Objective
We sought to assess feasibility and perioperative outcomes for laparoendoscopic single-site surgery (LESS) in early endometrial cancer.
Study Design
This was a retrospective multicentric study of 100 early endometrial cancer cases undergoing LESS from July 2009 through July 2011.
Results
All patients underwent total hysterectomy and bilateral salpingo-oophorectomy by LESS. Pelvic and paraaortic lymphadenectomy were performed in 48 and 27 patients, respectively. A median of 16 pelvic lymph nodes (range, 1–33) and 7 paraaortic lymph nodes (range, 2–28) were retrieved. Both median operative time (129 minutes; range, 45–321) and estimated blood loss (70 mL; range, 10–500) were greater when staging lymphadenectomy was performed ( P values = .001). Four intraoperative and 4 postoperative complications were observed. Conversion to standard laparoscopy and laparotomy was necessary for completion of 1 case each. Patients responded positively regarding cosmetic result and minimal postoperative pain control.
Conclusion
LESS further minimizes the invasive nature of surgery and is feasible for treatment of early-stage endometrial cancer.
Endometrial cancer is the most common malignancy of the female genital tract and accounts for 6% of all cancers in women. Most patients present with disease clinically confined to the uterus. When feasible, surgical management of endometrial cancer includes total abdominal hysterectomy, bilateral salpingo-oophorectomy (BSO), and pelvic and paraaortic lymphadenectomy. A laparoscopic approach for completion of these procedures was first proposed by Childers in 1993 and later compared to laparotomy in a randomized controlled trial, Gynecologic Oncology Group Lap-2. Although survival results continue to mature, initial publication established fewer complications and shorter hospital stay as benefits of the laparoscopic approach compared to laparotomy. Laparoscopy is thus the preferred surgical approach in management of endometrial cancer.
Laparoendoscopic single-site surgery (LESS) is an adaptation of laparoscopy intent upon further minimizing the invasive nature of surgery. This term was coined by a multidisciplinary consortium of surgeons who met at the Cleveland Clinic in July 2008, for single-incision laparoscopic surgery. Traditional laparoscopy is performed using multiple small incisions with ports for access within the abdomen. Contrarily, LESS utilizes only 1 skin incision, most often within the umbilicus, through which multiple instruments may be passed. Special equipment, including multichanneled ports and articulating instruments, help overcome challenges encountered, most commonly loss of instrument triangulation and crowding of the surgical field. Since its introduction, LESS has been utilized to successfully perform a multitude of procedures including cholecystectomy, appendectomy, nephrectomy, colectomy, adrenalectomy, and bariatric surgery. Within gynecology, LESS has been successfully used to perform hysterectomy, ovarian cystectomy, and adnexectomy. Beyond enhanced cosmetics benefits, proposed advantages include reduced pain and minimizing the morbidity secondary to multiple incisions. The objective of the present study was to assess the feasibility and perioperative outcomes for LESS in 100 women undergoing surgical treatment for early-stage endometrial cancer.
Materials and Methods
Patients and surgical characteristics
From July 2009 through July 2011, 100 women underwent LESS for clinical stage-1 endometrial cancer (n = 45, Cleveland Clinic; n = 43, Catholic University of the Sacred Heart of Rome; n = 12, Massachusetts General Hospital). The only inclusion criterion was presumed early-stage endometrial cancer. Although no exclusion criteria were defined, each center could freely choose the proper treatment for each patient. Standard exclusion criteria for any laparoscopic surgery (supposed extensive adherences or large uteri requiring morcellement) were used. Also excluded were morbidly obese patients who could not sustain a steep Trendelenburg position. The patients were informed about the LESS technique and signed a written informed consent, presenting the risk of laparoscopic and/or laparotomic conversion for completion of procedures. Clinical data, including patient demographics and perioperative measures, were obtained from retrospective chart review following approval by each study center’s institutional review board.
