Welcome, everyone. My name is Inger Desalle Eriksson, and I'm a gynecologic oncologist at the Norwegian Radium Hospital in Oslo, Norway. As a vice chair of the education committee for the IGCS and today's moderator, I'd like to welcome you to this surgical film festival on lymph node assessments in gynecological cancers. We are thrilled to have a full house today with attendees from more than 74 countries. First I want to mention a few housekeeping notes relevant to the Zoom platform of this festival. Please adjust your view to full screen mode, which can be done in the top right-hand corner of your screen, and also adjust your view settings to fit to window. Second, the quality and clarity of the video presentations are linked directly to the speed of your internet connection. Now high speed and a wired connection are best for viewing these videos. If the quality of your video stream is poor, however, during the presentations today, this webinar will be made available to view on the IGCS education portal in a timely manner. For additional video content, the IGCS has partnered with AHEL to provide educational videos on the SurgeryU platform, which can be found again in the IGCS membership education portal. There are many excellent videos on this platform available to you already. We do welcome video submissions to be considered for this platform. We also encourage you to consider submitting films to our journal, the International Journal of Gynecological Cancer. We have an incredible panel of surgeons from around the world who will be sharing their expertise on lymph node assessment in gynecological cancers today. Immediately following each film, there will be time for discussion, so please, we encourage you to submit questions via the Q&A feature at the bottom of your screen, and we will do our best to address as many questions as possible. Now, it's my great honor to introduce today's speakers. Joining us are Emma Rossi, Assistant Professor at the University of North Carolina in the United States, Reiner Kimmig from the West German Cancer Center, the University of Duisburg-Essen in Germany, Vance Broch, Assistant Attending in the Gynecology Service in the Department of Surgery at Memorial Sloan Kettering Cancer Center in the United States, Paolo Zanvetter, Head of Gynecology Service in the Department of Pelvic Surgery at Aristides Maltese Hospital in Brazil, and Eric LeBlanc from the Oscar Lombret Center in France. Now, without further delay, we will begin our session with Dr. Rossi setting the stage and discussing indications and benefits of lymphadenectomy and sentinel lymph node for GYN cancers. Dr. Rossi. Thank you very much for having me. We can advance the slide. I have no conflicts to disclose today. We can advance again. So I'm excited that we'll be viewing together some very excellent films that demonstrate the techniques of lymphadenectomy, but let's first discuss why we remove lymph nodes in the first place. In some select cases, there's a therapeutic benefit, particularly when the lymph nodes are grossly involved with disease, but for the majority of our patients, this is largely a diagnostic tool. Effectively, lymph node status serves as a biomarker, determines whether a patient's disease is a local disease for which we need local therapies, like surgery and radiation, or a disseminated disease, which we need to treat with systemic therapies. Next slide. And there are some challenges to lymphadenectomy. We don't know whether to always perform it, especially if we don't know that that specific technique is going to be associated with a survival advantage, such as endometrial cancer. It does require that clinicians have additional skill and training, and it exposes patients to additional risks. Next slide. So what does it mean to remove lymph nodes? Well, we have to think back a couple of slides of what is the purpose of this, and there are some really important goals that we have that we should keep in mind. There's really two different classes of lymph node removal. There's a targeted approach, the sentinel lymph node biopsy is an example of that. And then there's the more generalized or regional lymphadenectomy approach, which is the traditional approach. And if we're to consider that one is adequate in achieving the goals that we have of diagnostic accuracy, they have slightly different criteria for what make them likely to be accurate in diagnosing metastatic disease. So for the regional approach, in that concept, surgeons are considering what is the historical region that's most likely, what do we know from historical data, is most likely to harbor metastatic disease. And then we need to quantitatively remove all of the tissue from all of those regions most likely to harbor disease. So an effective regional lymphadenectomy needs to follow considerations for are we removing all of the tissue, a larger nodal count, for example, from all of the relevant regions. And an example of this might be in ovarian cancer staging, where it's important to remove lymph nodes from not just the pelvic, but also the para-aortic basin, and not just inframesenteric lymph nodes, but also those high para-aortic nodes below the renal vessels. In a targeted sentinel lymph node approach, our goals are a little different, and what determines whether that's effective at diagnosing metastatic disease is less about quantitative goals, but more about qualitative goals. So we don't look to the anatomy textbooks with targeted approaches to tell us where to operate. We look to the patient herself. We look to see where the drainage pathways are showing us to operate, and that's where we go. And so what's important is to look for the mapping, the channel, the pathways. And we know we've removed the correct node if we're finding that first in chain node that's most proximal to the origin of the tumor. And sometimes there are more than one channel, and sometimes the channels lead us in places that we don't normally remove lymph nodes in that conventional regional lymphadenectomy. Another important concept in qualitative evaluation with lymph node removal is considering bilaterality. This is particularly important when we're considering our non-lateralized organs, like the uterus, the cervix, and midline vulva tumors, in that we need to evaluate potentially both sides of the pelvis, aorta, or groins. And if, in a targeted approach, we don't see mapping to both sides, we have to evaluate whether surgically we need to do something else with that other side. And it's not just about surgeons and what surgeons do that influence the quality of our ability to diagnose metastatic disease. It's also what our pathologists do. Next slide. So in traditional regional lymphadenectomy, where pathologists have to deal with potentially dozens of lymph nodes, what they'll traditionally do is bivalve the node down its longitudinal axis, demonstrated here by that horizontal line across the purple node, and then perform H&E slides on both sides of the lymph node. But when we provide them with a targeted approach, like setting a lymph node biopsy, a smaller number of nodes to evaluate, they can look at them much more closely. They can bread loaf the node across its cross section, as you can see here, and pick up a potentially tiny little focus like this up here, where the capsule metastasis in green. Next slide. And so see what that's like. That helps to show pathologists that it could be metastatic disease. What to do with that disease is another clinical quandary, which we won't address right now. Next slide. So let's briefly talk about the different cancers that we treat and how lymphadenectomy is important for them. So in ovarian cancer, in the case of advanced disease, there may be a role for debulking of grossly involved disease, but probably not for removing grossly normal appearing nodes. But in early stage ovarian cancer, we know about 20% of clinical stage I ovarian cancers are associated with positive lymph nodes on surgical evaluation. And so for those women, it's important to evaluate them. Now, we haven't yet really developed robust and reliable ways to perform targeted lymphadenectomy, meaning sentinel lymph node biopsy for ovarian cancer, although you'll see some videos today which will show how that might be able to happen. So for most of us, we rely on that traditional regional lymphadenectomy approach. And for ovarian cancer staging, it's very, very important that we assess the regions most likely to harbor metastatic disease, which are those infarenal or high periodic nodes. And in the pelvis is actually the proximal obturator lymph nodes, the ones that kind of tuck behind bifurcation of the internal external iliac vein. It's also important for ovarian cancer to assess both sides of the pelvis or aorta, because we find in up to 30% of patients with a unilateral cancer, an isolated contralateral lymph node metastasis. And then