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This chapter should be cited as follows:
Mario R, Golia D’Augè T, et al, Glob. libr. women's med.,
ISSN: 1756-2228; DOI 10.3843/GLOWM.420733

The Continuous Textbook of Women’s Medicine Series – Gynecology Module

Volume 8

Gynecological endoscopy

Volume Editors: Professor Alberto Mattei, Director Maternal and Child Department, USL Toscana Centro, Italy
Dr Federica Perelli, Obstetrics and Gynecology Unit, Ospedale Santa Maria Annunziata, USL Toscana Centro, Florence, Italy

Chapter

Sentinel Lymph Node Mapping and Systematic Lymphadenectomy in Gynecological Cancer

First published: December 2024

Study Assessment Option

By completing 4 multiple-choice questions (randomly selected) after studying this chapter readers can qualify for Continuing Professional Development awards from FIGO plus a Study Completion Certificate from GLOWM
See end of chapter for details

INTRODUCTION

The primary goal of lymphadenectomy is to assess the presence of metastatic cancer, meaning that a thorough retrieval of lymph nodes within specific anatomical boundaries is crucial. Surgical staging often involves pelvic and sometimes aortic lymphadenectomy, depending on tumor characteristics. This procedure may also be performed for debulking lymph node metastasis. Traditionally, lymphadenectomy has been performed via laparotomy; however, minimally invasive surgery has proven equally effective in terms of the number of lymph nodes retrieved, complication rates, recurrence rates and overall survival, while significantly reducing postoperative morbidity. This includes decreased blood loss, shorter operation times and reduced hospital stays for the treatment of gynecological, urological, gastrointestinal and some lymphoid cancers.1 The randomized LAP‑2 trial by the Gynecologic Oncology Group (comprising researchers from a number of US hospitals and medical schools) demonstrated comparable effectiveness between laparoscopic and laparotomic procedures, with similar numbers of pelvic and para-aortic lymph nodes removed in both groups.2 The study also highlighted a statistically significant reduction in postoperative complications in patients undergoing laparoscopic lymphadenectomy compared with laparotomy, with fewer moderate to severe postoperative events and shorter hospital stays in the laparoscopic group. Indeed, as surgeons gain experience with laparoscopic lymphadenectomy, there is a marked reduction in the number and severity of complications, as well as shorter operative times, decreased blood loss and reduced hospital stays.2 Other studies have shown that there are no significant differences between robotic-assisted laparoscopy or standard laparoscopy in terms of disease-free survival and overall survival.3,4 In obese patients (body mass index > 30 kg/m2), robotic-assisted surgery is associated with a reduced hospital stay and reduced blood loss compared with those who underwent laparoscopic surgery.3,4

Sentinel lymph node mapping is a minimally invasive technique that is designed to detect occult metastases in lymph nodes without requiring extensive pelvic lymph node dissection. It is based on the principle that lymphatic drainage from a primary tumor follows a predictable pattern, with the first lymph node encountered (the sentinel node) being the most likely site of metastasis. If this node is free of metastasis, there is a high likelihood that other nodes in the chain will also be negative. Sentinel lymph node mapping reduces surgical complications and the risk of postoperative lymphedema compared with full lymphadenectomy, while maintaining similar accuracy in detecting nodal metastases. As the majority of patients will not have metastases, sentinel lymph node mapping spares them from unnecessary lymph node dissection.5 The indocyanine green tracer has shown promise for sentinel lymph node detection, achieving high bilateral detection rates regardless of the tracer used.6

LYMPHADENECTOMY IN CANCER MANAGEMENT

Endometrial cancer

Endometrial cancer is the most common gynecological malignancy in developed countries, with a rising incidence linked to increasing obesity and aging populations.7 It is typically diagnosed at an early stage due to the presentation of abnormal uterine bleeding, offering a favorable prognosis for most patients. Surgical staging is a cornerstone in the management of endometrial cancer, providing critical information for prognosis and treatment planning.8 The histological type, depth of myometrial invasion, tumor grade and the presence of lymphovascular space invasion should be documented for all patients. These factors, together with the presence of pelvic and/or para-aortic lymph node metastases, guide the decision to use adjuvant therapy, including chemotherapy or radiotherapy, as well as the extent of radiotherapy.8

