Peter, I think you're on mute still. I think you're, yeah, there you go. Navigate through that. Good morning and good evening and good afternoon. Again, thank you for, Linda, thank you for inviting me to speak. Something that I'm very, very passionate about, minimally invasive surgery, treatment for gynecological cancer. I think today, you know, we're gonna try to, I was asked to give a talk for on bioproscopic retroperitoneal node dissection. And let's see. Is it, is it, that's, I apologize, I, can you guys see my screen? Not yet. It's a little bit delayed. Can you guys see that? I was testing it with Susan and I was hoping that it's, I had given a webinar last week and they had difficult time. So can you see it? Not yet. No. Yeah, it was working fine earlier. We'll get there. Yeah. So, I don't know if it is like out to, it's sort of interesting because last week of the webinar I was giving, for some reason, everything was working and it didn't work. You can see me if you want and I can try if that'll work or if we could just, we can just wait. So you're trying to hit share screen and it's just not sharing? Yeah. Well, let's see. Is it sharing? I thought I did share the screen. Early, we're not seeing your shared screen yet. Okay, wait one second. Let me just get that. I apologize. Share screen. Okay. I apologize. There you go. Perfect. Can you see it now? Yep. Okay. All right. Everyone sees the screen? Perfect. So I think this is for the fellows and all for a laparoscopic pelvic and aortic node dissection and how to approach it. As you know, minimally invasive surgery has become a forefront and mainstay as one of the repertoires for us in treatment for gynecological malignancy and retroperitoneal node dissection for gynecological cancer, as you know, it's in the setting for endometrial, cervix and ovarian cancer. And when we really think about treating these cancer, I like to think about the procedure as where I'm performing the procedure, either the pelvic or abdominal dissection. You know, in the endometrial cancer and cervix cancer, the role of sentinel lymph node sampling has become a forefront. So much for the endometrial cervix, as we all know, is still being evaluated. And why do we need to, you know, if the sentinel lymph nodes is gonna be the future, you know, why do we need to do pelvic lymph node dissection and periodic node dissection? Because as GYN oncologists, I think we're one of the unique specialty where you may require to still perform this procedure. Certainly in the ovarian cancer setting, retroperitoneal node dissection is still an important, although recent articles have suggested the value of it. But I think it is one of the surgical repertoires that I think you need to have in your armatarium in providing care for our patients. So we'll talk about, I think it's always important for port placement in performing because this is, when we, you know, when I was a fellow, you know, there was one way that we did everything, you know, either transverse or midline. And if you did the transverse incision and you found cancer, you couldn't do an appropriate surgery and you failed at it for an oncological procedure. Well, that's no different when you're doing a minimally invasive surgery that port placement is exceedingly, exceedingly important. And for laparoscopic, you can see that this is just recently a month ago, this is the port placement that I use, very similar to the robotic port placement that I use and all. So just to orient you, this is the head and this is a pelvis right here. We basically put the four ports across. These are our working ports, right at the level of the anterior superior iliac spine. And then two camera ports. One is the pelvic port to do our pelvic dissection. And one is the suprapubic port, which is about two centimeter above the suprapubic bone. And this is the abdominal camera port to perform it. And then we usually use a 30 degree down scope. That's a port placement configuration that we use. So I'm gonna talk a little bit about the pelvic dissection and then we'll, more about the retroperineal periodic node dissection. So with the periodic node dissection, I really want the concept of what I think right here, this is the port that you can see in the diagram and the pelvic camera port at the level of the umbilicus and abdominal camera port. But more importantly, these four box technique, which I will talk to you about in the periodic. When we're doing minimally invasive surgery, particularly what I have found in robotic surgery, we really, really rely on anatomical boundary. I have become a better anatomist over the last decade in performing robotic surgery because you lose the tactile feedback. You no longer have the haptic feedback. So I rely a lot on my anatomical landmark to perform my lymph node dissection. So these are the anatomical for the external iliac lymph nodes, really