obviously different ovarian cancer subtypes are more or less likely to be associated with lymph node involvement, and so we may tailor whether or not we perform lymphadenectomy based on those factors as well. In cervical cancer, lymph node status is a really important prognosticator, and it helps guide our adjuvant therapy, both our surgical management, whether or not we proceed with radical hysterectomy, but also whether and where we direct our radiation if that's necessary. So imaging like PET is sensitive in only about three quarters of cases of positive nodes, so surgical evaluation is still important. Fortunately, we do have the development of a targeted sentinel node approach that's been shown in trials like the SENTACOL trial and other large prospective series to be very accurate in detecting metastatic disease, particularly for small tumors less than 2 centimeters. And in some cases, a regional periodic lymph node dissection is important, either therapeutically to debulk those nodes or diagnostically to help guide and minimize the radiation, particularly in premenopausal patients or those who are at risk for bowel toxicity. In endometrial cancer, there's a lot of controversy about lymphadenectomy. It was introduced as part of staging in the 80s when it was recognized that about 20% of women who look to have stage one disease actually have extra uterine disease, and we now subsequently know that survival is improved when you identify, when you treat that identified extra uterine disease with chemotherapy. But lymphadenectomy in and of itself, we know not to be therapeutically beneficial. Additionally, the question then or the challenge arises that endometrial cancer is predominantly a disease of overweight or obese women, and it's technically difficult to perform lymphadenectomy, particularly periodic lymphadenectomy in these patients. So what is the role of periodic dissection in endometrial cancer? Well, isolated periodic metastases probably only exist in about 1% of all comers with endometrial cancer, but in a higher percentage, that's 16% of women with deeply invasive, higher grade tumors, which has led, that kind of knowledge has led to development of selective lymphadenectomy algorithms, choosing certain patients that have high risk probability for harboring metastatic disease and only performing those extensive lymph node dissections on those patients. For example, patients with high grade deeply invasive disease. And then more recently, what we've developed is this targeted approach to lymphadenectomy, the sentinel lymph node biopsy, which we've found in both low grade cancers and more recently with the central trial in high grade cancers as well, to be very effective at fighting metastatic disease in about 98, 97% of patients. New slide. In vulva cancer, lymph node status is critical as a prognosticator, and lymph node relapse is lethal for most patients. Unfortunately, the complete inguinal femoral lymphadenectomy is one of the most potentially morbid procedures we perform on patients. And so fortunately, once again, we've developed this targeted approach, which has been shown to be highly accurate in finding metastatic disease, and that's the sentinel lymph node approach with very low rates of relapse in the groin. Surgery itself, completion of the regional lymphadenectomy in the groin, we know is superior to radiation alone when the nodes are positive. So there's some therapeutic role as well for lymphadenectomy in vulva cancer. In some patients, a pelvic nodal assessment is also relevant when it's helping to take care of lymphadenectomy. So, again, the sentinel lymph node biopsy is an important tool in the toolbox. Next slide. So some of the realities about lymph node dissection, as I mentioned before, it can be technically challenging, particularly in a world, in the Western world in particular, where we're seeing increasing rates of obesity. And so we have to ask what surgeons are able to accomplish. And film festivals like today are going to help expand that. We need to consider approaches like minimally invasive approaches and extraperitoneal approaches, and you'll see examples of how that can be done today. We also need to augment what we can with imaging modalities and improve the accuracy of those, and ensure that everybody around the world has access to sentinel lymph node technology. And keep in mind that different places that technology may or may not be available. For example, near infrared imaging and nuclear medicine can sometimes be hard to come by. And so for those surgeons, they may rely on a colorimetric method, which means visual identification of the channels using blue dyes alone or black dye carbon nanoparticles, both of which unfortunately seem to be associated with a little bit lower rates of detection. Next slide. Lymphadenectomy is toxic. It increases operative time and risks retroperitoneal structures to operative injury. And then post-operatively, we know about 20% of patients can develop lymphocysts, about half of women can develop genitofemoral nerve dysfunction, and groin cellulitis is a major issue for women undergoing groin dissection. And then there's lymphedema. So in GOG244, we saw that rates of lymphedema, or at least increase in lower limb measurement size, were as high as 30% in women with endometrial and cervical cancer who'd undergone lymphadenectomy, and nearly half of women with vulvar cancer. It's an underreported issue with major quality of life implications. And we see it more so the more lymph nodes we remove. As you'll see from this next slide, where with increasing removal of lymph node counts in the black line, we see increasing rates of lymphedema in the blue line. Next slide. So how do we reduce this morbidity? Surgical education, learning better techniques, considering expanding your minimally invasive surgical portfolio, and developing skills in an extraperitoneal approach, and developing skills in the sentinel lymph node biopsy technique to offer that to patients, which has been associated with decreased morbidity. So in the future, lymph node assessment continues to be an important both therapeutic and diagnostic biomarker for the diseases we treat, but we need to continue to advance our science and knowledge of how to do it in a less toxic way. Thank you. Thank you very much, Dr. Rossi. That was excellent. We will now move on to our first film with Dr. Rainer Kimmig on SLN mapping in ovarian and uterine cancers. Yeah. Thank you very much, Anne, for this introduction. I'm Rainer Kimmig from Essen in Germany, and I have, in fact, no conflict of interest, but I work a lot together with the robotic companies, I have to admit, especially Intuitive and Medtronic. You will see now in the presentation just the video, and Emma did a very good introduction to the aim of lymphadenectomy, but you have first to find, could you start the video just, if you want to find the central node or to do a regional lymphadenectomy, or on the other hand do a complete lymphadenectomy, you have to know anatomy. And it's not parendum, it's always built in the same way. There are three pathways of lymphatic drainage from the inner female genital tract. The first one is coming from the deep cervix, the vagina, and is going to number one. You see here in the graphics, it's the line along the internal iliac pathway and the pre-sacral and comes behind the vessel in the lumbar part. The second one is coming from the endometrium and corpus and also from the ovary, and is going to the lymph nodes along the uterine artery and the iliac vessels, and the third one is going directly to the parotid nodes along the infundibular pelvic. And I show you that there is a difference from injection in the different regions. Here the cervical injection shows you that there are the two lower pelvic drainages, medial of the vessels and lateral of the vessels. Here's the common iliac area, and if we open now, the baritoperitoneum on the right, you will see on the left, the ureter, the crossing of the iliac vessels and medially of the interna, you will see the deep internal pathway coming to the pre-sacral region on the left side, the number one, and the arterial drainage along the uterine artery crossing the vessels and going to lateral, which was signed by number two. Here the preparation of the deep drainage of the pelvic region is shown, and if you look for the sentinel node, you have to realize that the sentinel node is always defined as the first node in the drainage. So these nodes prepared here are first line nodes, but never the sentinel, because it's just postponed. And if we prepare downward, then you will see that at the end of this preparation, you will see the sentinel. If you want to pick the sentinel only, you have to look for it, and you have to be sure that it's the last one before you will enter the vessel of the uterine artery or vein in the organ in the