Sentinel lymph node mapping in minimally invasive surgery: Role of imaging with color-segmented fluorescence (CSF)

Objective Sentinel lymph node mapping, alone or in combination with pelvic lymphadenectomy, is considered a standard approach in staging of patients with cervical or endometrial cancer [1–3. The goal of this video is to demonstrate the use of indocyanine green (ICG) and color-segmented fluorescence when performing lymphatic mapping in patients with gynecologic malignancies. Methods Injection of ICG is performed in two cervical sites using 1 mL (0.5 mL superficial and deep, respectively) at the 3 and 9 o'clock position. Sentinel lymph nodes are identified intraoperatively using the Pinpoint near-infrared imaging system (Novadaq, Ontario, CA). Color-segmented fluorescence is used to image different levels of ICG uptake demonstrating higher levels of perfusion. A color key on the side of the monitor shows the colors that coordinate with different levels of ICG uptake. Color-segmented fluorescence may help surgeons identify true sentinel nodes from fatty tissue that, although absorbing fluorescent dye, does not contain true nodal tissue. It is not intended to differentiate the primary sentinel node from secondary sentinel nodes. The key ranges from low levels of ICG uptake (gray) to the highest rate of ICG uptake (red). Results Bilateral sentinel lymph nodes are identified along the external iliac vessels using both standard and color-segmented fluorescence. No evidence of disease was noted after ultra-staging was performed in each of the sentinel nodes. Conclusion Use of ICG in sentinel lymph node mapping allows for high bilateral detection rates. Color-segmented fluorescence may increase accuracy of sentinel lymph node identification over standard fluorescent imaging. The following are the supplementary data related to this article.