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LAPAROSCOPY IN GYNECOLOGY
ONCOLOGY
KHALID SAIT Professor
Director of Gynecology Oncology Unit
Chairman of Scientific chair of prof.Abdullah
Hussain Basalamah for Gynecological cancer
Faculty of Medicine
King Abdulaziz University Hospital
CLINICAL SERVICES FOR
GYNECOLOGICAL CANCER SURGERY
Robotic
Laparoscopy
Open
LAPAROSCOPY
LAPAROSCOPY IN GYNECOLOGIC
ONCOLOGY
„ Laparoscopically assisted vaginal hysterectomy
„ Total simple and radical hysterectomy
„ Pelvic and aortic node dissection
„ Omentectomy
„ Advanced bowel surgery
ADVANTAGE
„ Improvement of vision
„ Precision of dissection
„ Reduce in preoperative morbidity
„ Reduce hospital stay
„ Patient’s satisfaction
ADDITIONAL BENEFIT
„ Less adhesion
„ Less bowel complication if radiation required
LAPAROSCOPY IN ENDOMETRIAL
CANCER
„ Childers 1992
„ Ghezzi ( small RCT)
„ Obermair……………………..
SURVEY OF MEMBERS OF SGO
„ 47 % of responders advocated the use of
laparoscopy for surgical staging of endometrial
cancer in 2004
„ 87% of responders advocated the use of
laparoscopy for surgical staging of endometrial
cancer in 2009
REASONS FOR THIS INCREASE…..
„ Result of the ever-growing number of
reports attesting to its technical feasibility,
safety, and practicality
IMPORTANT POINT
„ Learning curve
„ Select the best candidates
„ Size of the uterus less than 8 cm to avoid
marcellation and dissmination of cancer
„ Proper equipment and patient position
REASONS OF UNACCEPTABILITY FOR
SOME…
„ Lacking of level I evidence
LAPAROSCOPY IN ENDOMETRIAL
CANCER
„  LAP -2 ( with nodes)
„  2413 Eligible patients
„  Multi-institutional RCT
„  Open vs Laparoscopy assistant
„  Result :
„  Laparoscopy is feasible with longer operative times, comparable
complications and shorter hospital stay
„  Better quality of life at 6 weeks, but same at 6 month( apart from body
image )
„  Conversion rate 25 %
LAPAROSCOPY IN ENDOMETRIAL
CANCER
„  LACE trial ( Stage I Australian randomized trial )
( with node depends on …..)
„  Result:
„  Open surgery : 142
„  Laparoscopy : 190
„  Significantly greater improvement in quality of life in laparoscopy group
In early and late stage of recovery and Intraoperative adverse effect
were similar
„  Post operative severe adverse effect were more in open surgery
„  Conversion rate 3.8 %
LAPAROSCOPY IN ENDOMETRIAL
CANCER
„  Netherlands study ( no nodes)
„  RCT
„  OPEN : 94
„  Laparoscopy: 185
„  Less major complication in laparoscopy
„  No different over time in the quality of life in both group
„  In laparoscopy group: less blood loss, less pain medication, shorter
hospital stay and faster recovery
„  Conversion rate: 4.3 %
MOST IMPORTANT GOAL OF CANCER
SURGERY
„ Cancer free survival
„ Data still immature
„ Retrospective….
„ RCT ( three studies)
follow up were 38 – 79 months
---sample size were not sufficient to provide
adequate statistical power to reveal modest but
meaningful difference in survival
LAPAROSCOPY IN OBESE WOMEN WITH
ENDOMETRIAL CANCER
„ Eltabbakh : BMI: 28-60
„ Succ. rate 88 %
OBESITY AND LAPAROSCOPY IN
ENDOMETRIAL CANCER
„  Trocher placement is challenging
„  Bleeding from abdominal wall vessels
„  Restricted operative field( fat , bowel)
„  Difficult to achieve pneumoperotinum to elevate ant. Abd. wall
„  Difficult to place patient in steep trendelburg because of ventilation
consideration
„  Difficulty in doing para-ortic node
„  Conversion rate 7.5-36%( BMI >35)
SAUDI ARABIA LAPAROSCOPIC
EXPERIENCE( KAUH) SEP 2011-AUG 2012
„ Endometrial cancer(20)
1- 50 % Robotic
2- 10 % laparoscopy
3- 40 % open
LAPAROSCOPIC IN OVARIAN CANCER
„ Childers
„ Tozzi
„ Chi
„ Leblanc
„ Abu- Rustum
„ Litell
SURVEY OF MEMBERS OF SGO
„ The use of laparoscopic for Early ovarian cancer in
2004 not considered
„ 62 % of responders advocated the use of
laparoscopic in early ovarian cancer in 2009
LAPAROSCOPIC IN EARLY OVARIAN
CANCER
„ 300 patients reported
„ Case serious (9-42 patients)
„ Low rate of conversion and reasonable
intraoperative complication
LIMITATION IN LAPAROSCPY IN EARLY
OVARIAN CANCER
„ No RCT
„ Lack of level I evidence in term of : rate of
upstaging and number of node retrieved and
survival
„ Its rare, and has long life expectancy
„ Need 1000 patients to demonstrate slimier
oncologic out come
Which is difficult to do …
OMENTECTOMY
LIMITATION IN LAPAROSCPY IN EARLY
OVARIAN CANCER
„ Not allow inspection of whole peritoneum,
mesentery, behind the liver and high part of left
diaphragm
„ Port site mets. (2%) ???
