Video Article Pelvic Lymphadenectomy; Step-By-Step Surgical Education Video İlker et al. Pelvic Lymphadenectomy Selçuk İlker 1 , Bora Uzuner 2 , Erengül Boduç 2 , Yakup Baykuş 3 , Bertan Akar 4 , Tayfun Güngör 1 1 Department of Gynecologic Oncology, Health Sciences University, Zekai Tahir Burak Woman’s Health Education and Research Hospital, Ankara, Turkey 2 Department of Anatomy, Kafkas University Faculty of Medicine, Kars, Turkey 3 Department of Obstetrics and Gynecology, Kafkas University Faculty of Medicine, Kars, Turkey 4 Department of Obstetrics and Gynecology, Istinye University; WM Medical Park Hospital, Kocaeli, Turkey Adress for Correspondence: İlker Selçuk Phone: +90 530 201 05 46 e-mail: ilkerselcukmd@hotmail.com ORCID: orcid.org/0000-0003-0499-5722 Abstract Pevic lymph node dissection is one of the leading surgical procedures in gynecologic oncology practice. Learning the proper technique with anatomical landmarks will improve the surgical skills and confidence. This video demonstrates a right side systematic pelvic lymphadenectomy in a cadaveric model. Keywords: lymph node, anatomy, gynecologic oncology, lymphadenectomy, surgery Introduction Pelvic lymphadenectomy is a supplementary part of staging and treatment in gynecologic oncology. Additionally, it influences the prognosis and guides the adjuvant treatment. The role of lymphadenectomy in ovarian cancer is controversial, in endometrial cancer high risk patient groups deserve lymphadenectomy and in cervical cancer lymphadenectomy is a complementary part of surgical treatment. Lymphadenectomy could be performed in a selective or systematic approach. This video demonstrates a right side systematic pelvic lymphadenectomy in a cadaveric model. Pelvic lymphatic drainage Drainage from the lymphatics of perineum, lower extremity, lower abdominal wall and pelvic viscera (except sigmoid colon) is to the pelvic wall lymph chain. Upper paracervical (supraureteral paracervical) and lower paracervical (infraureteral paracervical) pathways are the basic routes of pelvic lymphatic drainage(1). Additionally, a lymphatic branch from the ovary runs downward from the utero-ovarian ligament and follows ovarian-uterine artery branch, consequently drained via the upper paracervical pathway(2). Pelvic lymph nodes mainly include the external iliac, internal iliac and obturator lymph nodes which are below the bifurcation of common iliac artery. The lymphatic tissues lay on the external iliac vessels anteriorly and medially, over the internal iliac vessels, at the interiliac junction, and over the obturator nerve; by the way to achieve a complete (systematic) pelvic lymphadenectomy these lymph nodes should be removed(3). The borders of pelvic lymph nodes are genitofemoral nerve laterally, bifurcation of common iliac artery cranially, deep circumflex iliac vein caudally, obturator nerve inferiorly and obliterated umbilical artery medially(4). Sacral lymph nodes are generally not encountered in pelvic lymph node group and dissection of it is not a routine part of pelvic lymphadenectomy. Sentinel lymph node mapping studies also showed that sentinel lymph nodes are rarely detected in the presacral area(5), however if there is a bulky lymph node it should be dissected. Surgical technique In order to achieve a successful pelvic lymphadenectomy; firstly a good anatomic exposure should be maintained to visualize all the surgical field (Figure 1), secondly lymph nodes over the external and internal iliac vessels are dissected then obturator lymph nodes are removed. After exploring the abdomino-pelvic cavity, uterus is drawn over to the contralateral pelvic side wall, caudo- medially. The lateral parietal peritoneum is incised between the round ligament and infundibulopelvic ligament, so the retroperitoneal space is accessed (transection of the round ligament to access the retroperitoneal area is optional). The incision is enlarged and the peritoneum is cut parallel to the infundibulopelvic ligament. The ureter is identified at the base of the posterior sheet of broad ligament. Pararectal space is developed between the internal iliac artery (lateral) and ureter (medial). Paravesical space is developed between the bladder (medial) and pelvic side wall Uncorrected Proof