Educational video Robotically assisted peritoneal mesometrial resection (PMMR) in endometrial cancer supported by ICG labeling of the compartmental lymphatic system Rainer Kimmig ⁎, Bahriye Aktas, Paul Buderath, Martin Heubner West-German Cancer Center, Dpt. Gynecology and Obstetrics, University of Duisburg-Essen, Germany article info Article history: Received 22 January 2016 Received in revised form 14 March 2016 Accepted 15 March 2016 Available online 19 March 2016 Keywords: Peritoneal Mesometrial Resection PMMR endometrial cancer ICG robotic surgery compartmental surgery Abstract Lymphatic network is derived from embryonal veins and thus con- fined to the embryologically derived organ compartment (Ribatti and Crivellato, 2010; Yang and Oliver, 2015). Labeling the uterine lymphatic system may facilitate oncological surgery within the compartment bor- ders of the corresponding morphogenetic fields (Dahmann et al., 2011; Höckel, 2015). Before peritoneal mesometrial resection (PMMR) for endometrial cancer (Kimmig et al., 2013a, 2015) 4 × 0.5 ml of a 1.66 mg/ml Indocy- anine green solution (ICG pulsion®, PMS SE, Feldkirchen, Germany) were injected into the uterine corpus. The fundal and midcorporal area was identified using an Iowa trumpet as a probe transcervically and ICG was applied at 3 and 9 o'clock, 5 mm in depth through the con- secutively inserted needle. The fluorescent lymphatic network of the uterine corpus is visual- ized including collecting and connecting vessels to the draining lymph compartments. The borders of the Müllerian uterine system, bladder and rectum compartments can clearly be identified by border lamella and the topical course of the lymphatic channels. Same is true with Gynecologic Oncology Reports 16 (2016) 24 ⁎ Corresponding author at: West German Cancer Center, University Hospital Essen, Dpt. Obstetrics and Gynecology, Hufelandstr. 55, D-45133 Essen, Germany. E-mail address: rainer.kimmig@uk-essen.de (R. Kimmig). respect to the drainage along the vascular mesometrium and the infundibulopelvic ligament. Lymphatic drainage of the uterine corpus and cervix is partially different (Kimmig et al., 2016); this represents the anatomical basis for the differences in technique of PMMR com- pared to total mesometrial resection (TMMR) (Höckel et al., 2009; Kimmig et al., 2013b); pelvic part of robotic PMMR following ICG label- ing using a da Vinci Xi system is demonstrated. The compartment visualization by ICG may help the trainee to un- derstand surgical anatomy and to improve the learning curve, the ex- pert to adapt to individual situations. Furthermore, it enables to exactly define a surgical technique for scientific studies and clinical use. Appendix A. Supplementary data Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.gore.2016.03.004. References Dahmann, C., Oates, A.C., Brand, M., 2011. Boundary formation and maintenance in tissue development. Nat. Rev. Genet. 12, 43–55. Höckel, M., 2015. Morphogenetic fields of embryonic development in locoregional cancer spread. Lancet Oncol. 16 (3), e148–e151. http://dx.doi.org/10.1016/S1470- 2045(14)71028-9 (Mar). Höckel, M., Horn, L.-C., Manthey, N., et al., 2009. Resection of the embryologically defined uterovaginal (Müllerian) compartment and pelvic control in patients with cervical cancer: a prospective analysis. Lancet Oncol. 10, 683–692. Kimmig, R., Aktas, B., Buderath, P., et al., 2013a. Definition of compartment-based radical surgery in uterine cancer: modified radical hysterectomy in intermediate/high-risk endometrial cancer using peritoneal mesometrial resection (PMMR) by M Höckel translated to robotic surgery. World J. Surg. Oncol. 11 (1), 198 (Aug 16). Kimmig, R., Aktas, B., Buderath, P., Rusch, P., Heubner, M., 2016. Intraoperative navigation in robotically assisted compartmental surgery of uterine cancer by visualisation of embryologically derived lymphatic networks with Indocyanine-green (ICG). J. Surg. Oncol. http://dx.doi.org/10.1002/jso.24174 (Jan 21). Kimmig, R., Wimberger, P., Buderath, P., et al., 2013b. Definition of compartment-based radical surgery in uterine cancer: radical hysterectomy in cervical cancer as 'total mesometrial resection (TMMR)' by Michael Höckel translated to robotic surgery (rTMMR). World J. Surg. Oncol. 11 (1), 211 (Aug 26). Kimmig, R., Iannaccone, A., Aktas, B., et al., 2015. Embryologically based radical hysterec- tomy as peritoneal mesometrial resection (PMMR) with pelvic/paraaortic lymphade- nectomy for loco-regional tumour control in endometrial cancer – first evidence for efficacy. Arch. Gynecol. Obstet. http://dx.doi.org/10.1007/s00404-015-3956-y. Ribatti, D., Crivellato, E., 2010. The embryonic origins of lymphatic vessels: an historical review. Br. J. Haematol. 149, 669–674. Yang, Y., Oliver, G., 2015. Development of the mammalian lymphatic vasculature. J. Clin. Investig. 124, 888–897. http://dx.doi.org/10.1016/j.gore.2016.03.004 2352-5789/© 2016 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Contents lists available at ScienceDirect Gynecologic Oncology Reports journal homepage: www.elsevier.com/locate/gynor