„ Tumor rupture ( big topic to discuss…)
…….largest review by Vergote of 6 international
data base including 1545 pts. in which found that
rupture is an independent predictor of disease free
survival
SAUDI ARABIA LAPAROSCOPIC
EXPERIENCE( KAUH) SEP 2011-AUG 2012
„ Ovarian cancer
Suspicious ovarian mass
100 % open
„ Staging after initial oophorectomy for ovarian
cancer ( 10 cases)
50% laparoscopy
50 % open
LAPAROSCOPY IN CERVICAL CANCER
„ Daniel Dargent
„ Spirtos
„ Abu-Rustum
„ Nezhat
SURVEY OF MEMBERS OF SGO
„ 11 % of responders advocated the use of
laparoscopic for cervical cancer in 2004
„ 38 % of responders advocated the use of
laparoscopic for cervical cancer In 2009
LAPAROSCOPY IN CERVICAL CANCER
„ More than 400 LRH reported
„ Concerned:
Cure rate
Radicallity
Number of L. Node removed
LIMITATION OF LAPAROSCOPY IN
CERVICAL CANCER
„ No RCT
„ One serious of 139 patients , median follow up 92
months
Over all survival rate 92.8 % and progress free
survival 91 %
LAPAROSCOPY IN CERVICAL CANCER (RH)
„ Largest serious of 200 patients
„ Median operative time 210-250 mints
„ Less blood loss
„ Shorter hospital stay
„ Conversion rate close to zero %
SAUDI ARABIA LAPAROSCOPIC
EXPERIENCE( KAUH) SEP 2011-AUG 2012
„ Cervical cancer(8)
50 % robotic
50 % open
LAPAROSCOPY IN PELVIC AND PARA-
AORTIC LYMPH NODE DISSECTION
„ Deniel Dargent 1989
„ Querleu
„ Nezhat 1992
„ Scibner
LAPAROSCOPIC NODE DISSECTION
„ Trans peritoneal node dissection
„ Several RCT showed that number of node count
not significantly different from open
„ Learning curve
„ Conversion rate 12-18%
LAPAROSCOPY IN PELVIC EXENTERATION
„ Plante
„ Roy
„ Kohler
TEACHING LAPAROSCOPY
ONCO-GYNECOLOGY
„ Learning curve is a real concern
„ Pelvic node: need 7 cases under supervision
„ Para aortic node need 15 cases
CONCLUSION
„ Operative technique in gynecologic oncology have
been adapted to lend themselves to laparoscopic
approach
„ The operative technique are feasible , safe and
effective
„ There is will and desire by gynecological oncologist
to offer minimal invasive surgery options to their
patients, while in the same time patient demand is
also on the rise
Laparoscopy in Gynecologic Oncology - Benefits and Techniques

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Laparoscopy in Gynecologic Oncology - Benefits and Techniques

  • 1. LAPAROSCOPY IN GYNECOLOGY ONCOLOGY KHALID SAIT Professor Director of Gynecology Oncology Unit Chairman of Scientific chair of prof.Abdullah Hussain Basalamah for Gynecological cancer Faculty of Medicine King Abdulaziz University Hospital
  • 2. CLINICAL SERVICES FOR GYNECOLOGICAL CANCER SURGERY Robotic Laparoscopy Open
  • 4. LAPAROSCOPY IN GYNECOLOGIC ONCOLOGY „ Laparoscopically assisted vaginal hysterectomy „ Total simple and radical hysterectomy „ Pelvic and aortic node dissection „ Omentectomy „ Advanced bowel surgery
  • 5. ADVANTAGE „ Improvement of vision „ Precision of dissection „ Reduce in preoperative morbidity „ Reduce hospital stay „ Patient’s satisfaction
  • 6. ADDITIONAL BENEFIT „ Less adhesion „ Less bowel complication if radiation required
  • 7. LAPAROSCOPY IN ENDOMETRIAL CANCER „ Childers 1992 „ Ghezzi ( small RCT) „ Obermair……………………..