the lateral, the psoas muscle, the paravesical and pararectal spaces are my medial boundary and the ureter. And the anterior, what I would call anterior is the distal about circumflex iliac vein is our boundary. And the common iliac is the posterior orthocephalic boundary and important structures that you have to remember when you're performing this is to make sure that you don't compromise is the external iliac artery and vein, of course, and the genital and the ilioinguinal nerve. And then followed by what I call level one lymph nodes are the external iliac pelvic lymph nodes. And level two lymph nodes, what I describe as the obturator lymph node. These are lymph nodes that resides in the obturator fossa and the lateral boundary for that is the obturator internus muscle, which we look for, the paravesical and the parametral and the pararectal spaces depending on the distal obturator nodes or the proximal obturator nodes and the obturator canal and the bifurcation of the external and internal iliac vessels in the cephalop boundary. And these are the pertinent structures, the obturator nerve, artery and vein as the pertinent structures that you have to be careful of to make sure that it doesn't get compromised. So this is basically, this was a patient that I had to actually go and restage it back because of the deep myometrial invasion and all. So she had her hysterectomy. And the first thing that we really do is start in a posterior broadly ligament and opening. And you see the ureter right here. This is all scarred down and we open up the right anterior broadly ligament and we continue the dissection along and identifying the ureter. And what I'm shooting for is the obliterated umbilical artery because this is the anatomical landmark that we use and we drop right down there and this is the avascular space to develop the paravesical space. And once you've developed the paravesical space, you can see the lateral boundary is the external iliac artery and vein and the very first structure that I will identify is the accessory obturator vein. Once we have developed the paravesical in the paravertebral space, we're gonna start our dissection laterally. I would always suggest starting the dissection on the common iliac because the vein is a very thin wall structure. We start our dissection cephalad right along, lateral to the common iliac, to the psoas and then we basically skeletonize the vessels and then distally and come across the circumflex iliac vein. And once we know that you can see that the assistant is basically retracting the obliterated umbilical artery, opening up the paravesical space and we basically dissect along distally and roll the tissue from laterally to medially and drop down into the obturator fossa. You can see the accessory obturator vein right here. So we get access to the obturator lymph nodes. And as soon as we see the accessory obturator vein, here's the obturator membranous fascia right here, the lateral boundary. And we're gonna follow this accessory obturator vein down where we can identify the obturator nerve because that's the major, and that is the extent of the structure. So here, we're gonna follow this gingerly and here's your external iliac vein with the accessory obturator vein. And we're gonna, and you have to be very careful when you're skeletonizing and you can see that I'm doing a blunt dissection here and I'm gonna find the obturator nerve. And as soon as I find the obturator nerve, I stay on this obturator nerve and to clean off all the vessels, I mean, all the lymph nodes, skeletonize it off the obturator fossa. So we start proximally, go distally or cephalad and then caudate all the way to the pubic bone. Here's the obturator nerve as we skeletonize it. And you can see that that's, and then there's your obturator vein. And as it courses into the obturator canal. So we will clean off all these lymph nodes along here. So these are the medial lymph nodes that we're gonna be removing or the obturator fossa lymph nodes. Once we clean that all off, we'll then go and find the, here's a lymphatic channel of it. We're gonna seal that off and then get that off the obturator vein. And we'll dissect all the way down to the levators. Now, one can argue, do you need this extensive lymph node dissection on an endometrial cancer? Not necessarily. I mean, this is a patient that we, after the obturator lymph nodes are removed, we're gonna come clean the lymph nodes that interpose between the external iliac vein and artery and psoas muscle. That's really important to come immobilized because if you try to tease off the lymph nodes from medial, you're gonna pull a lot. There's a lot of vessels or vein, venules, particularly the lateral gluteal vein that you can pull off that you can get into the bleeding. So when you're performing this dissection, you can see I'm gingerly retracting the vessels