mesometrium. So but here it's shown the whole targeted first line region so that you can understand where the vessels come from and how to prepare the nodes. Now you look to the left on the right side, you see here the ureter and also the hypogastric plexus, and you see that this drainage of the deep pelvic pathway along the veins and the internal vessels is going along the nerve and then reaching the internal iliac region and in the consequence, also the presacral region and subaortic nodes. This is typically cervix, and you almost never find node metastases in endometrial cancer here, at least not sentinel node metastases. And but these nodes are also marked with a cervical injection. So this is needed for cervix, but not really for endometrium what you see here. This is the first. And now you see directly here, if we open up the sentinel node, which is the first node in this line below the scissors right now, and if I cut this, then we will see it in the end before we switch to the second. Yes, this is the sentinel node of the deep line because this is the last one before we come into the mesometrium. Now I show you how we inject the corpus if you want to do that. We take this IVA trumpet, we know from the pudendal anesthesia, we put the needle through and then you have about one centimeter needle at the tip, and then you can use this IVA trumpet as probe, go into the ureters, feel easily the corpus on the right, on the left, and stitch with the needle in and now you will see how it comes. You can control for your injection and you see easily the coloring. And now look at the cervix. It's not colored at all. It's just the corpus color. And then you will see the drainage of the corpus. This is a surgery where we removed all the drainage system. And now if we now look in the preparation, you will see that there is a difference. You see now only the two channels, the one from along the uterine artery, here you see we open the field of the umbilical artery, we see the superior vesicle. And if we open now the drainage to the iliac vessels, we will see that the green channels are coming along the uterine artery and crossing the umbilical. And here you will find now the first line nodes of the corpus. And I told you already, these are also first line nodes of the cervix. And this is the reason why it works if you inject the cervix that you find these nodes also for the corpus there. And then if you dissect the nodes medially to the big vessels, then you will have some dissection. Let's name the first line nodes or targeted compartmental lymphadenectomy. If you look just for the sentinel, you have again to go backward in direction to the uterus and find the first node in this line. And this is not always very easy. So the question is whether it may be safer to do it like we normally do it to remove the first line nodes, which are normally about two to four nodes on each side. Not very much more, but complete the drainage system. Now you see the node, this is the central node behind the vein, which is cutted now. This is the one line, it goes around the vessels to lateral, below the vein, and the other node upward is the node which is normally located in the bifurcation of the artery. And if you mobilize now this tissue, then you can see that the lymphatic channel crosses. Now we have to mobilize this upper branch of the lymphatics. And now you see, if you pull it medially, where the green channel comes from, it crosses the umbilical artery exactly there where the uterine artery is branching off. So if you look at the green and you open there, you will always find the uterine artery below. So this is also easy to look for the uterine artery. And then if you prepare now in direction to the uterus, you can either decide now to use these nodes or your sentinel if you took just the first one for examination. Or you can also dissect the whole lymphatic system down to the uterus, which is the strategy of the compartmental ontogenetic-based surgery, not only to pick out some parts, but to remove the whole system. So this will be now cutted at the channel in the mesometrium and put into a bag. And if you look now at the nodes in the bag, you will see that there is the central node. And after the central node, there are two channels going around the iliac vessels. Now we will see it in this case. This should show you in another case, this is now cervical cancer, which has the same drainage in the upper pelvic drainage along the uterine artery, as I told you, as the endometrial. But in this patient, this was a patient which decided to have an organ preserving treatment, fertility preserving. And so we decided to remove the whole lymphatic drainage until we reached the uterine wall. Here you see the uterine artery and the nodes, the central node you saw, it was the big one directly at the pelvic sidewall. And now we remove the vessel down to the uterus. And we see that there is no other intercalated node. And now we come to the branching, where the vessels are gathering the lymphatics coming from below from the cervix. Here you see the branching and from above from the corpus. And then all the fluid from corpus and from cervix is going along this vessel to the pelvic sidewall. And again, you understand why you can inject the cervix and find the central nodes of the corpus. And then we dissect it here directly at the uterine sidewall. So we are safe in this case that we remove the whole lymphatic system in this organ preserving situation for cervical cancer. But again, to understand, there is no central node, especially for endometrial or for cervix or for ovarian. The central nodes are always the first nodes in the lymphatic drainage, and they are just three lines. And this is very stable. I almost ever found these three drainage, which is coming the lower pelvic, the upper pelvic. And then the last thing what I show you is the paroortic drainage along the infundibular pelvic ligaments. And it's almost identical with some anatomic variations, but just variations and not completely different drainage. So this gets now what I told you before, you will see when I put it in the bag, how the central node is reached with a green channel and then divides in two channels. And these are the two channels surrounding, now you will see, here you see it, surrounding the iliac artery and vein, ventrally and dorsally. So now the last part of the video shows you the upper drainage along the infundibular pelvic ligament. This is an early ovarian cancer. And we changed our policy not to do a complete systematic lymphadenectomy of all the regions of no importance in that case, but do a so-called targeted compartmental lymphadenectomy. And we can inject either in the corpus, if the corpus is still there, or as you see here in the infundibular pelvic ligament. And then you will see the lymphatic channels accompanying the ovarian vessels. And normally there is one vessel along the artery and one along the vein. Here in this case, we have two along the veins and one along the artery. I also saw two and two. So this is also slightly variable, but normally it's just two vessels. And you prepare along the infundibular pelvic ligament and resect the vessels. And these vessels will guide you to the paroortic first line nodes and also to the paroortic central node. So you can again decide whether you want to dissect either the whole regional nodes as a package, as a compartment, or you want to take just the central node, or you want to do still a systematic lymphadenectomy irrespective of whether it's strained there or not. But the basis for that is the knowledge of the anatomy. Now you see again here the vessels. And we switch now the camera and looking from down upward to the abdomen. And I will show you how these vessels run on the right side paroortically. Now you see here, we look upward, we see the cable vein, and now we see the central node. And together with the first line nodes, it's already published in journal Gein Onk. I took that from this video. And if you mobilize now cautiously the duodenum from this part, then you will see the anatomical relevance or a neighborhood to the structures. You will, on the one hand, you will see that there is not only one draining vessel and not only one sentinel node. This is the arterial central node you see here. And this is normally a little bit above the mesenteric inferior artery, which you will see on the right side a little bit below. But then if you continue to prepare, you see a second small channel going along the ovarian vein. And this is curving higher up. Now you see it very well, the upper in another node. And this node is rather inter-autocavally between the big vessels and is going more to the dorsal part. The arterial part is always ventrally of the vessels. Now on the left side, you see the urate is far away. And we prepare the ovarian vein. And when you mobilize, coagulate, and cut the