From Avoiding Empty Packets to Real-Time Diagnosis: The Value of Robotic Ultrasound-Guided Surgery in Sentinel Lymph...

Sentinel lymph node (SLN) mapping is recommended for staging in endometrial and cervical cancers,^1,2 offering lower morbidity than systematic lymphadenectomy. However, limitations persist, including low frozen-section accuracy, tissue loss during molecular analysis, and empty packets, especially in obese patients.³ In digital surgery, robotic intraoperative ultrasound has emerged as a promising tool to overcome these challenges, enhancing real-time decision-making and diagnostic accuracy.⁴ This video presents three ultrasound-based scenarios illustrating the potential of this image-guided surgical technique.⁵ PATIENTS AND METHODS: A prospective clinical study (R-LYNUS, NCT06621823) is ongoing to evaluate robotic intraoperative ultrasound for SLN assessment. Procedures are performed on the da Vinci Xi platform using the Arietta L43K(2-12 MHz, Hitachi) drop-in probe. Real-time ultrasound is displayed in split-view mode via Tile Pro, allowing simultaneous ultrasound and endoscopic visualization. SLN imaging is performed in vivo and ex vivo according to Vulvar International Tumor Analysis (VITA) consensus. Patients undergoing robotic SLN dissection for cervical or endometrial cancer are included, with final histology as reference.

Three intraoperative scenarios were observed: (1) normal SLN morphology; (2) adipose tissue without nodal structures (empty packets); and (3) nodes with cortical thickening, heterogeneous echostructure, and transcapsular vascularization suspected of metastasis. Ultrasound findings correlated with histology in all cases, supporting its role in real-time staging.

Robotic intraoperative ultrasound is feasible, safe, and reproducible, potentially preventing empty packets and enabling nodal assessment without tissue loss. Integration of high-frequency ultrasound could further improve spatial resolution and metastatic detection. Incorporating ultrasound into robotic systems paves the way for multi-console tele-image-guided surgery, promoting remote collaboration and precision in gynecologic oncology.