The role of lymphadenectomy in endometrial cancer remains controversial. Survival benefits for pelvic and para-aortic lymphadenectomy have been demonstrated in patients with high-risk or intermediate/high-risk disease.9 The risk of para-aortic metastasis when no metastatic lymph nodes are identified in the pelvic region depends on lymphovascular space invasion status, tumor histology and grade.10 Randomized trials have not shown a survival benefit for lymphadenectomy in early-stage endometrial cancer.11,12 Furthermore, a Cochrane review found no evidence that lymphadenectomy reduced the risk of death or recurrence in endometrial cancer compared with no lymphadenectomy.13 The most recent guidelines from the European Society of Gynaecological Oncology (ESGO), the European Society for Radiotherapy and Oncology (ESTRO) and the European Society for Medical Oncology (ESMO) suggest that sentinel lymph node biopsy may be considered for staging in patients with low- to intermediate-risk endometrial cancer, and that lymphadenectomy may be omitted in cases without myometrial invasion. In high-risk tumors (non-endometrioid histology regardless of myometrial invasion, high-grade [grade 3] endometrioid histology and myometrial invasion > 50%), lymphadenectomy of pelvic and/or para-aortic nodes may be justified, with sentinel lymph node biopsy as an option. Minimally invasive surgery remains the preferred surgical approach, even in patients with high-risk carcinoma.8

The Cancer Genome Atlas Research Network has identified four molecular subgroups of endometrial cancer based on mutational status and somatic copy number alterations, each with distinct clinical outcomes and potential for targeted therapies. These groups include polymerase epsilon (POLE) ultramutated, microsatellite instability hypermutated, copy number low and copy number high.14 The PORTEC‑3 randomized controlled trial demonstrated an overall survival benefit for chemotherapy added to radiation for high-risk endometrial cancer, particularly in serous endometrial cancer and p53-mutant endometrial cancer.15 Detection of molecular subgroups such as p53-mutant endometrial cancer can guide personalized treatment decisions, with some evidence suggesting that patients in the mismatch repair-deficient subgroup may not benefit from adjuvant chemotherapy and that treatment de-escalation may be appropriate in this subgroup as well as the POLE subgroup.16 Ongoing studies such as PORTEC‑4a are evaluating the use of molecular profiles to personalize adjuvant treatments. The role of sentinel lymph node mapping in endometrial cancer management is particularly questioned in p53-mutant tumors, for which adjuvant chemotherapy is beneficial regardless of disease stage. However, for patients with p53 wild-type tumors, sentinel lymph node mapping remains valuable for nodal staging and treatment planning based on molecular classification. Future studies should explore the integration of molecular classification into sentinel lymph node mapping strategies to optimize endometrial cancer management.16

Cervical cancer

Cervical cancer is the only gynecological cancer that is clinically staged based on tumor size, vaginal or parametrial involvement, bladder/rectum extension and distant metastases. Imaging studies aid in accurately defining the extent of disease and tailoring treatment, although they do not affect clinical staging. While imaging can be used to assess pelvic and para-aortic lymph node metastases, these are not included in clinical staging, so lymphadenectomy is often performed for patients with early-stage cervical cancer or selected cases of locally advanced disease. Important prognostic factors include tumor size, stage, depth of tumor invasion, lymph node status, lymph vascular space invasion and histological subtype, with lymph node involvement being the most significant prognostic factor. In FIGO stage IA1 cervical cancer without lymphovascular space invasion, the likelihood of lymph node metastasis is less than 1%, making lymph node assessment unnecessary. These patients may be managed using conization or simple hysterectomy, depending on the need for fertility preservation.17,18 In lymphovascular space invasion-positive stage IA1 disease, surgical management of pelvic lymph nodes, including sentinel lymph node biopsy, should be considered and discussed with patients. For patients with cancer at stages IA2, IB (IB1/IB2) or IIA1 who do not wish to preserve fertility, radical hysterectomy with bilateral lymph node dissection (with or without sentinel lymph node) is the standard treatment.17,18 It has been reported that sentinel lymph node mapping has a detection rate of 95% and a sensitivity of 100% for identifying lymph node disease in cancers at stages IA2–IB1 (< 2 cm).19 Analysis from the SENTICOL I and SENTICOL II trials indicates that omission of pelvic lymphadenectomy in patients with negative bilateral sentinel lymph node does not increase the risk of recurrence.20 The SENTIX trial demonstrated that sentinel lymph node mapping resulted in high bilateral node detection rates in experienced centers, with implications for improved staging and management of cervical cancer.21 Most sentinel lymph nodes are located below the iliac vessel bifurcation, emphasizing the importance of thorough pelvic exploration during surgery.

