CHAPTER      10

Minimally Invasive Surgery in Gynecologic Cancer

DENIS QUERLEU MARIE PLANTE YUKIO SONODA WALTER GOTLIEB ERIC LEBLANC

Early history of laparoscopic surgery in gynecologic oncology came to an end when the whole range of surgical procedures used in uterine cancer, including pelvic exenteration, was demonstrated to be feasible laparoscopically (1). In a second phase, accumulation of evidence including long-term follow-up of patients managed laparoscopically, results of randomized controlled studies, and meta-analysis has led to unanimous acceptance of the concept of minimal invasive surgery (MIS) in gynecologic cancer. However, notwithstanding the spread of the technique in almost every country in the world, the open approach is still widely used in small institutions with limited caseload, or in academic centers without trained teachers and proctors, which implies that more efforts still have to be made in teaching and in concentrating the management of gynecologic cancer in experienced hands.

In this chapter, the evidence of short- and long-term benefits and safety of the laparoscopic approach, the teaching and learning issues, and the new technical developments will be detailed.

BASICS OF LAPAROSCOPIC SURGERY IN GYNECOLOGIC CANCER

The goal of this section is not to describe the standard technique of laparoscopy; this can be found in general gynecology textbooks. Two issues will be addressed: the risk of bowel and vascular complications related to the laparoscopic approach, and the pitfalls of the laparoscopic approach in cancer patients. Indeed, the potential for inducing severe intraoperative surgical complications and to favor tumor growth and port-site implants is not negligible. The goal of this section is to contribute to the prevention of such complications. Additional tips to make the laparoscopic surgeon’s life easier will also be given. An insight on training issues that are critical to the development of laparoscopic surgery versus open and robot-assisted laparoscopic surgery will conclude the section.

Laparoscopic Entry

Laparoscopic surgery was initially performed via CO₂ insufflation to create a pneumoperitoneum through the umbilicus – a place where the layers of the abdominal wall are fused followed by blind insertion in the umbilicus of a 10-mm trocar to accommodate the endoscope. This mode of entry was responsible for bowel and vascular complications, some of them lethal. The use of disposable trocars with retractable blades for direct trocar insertion did not appear to significantly reduce the risk of bowel or vascular injuries. This is of particular concern since the majority of complications following laparoscopic surgery are related to trocar insertion.

For that reason, the “open” technique in which the fascia and the peritoneum are surgically opened and the trocar inserted under direct visualization is considered by many to be the safest access technique. However, this is likely not to be true in patients with a history of laparotomy, as the majority of bowel adhesions are located on the midline below the umbilicus, at a location where even an “open” technique can result in bowel injury. Bonjer et al. (2) reviewed the literature and compared data between 12,444 open laparoscopic and 489,335 closed laparoscopic cases. Rates of visceral and vascular injury were 0.083% and 0.075%, respectively, after closed laparoscopy, and 0.048% and 0.0%, respectively, after open laparoscopy (p = 0.002). Mortality rates were 0.003% for the closed and 0.0% for the open laparoscopy techniques. In another randomized trial of blind versus open laparoscopy for laparoscopic cholecystectomy, the major complication rate was 4% in the blind group and 1.3% in the open group, respectively (p < 0.05) (3). However, a large series comparing 8,324 cases of direct laparoscopic entry versus 1,562 cases of open laparoscopy for gynecologic procedures did not show a difference in the rate of major complications. On the opposite, there were more conversions to laparotomy in the open technique group (4). A review on laparoscopic entry concludes that there is no evidence that the open entry technique is superior or inferior to other entry techniques currently available (level II-2C evidence) (5). The visual entry cannula system may represent an advantage over traditional trocars, as it allows a clear optical entry; however, that does not necessarily avoid all visceral or vascular injuries (5).