vein, then you can lift up the whole lymphatic system of the drainage of the right ovary. And don't forget, these are the same nodes which strain the uterine fundus. So it's, these are also the nodes which would be positive in endometric cancer of the uterine fundus if there is metastasis. So we coagulate and cut it. And then we will go to the venous sentinel node, just starting to prepare. And to the end of this video that you see also the left side, because it's slightly different, we then switch to the left side. Now you see, this is a sentinel number three of the third line from the venous part. And we have the sentinel below from the arterial part. Now on the left side, it's different. It's a little bit more difficult because there is the sigmoid. But you see here also the vessels coming from the ovarian vein. It's, you have also to recognize that the lymphatic system is never laterally of the ovarian vein. It's always medially. So don't look for nodes laterally of the ovarian vein in our tumors. But here you see very well, medially, the sentinel nodes drained from the artery and the vein. And again, if you prepare the vein and coagulate and cut it, you can take either the sentinel nodes only or the whole lymphatic system here, which we call compartmental targeted lymphadenectomy. So that's it. I hope you saw that there are three lines of lymphatic drainage. They are very constant. And if you know this anatomy, you can decide what you want to do and you will find the right nodes. Thank you. Thank you, Rainer. We will now open up to a discussion regarding this video. And I do remind you that you can use the Q&A feature at the bottom of your screen. We've had some questions come in on this Rainer. So in regards to, let's see here, your video initially, one of the comments Rainer was that with this ICG dye, it may look like a total mesometrial resection more than really than the sentinel lymph node biopsy. And the question I've submitted here says that they tend to use the first node colored on each side. And could you comment on that perhaps? Yes, I will comment that. I can't show you videos just picking the sentinel node because I'm convinced that this is a diagnostic procedure and has nothing to do with therapy except indirectly. So we normally do it like I showed you, but the aim was also not to show you how to pick a green node to say this is a sentinel and take it out because that's easy. That can be done by an intrainee very early. I wanted to show you how the lymphatic system is arranged, how you find the situation. And it's not necessary that you remove all the nodes I showed you. You can look for the drainage. You can find the first node. You can define it and take it out. And then you have a diagnostic sentinel lymphadenectomy. But you have to know that there is a deep pelvic, the superficial pelvic, and the paraortic drainage. And this is drained from the different regions of the uterus and has nothing to do with the tumor itself. It's always the same as anatomy. Thank you, Rainer. That's great. We've also had a question in regards to docking. Now, some people might do this via traditional laparoscopy, some robotically assisted as yourself, and some might have access to the XI and others the SI. In regards to doing both pelvic and paraortic lymphadenectomy, how would you dock? Yes, it's easy in XI. Let's start with that. We dock first at the umbilicus and right and left of the umbilicus and look down to the pelvis. We do the pelvic. And then we re-dock. We dock off. We re-dock with the direction to the liver. And then we do the paraortic region. That's very easy. It took two or three minutes to change the docking. So it's no longer a problem. Always at the level of the umbilicus. In the SI, it's more difficult. When I had the SI, I did it that I put the trochars as high as possible, a little bit below the arch of the torx. And then it's possible to normally to reach the infernal region, not in all cases, but in most. So I did not re-dock again. And the third possibility is to do it 45 degrees as a side docking and coming from below. Also again, along the umbilicus to do first the pelvic and then coming from above the 45 degrees and do it upward like Henrik Falconer does it. And in laparoscopy is easier because you can just turn the side and then look up and down as you like to. Absolutely. Thank you. I agree with that. Also in regards to sentinel lymph nodes, and particularly maybe an ovarian cancer and obese women, do you have any tips or tricks? Your patient in this video was obviously of a lower BMI, which is great for educational videos, but then in real life, they might have a higher BMI. Yes. It is our all experience that it's the higher the BMI, the more difficult and the shorter the patient in addition also. And I just have the tips, what I do normally, I do it always first. If I have to do parotic, don't do pelvic first, do always the parotic first, because at the end of the surgery, everything is much more difficult. The second thing is use the so-called T-lift if it's not easy to lift up the bowel and then leave some peritoneal flap to the mesentery of the bowel. And then you can stitch with the T-lift, you can take one of the sponges you saw in my film, stitch through so that the tissue doesn't rupture. And then you can lift up like a tent, your peritoneum, and then it's much easier with three arms. You have a third arm also to lift up again other tissue and to work with two arms in this region. And I would say in 90, 95 percent, you will succeed with this. And maybe there are some patients you will not do a really adequate lymphadenectomy in that way. Thank you. We have very many questions coming in, but I think in the interest of time, we're going to move on to our next video. And then perhaps we'll see if at the end of the session, we can revisit some of these questions that have come in. Thank you very much, Rainer. We will now move on with Dr. Vance Roach on inguinal femoral sentinel lymph node evaluations in patients with vulvar cancer. Please. Okay, thank you so much for that introduction. I'm very pleased to present today. I have nothing to disclose. And we all know that vulvar cancer is a rare disease, representing 6 percent of all gynecologic cancers. Globally, in 2018, over 44,000 new cases and 15,000 deaths were attributed to vulvar cancers. In patients with early stage disease, the traditional surgical approach includes a radical resection of the vulva along with inguinal femoral lymphatics. And while oncologically successful, this radical resection is fraught with complications and morbidity, as Dr. Rossi pointed out earlier, including infection, wound breakdown, sexual dysfunction, pain, and others. And in order to reduce the morbidity of this resection, the traditional longhorn or butterfly resection has given way to the double or triple incision approaches, where the primary tumor is resected with separate incisions from the inguinal femoral lymphatics. This approach considerably reduces the morbidity of the resection, but complications specifically related to lymphadenectomy are unchanged. And these include lymphedema, acute and chronic infection, and wound breakdown. So in an effort to spare patients the morbidity associated with complete inguinal femoral lymphadenectomy, the oncologic safety and efficacy of sentinel lymph node biopsy was evaluated in two prospective studies, GOG 173 and the Groins V study. In GOG 173, the authors noted a false negative predictive value of 3.7 percent in all patients who underwent SLN biopsy and 2.0 percent in patients with tumors less than four centimeters. In the Groins V study, the authors reported a groin failure rate of 2.5 percent among patients who had negative sentinel lymph nodes. And with the safety and efficacy of SLN biopsy for vulvar cancer having been established, the use and technique of SLN mapping has progressed over time. So in the next 10 or so minutes, I'm going to review the evolution of inguinal femoral SLN biopsy in vulvar cancer. I'm going to discuss our experience with this procedure at Memorial Sloan Kettering, and I'll show a video demonstrating the use of SLN mapping for this cancer, highlighting near-infrared imaging and ICG for identification of the sentinel lymph node. The use of blue dyes and radiocolloid lymphocentigraphy dominated mapping techniques in the early stages of the adoption of SLN mapping for vulvar cancer. In the case of GOG 173, all women underwent mapping with blue dye, and two years after the study was activated, the use of lymphocentigraphy was also required as it was noted to have to significantly improve SLN detection. 