How to Perform Bilateral Sentinel Lymph Node Biopsy in Vulvar Cancer with Indocyanine Green by Video-Endoscopic Approach.

Background: The standard surgical treatment of early stage vulvar carcinoma  < 4 cm consists of resection of the vulvar tumor with sentinel lymph node (SLN) biopsy (Oonk in Int J Gynecol Cancer 33:1023-1043, 2023). Video-endoscopic inguinal SLN biopsy with indocyanine green (ICG) has been described (Capomacchia et al. in Int J Gynecol Cancer, 2024). However, ICG induces fleeting mapping of lymphatic pathways, making bilateral SLN mapping more challenging. The aim of this video is to show how to perform bilateral inguinal SLN biopsy with ICG by video-endoscopic approach.

Patients And Methods: We present the case of an 81-year-old patient with a 3.8 cm midline vulvar cancer. Bilateral inguinal SLN biopsy was performed by video-endoscopic approach using ICG along with radioactive tracer. The surgery was performed in a tertiary cancer center.

Results: The day before the surgery, radioactive tracer was injected in the peritumoral area. The procedure began with the placement of a 12 mm trocar at the apex of the femoral triangle and two 5 mm trocars in both thighs. The working space was developed, and a blunt dissection was bilaterally performed up to the inguinal ligament. ICG was then injected into the four cardinal points around the tumor. SLNs were bilaterally visualized and then resected. A gamma camera was used to ensure that the ones removed were the correct SLNs. There were no intra- or post-operative complications.

Conclusions: To minimize the fleeting uptake of ICG, dye injection should be performed after bilateral positioning of the trocars and development of surgical spaces. A double check with a gamma camera is needed as radioactive tracer is still considered the standard approach for SLN biopsy in vulvar cancer.