In patients with prior midline incisions, the use of the Veress needle in the left upper quadrant to first insufflate the abdomen prior to the trocar entry is favored. Once the pneumoperitoneum is established, the location of the first trocar is chosen at a place where the absence of adhesion is evident, as assessed by a 5-mm endoscopy through the left upper quadrant or the use of the “bubble test.” This test consists in exploring the abdominal cavity by puncturing the abdominal wall using a fine needle plugged to a syringe containing 1 to 2 mL of saline. If bubbles are not freely aspirated, there is a suspicion of bowel or omental adhesions. Using multiple punctures if necessary, an area free of adhesions large enough to safely accommodate the endoscope is defined. Although the umbilicus is the traditional site of placement of the first trocar, one must be prepared to use any position in the midline or any site of the abdomen, provided the risk of adhesion is low. It is the policy of the senior author to combine this technique (left upper quadrant insufflation, bubble test) with the use of trocar insertion under direct vision using the Ternamian trocar (6).

The ancillary trocars are placed under laparoscopic vision. Generally, one 10-mm trocar is placed in a suprapubic location. Two 5-mm trocars are then placed on the horizontal line of the umbilicus, 10 cm lateral to it. This trocar position has many advantages. It allows access to the entire abdomen, from the pelvis to the diaphragm. It provides an adequate angulation between instruments, with a maximum distance between trocars. It provides a direct access, with a virtually 0-degree angle, to the ureteric tunnel at the time of radical hysterectomy. It is more adapted to performance of procedures at the abdominal level such as omentectomy or paraaortic lymph node dissection. Finally, it avoids injuring the iliohypogastric nerves that run oblique in the abdominal wall below the umbilical horizontal line, thus avoiding short and long-term postoperative pain. Any adhesion impairing vision or correct placement of trocar is taken down. When extensive adhesions are encountered, the first 5-mm trocar is placed in an area free of adhesions. Scissors are then introduced and other adhesions are divided to place the other trocars.

Port-Site Metastasis and Risk of Tumor Dissemination

In the early laparoscopic era, there has been concern about the apparent increased rate of port-site metastases following laparoscopic procedures. The first reports concerned borderline tumors of the ovary (7). Isolated case reports of abdominal wall metastasis following laparoscopic surgery for a variety of gynecologic cancers have been reported and reviewed by Ramirez et al. in 2004 (8). The fact that wound recurrences are not uncommon after conventional surgery clearly attenuates the responsibility of laparoscopic surgery in the occurrence of abdominal wall recurrences.

In addition, series from experienced centers have shown that the incidence of port-site growth is low. Zivanovic et al. (9) extended the investigation in the same institution and reported 18 abdominal wall metastases in 1,634 gynecologic cancer patients. Fifteen cases occurred in 767 patients with adnexal/peritoneal malignancy (2%), 2 in 160 cervical cancer patients and 1 in 457 endometrial cancer patients. Seventeen out of 18 of these patients had peritoneal disease, which indicates that abdominal wall metastases are extremely uncommon in the absence of peritoneal disease. In addition, they reported 2 cases in breast cancer patients with intra-abdominal disease, and reported on the outcome of a total of 20 patients. The median survival of patients in whom port-site metastases occurred within 7 months was 12 months, while the median survival of patients who developed port-site metastases after 7 months was 37 months. The conclusion is that the natural history of port-site metastases basically reflects the aggressiveness of the underlying tumor. Martinez et al. (10) reported on 921 patients who underwent laparoscopic staging for cervical cancer and 295 for endometrial cancer. The overall incidence of port-site metastasis after laparoscopy for cervical and endometrial cancer was 0.43% and 0.33%, respectively. Excluding patients with peritoneal carcinomatosis, the rate of port-site recurrence in this series lowered to 0.16%. The rate of isolated port-site metastases was 0%.