laterally, holding position, and the mobilization of the lymph nodes are on the psoas muscle. I don't dissect along here. Once I have mobilized the lymph nodes off the pelvic sidewall, I'll come off immediately. And the important point here and here, these are the more cephalic obturator lymph nodes. The first thing I do is, first of all, take your assistant, open up the paraplesical space, and I find the accessory obturator vein and find the obturator nerve and stay on top of the obturator nerve right here. And I work my way towards cephalic. And this is removal of the pelvic lymph nodes. So after you do this, there's your lymphadenectomy for the pelvic. After you do this, we're gonna go ahead and do the aortic node dissection. And this is, in the aortic node dissection, these are the anatomical boundaries of this again. And I can leave this for the fellows. You could have these slides so that you can review it and all. But what you're really looking, I call it the four-box technique. So here's the four-box technique. When you're doing a minimally invasive surgery, aortic node dissection, you do not have the luxury of having the entire midline incision open and the bowel packed away, and you can get the whole exposure of this. You have to work within the box. And really, I call it the four-box technique, where the IMA is the midline, and I bisect this in four quadrants. So you have the right infra-IMA lymph node, right supra-IMA lymph node, followed by left infra-IMA, which is box three, and left supra-IMA, or what we call, this is what I call the holy grail, where everybody tries to get there, the left renal vein and all. You often hear, we do an aortic node dissection, we can get up to the level of the IMA, but above the IMA, sometime on the right side, you can get, but on the left side, it's much more challenging, particularly for patients with high BMI. When you think about this four-box technique, what I'm essentially doing is really identifying the anatomical structure that allows you to perform and remove these lymph nodes, the right infra-IMA fossa, right supra-IMA fossa, left infra-IMA fossa, and left supra-IMA fossa. These are divided into four quadrants, and then usually the upper port or lower pelvic port placement. So this is the laparoscopic version that a lady that I just did literally a month ago. So what you wanna start off is the dissection, two centimeter medial to the sacral promontory. This is the same approach I use. It is medial to the common iliac, and we're gonna incise this peritoneum within the mesenteric fold and go up cephalad just very much in the same way. Here's the mesenteric fold, very much in the same way than open. And what we're gonna do is shoot for the duodenum because the duodenum is gonna be, the left renal vein is gonna lie inferior to the duodenum. So here it is, we're removing the right infra-IMA, starting the dissection right at the common iliac, and you're gonna elevate these lymph nodes and skeletonize and using the ligature here. And basically here's the caval wall. I encourage you to start the dissection on the common iliac because the walls are a little thicker, and then find the caval wall and develop this plane. Once you have that, I always like to use a Raytech. The Raytech. Now, in this case, I showed you this because you have to be careful. I pushed the Raytech and trying to mobilize, and I denuded the duodenum right here. You can see that. So we had to end up repairing that. So you wanna be very careful when you're, even when I was bluntly dissecting it, you denude, I ended up denuding that. So we ended up reinforcing the seroso because one of the injuries that you can have when you're doing a high supra-aortic nose, you could potentially compromise the duodenum without recognizing it. So we're gonna start a dissection on the box two. This is the right supra-IMA staying on the caval wall. Here is the cava, okay? And then we're gonna, here's the aorta. And elevating the tissue, and I hope you can see, I'm staying away from the cava wall, the energy. You wanna stay away from the energy level so that you don't have potentially compromised the vasculature. So I'm constantly grasping the tissue ventrally, skeletonizing the tissue. Here, I'm pulling up again, and I start my dissection right here. So this is box number one. We did the box number two first because right up there. And here, I'm gonna elevate the tissue off the caval wall, very much the same way that we would do on an open. And I can see the caval wall clearly, and we will mobilize this tissue here. So after completion of the box one, we're gonna roll the tissue from medially to laterally. Once we see the cava laterally, we're gonna come off the tissue, and you're gonna stay on the right, the ureters on the peritoneum. You can see that right ureter right here. And this is completion of the box one and box two. After