92.5 percent of patients had at least one SLN identified, and 61 percent of these patients had nodes which were both blue and identifiable with radiocolloid localization. The 2014 meta-analysis of mapping techniques demonstrated SLN detection rates of 94 percent with radiocolloid lymphocentigraphy alone, and 68.7 percent with blue dye alone. In 2010, the use of near-infrared imaging and endocyanin green was described for inguinofemoral SLN mapping in vulvar cancer. This technique has the unique advantage of allowing surgeons to use visual cues in real time to identify lymphatic channels and lymph nodes. Depicted on this slide are images of a handheld near-infrared light source and camera on the left. The middle image is a picture of the groin lymphatic drainage as seen transdermally after injection of ICG, and on the right and bottom images are sentinel lymph nodes in which ICG has coalesced. On the right, the ICG is visualized as bright white on a black background, and on the bottom is what's called color-segmented fluorescence mode, where highest uptake of ICG is shown as red and orange hues, and blue hues show lower uptake of ICG. So given the progression of detection techniques over time, we sought to characterize our institutional experience with SLN mapping for vulvar cancer, specifically focusing on oncologic outcomes as well as the utilization of SLN mapping techniques over time. We looked at our experience with patient who'd undergone groin mapping for vulvar cancer at Morris Home Cuttering from January 1st of 2000 to 2019. In total, 160 patients representing 265 at-risk groins, meaning groins where SLN mapping was attempted, were included in our analysis. The median age was 63 years and medium BMI was 27.3 in these patients. This table summarizes the demographic and pathologic features of patients included in our study. The majority of these patients were white and had squamous cell histology. Approximately one quarter of patients had mucosal melanoma. 14.7% of all at-risk groins, irrespective of histology, were found to have a positive central lymph node. When focusing specifically on those patients with squamous cell carcinoma, 114 patients representing 195 at-risk groins were evaluated. The median tumor size ranged from 0.1 to 11 centimeters, and among these patients, 12.8% had positive SLNs. 68% of these patients underwent completion lymph node dissection, and 68% had adjuvant radiation therapy. 36% of patients had both completion lymph node dissection and groin radiotherapy. Among patients who had positive sentinel lymph nodes, the two-year isolated groin failure rate was 4%, and among patients who had negative sentinel nodes, the two-year isolated groin failure rate was 1.2%. When examining the modality of SLN detection, we found an SLN detection rate of 96.2%, irrespective of modality, and this table demonstrates which modalities or combination of modalities were used for SLN detection. The most common mapping technique was a combination of blue dye and lymphocentigraphy utilized in 41.5% of groins. A combination of ICG and lymphocentigraphy was utilized in 36.2% of groins, and ICG was utilized alone in 10.2% of groins. This table summarizes detection rates for the various detection methods that we employed. When blue dye and lymphocentigraphy are used, the detection rates were 91.8%. Among the 96 groins that underwent mapping with ICG and lymphocentigraphy, 100% of SLNs were detected. When ICG was utilized alone, 26 of 27, or 96.3 of SLNs were detected. Among the 110 groins that underwent mapping with lymphocentigraphy and blue dye, four groins mapped with lymphocentigraphy alone. Among the 96 groins mapped with ICG and lymphocentigraphy, 14 failed to map with lymphocentigraphy and mapped with ICG alone, representing 14.6%. Among all 148 groins for which ICG was utilized for mapping, either alone or in combination with another method, ICG alone failed to map SLN in two groins, or 1.4%. This graph demonstrates the utilization of detection modalities over time. On the x-axis are years, and the y-axis is the percent of cases which utilized a mapping technique. In the first decade of our experience, all patients underwent mapping with lymphocentigraphy and blue dye. However, when ICG mapping was first utilized at our institution in 2012, it's become the most popular mapping technique. In the first four months of 2019, ICG was utilized in all cases, whereas blue dye was utilized in only 16.7% of cases. It's fair to say that this has become the preferred mapping modality at MSK. I want to make clear that while many of us have transitioned to utilizing ICG alone for groin mapping, the NCCN guidelines continue to recommend the use of lymphocentigraphy with a colored dye, either ICG or blue dye, for groin mapping. And with that introduction, I'd like to present a video demonstrating the technique of SLN mapping in bulbar cancer, and I'll highlight the use of ICG in near-infrared imaging. So as I said earlier, a full groin dissection is associated with considerable morbidity. The resection is extensive and the entirety of the nodal packet is removed, and this puts patients at risk of immediate post-operative adverse events and of lower extremity lymphedema and all its attendant complications. And for this reason, SLN mapping has become more popular in appropriately selected patients. Patients who are appropriate to consider SLN mapping are those who have a unifocal vulvar cancer, who have a tumor of less than four centimeters, and who have no suspicious lymph nodes on imaging or exam. There are three mapping modalities used in common practice. The first is the use of blue dye, either methylene blue or lymphocyanin, lymphocentigraphy, typically radiocolloid technetium 99, and more recently endocyanin green with near-infrared imaging. This is a patient who was found to have a two centimeter ulcerated midline squamous cell carcinoma. She had no suspicious nodes on imaging or on exam and was an appropriate candidate for SLN mapping and biopsy, for which she was counseled and agreed. In this patient's case, we elected to utilize near-infrared imaging and ICG for mapping, as well as lymphocentigraphy. ICG is dispensed as a powder and reconstituted as a solution and sterile saline for interstitial injection. ICG is well suited for near-infrared imaging as it has a spectral absorption of approximately 800 nanometers, which is in the near-infrared range. ICG is injected into the dermis bilaterally. NCCN recommends injecting at 2, 5, 7, and 10 o'clock positions with approximately 1 to 2 milliliters of solution and inject it at each site for a total injection of 4 milliliters. The dermis is the ideal location for injection and is associated with excellent uptake into the inguinal femoral lymphatics. If you're utilizing blue dye, the procedure is the same, but with one of the blue dye options. So in addition, this patient underwent preoperative lymphocentigraphy, and here a gamma probe is confirming uptake in the site of injection as well as in the groin lymphatics. Some surgeons like to use this preoperative incision marking with the gamma probe, and that's exactly what we're doing here. So in this case, we're showing the use of a near-infrared camera attached to a boom on a tower that can be placed hovering over the groin. We also frequently use a handheld near-infrared camera, which is a bit less bulky. Patients prepped and draped for access to the bilateral groins and to the vulva, and the groin dissections are the first part of the surgery. The vulvar tumor section is the second bit. So here, this is showing ICG uptake at the site of injection as well as in the patient's right-sided lymphatic channel. So that white light that's seen on the left side of the screen, the patient's right, is the lymphatics leading into the right inguinal femoral region. That confirms uptake in that area and also helps localize, again, the location of the incision that we might make. So with the localization performed, we make an incision. The incision is considerably smaller than what we would make for a full groin dissection, as we're targeting only the sentinel node. And here, the gamma probe is shown sterilely draped, and it's also used in this setting for localization of the sentinel node after the incision is made and ensuring that we're in the proper spot. And the near-infrared light sourcing camera is also used. So here, you can see after the incision is made that white light on a black background corresponding to ICG coalescences is seen. I mentioned earlier that these can be optimized for different color outlays as you prefer, either white light on a black background, the color-segmented fluorescence mode, or green with a normal anatomic outlay. So again, the camera can be used to localize the node and can be being shown during the dissection to ensure that you're dissecting the node precisely and not taking any unnecessary tissue. And as some of the layers of fat over the node are removed, the node becomes far more apparent with the near-infrared light sourcing camera. And in this case, a laser pointer shows the area of focus of the near-infrared light sourcing camera. That's