In contrast, there is evidence that the presence of peritoneal malignancy or ascites is a risk factor for port-site metastases. Vergote et al. observed 17% of port-site metastasis after laparoscopic surgery in patients with advanced ovarian cancer (11). However, port-site metastases are not lethal by themselves and are not associated with a worse outcome, as they are as chemosensitive as the underlying peritoneal disease and then generally reflect the aggressivity of the tumor (11). As a majority (22 out of 30) of port-site metastases in Vergote’s series were not clinically diagnosed, it is reasonable to recommend the resection of the laparoscopic ports in a full-thickness fashion at the time of the subsequent laparotomy after a laparoscopic assessment of advanced ovarian cancer. Indeed, Heitz et al. found 47% incidence of port-site implant at the time of pathological examination after routine resection of trocar site in 66 patients who underwent laparotomy after diagnostic laparoscopy (12). This implies that complete cytoreduction must be followed by trocar site resection. The conclusion is that port-site implant is not a complication of laparoscopic surgery in the absence of ascites or peritoneal malignancy. The early reports of port-site metastases may have been the result of faulty technique resulting in direct contamination of the abdominal wall by tumor cells.

Finally, it is logical to place all trocars in the midline when performing a laparoscopic evaluation of a clinically advanced adnexal or peritoneal cancer, to avoid muscle involvement and to easily resect the trocar sites at the time of final laparotomy. In addition, it is advised against placing the optical trocar in the umbilicus, which is a preferential site for abdominal wall tumor even in the absence of surgical scar, and would have to be fully resected at the time of final surgery.

The Issue of Intraoperative Rupture of Ovarian Masses

A recent population-based study in Norway definitively demonstrated that intraoperative rupture is associated with a worsened prognosis compared to no rupture, although to a lesser extent than spontaneous rupture (13).

The importance of the issue in laparoscopic surgery is the finding that inadvertent and unprotected ovarian cyst rupture is more frequent at laparoscopy compared to laparotomy with increased tumor size (14). On the basis of this evidence, and on concerns about the risks of peritoneal dissemination (see below), it is generally recommended that definitive surgery should be performed within 1 week in ruptured stage I cases. Although the grade of the tumor and the presence of ascites in stage I cancer of the ovary may have more important relation to survival than is rupture of the ovarian capsule at surgery, avoiding the rupture of low grade or stage IA is obviously an objective that gynecologic oncologists and general gynecologists must share, as adjuvant chemotherapy may have to be considered after extensive spillage. All pelvic masses should be considered potentially malignant, and consequently, every effort should be made to avoid rupture.

Influence of Pneumoperitoneum on Tumor Growth

On the basis of a review of experimental data, Canis et al. concluded that the risk of dissemination following laparoscopic surgery is increased when a large number of malignant cells are present (15). However, the results of various experiments are not consistent and the extrapolation of results obtained in experimental settings may be hazardous. On the contrary, using an ovarian cancer xenograft animal model, studies from Lécuru et al. seems to indicate that CO₂ laparoscopy has a minor impact on visceral metastasis and survival and has no deleterious effect on tumor growth compared to gasless laparoscopy (16). In the laboratory of the first author, survival of mice injected intraperitoneally with ovarian tumor cell lines was similar after laparotomy, CO₂ laparoscopy, or Helium laparoscopy (17). Similar results have been shown in humans. Abu-Rustum et al. retrospectively reviewed patients with persistent metastatic intra-abdominal peritoneal or ovarian cancer at the time of second-look surgery. There was no difference in overall survival between patients who underwent laparoscopy or laparotomy (18). Data from animal studies suggest that the underlying immune or metabolic status of the host has a marked independent effect on tumor spread and implantation (19). Of interest are recent data showing that an 8-mm Hg pressure pneumoperitoneum is preferable to a 12-mm one. As a consequence, low pressure pneumoperitoneum may be preferable (20).