Intraoperative complications were defined as injuries to bowel, bladder, uretere, nerves, or blood vessels or an estimated blood loss (EBL) >500 mL. Preoperative and postoperative pain assessment (4 hours postoperative) were performed in 88 patients using a validated visual analog pain scale, scored from 0-10 (with 0 being “no pain” and 10 being “agonizing pain”). Patients were allowed to go home when they were fully mobile, apyrexial, and passing urine satisfactorily. Postoperative complication was defined as any adverse event occurring within 30 days from surgery, and considered severe if it resulted in unplanned admission, blood transfusion, or secondary surgical procedure. In 88 patients, the cosmetic outcome of the umbilical scar was evaluated by patients at days 1 and 30 after surgery. A subjective satisfaction value from 1-10 (with 0 being “bad” and 10 being “excellent”) was assigned.
Surgical technique
Hysterectomy
Following the induction of general anesthesia, the patient was positioned in the dorsal lithotomic position with both legs supported in stirrups with a Trendelenburg tilt. The position of surgeon and assistant around the operative table varied between hospitals in an effort to achieve the most ergonomic approach. The Hasson technique was used to gain access to the abdomen and a single multichannel port (Triport; Olympus Winter & Ibe GmbH, Hamburg, Germany; GelPoint and/or SILS port; Covidien, Mansfield, MA) was placed through a 12- to 20-mm fascial incision as previously reported. Once pneumoperitoneum was achieved (12–15 mm Hg), intraabdominal visualization was obtained with introduction of either a 5-mm 30-degree laparoscope (EndoEYE; Olympus Winter & Ibe GmbH) or, alternatively, a 5-mm 0-degree laparoscope with a flexible tip (EndoEYE) . A variety of 5-mm instruments, straight, articulating, and/or double-bended (Olympus Winter & Ibe GmbH), were inserted into the remaining 2 port channels to facilitate surgical tasks including suction/irrigation, bipolar coagulation, and tissue sealing and transection (eg, PKS cutting forceps, 5 mm-43 cm, Gyrus ACMI, Hamburg, Germany; or Sonosurg 5 mm, Olympus Winter & Ibe GmbH; or Ligasure 5 mm, 5-37 cm, blunt tip; Covidien). Clashing between instruments within the patient and between hands of the surgeons externally was minimized by incorporating use of an articulating or double-bent instrument or by combining straight instruments of different length (eg, 33 and 43 cm). Changes in the position of the instruments and laparoscope between port channels were necessary depending upon the surgical task undertaken and the preference of the surgeon. Careful inspection of the entire abdominal cavity was performed to identify any lesion suspicious for extrauterine disease. Peritoneal washings were obtained and an intrauterine manipulator was placed according to surgeon preference. The round ligaments were transected bilaterally allowing for retroperitoneal access and eventual development of the pararectal and paravesical spaces for inspection ± removal of the pelvic lymph nodes. Simple hysterectomy and BSO were performed in a fashion replicating open technique. Colpotomy was accomplished variably using either a bipolar hook (PKS plasma J hook, Gyrus ACMI) or ultrasonic shears. The uterus and adnexa were extracted through the vagina and sent for frozen section pathology analysis at the discretion of the surgeon. The vaginal vault was closed variably according to the discretion of the surgeon either laparoscopically or vaginally. The umbilical incision was approximated in separate layers.
Lymphadenectomy
According to the Mayo algorithm, pelvic lymphadenectomy was performed based on frozen section analysis and/or presence of extrauterine disease. Extension up to the inferior mesenteric artery was established according to surgeons’ preferences or attitudes. Detailed descriptions of the LESS technique for pelvic and paraaortic lymphadenectomy have been previously published. The anatomical margins for pelvic lymph node dissection were: the ureter medially; the body of the psoas muscle laterally; the obturator nerve inferiorly; the deep circumflex iliac vein caudad; and the bifurcation of the common iliac artery cephalad. The cephalad boundary of paraaortic lymphadenectomy on the right side was the insertion of the right ovarian vein into the vena cava. The cephalad boundary of the left side dissection was either the bifurcation point of the inferior mesenteric artery on the aorta or left renal vein and was at the discretion of the surgeon.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