not the case for all the available cameras. And once the node is well dissected, you can see that that bright light is very obvious corresponding to the sentinel lymph node. And now that that sentinel lymph node is identified, it's removed. And then we do check these nodes ex vivo for ICG uptake as well as with the gamma probe. And we also check the nodal bed with the gamma probe as well as the near-infrared camera to ensure that we haven't missed anything or taken out the wrong node. So that procedure is then repeated on the patient's right side. And again, you see a very obvious sentinel node with the ICG uptake there. And then that node is removed. And again, we check the nodal resection bed for ICG uptake as well as with the gamma probe. For anybody who has ever met me, you realize that's not me who's doing the surgery on this video. I want to thank Mario Latteo who allowed me to video him doing this procedure. He doesn't have a beard. I think it's pretty obvious that that wasn't me. So thanks very much to Mario. And that's the end of the video. So this is clearly a huge advance in the field of surgery for us and these women who've had great morbidity after surgery to progress to sentinel lymph nodes. Could you please describe the SLN injection procedure in patients who might come and be referred to you who've had their vulvar lesion removed somewhere else? Is this a technique that you could also use for those patients? It's an excellent question. And we see this very, very frequently, particularly with people with very small tumors which were removed with a biopsy and for whom SLN mapping is appropriate. The important part is to highlight the inguinal femoral lymphatics. And those typically aren't disrupted when people have had the primary tumor removed. You can inject the scar or the area where the lesion was at the leading edge. That's probably the best thing to do. Sometimes it's important if you can't find it, if it was a particularly small lesion, to just talk to that surgeon. Where was this? Or ask the patient where it was and then can inject. What we found also is that anywhere along the vulva, particularly if you're doing bilateral mapping, you can inject up and closer even into the mons, although ideally in the vulva. And that'll have the same inguinal femoral mapping. So if you're really lost, mapping in that area is pretty consistent and can be done that way. Thank you. Thank you very much. Another question here is when using technetium, because clearly ICG isn't available to all colleagues and we might use technetium as well, what's your experience or your recommendations in regards to using scintigraphy? So how far in advance of surgery would you inject the patient with technetium or a radioactive substance and then imaging in addition to using the gamma probe intraoperatively? Typically we inject technetium at least two to four hours before the procedure. And it's one of the reasons why ICG is becoming much more popular. It just eliminates an extra procedure for the patients. They don't have to get the lymphocintigraphy. They don't have to be in the facility for as long. They don't have to have a separate injection. But you know, again, it's ICG and near-infrared imaging isn't available to everyone. So typically we try to do that about two to four hours before the procedure. Some people do it a day before and get that lymphocintigram so they can see where the node might be. You know, in our practice, I found that the actual pictures from that lymphocintigram is not terribly helpful. Localizing the node with a gamma probe is very, very helpful. And I think the one challenge, particularly in patients who have a little bit more adipose tissue in that region, we find that the gamma probe is quite useful in localizing the node when there's a great deal of tissue between the skin and the node. And so, you know, that's one of the things that, you know, we continue to evaluate with our use of ICG is really can that replace the gamma probe in that setting. But you know, I think for the majority of our patients it can. And certainly in our experience, we're only two patients of the, you know, two groins of the over 150 groins that we've evaluated. We weren't able to find the node with ICG. So I do think it's quite a useful technique and probably in the future as the technology becomes more available, we'll replace lymphocintigraphy altogether. Thank you. Thank you very much, Vance. And a final question on this topic, just in the interest of time. Some of these patients recur and they might recur with a second primary tumor in a different location. So if you've done a resection of a primary tumor with a sentinel lymph node dissection, and let's say the patient comes back some years later with a new primary, would you then do a sentinel lymph node technique again? It's a good question. You know, different histologies kind of allow us to extrapolate from different bodies of data. You know, there's not any prospective data that would look at repeat sentinel node biopsy for either recurrence or for a second primary. We can extrapolate for vulvar can't, vulvar melanomas a little bit from the vulvar data, the melanoma data, and we often do repeat sentinel node biopsy in patients who have secondary vulvar melanomas. But, you know, that data is being driven a little bit by cutaneous melanomas rather than by truly vulvar cancers. So, you know, it's a little bit of a more data-free zone than in primary tumors, but we have done it. We have that experience. We do find that the mapping is, you know, it still works. The lymphatics aren't totally disrupted and you can be successful in that setting. Just knowing when canceling patients that the data for its utilization is maybe a little bit less robust. Thank you. Thank you, everyone, for your great questions. We're now going to start our next film, X-Repair to Neal Dissection with Paolo Zanvetter. Please. Good morning. Good morning, everyone. I'm Paolo Zanvetter from Brazil. I would like to thank the International Gynecological Cancer Society for promoting this educational event and the organizer for inviting me to participate in this great presentation. Now we are going to discuss about dissection of lymph nodes by X-Repair to Neal Root by laparoscopy. I declare I have no conflict of interest. And we all know that lymph node staging can be performed by tomography, resonance, PET scans, capacities, and surgical staging. Next. This is an aspect of a topographic anatomy of retroperitoneal and lymph nodes, big vessels, valves, cava, and ureters. Next. And now two exams that show the presence of metastases in pelvic lymph nodes and with no signs of retroperitoneal metastases. Here, you can see in the literature a great sensitivity and specificity of PET, relation of resonance and tomography. Next. On this slide, we analyze the presence of a negative PET result in retroperitoneum. We find a positive histology for metastases in this location, we find a positive histology for metastases in this location. Depending on positivity of PET in pelvic region, false negative in retroperitoneum can vary from 90% in the pelvis if negative PET scan results to 22% on average with PET positive in pelvis. Next. An example of surgical specimen according to anatomical sites. Next. And here, this table shows the results of our institution. We found in two different periods, one in 2011 at the beginning of learning curve, and another in 2018. The selection criteria was the negative finding for retroperitoneal metastases on tomography or resonance in patients with cervical cancer, stage 1b3, 1b3, 2, 4a. Note that positivity in the retroperitoneum was similar, finding 20.9% of positive retroperitoneum in 2011, and 23.7% in 2018. As additional finding, we found around 1% of peritoneal metastases, and in this case, the phantanectomy was not performed. Next. Now the video of laparoscopy, surgical staging. Our institution. Here are the landmarks for the trochers. We start staging the peritoneal cavity, searching for implants, perform the peritoneal washing. Here, the insufflation of esoperitoneal space must be monitored visually to observe any perforation. Dissecting with digital dissecting of the virtual retroperitoneal space. These are the trochar placement. We can see the insufflation for retroperitoneal, esoperitoneal space. And now we start with laparoscopy dissection, in the virtual retroperitoneal space on the left side, searching for the anatomical landmarks, such as left gonadal vessels, left ureter, muscular psoas, iliac common vessels and aorta. Apogastric nerves, starting the lymphadenectomy by left iliac artery. You can dissect with preserving nerves or sacrificing these nerves. Here above the promontoria, below the bifurcation, aortic bifurcation, there are a lot of branches of the apogastric nerve. And on the right side, searching for the left, right ureter, is another