Ovarian cancer

Ovarian cancer staging requires surgery, with over 75% of patients diagnosed at stage II or higher. In these advanced cases, lymphadenectomy has limited prognostic value compared with its use in patients with disease confined to the ovaries. However, removal of suspicious or enlarged lymph nodes during tumor debulking surgery is critical for achieving optimal cytoreduction.22 Some evidence suggests that lymphadenectomy may have a therapeutic role in a subset of patients with advanced disease.23 In early-stage ovarian carcinoma, lymph node involvement is an early and asymptomatic event that can affect disease progression. The incidence of positive lymph nodes in patients with early-stage ovarian carcinoma ranges from 5.1 to 15%.24,25 Systematic pelvic and para-aortic lymphadenectomy is critical for accurate staging and potential therapeutic benefit in early-stage ovarian carcinoma, as lymph node sampling alone may miss metastatic nodes. Data on the use of sentinel lymph node mapping in ovarian cancer are limited, primarily due to the unpredictable spread of tracer after injection through the ovarian cortex and the high risk of tumor dissemination.26 The abdominal and pelvic routes are the primary lymphatic pathways for ovarian tumors, while the inguinal pathway, which regresses during embryonic development, may persist in a few women and account for rare cases of isolated inguinal metastasis.27,28 Near-infrared fluorescence imaging with indocyanine green has emerged as a promising tool for sentinel lymph node mapping in gynecological cancers, especially in minimally invasive approaches. Buda et al. recently demonstrated the feasibility of using indocyanine green for sentinel lymph node mapping in ovarian cancer during laparoscopy.29 However, given the limited data, sentinel lymph node mapping is not yet a standard part of ovarian cancer staging guidelines.

LYMPHATIC SYSTEM

Before describing the processes of sentinel lymph node mapping and lymphadenectomy, it is useful to provide an overview of the composition and layout of the lymphatic system. The pelvic lymph nodes vary in location and groupings based on their anatomical position.

Perivisceral lymph nodes

Perivisceral lymph nodes display individual variability and are located within the subperitoneal and mesovisceral connective tissue surrounding the pelvic organs. These nodes are divided into specific groups based on their anatomical location:

  • parametrial or paracervical lymph nodes are situated within the parametrium or paracervix
  • paravaginal nodes reside in the connective tissue of the paracolpium
  • pelvic paravasal lymph nodes are found surrounding the external, internal and common iliac vessels.

Afferent lymphatic collectors from the viscera drain into these nodes and efferent lymphatic vessels emerge from them, leading towards more cranial lymph nodes, and, ultimately, emptying into the lumbar trunks, which merge with the intestinal trunks (draining the abdominal viscera) to form the cisterna chyli.

External iliac lymph nodes

The external iliac lymph nodes are arranged into three chains.

