Study objective: To determine the importance of a dual (cervical and fundal) indocyanine green (ICG) injection and thorough dissection for the detection of sentinel lymph nodes (SLNs).
Design: Description and step-by-step demonstration of the surgical procedure using video (Canadian Task Force classification III).
Setting: Hospital Universitario Donostia, San Sebastián, Spain.
Patients: A 60-year-old woman with a diagnosis of IAG1 endometrial adenocarcinoma (EC).
Interventions: The patient received a cervical and transcervical fundal ICG injection for para-aortic and pelvic SLN detection in the setting of a research protocol, followed by a total hysterectomy and bilateral salpingo-oophorectomy with a frozen section of the uterus as a standard approach . Institutional Review Board approval was obtained for the research protocol of this study.
Measurements and main results: Dual ICG injection  adds the benefit of a cervical injection (that best evaluates the pelvic region ) to the fundal injection, with better spread to the lumboaortic pathway  so as not to lose the aortic drainage and aortic SLN, whose relevance is still discussed due to its low incidence of metastasis . This search does not add to the associated morbidity but is associated with increased operative time. For pelvic SLN dissection, patience and good training are key; the surgeon must always be on the lookout for uncommon pathways if no SLN is detected in the classical areas. The final histological classification was upgraded to a grade IIIC2 (ie, micrometastasis in the aortic and pelvic-right pararectal space) EC, 3 cm G1 with no lymphovascular invasion.
Conclusion: Dual ICG injection allows comprehensive mapping not only of pelvic SLNs, but also of para-aortic SLNs, in EC, maximizing the identification of all possible affected areas. Nonetheless, the relevance of its added benefit requires further evaluation.
Keywords: Endometrial cancer; Indocyanin green; Sentinel lymph node.
Copyright © 2018 American Association of Gynecologic Laparoscopists. Published by Elsevier Inc. All rights reserved.