Sentinel Lymph Node Mapping and Staging Surgery Via Gasless Transvaginal Natural Orifice Transluminal Endoscopic Surgery: A Case Report of an Endometrial Cancer Patient and Comorbid Rheumatic Heart Disease

Abstract

BACKGROUND Conventional laparoscopic surgery and transvaginal natural orifice transluminal endoscopic surgery (vNOTES) both use CO2 pneumoperitoneum to expose the surgical space. However, CO₂ pneumoperitoneum is undoubtedly dangerous for patients with rheumatic heart disease (RHD) and can cause cardiopulmonary impairments. Therefore, we selected the sentinel lymph node (SLN) mapping strategy to guide the staging surgery via gasless vNOTES for an endometrial cancer (EC)-patient with comorbid RHD. Here, we discuss whether our selected surgical method was safe and feasible for this patient. CASE REPORT A 43-year-old woman with a history of RHD, severe mitral regurgitation, and pulmonary hypertension for more than 30 years received diagnostic curettage for irregular vaginal bleeding for more than 1 month. Pathological examinations revealed the occurrence of highly differentiated intrauterine endometrioid adenocarcinoma. She was admitted to the gynecological ward of our hospital for further surgery. We performed EC staging surgery with SLN mapping via gasless vNOTES and adopted a series of effective measures to solve the intraoperative complications of surgical space exposure. Surgery was successful. The patient recovered well and was discharged 5 days after surgery. She has been followed up in the gynecological clinic for nearly 1 year. At the time of this report, she had good recovery, no recurrence and metastasis, and normal tumor markers. CONCLUSIONS For EC patients with comorbid RHD pathology, application of staging surgery with SLN mapping via gasless vNOTES was shown to be safe and feasible. This approach is expected to be highly effective for patients with contraindications to CO2 pneumoperitoneum laparoscopy.

Figure 1.

The transvaginal natural orifice transluminal endoscopic surgery (tvNOTES) operating platform. (A) The tvNOTES port was inserted through the vagina into the peritoneal cavity, but the sealing cap of the port was not installed. (B) Instruments were easy to access, and the assistant surgeon could assist the chief surgeon through the port directly. The monitor was placed in front of the chief surgeon.

Figure 2.

The abdominal wall suspension device setting. (A) The steel needle ran subcutaneously 5 cm above the pubic symphysis, the puncture length was about 10 cm, and both ends were fixed and suspended on the suspensory holder. (B) The pelvis was clearly exposed, and (C) the whole abdominal cavity could be thoroughly explored.

Figure 3.

The retroperitoneum suspension needle setting. (A) The needle was passed through the abdominal wall and then to the retroperitoneum. (B) The exposed surgical field after retroperitoneum suspension.

Figure 4.

Bilateral pelvic and paraaortic sentinel lymph node (SLN) (shown by white arrow). (A–D) The SLN could be exposed and dissected.