  • The lateral chain consists of two to four lymph nodes situated between the external iliac artery and the psoas muscle. The largest of these is the external retrocrural or lateral lacunar lymph node, located near the origin of the epigastric and circumflex iliac vessels. This chain collects lymph from the inguinal lymph nodes, perineum, lower abdominal wall, clitoris, lower third of the vagina, anal canal and uterine fundus.
  • The intermediate chain comprises two or three lymph nodes located between the internal surface of the external iliac artery and the upper part of the external iliac vein and receives lymph from the internal iliac and obturator lymph nodes.
  • The medial chain comprises three or four lymph nodes positioned medially and caudally to the external iliac vein, overlying the obturator nerve and extending from Cloquet’s node to the bifurcation of the common iliac artery. The medial chain drains lymph from the bladder, membranous urethra, cervix, upper two-thirds of the vagina and inguinal lymph nodes.

Afferent vessels to these chains contain lymph from the superficial and deep inguinal lymph nodes and deep lymphatic vessels of the anterior abdominal wall below the umbilicus. The lateral chain may also receive lymph from the clitoris via the inguinal canal.

Internal iliac lymph nodes

There are typically three or four internal iliac lymph nodes, which are arranged around the origin and along the branches of the hypogastric artery. These nodes drain into the common iliac lymph nodes, and further direct lymph toward the lumbar nodes.

Common iliac lymph nodes

The common iliac lymph nodes, numbering between six and 10, are organized similarly to the external iliac nodes into three chains.

  • The lateral chain consists of one to three lymph nodes located between the psoas muscle and the common iliac artery.
  • The intermediate chain comprises one to four nodes located behind the common iliac vein, in the lumbar fossa, between the fifth lumbar vertebra and the entire length of the psoas muscle.
  • The medial chain consists of two to four nodes located at the bifurcation of the common iliac arteries, in front of the left common iliac vein and the intervertebral disc between L5 and S1. This group is often referred to as the promontory group.

They collect lymph from the internal and external iliac nodes and direct it towards the lumbar nodes, particularly the lateroaortic group.

Efferent pathways of the common iliac lymph nodes

The efferent vessels from the common iliac lymph nodes follow specific pathways.

  • Lateral and intermediate chains originate from the internal and external iliac nodes. The efferent vessels drain into the left lateroaortic nodes, while those from the right lateral chain drain into the right laterocaval and preaortic nodes. Efferent vessels from the right intermediate chain drain into the retroaortic and retrocaval nodes.
  • The medial chain’s efferent vessels follow two main pathways: an anterior pathway draining into the preaortic nodes and occasionally the lateroaortic and laterocaval nodes, and a posterior pathway directed towards the retroaortic nodes.

Lumbosacral region and lateroaortic lymph nodes

In the lumbosacral region, the lateroaortic lymph nodes, located adjacent to the abdominal aorta and anterior to the vertebral column, are mostly involved in the pelvic lymphatic drainage system. These nodes are positioned laterally near the psoas muscle, extending cranially towards the left renal hilum.30

SENTINEL LYMPH NODE BIOPSY

This section outlines the procedural phases and technical considerations for sentinel lymph node mapping and dissection using indocyanine green, emphasizing its diffusion patterns, anatomical landmarks, and operative strategies to optimize surgical outcomes.

The diffusion of indocyanine green is rapid and may be conceptually divided into three temporal phases: early, intermediate and late. The early phase occurs immediately after infiltration, lasting from a few seconds to 2 min, highlighting the injection site and associated parametria. During the intermediate phase, which occurs between 2 min and 20–30 min after infiltration, the entire lymphatic system (lymphatic ducts and regional lymph nodes, and level-1 and level-2 sentinel nodes) draining the injection site becomes progressively outlined (Figure 1).

1

Sentinel lymph node visualization using indocyanine green: (a) external iliac lymph node type 1; (b) presacral lymph node type 2.