that, we're gonna hop on over to box two. I mean, three and four on the left aortic. And what this is, is your assistant's gonna grab the left lateral edge, the superior edge. And here, we're going to basically identify the left renal vein. This is at the duodenum, and this is your left renal vein right here. And you can see that there's an enlarged node right here on this infrarenal. So we're gonna start right on top of the aorta to skeletonize and remove that tissue. And after that, we're gonna stay on the aorta, roll medially again to laterally. And here, this is the anterior aorta, right below the renal vein. And we're gonna roll off laterally to go and find the ovarian vein, where it inserts into the vena, not vena cava, but the left renal vein. So here, we just removed the interaortic cava lymph nodes. You have to be very careful when you're removing this interaortic cava because there is the assagus vein, which you could potentially compromise and you can cause chylus ascites. So you wanna get either clip or good seals of this. Now, this is a transperitoneal approach. This is not an extraperitoneal approach that we're doing. So here, I'm starting my dissection, continue up, and we're going to identify the left ovarian vein as it inserts into the left renal vein. And here is the left renal vein right here. You can see right here. And we're gonna, once we find the left renal vein, we're gonna drop down laterally and identify the ovarian vein right here. I don't know if you can see that right here, the ovarian vein coming in and inserting into the renal vein, which is up here. So once we clean off the entire box number four, left renal vein there, and the ovarian vein insert, we're gonna drop down to box number three. This is right over the sacral promontory. You've gotta incise this peritoneum inferiorly to the sacral promontory so this peritoneum can be retracted laterally. We then identified the left common iliac vessel, and we're gonna drop right down and identify the left ureter, which is right here. It showed it on the previous. And I'm gonna stay right on top with the left common iliac vessel, and then work my way up, cephalic, anterior to the aorta. Okay, now you can see the limitation of laparoscopic surgery right here. I mean, you don't have a wristed instrument. We're limited by the port placement, and we have to angulate it. And that's why the four ports that I put in there, that allows me to interchange the ports and all that. So this is removing the lower inter-aortic caval lymph nodes. The IMA is right here. So once we remove that. So here is the IMA right here. That's coming here. And this is box number three. And we're gonna remove the lateral lymph nodes along the lower aortic lymph nodes. This box number three is a really, really difficult. So I don't know if you noticed, I jumped from the port in the right lower quadrant, inner core to the outer quadrant, so I could get access. So after removal of this periaortic lymph nodes. So the key here in doing a periaortic node dissection and pelvic node dissection via MIS, is really about anatomical recognition. You've got to, here's your ovarian vein, and the ureter is right under there. Your ovarian vein inserting into the vena cava. Here's your left renal vein, and the IMA, and the common iliac. So here's your IMA of that. Okay. I know there's a lot of movement in laparoscopic surgery. I know we're out of time, but here's what I wanna show you. When Linda asked me to give this, quite honestly, so this was my laparoscopic aortic node dissection with argon beam in 2000. I wanna show you, okay? This is my robotic XI that I do. So you can see the stability. We all know that of it, of the difference of the technology. This is box number three. That's the left infra IMA lymph node. Here's the IMA, but we were doing this. So this is with the XI, you can see the ureter. You can skeletonize and all of that, the technology, the difference of it. And what's more interesting is, this was a similar dissection. This is the laparoscopic periodic lymph node dissection. And this is using the most recent, the newest technology, what's called the synchrocele, which is very much like the vessel sealer that I use laparoscopically. So same dissection, I'm performing up to the level of the duodenum and the technology in advance. I know that Vietnam has, Da Nang has limited and all, but hopefully the technology, you know, you can catch up and all, because we can really offer our patients, here's your renal vein with the, as technology advances and all, we can offer our patients better care and all of that. So with that, I'll stop and take questions or if there's time. Thank you. No, thank you, Peter. And all I can tell you is that.

minimally invasive surgery

gynecological cancer

bioproscopic retroperitoneal node dissection

endometrial cancer

cervical cancer

ovarian cancer