Fluorescence-assisted sentinel (SND) and pelvic node dissections by single-port transvaginal laparoscopic surgery, for the management of an endometrial carcinoma (EC) in an elderly obese patient

Abstract Objective To explore the feasibility of an oncologically acceptable management for an intermediate-risk endometrial cancer (EC) in an elderly, using the combination of transvaginal single-port laparoscopy and sentinel node policy. Methods For this 85-years old patient, BMI 32 kg/m2 , with IB grade 2 endometrioid EC, a single vaginal approach was attempted [1] to perform a total hysterectomy, bilateral salpinago-oophorectomy and pelvic node assessment guided by SND [2]. Injections of indocyanine green (ICG) were performed at 3 and 9 o'clock and 2 depths [3] into the uterine cervix A simple vaginal hysterectomy was first performed using a 5 mm vessel sealer (LigaSure®-Medtronics) to limit ICG leakage. As poorly accessible, adnexas were divided close to cornuas; uterine corpus was delivered vaginally. Then, a single port device (Gelpoint®-Applied), equipped with 3 trocars for optique and instruments, was installed through vagina. After transvaginal pneumoperitoneum insufflation, bowel loops were cleared from the pelvis. Latero-pelvic peritoneum was incised between external iliac pedicles and ureters. Following the algorithm, node dissection was limited to sentinel node clearly identified on the right side under color-segmented fluorescence (Pinpoint®-Novadaq), but a full pelvic dissection completed an unsatisfactory SND on the left side. Procedure was terminated with salpingo-oophorectomies. After protected vaginal specimen delivery, the single-port device was removed and vagina was closed as usual. Results Patient was discharged on the 1st post-operative day. Final pathology confirmed the FIGO stageIB grade2 EC. Conclusions A transvaginal laparoscopic pelvic SND after vaginal hysterectomy is feasible. This single-port “NOTES” strategy bridges the previous gaps of a pure vaginal approach and seems interesting in fragile EC patients.