In the late phase, approximately 1 hour after infiltration, known as vascular transition, indocyanine enters the bloodstream and subsequently returns to the dissection site via a hematogenous route, partially highlighting larger vessels and contaminating the surgical field. Once pneumoperitoneum is established and laparoscopic or robotic optics are introduced, the search for pelvic lymphatic fluorescence begins transperitoneally. This fluorescence is not always evident, particularly in obese patients or cases involving deep sentinel nodes. The first step involves incising the peritoneum of the broad ligament parallel to the umbilical artery, using classical anatomical landmarks of lymphadenectomy to medialize the ureter (Okabayashi’s space). It is essential to identify the obliterated umbilical artery and the umbilical lamina, which distinguish the visceral compartment of the pelvic organs from the lymphovascular compartment, beyond which regional lymph nodes can be identified. Throughout these maneuvers, it is beneficial to frequently alternate between classical and near-infrared vision to identify lymphatic vessels and enable tracking to proximal lymph nodes. Dissection at this stage should be performed prudently to prevent interruption of lymphatic vessels, avoiding contamination of the surgical field with tracer leakage.

After ensuring exposure of nerves, blood vessels and ureters, and identifying anatomical landmarks, the sentinel lymph node (or nodes) is identified and removed, sealing the afferent and efferent vessels using ultrasound or bipolar instruments. Often, there are two or three lymph nodes per side rather than a single one, and all of these should be selectively removed and sequentially numbered from the most proximal to the most distal relative to the tumor (level-1, level-2 sentinel nodes, etc), providing the pathologist with the precise anatomical locations of the lymph nodes (iliac, hypogastric, deep common, etc). Any enlarged lymph nodes, even those that are non-fluorescent, must be removed and sampled separately after sentinel lymph node excision. If no lymph node is identified, lymphatic drainage may follow the posterior path of the mesoureter; thus, exploration should begin in more cranial areas, from the common iliac and presacral nodes to the lumbosacral region (type 2).31 If searching for the lymph node, even in unusual sites, is unsuccessful, a second drug injection may be administered. If no fluorescent lymph node is identified even after the second infiltration, systematic lymphadenectomy of the hemipelvis becomes mandatory. Use of indocyanine is also beneficial for more extensive lymphadenectomy, as mapping the entire regional lymphatic system in the intermediate and late phases allows visualization of both level-1 and level-2 lymphatic chains, extending to the aortic lymph nodes. This mapping guides the surgeon during parametrial dissection for radical hysterectomy and systematic lymphadenectomy, rendering the entire lymph node compartment visible relative to perivascular fat.5,32

SYSTEMATIC PELVIC LYMPHADENECTOMY

Pelvic lymphadenectomy commences with the identification of key anatomical landmarks: the umbilical artery, iliac vessels, ovarian vessels, ureter and round ligament (Figure 2). After adhesiolysis, the round ligament is transected near the pelvic wall, and the peritoneum is opened in a caudocranial direction, bisecting the angle between the iliac and ovarian vessels. The lateral pararectal space (Latzko’s space) is then accessed, with its boundaries being defined by the ureter medially and iliac vessels laterally. This maneuver facilitates visualization and mobilization of the prevesical umbilical lamina, representing the medial limit of the lateral paravesical space. This space is further delineated laterally by the iliac vessels, ventrally by the space of Bogros, dorsally by the lateral parametrium, caudally by the pelvic floor, and cranially by the broad ligament. Dissection proceeds between the obliterated umbilical artery and external iliac vessels, exposing the paravesical space medially and the obturator space laterally. Caudal dissection proceeds to the levator ani muscle, preserving the integrity of the prevesical umbilical lamina, obliterated umbilical artery and obturator neurovascular bundle (the deep limit of lymphadenectomy). Lymph nodes are meticulously isolated and mobilized laterally towards the iliac vessels, extending cranially to the iliac bifurcation and caudally along the ischiopubic ramus to the obturator canal, where the corona mortis (the venous anastomosis between the external iliac and obturator vessels) is located and identified. The psoas and internal obturator muscles are laterally retracted, allowing identification and preservation of the genitofemoral nerve (Figure 3). Dissection proceeds craniocaudally from the ischial spine to the ischiopubic ramus and corona mortis. The caudal limit is defined by the often-identifiable retrocrural lymph node, situated just below the circumflex artery.

