A first report of robotic-assisted sentinel lymph node mapping and inguinal lymph node dissection, using near-infared fluorescence, in vulvar cancer.

Abstract

e17027 Background: Vulvar carcinoma is a rare gynecologic malignancy which has seen a considerable evolution in surgical techniques over the last several decades. However, the morbidity associated with inguinal lymph node dissections remains significant. The majority of patients undergoing full lymphadenectomy will have some complication, with wound breakdown being the most common. In males, robotic inguinal lymph node dissection has been described for penile cancer. This report represents a first use of near-infared fluorescence for sentinel inguinal lymph node mapping, and the first description of complete robotic inguinal lymph node dissection for patients with vulvar malignancies. Methods: Bilateral robotic-assisted inguinal lymph node mapping and and lymphadenectomy was performed using the daVinci Xi system with a near-infared fluourescence. Results: The patient presented at 81 years old with a 3 cm lesion on the left labia. In the operating room, the vulvar lesion was injected circumferentially with indocyanine green. A 1 cm incision was made in the skin over the apex of the left femoral triangle carried past the underlying campers fascia. The tissue plain was developed overlying the femoral triangle using a tissue expander balloon. Under visual guidance, an 8 mm camera port and two 8 mm instrument ports were placed and the robot docked. The ipsilateral sentinel lymph nodes were identified using near-infared fluorescence and resected. We then performed a complete left superficial inguinal lymph node dissection. The right side was then performed in identical fashion. No sentinel node was identified on the right side. Radical hemivulvectomy was then performed without difficulty. All 11 lymph nodes were negative for disease. She was returned to the OR once for replacement of her JP drains. Her postoperative course was otherwise unremarkable and she is currently 15 months postoperative without complications or recurrence. Conclusions: Sentinel lymph node mapping and superficial inguinal lymph node dissection using robotic-assisted techniques and near-infared fluorescence is feasible and warrants further investigation.

Fluorescence Guided Surgery

“…This allows the surgeon a high definition and high magnification view of the surgical site while being able to take advantage of the high precision and accuracy of the robotic arms [203]. The combination of fluorescence with robotic surgery has been utilised for some of the previously described applications, such as in identifying SLNs during laparoscopy [204] and assessing tumour margins for cancers such as that of the kidney [205], with current research publications focussing on these types of applications as well [206,207]. It is clear that applications surrounding the improvement of cancer surgery are of the greatest interest to researchers for robotic-based surgery as well as in the more general area of FGS both now and in previous years and it will most likely be the primary focus of future FGS research as well.…”