Minimally Invasive Surgery

Pedro T. Ramirez, Michael Frumovitz, and Pedro F. Escobar

INTRODUCTION

Minimally invasive surgery is currently considered a safe and viable option in the management of most gynecologic malignancies. Compared to standard laparotomy, laparoscopic or robotic surgery is associated with lower blood loss and transfusion rates, lower intraoperative complication rates, decreased analgesic requirements in the immediate postoperative period, shorter length of hospitalization, lower postoperative complication rates, quicker return of bowel function, and improved short-term quality of life.

This chapter provides an overview of the standard laparoscopic procedures and robotic surgery. Details on the preoperative evaluation and postoperative care of patients undergoing the procedures described and specific steps for the more commonly performed procedures are provided. Because the anatomical dissections are the same as for open procedures (see Chapters 25 and 26), the illustrations and figures are limited to those aspects specific to the minimally invasive surgical approach.

LAPAROSCOPIC SURGERY

Cervical Cancer

Laparoscopic Radical Hysterectomy

Procedure Overview

Since the initial publications by Nezhat et al¹ and Canis et al,² several retrospective studies have documented the safety and feasibility of total laparoscopic radical hysterectomy (TLRH), with a major complication rate of just 5%.³ In a study by Frumovitz et al,⁴ the authors compared 35 women who had undergone TLRH to 54 women who had open radical hysterectomy (ORH) and found significantly less blood loss, shorter length of hospital stay, and increased operative time for the TLRH group. Transfusion rates were low in both groups (15% for ORH vs. 11% for TLRH). Intraoperative and postoperative noninfectious complications were the same for both groups, but the ORH group had a significantly higher postoperative infectious complication rate than the TLRH group (53% vs. 18%, respectively). These complications included postoperative febrile morbidity, wound cellulitis, urinary tract infections, pneumonia, and intra-abdominal abscesses.

In evaluating oncologic outcomes, it appears that there is equivalency between TLRH and ORH. In their large series of 295 women who underwent TLRH, Chen et al³ reported overall disease-free survival rates of 95% for women with stage IA disease and 96% for women with stage IB disease.

Preoperative Management

Patients with early-stage cervical cancer scheduled for a radical hysterectomy should routinely undergo a chest x-ray and blood type and cross. The use of other imaging modalities such as computed tomography (CT) or magnetic resonance imaging (MRI) scans is not recommended, unless there is evidence to suspect metastatic disease.

All patients should undergo bowel preparation 1 day prior to surgery and receive antibiotic prophylaxis on the day of surgery. The choice of bowel preparation used by the authors is HalfLytely (polyethylene glycol), and the antibiotic regimen most frequently recommended is cefoxitin 2 g intravenously. Although there is no standard regimen for thromboembolic prophylaxis, patients should either undergo administration of subcutaneous heparin (5000 U) preoperatively or have compression devices used during the procedure and subsequently until ambulation.

Surgical Technique

Initial Steps. After induction of general anesthesia, the patient is placed in the low lithotomy position using Allen stirrups. Typically, the patient’s arms are tucked at her sides. Care must be taken to protect the patient’s hands and fingers when the foot of the table is raised or lowered (Figure 31-1). Monitors are placed at the foot of the table.

FIGURE 31-1. Patient positioning for laparoscopic surgery.

After the patient is prepared and draped, a Foley catheter is placed under sterile conditions. A sterile speculum is then placed into the vagina, and a single-toothed tenaculum is used to grasp the anterior lip of the cervix. A uterine manipulator is placed. The preferred uterine manipulator used by the authors is the V-Care manipulator (Conmed Endosurgery, Utica, NY).

Incision Placement. A 12-mm Xcel Bladeless Trocar (Ethicon Endo-Surgery, Cincinnati, OH) that incorporates a 0-degree laparoscope is placed at the level of the umbilicus and introduced into the abdominal cavity under direct visualization. In patients with a prior midline incision, the initial entry into the abdominal cavity is made approximately 2 cm below the left costal margin at the level of the midclavicular line to avoid injury to bowel adherent to the anterior abdominal wall. Once the trocar has been safely introduced into the abdominal cavity, the cavity is insufflated. The intra-abdominal pressure is maintained at 16 mm Hg. Two additional 5- or 12-mm Xcel Bladeless Trocars are placed in the right and left lower quadrants, and an additional 5-mm Xcel Bladeless Trocar is inserted in the midline above the pubic symphysis (Figure 31-2).

FIGURE 31-2. Trocar placement for standard laparoscopic procedures. LLQ, left lower quadrant; RLQ, right lower quadrant.

Retroperitoneal Exploration. The pelvis and abdomen are thoroughly explored to rule out intraperitoneal disease. The bowel is then mobilized into the upper abdomen, and the round ligaments are transected bilaterally. An incision is made in the peritoneum over the psoas muscle immediately lateral to the infundibulopelvic ligament. The infundibulopelvic ligament is retracted medially to permit identification of the ureter. The iliac vessels are also exposed at this time. The lymph-bearing tissue is then probed to rule out any obvious metastatic disease to the pelvic lymph nodes. Any suspicious nodes are removed and sent for frozen-section examination. Barring obvious lymph node metastasis, the pelvic lymph node dissection is completed after the radical hysterectomy.