2

Visualization of the principal anatomical landmarks for pelvic lymphadenectomy.

3

Limits of lymphadenectomy (robotic-assisted laparoscopy): (a) medial; (b) cranial; (c) lateral; (d) ventral and caudal.

The obliterated umbilical artery is then isolated laterally, freeing it from the underlying adipose tissue (the caudal limit of the retrograde lymphadenectomy along the hypogastric vessels). The adventitia of the external iliac artery is exposed, and the adventitial lymphatic layer surrounding the parietal pelvic vasculature (Delbet’s hypogastric sheath) is removed, containing external and interiliac lymph nodes. This dissection continues to the common iliac artery bifurcation. Lymph nodes are devascularized by lateromedial traction, separating them from the arterial and venous walls.

The obturator lymph node fibro-adipose tissue is retracted medially, creating a plane beneath the external iliac vein. Careful dissection continues until the obturator nerve is visualized and isolated. Special attention is given to the proximal margin near the common iliac artery bifurcation, where lymph nodes may adhere more tightly to the hypogastric vessels. After separating the external iliac lymph nodes from the external iliac artery, the lymph node package is medialized and moved cranially. The package is freed from the obturator nerve and veins, as well as the inferior gluteal veins.

Finally, the peritoneum overlying the sacral promontory and common iliac arteries is incised. Following Luschka’s law (stating that the left ureter crosses the iliac artery approximately 1.5 cm distal to the bifurcation of the common iliac artery, whereas the right ureter crosses the iliac artery approximately 1.5 cm proximal to the bifurcation), the ureter is devascularized, completing the pelvic lymphadenectomy. This peritoneal incision may be extended to facilitate para-aortic dissection, extending to the inferior mesenteric artery or the left renal vein.33 Lymph node packages are collected along the common iliac vessels, aorta and vena cava, paying close attention to the ovarian and renal vessels and the inferior mesenteric artery. Precise lymphatic vessel dissection and coagulation are recommended to minimize postoperative lymphorrhea. Coagulative stripping with bipolar instruments should be avoided to prevent this complication.34

PARA-AORTIC LYMPHADENECTOMY

For para-aortic lymphadenectomy, the peritoneal incision on the right common iliac artery is extended caudocranially along the aorta to the level of the duodenum, connecting the incision with the cranial incision reaching the left common iliac artery. The mesentery of the sigmoid colon is retracted ventrally, and the areolar tissue between the left common iliac artery, the aorta and the mesentery of the sigmoid colon is opened using a combination of blunt and sharp dissection to reveal the left psoas muscle and the laterally retracted left ureter. The ease with which this exposure is achieved depends on efficiently packing the small intestine in the upper abdomen above the level of the inferior mesenteric artery and avoiding redundancy of the sigmoid colon. It is essential to identify the inferior mesenteric artery before starting the lymph node dissection to prevent its unintentional inclusion in resection of the areolar tissue of the mesosigmoid. Once adequate exposure has been achieved, the para-aortic lymph node package should be lifted, and the plane between the large vessels and adjacent lymph nodes should be dissected. This dissection extends cranially, commencing above the aorta and proceeding mediolaterally. Thin pedicles are developed before sectioning to identify the perforating vessels. The lymph node chain is subsequently dissected at the cephalic end up to the left renal artery, ensuring proper isolation of the inferior mesenteric artery. To complete the pre- and para-aortic dissections, the lymph nodes between the aorta and the vena cava should also be excised. To obtain the necessary exposure for dissection of the paracaval lymph nodes, the assistant should lift the incised peritoneum covering the inferior vena cava and the right common iliac artery. Creating this peritoneal window allows lateral retraction of the right ureter and clear visualization of the vena cava and aorta. The space between the lymph nodes and the large vessels is further developed by blunt and sharp dissection within the areolar plane between the lymph nodes and the peritoneum.