Gasless Laparoscopy in Oncologic Surgery

Due to concerns regarding the potential increased risk of tumor dissemination associated with CO₂ laparoscopy, some have advocated the use of gasless laparoscopy. The results of animal studies on peritoneal tumor growth and abdominal-wall metastasis comparing gasless laparoscopy, CO₂ laparoscopy, and laparotomy are conflicting (16,21). In contrast, a higher rate of port-site metastasis with gasless laparoscopy has been reported in some experiments (22). Although it can be used in patients for whom general anesthesia and CO₂ pneumoperitoneum are contraindicated, as it does not significantly increase the intra-abdominal pressures and since the procedure can also be performed under epidural anesthesia, gasless laparoscopy is not widely used.

Teaching and Learning Laparoscopic Surgery

Mastering laparoscopic surgery involves, apart from the skills and knowledge required to perform the same procedure by laparotomy, a variety of specific skills: translation of 3-D into 2-D perception, hand-eye coordination, ambidexterity, camera navigation, remote handling of instruments, modified tactile feedback, and fine motor skills to overcome the fulcrum effect and the lever forces. Several models can be used in resident, fellowship, or catch-up teaching programs: cadaver surgery, animal models, video trainers, and virtual reality (VR). The most realistic model is the animal model, generally the pig model (23). The cheapest is the video trainer. The “box model” training does improve surgical dexterity and economy of movement during virtual reality laparoscopy. Clevin et al. (24) used the metrics derived from a virtual reality laparoscopic trainer to assess whether a low cost box model trainer is a tool for the training of skills relevant to laparoscopic surgery. Sixteen gynecologic residents with limited laparoscopic experience were randomized to a group that received a structured box model training curriculum, and a control group. Objective parameters were registered by the computer system. The trained group showed significantly greater improvement in all performance parameters: economy of movement (p = 0.001), time (p = 0.001), and tissue damage (p = 0.036), confirming the positive impact of box-trainer curriculum on laparoscopic skills acquisition.

The much more expensive simulation-based training environment offers much promise as an alternative arena to cadaver, animal, or patient training. There is evidence suggesting that the skills acquired in simulation transfer to the real setting (25). In addition, it allows objective measurement of psychomotor skills. However, realism is still far from perfect, and more studies are required to strengthen the evidence base and to provide the evidence needed to determine the extent to which simulation should become a part of surgical training programs. In a review of 23 randomized trials (12 VR vs. video, 3 VR vs. VR, 4 VR vs. no or standard training, and 4 VR vs. video vs. no or standard training), Gurusamy et al. (26) identified only 3 trials at low risk of bias. VR – compared to no training – decreases the time to complete a task, increases accuracy, and decreases errors. Although the benefit of VR versus video training is not demonstrated for every criterion, a VR-trained group is more accurate than video trainer group, and shows a better composite operative performance.

As a substantial number of active gynecologic oncologists have not been trained during their fellowship, they have to catch up. Visiting surgeons may monitor established surgeons during the learning curve of an advanced laparoscopic procedure (27). Five-day–mini-residencies for urologists have been shown to result in improvement of skill tasks. However, skill acquisition is not durable if not consolidated by experience. This is in accordance with the findings of Worley et al., who showed that surgeon volume is associated with higher complexity procedures, lower rate of conversions, less complications, and shorter hospital stay (28).

In addition, fundamental abilities (e.g., psychomotor skills, visuospatial ability, and depth perception) are critically important. In a pivotal paper of a VR trainer on this sensitive topic, Grantcharov et al. assessed the learning curve of 37 residents with limited laparoscopic experience (29). Five percent were proficient from the beginning, 70% needed 2 to 9 repetitions, 16% improved but did not reach the predefined criteria, and 8% underperformed and did not improve. The question is whether the residents lacking psychomotor skills required to perform laparoscopic surgery should be discouraged to engage in a general surgery or gynecologic oncology training involving laparoscopic surgery. It is not clear whether robot-assisted surgery is advisable to help the 16% group of low performers exposed to nonrobotic laparoscopic surgery.

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