landmark, and the bifurcation of the common, right common artery, iliac artery, performing dissection and lymphadenectomy. This field is above, below the artery mesenteric inferior, and the right side of the vena cava inferior. With the, we are performing dissection in the aorta, there are small vessels to negate with energy device. Cranially, we perform the lymphadenectomy in the left side of the aorta, showing the lumbar vessels. Lymphadenectomy of space interaorta cava. and dissection cranially, reaching left renal vessels and gonadal vein. Always medially left ureter, as Dr. Kimmig said, and this above the vena cava inferior, near the renal vessels. Next to the final dissection, another small vessel from the vena cava. And here is the final aspect. Note that it's a procedure with small bleeding, despite being performed in an area of high risk of vascular injury. There are some maneuvers to elevate the aorta and vena cava, to as I'm going to show in this video. By ligatures of lumbar vessels you can elevate the cava to access inter-cavaortic posterior space or retro-cava or retro-aortic space for the bulking surgeries. You have to perform vascular clamps, laparoscopic and to open surgery with a table prepared. This is how we do with metroperitoneal lymphadenectomy by extraperitoneal route. Thank you very much. Thank you, Paolo. This is very, very interesting to see this approach for this type of surgery. So we're going to start taking questions from our participants and some of the questions that have come in already is, how do you prevent and treat any lymphatic leakage in the postperiortic lymphadenectomy? I perform a communication by peritoneal and extraperitoneal spaces in the left side at the end of surgery. Thank you. Do you have anything available to you in the OR and open in regards to if you were to have a sudden vascular injury? Yes. We have Satinsky laparoscopic clamps and we are prepared for vascular surgery and a table for open surgery ready to find time. Yeah. Very good. Thank you. I do think you did briefly touch on this, but we've also had a question in regards to the trocar placement for this type of surgery and could you elaborate on that, please? The first trocar, we perform the peritoneoscopy of the trocar at the umbilical point. After we perform the second trocar, it's above the left crease, iliac crease. The third one is in the medial axillary line and the fourth is subcostal on the left side in this sequence. Right. So like a U. Yes. Like a U. Yeah. Exactly. The right hand must be a little above of the left brain to perform surgery. And as a main surgeon, would you be on the patient's right or left side? All the surgeons on the left side. All the surgeons on the left side. Great. Thank you. Okay. That's great. We're going to save something. Ah, one final question I think that we'll squeeze in here for you before we move on. Do you think that you need a balloon trocar for the first port, for the camera port? Do you use this or could you- I've never used this balloon trocar, never used. You can perform a little suture around the first trocar, just this. Thank you. Thank you very much. We're now going to move forward with our segment on periordic lymph node dissection with Eric LeBlanc. Hello, good morning or good afternoon, everyone. Thank you, Anna. Thank you, Mandy, for the invitation to participate in this video meeting. I have the honor to close this session with the most extensive surgery with the periordic node dissection already initiated by an excellent presentation by Paolo. As you know, periordic node involvement is an important event in uterine carcinoma course as the tumor is upstaged to 3.2 in both updated classification. This is the last step before the stage four. However, this step is still curable, but needs an adapted management. That's why this information, this spartic information is so important. Unfortunately, it's not as demonstrated by Paolo and by Mrs. Rossi to detect the low volume metastasis. So, surgery has been performed for long, especially by laparotomy, trans or extrapartum to get this pathological information. Laparotomy carries an important mobility, especially when radiation therapy is considered after surgery. This mobility has been dramatically reduced by the use of the minimally invasive surgery in the starting in the 90s, as shown in the retrospective and randomized study without compromising the oncological results. The previous, yes, this is a summary of the most important indication in uterine carcinoma. As you know, it's more controversial for cervical carcinoma because if it helps to tailor the chemoradiation fields, the advantage on survival is controversial. It's negative in the late randomized trial in 2001, but positive in the most recent CURLOS trial. And as the progression of invasion isn't stepwise, infra-horizontal dissection are enough to get the information. For endometrial cancer, it is the same as for ovarian cancer. The distribution of parotid involvement is ubiquitous in the infra-mesenteric or supra-mesenteric area. So, infra-renal dissection are recommended, especially in high-risk tumors, 1B, 2B, or type 2 endometrial carcinoma to tailor the further management. Next slide, please. We already saw the excellent video by Paolo on the extra-peritoneal approach. I will define the trans-peritoneal approach, which has advantages to be more popular to surgeons in spite of some inconveniences, especially in obese patients, especially in the infra-mesentery dissection. Next slide. To perform a trans-peritoneal parotid dissection, the patient is placed flat on the table with a steep treadle and bog. The surgeon is between the patient's leg and the first assistant on the left side, holding the, on the left patient's side, holding the camera and the retractor. For positioning of the trochards, we need six trochards, three 10 millimeters, one for the retractor under the left costal margin, one 10 millimeter on the, in the umbilicus, and one 10 millimeter above the pubic bone, and three five millimeter, two in the flank for instruments, and one in the iliac fossa for the irrigation device. Next slide. So let's see the film now. So this operation was performed after a pelvic dissection. So the first step is to store the small bowel loops in the upper abdomen, and they will be kept in this position thanks to the steep treadle and bog, and then the peritoneum is incised in front of the right common iliac pedicle, above the ureter. This incision is pursued along the axis of aorta until the third genome became, become visible. And so the duodenum is then mobilized, and it is kept in this position thanks to a retractor that will lift the duodenal pancreas and keep straight the wall of the tent, and keep the vision comfortable. In obese patients sometimes, as mentioned by Rainer, sometimes you need T-lift or other device to elevate this peritoneal fold. And then using only a monopolar or bipolar current, you can separate gently the nodes from the vessel wall, taking care, especially on the, on the caval side, with phallus vein. I mean direct lymphovenous anastomosis, as you can see here. You have to keep very careful because hemorrhage can be very serious at this step. So the gonadal vein is, is clipped. You see the ureter on the right side moving. And at that moment, you can safely remove the lateral caval nodes from the psoas muscle without difficulty. The advantage of the, of the transperitoneal approach compared to the extraperitoneal approach is a very good view on the ante-autocarval space, as you can see here, it's much easier to, to resect the nodes at this level compared to the extraperitoneal in which you have to elevate the aorta clip, the lumbar vessel, which can be sometimes a problem if the clip slips. And so you see here a right gonadal artery, which is coagulated and cut. The nerves were preserved in this patient, which is not absolutely necessary in women, excuse me. It's more important in male patients because the postganglionic sympathetic nerves are useful for the ejaculation process. In women, the, the sacrifice doesn't change anything apparently. And so you dissect up to the left renal vein with a monopolar and bipolar scissors. Now we use more easily the ligature device. I prefer the ligature device and the ultrascision because I, I don't trust in the, in the coagulation property of this, of this device. I'm sorry. So we are on the left side, removing the lateral aortic nodes. And first we open the space under the inferior mesenteric artery. And the first limit we have to check is of course the left ureter, which should be rapidly visible here. And from then, everything between the ureter and the aorta can be removed without any other difficulty. We will see in depth the aspect of the sympathetic chain. So nodes are very easily mobilized there, but you have to skip around the inferior mesenteric artery. Some surgeons say