Surgical technique article: Meticulous, Reproducible Technique of Bilateral Laparoscopic Pelvic Lymphadenectomy in Gynaecological Oncology Sparing Corona Mortis-a Case Report

Introduction Gynaecological Oncology, and gynaecological cancer surgery has developed by leaps and bounds in the last few decades(1). There has been further development in this subspecialty, with trainees going for further ovarian cancer cytoreductive surgery fellowships after their subspecialization, to learn the nuances of upper abdomen, hepato-biliary steps to ensure complete debulking to no visible disease, and even further to Video Assisted Thoracic Surgery, along with Hyperthermic Intraperitoneal Chemotherapy(HIPEC), Normothermic Intraperitoneal Chemotherapy(NIPEC) and Hyperthermic Intrathoracic Chemotherapy(HITHOC). The other surgical subspecialisation in Gynae-Oncology, is the development of the minimally invasive route for uterine and cervical cancer surgeries including radical hysterectomies and retroperitoneal lymphadenectomies. Particularly, in cancer cervix, with the advent of the Querleu Morrow classification defining radicality of hysterectomy, developing pelvic spaces, to ensure good access to lymph nodes, avoid damage to ureters and iliac vessels, is now an absolute basic to gynaecological cancer surgery(1). The nerve sparing approach also depends on correctly developing the medial pararectal space of Okabayashi, and the fourth space of Yabuki(2). Recently, there has been lot of stress, on role of sentinel lymph node biopsy, to avoid complications of lymphocyst and lymphedema, with systematic pelvic lymphadenectomy. Bilateral sentinel lymph nodes is definitely advocated in the standard minimally invasive approach to uterine cancers, and has now also been accepted as a reasonable alternative in high risk uterine cancers. However, the art of opening the retroperitoneum and accessing the pelvic spaces, remain of paramount importance, particularly in resource poor settings, where the ICG detection camera is not available, or lack of Indo-Cyanine Green, or even in situations of failed mapping of sentinel nodes, where systematic retroperitoneal lymphadenectomy is mandated, to complete staging, and also improve survival, while removing bulky, likely metastatic nodes in advanced disease. Robotic platforms of minimally invasive surgery are becoming widely accessible, but is still not always available in resource poor countries, to add to the cost constraints with robotic surgery packages. Hence this article highlights a step-by-step approach, to laparoscopic bilateral systematic pelvic lymphadenectomy, which is absolutely essential for complete staging surgery of cervical and low risk uterine cancers, and a starting point for complete staging of borderline ovarian tumours and high grade endometrial cancer surgeries. This particular lady was diagnosed, pre operatively as stage1b endometrioid uterine adenocarcinoma grade2, after biopsy, MRI pelvis and CECT chest and abdomen. The role of radiologist is very important in pre-operative surgical staging in these patients, and psychologist in pre and post operative assessment of these patients regarding their expectations from the surgery and debriefing future repercussions.