The infrarenal lymph nodes are a group of lymph nodes between the inferior mesenteric artery and the renal vessels that are removed only in cases of a strong suspicion or the presence of high-risk neoplasms, as exposure of this region is challenging. They are removed after obtaining adequate exposure, which is achieved by incising the peritoneum between the inferior mesenteric artery and the duodenum to the left along the mesentery of the descending colon to the inferior mesenteric vein. On the left side, the dissection plane is above the ventral surface of the aorta. It is important to identify the left renal and ovarian veins and arteries, which can be achieved by dissecting the areolar tissue beneath the duodenum, followed by careful cephalic retraction of this organ. Lateral retraction of the ureter is performed by the assistant to optimize the surgical field. The dissection of the left lymph node bundle proceeds to the level of the left renal vein, where excision is performed. On the right side, the lower paracaval dissection is extended upwards, reaching the area between the right ovarian vein and the right renal vein to ensure comprehensive lymph node excision in the paracaval region. This careful approach is critical to maintain adequate exposure and ensure complete removal of the lymph nodes while minimizing the risk to surrounding structures.

COMPLICATIONS

Possible complications of laparoscopic lymphadenectomy arise from both the laparoscopic approach, regardless of the procedure performed, and the lymphadenectomy procedure, irrespective of the surgical approach used. Complications associated with the laparoscopic approach include induction injuries due to pneumoperitoneum and access techniques, which may lead to intestinal, urinary or vascular injuries, as well as subcutaneous emphysema and gas embolism. Among the three pneumoperitoneum induction methods (Veress needle, Hasson technique and direct entry), use of the Hasson technique is associated with a reduced risk of failed entry attempts. Although slight differences exist, there is minimal evidence to suggest significant variations in visceral or vascular complications between the techniques, with the direct technique showing a slightly reduced risk compared with use of the Veress needle.35,36 In the context of lymphadenectomy, notable complications include intraoperative injuries to nerves, blood vessels and the urinary system, as well as postoperative issues such as cardiovascular complications and interruption of lymphatic drainage. Despite the potential for serious complications, the incidence of major organ and vessel injuries during lymphadenectomy remains relatively low. Pelvic lymphadenectomy may result in vascular injuries to the obturator and iliac vessels, while para-aortic lymphadenectomy carries a risk to the common iliac, lumbar, gonadal and renal vessels, as well as the aorta, inferior mesenteric artery and vena cava. The hypogastric vessels, particularly the venous branches, are most susceptible to injury, with a higher incidence at the distal branches due to anatomical variants.

Managing vascular injuries requires immediate attention to control bleeding. Techniques vary based on the type and size of the injured vessel. and may involve the use of packing, monopolar or bipolar electrodes, metal clips or sutures.37 It is crucial to secure bleeding quickly, and if blood obscures visibility or if dealing with a large vein where direct grasping with forceps may cause further lacerations, tamponade using a laparoscopic clamp or aspirator may be necessary. Small venous bleeds can often be temporarily controlled with pressure alone while completing the procedure. Metal clips and laparoscopic sponges can be effective, although they carry risks such as the possibility of retained gauze. Rapid control is essential in arterial bleeding to prevent significant blood loss. Mismanagement may occur during suction, in which improper aspiration may exacerbate exposure and delay control. A common error in managing vascular injuries arises during blood aspiration, particularly when the aspirator tip is not fully immersed in the blood. This can lead to aspiration of gas along with the blood, which reduces the visibility of the operative field and triggers a cascade of complications, ultimately wasting valuable time. Small arterial and venous bleeds can be managed using monopolar or bipolar electrosurgery or using ultrasonic energy devices. Bipolar current is exceptionally useful for controlling more significant venous and arterial bleeding. Bipolar coagulation may be applied directly on the vessels or transmitted along the instrument to induce supercoagulation. However, it is contraindicated in cases involving vascular injuries of large-caliber vessels or vessels that should not be sacrificed. In such situations, clips or suturing techniques are preferred. Laparoscopically applied clips are effective in controlling even significant vascular injuries. When applying metal clips to vessels, the preferred technique involves first dissecting the mesovascular and perivascular tissue using monopolar or bipolar scissors. This creates a clear plane, free from adjacent tissues, ensuring proper application of the clip. Before final application, the positioning of the clip should be verified using laparoscopic forceps to ensure secure placement. This step is crucial for preventing further complications and ensuring optimal control of the vascular injury.