that you can safely, systematically devise the inferior mesenteric artery. Maybe they are right for in gestative surgery that has no consequences, but if the colon is not removed, sometimes you can have colon necrosis, sigmoid colon necrosis. So you have to take care with this step. So this is the final aspect after the whole dissection on both sides. Well, next slides. Nodes are removed in the back in any case, of course. Next slide, please. So another variation is the use of the single port technique, which is interesting for staging of locally advanced abyss cancer, which is not necessary to remove nodes above the inferior mesenteric artery. So the steps are exactly similar. But to be honest, it's not very comfortable. And I will not advocate this approach. For staging of locally advanced cancer for elective parotid dissection, I strongly believe that the extraparetone approach is much more indicated. But finally, the results is exactly totally equivalent. But it takes a longer time. Let's move to the final. So the nodes that can be removed directly through the ports, and we finish with the infra-arterial dissection. Let's move to the final video, which is the final aspect of the robotic technique. So the ports for the robots are placed above the ombilicus for the camera and lateral to the ombilicus for the operative trochars. The robots is between the legs or placed on the right side of the legs. So very inferior. Next slide. And it's a 30 second video of the final aspect. You see it's exactly equivalent to the transperitoneal laparoscopic approach you saw before. It's important to use clips at the upper part of the nodal dissection because there are often important lymphatics there. And if you don't put clips, you expose the patient to a callous leakage, which is always problematic to solve. Next slide. So now how to choose between extra- or transperitoneal approach. There are several retrospective theories such as our series. But in fact, when you are used with one technique, you are the best compared to other ones. And on the only randomized study comparing the two approaches with certain proficiency with the two approaches, there was no clear difference between the two approaches. So the best one is in fact the best mastered. But as someone sometimes you have to select one or the other, it's important to master both approaches. Next. And this is our experience with the robotic technique. So we perform more than 1,000 laparoscopic parotid dissection with only 60 robotic approach. Most of them were extra-peritoneal. And in our hands, laparoscopy was faster to perform without the robotic assistance. As 40 cases seems necessary to master the robotic approach, probably we were in our learning curve and this result is not very strong. The outcomes are equivalent and the mobility is equivalent. Next slide. So conclusion. We can say that the laparoscopic parotid dissection is safe in trained and experienced hand and for which the robotic assistance is finally of low help. Excuse me, a rhino, but this has been demonstrated by a randomized trial. But what is important to consider is a laparoscopic parotid dissection is not a simple surgery. And the selection of indication is really necessary. And I hope in the future of the Sentinel node policy will reduce the indication of this surgery. And to finish to which approach to privilege to be the pragmatic, I would say that the trans-peritoneal approach should be privileged anytime it follows a trans-peritoneal pelvic lymphanectomy since the space are open and the extra-peritoneal approach is infeasible. But any case, an elective dissection is required. An extra-peritoneal approach is probably the best or in case of overweighted patient. I thank you very much for your attention. Thank you. Thank you very much, Eric. It's wonderful to see these films and also performed both by the traditional laparoscopy approach and robotically. You know, you mentioned at the end there, we're opening up to questions now. So please don't be shy these final minutes to our participants. Eric, what do you think? You know, you did mention in the end here that you were hoping that the Sentinel node technique, you know, will become acceptable and perhaps this procedure won't be necessary. Are there any gynecologic cancers in the early stage where we're doing a staging procedure where you feel that Sentinel lymph node is not appropriate? Oh, that's a good question. Sorry to pick a question. Probably no variant cancer. Sentinel node is very difficult. I was amazed by the demonstration by Reiner, but I tried the same with much less successful results. But probably in uterine cancer and in vulvar cancer, Sentinel nodes are really a very good place. And I strongly believe that in endometrial cancer, especially the use of the Sentinel node will reduce the indications of parotid dyslexia. Thank you. And with this in mind, how do you think this might potentially affect the training of younger colleagues moving forward in regards to being able to perform this dissection? Yeah, for sure. For sure. As indication of decreasing, the skill will decrease as well. And so probably the nodal dissection should be referred to expert centers in which the nodal dissection in generally is a routine. Thank you. And one final question before we move to our closure here. You did mention the leakage of the chylose fluid, you know, and how important it is to use clips when you do your upper dissection. We do try to minimize complications, but we might still have this complication. And what's your best advice in dealing with this particular complication? Oh, yes. It's my big problem. It's just a complication. So chylose or not chylose. In fact, it's easier when it's chylose because when it's chylose, usually you can reduce the flow with somatostatin drugs and to follow a low-fat diet, which is usually it works very well. Otherwise, when we observe this complication, we have a special local technique. So it's only local. We put a drain with the radiologist and we keep this drain at least 10 to 15 days in order to keep the lymphocyst empty. Okay? And so that we expect that during this period, there will be adhesions on the lymphocyst wall. And after 15 days, the drain, and we observe the patient. Generally, the lymphocyst triggers, but with a lower volume and generally with no consequences on the venous flow or the urinary flow. And so it can be respected. If not, we will do a second drainage, prolonged drainage. And if the third time it triggers with always the same problem, we consider surgery. So surgery of lymphocyst or recurrent lymphocyst is really at the end of the light methods. Yeah. Thank you. Thank you very much. We haven't done too bad in sticking to our time schedule. And our speakers have been diligent in answering questions in the Q&A tab while we've been moving along. So I think we'd like to thank you all for participating. And before we close though, I do wanna provide a quick announcement in regarding our IGCS 2020 meeting. As you all know, the current pandemic unfortunately does not allow us all to meet up in Rome as we had planned. But we're very, very excited about this ex digital annual global meeting being held September 10 to 13, which will be presented in a fully digital format. And on our meeting website, you'll find an informative video. This is it. We won't play it now, but you can please visit our website and have a look at this video yourself. It'll walk you through the features that enhance this new ex digital format way beyond our traditional webcasts or broadcasts. So webinars, sorry, and broadcasts. So this is technology moving forward. Also registration is live and abstract submission is being accepted through July 15. And our late breaking abstract submission, July 22nd to August 15. And we would like to thank our speakers again for their time, their expertise and their insight today. Like to thank all of you for attending. You will be receiving an email from the IGCS with a link to this recording so that you can go back and have another look. We look forward very much from the IGCS to continue this surgical education again in July. And we will be giving you information regarding this posted on our website soon. I would also like to take this opportunity for a special shout out and thank you to the IGCS team who you haven't seen on the screen today who've done a tremendous job behind the scenes, Mandy and also to Vance who's been a presenter today, Vance Broach, but is also the head of our surgical education via the education committee for the IGCS. Thank you all very much and enjoy your weekend.

near-infrared imaging

endosyanin green

sentinel lymph node mapping

vulvar cancer

lymphatic uptake

detection modalities

periortic lymph node dissection

gynecologic cancers

transperitoneal approach

extraperitoneal approach

robotic-assisted surgery

complete lymph node dissection