof of sentinel nodeUse ex-vivo green fluorescence to prove the sentinel nodeMandatory
Specimen labelingLabel specimens according to laterality (right/left) AND nodal station (obturator/external iliac/internal iliac/presacral/common iliac/aortic/caval)Mandatory
UltrastagingUse enhanced pathology techniques, such as immunohistochemistry, for ultrastaging of sentinel nodesMandatory
  • Final consensus on mandatory and prohibited steps of sentinel lymph node dissection (SLND) by minimally invasive surgery in endometrial cancer.

  • ICG, indocyanine green.