Urinary tract injuries are among the most frequent injuries to adjacent structures during lymphadenectomy, with an incidence of 1–8%. Most urinary tract injuries are identified intraoperatively, allowing immediate corrective action and reducing the impact on patients. Ureteral injuries may include laceration, ischemic stenosis and ureteral avulsion, commonly occurring in the middle third of the ureter, followed by the distal third and the ureterovesical junction. Factors that increase the risk include previous surgery, inflammatory bowel disease and distorted pelvic anatomy. The preoperative use of a ureteral stent does not reduce the risk of injury during laparoscopic lymphadenectomy. To reduce the risk of ureteral injury, prompt identification of the ureter during the procedure is essential, and if there is doubt about the integrity of the ureter, it is preferable to place a ureteral stent prophylactically. Ureteral injuries may be managed by ureteral reimplantation or anastomosis if the ureteral ends are healthy and adequately vascularized. In less favorable cases, nephrostomy or ureterostomy may be necessary. Nephrostomy is generally preferred over ureterostomy due to its advantages in terms of patient comfort and enabling future reconstructive procedures to be performed. However, the choice between these two options largely depends on the surgeon’s experience and the specific circumstances of the case. Ureteral injuries, particularly those associated with delayed diagnosis or treatment, can result in significant complications, including loss of renal function. Prompt recognition and management are crucial to mitigate these risks and preserve renal function. Bladder injuries are usually sutured without additional interventions unless ureteral orifice damage is involved. Postoperative complications after lymphadenectomy may be gastrointestinal (ileus, anastomotic leak), cardiovascular (deep vein thrombosis, pulmonary embolism), respiratory (atelectasis, pneumonia), infectious (wound infection, abscess) or urological (urinary tract infection, urinary retention), with lymphocele also being a common risk.37,38 This risk is heightened in procedures that involve both pelvic and para-aortic lymphadenectomy. The use of surgical clips on lymphatic vessels can mitigate the risk of lymphocele formation.

PRACTICE RECOMMENDATIONS

  • Indocyanine green is the tracer of choice for sentinel lymph node mapping in gynecological cancers, achieving high bilateral detection rates.
  • In cases of failed sentinel lymph node detection with a single tracer injection, re-injection or systematic lymphadenectomy should be considered to ensure comprehensive staging.
  • A comprehensive understanding of pelvic and para-aortic lymphatic anatomy improves the accuracy of sentinel lymph node mapping and systematic lymphadenectomy and reduces complications.
  • Systematic pelvic and para-aortic lymphadenectomy is essential in early-stage ovarian cancer for detecting occult metastases, ensuring accurate staging, and guiding adjuvant therapy. However, in advanced stages, lymphadenectomy should be limited to grossly suspicious or enlarged nodes to support optimal debulking.
  • Robotic-assisted laparoscopy or standard laparoscopy is recommended, particularly for obese patients, to minimize intraoperative blood loss, reduce hospital stay, and enhance recovery while maintaining oncological outcomes.
  • For early-stage endometrial or cervical cancer, minimally invasive techniques with sentinel lymph node mapping are advised to reduce surgical morbidity while maintaining accurate staging.
  • Patient factors, such as obesity, comorbidities, and prior surgery, must be carefully evaluated to optimize outcomes and minimize complications.
  • Extensive pelvic and para-aortic lymphadenectomy poses a significant risk of complications, which increase with proximity to critical structures and in patients with high-risk factors such as obesity or comorbidities.
  • Prevention of complications requires meticulous patient selection, precise surgical techniques, and vigilant postoperative management, while early detection of complications through close monitoring reduces morbidity and mortality.


CONFLICTS OF INTEREST

The author(s) of this chapter declare that they have no interests that conflict with the contents of the chapter.

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