Parametrial and Bladder Dissection. The paravesical space is dissected by following the external iliac vessels distally and placing medial traction on the superior vesical artery. The pararectal space is identified by dissecting between the internal iliac vessels and the lateral aspect of the ureter. Once these spaces have been created, one can easily identify the uterine vessels. After identification, the uterine vessels are transected at the point of origin from the internal iliac vessels. The uterine artery and vein are transected together. The bladder peritoneum is incised across the anterior aspect of the uterus and dissected down off the cervix. The bladder should be mobilized to below the level of the cup of the uterine manipulator to assure there is an adequate surgical margin of at least 1 to 2 cm. This can be performed by pushing the uterine manipulator cephalad with the uterus straight along its axis. We take particular care at this point in the procedure to completely separate the bladder fibers from the anterior vagina because this facilitates closure of the vaginal cuff at the end of the procedure.

The ureters are separated from their medial attachments to the peritoneum. The parametrial tissue is mobilized medially over the ureters. The ureters are unroofed to the point of their insertion into the bladder bilaterally. The lateral aspect of the vesicouterine ligament is then divided, and the bladder is further mobilized inferiorly to ensure adequate vaginal margins. The uterus is anteflexed using the uterine manipulator, and blunt graspers are used to apply counter traction across the posterior cul-de-sac. The peritoneum above the sigmoid colon and rectum is then incised, exposing the rectovaginal space. The attachments between the rectum and the vagina are cut in the midline, exposing the uterosacral ligaments. The uterosacral ligaments are then divided.

Circumferential Vaginotomy and Closure. Once the previously described procedures are complete, the cervix is now free of all its vascular and suspensory attachments, and the specimen can be removed. A circumferential incision is made into the vagina along the ring of the uterine manipulator. The specimen is completely separated from the upper vagina and removed. The vaginal cuff is sutured laparoscopically.

Postoperative Management

Patients undergoing laparoscopic radical hysterectomy are routinely placed on a demand intravenous analgesic pump and an oral analgesic regimen. All patients are ordered a regular diet on the evening of surgery. A Foley catheter is left in place postoperatively for a total of 5 to 7 days. A trial of void is attempted at that time, and if the postvoid residual is less than 150 mL, the catheter is removed. If the patient fails the voiding trial, then the catheter is left in place for another week. We do not routinely recommend thromboembolic prophylaxis postoperatively in patients undergoing minimally invasive surgery. A study by Nick et al⁵ in patients undergoing laparoscopic surgery showed that the rate of a deep venous thromboembolism or pulmonary embolism was 0.7%.

Laparoscopic Staging for Locally Advanced Cervical Cancer

Procedure Overview

Surgical staging of patients with locally advanced cervical cancer remains controversial. An open transperitoneal approach is associated with high morbidity and mortality secondary to bowel complications, particularly when surgery is followed by radiotherapy. An extraperitoneal approach by laparotomy has been shown to decrease the complication rate from 30% to 2% compared with the transperitoneal approach.⁶

As many as 22% of patients with stage IB2 to IV cervical cancer and negative para-aortic lymph nodes on preoperative CT or combined positron emission tomography (PET)/CT imaging will be found to harbor metastatic disease in the para-aortic nodes when submitted to laparoscopic extraperitoneal staging.⁷ These findings strongly argue for the consideration of surgical staging in patients with locally advanced cervical cancer for diagnostic purposes. In addition, LeBlanc et al⁸ found a therapeutic effect from surgical staging of locally advanced cervical cancer. In their study of 184 patients with stage IB2 to IVA cervical cancer, they found that women with microscopic metastatic disease to the para-aortic lymph nodes had the same survival as women who had pathologically negative lymph nodes.

Preoperative Management

Patients scheduled to undergo surgical staging of locally advanced cervical cancer routinely undergo a PET/CT imaging evaluation. Alternatively, a CT scan of the chest, abdomen, and pelvis is recommended. Patients should have no evidence of metastatic disease prior to undergoing surgery. Routine bowel preparation, antibiotic prophylaxis, and thromboembolic prophylaxis are recommended.

Surgical Technique

Initial Steps. The patient is placed in a supine position under general anesthesia with the right arm adducted and secured and the left arm placed at a right angle to the patient. A 5-mm endoscope is placed at the inferior margin of the umbilicus. The abdominal and pelvic cavities are inspected for intraperitoneal metastatic disease.

Development of Extraperitoneal Space. If the intraperitoneal inspection is clear, a 15-mm incision is made 3 to 4 cm medial and superior to the left anterior iliac spine. The skin, fascia, transverse muscles, and deep fascia are incised, with care taken not to open the peritoneum. The surgeon’s left forefinger is introduced in the incision to free the peritoneal sac from the deep surface of the muscles of the abdominal wall under laparoscopic monitoring. A 10-mm balloon-tip trocar is then placed in the extraperitoneal space of the flank. The retroperitoneum is insufflated to a pressure not exceeding 15 mm Hg. At the same time, the peritoneal cavity is deflated. The laparoscope is then introduced through the balloon-tip trocar. A second 10-mm trocar is then introduced into the extraperitoneal space. The penetration point is located in the midaxillary line under the subcostal margin approximately 5 cm cephalad to and 3 to 4 cm lateral to the initial point. A 5-mm trocar is then placed 3 to 4 cm cephalad to this second 10-mm trocar (Figure 31-3).

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