  • 8. SURVEY OF MEMBERS OF SGO „ 47 % of responders advocated the use of laparoscopy for surgical staging of endometrial cancer in 2004 „ 87% of responders advocated the use of laparoscopy for surgical staging of endometrial cancer in 2009
  • 9. REASONS FOR THIS INCREASE….. „ Result of the ever-growing number of reports attesting to its technical feasibility, safety, and practicality
  • 10. IMPORTANT POINT „ Learning curve „ Select the best candidates „ Size of the uterus less than 8 cm to avoid marcellation and dissmination of cancer „ Proper equipment and patient position
  • 11. REASONS OF UNACCEPTABILITY FOR SOME… „ Lacking of level I evidence
  • 12. LAPAROSCOPY IN ENDOMETRIAL CANCER „  LAP -2 ( with nodes) „  2413 Eligible patients „  Multi-institutional RCT „  Open vs Laparoscopy assistant „  Result : „  Laparoscopy is feasible with longer operative times, comparable complications and shorter hospital stay „  Better quality of life at 6 weeks, but same at 6 month( apart from body image ) „  Conversion rate 25 %
  • 13. LAPAROSCOPY IN ENDOMETRIAL CANCER „  LACE trial ( Stage I Australian randomized trial ) ( with node depends on …..) „  Result: „  Open surgery : 142 „  Laparoscopy : 190 „  Significantly greater improvement in quality of life in laparoscopy group In early and late stage of recovery and Intraoperative adverse effect were similar „  Post operative severe adverse effect were more in open surgery „  Conversion rate 3.8 %
  • 14. LAPAROSCOPY IN ENDOMETRIAL CANCER „  Netherlands study ( no nodes) „  RCT „  OPEN : 94 „  Laparoscopy: 185 „  Less major complication in laparoscopy „  No different over time in the quality of life in both group „  In laparoscopy group: less blood loss, less pain medication, shorter hospital stay and faster recovery „  Conversion rate: 4.3 %
  • 15. MOST IMPORTANT GOAL OF CANCER SURGERY „ Cancer free survival „ Data still immature „ Retrospective…. „ RCT ( three studies) follow up were 38 – 79 months ---sample size were not sufficient to provide adequate statistical power to reveal modest but meaningful difference in survival
  • 16. LAPAROSCOPY IN OBESE WOMEN WITH ENDOMETRIAL CANCER „ Eltabbakh : BMI: 28-60 „ Succ. rate 88 %
  • 17. OBESITY AND LAPAROSCOPY IN ENDOMETRIAL CANCER „  Trocher placement is challenging „  Bleeding from abdominal wall vessels „  Restricted operative field( fat , bowel) „  Difficult to achieve pneumoperotinum to elevate ant. Abd. wall „  Difficult to place patient in steep trendelburg because of ventilation consideration „  Difficulty in doing para-ortic node „  Conversion rate 7.5-36%( BMI >35)
  • 18. SAUDI ARABIA LAPAROSCOPIC EXPERIENCE( KAUH) SEP 2011-AUG 2012 „ Endometrial cancer(20) 1- 50 % Robotic 2- 10 % laparoscopy 3- 40 % open
  • 19. LAPAROSCOPIC IN OVARIAN CANCER „ Childers „ Tozzi „ Chi „ Leblanc „ Abu- Rustum „ Litell
  • 20. SURVEY OF MEMBERS OF SGO „ The use of laparoscopic for Early ovarian cancer in 2004 not considered „ 62 % of responders advocated the use of laparoscopic in early ovarian cancer in 2009
  • 21. LAPAROSCOPIC IN EARLY OVARIAN CANCER „ 300 patients reported „ Case serious (9-42 patients) „ Low rate of conversion and reasonable intraoperative complication
  • 22. LIMITATION IN LAPAROSCPY IN EARLY OVARIAN CANCER „ No RCT „ Lack of level I evidence in term of : rate of upstaging and number of node retrieved and survival „ Its rare, and has long life expectancy „ Need 1000 patients to demonstrate slimier oncologic out come Which is difficult to do …
  • 24. LIMITATION IN LAPAROSCPY IN EARLY OVARIAN CANCER „ Not allow inspection of whole peritoneum, mesentery, behind the liver and high part of left diaphragm „ Port site mets. (2%) ??? „ Tumor rupture ( big topic to discuss…) …….largest review by Vergote of 6 international data base including 1545 pts. in which found that rupture is an independent predictor of disease free survival
  • 25. SAUDI ARABIA LAPAROSCOPIC EXPERIENCE( KAUH) SEP 2011-AUG 2012 „ Ovarian cancer Suspicious ovarian mass 100 % open „ Staging after initial oophorectomy for ovarian cancer ( 10 cases) 50% laparoscopy 50 % open
  • 26. LAPAROSCOPY IN CERVICAL CANCER „ Daniel Dargent „ Spirtos „ Abu-Rustum „ Nezhat
  • 27. SURVEY OF MEMBERS OF SGO „ 11 % of responders advocated the use of laparoscopic for cervical cancer in 2004 „ 38 % of responders advocated the use of laparoscopic for cervical cancer In 2009
  • 28. LAPAROSCOPY IN CERVICAL CANCER „ More than 400 LRH reported „ Concerned: Cure rate Radicallity Number of L. Node removed
  • 29. LIMITATION OF LAPAROSCOPY IN CERVICAL CANCER „ No RCT „ One serious of 139 patients , median follow up 92 months Over all survival rate 92.8 % and progress free survival 91 %
  • 30. LAPAROSCOPY IN CERVICAL CANCER (RH) „ Largest serious of 200 patients „ Median operative time 210-250 mints „ Less blood loss „ Shorter hospital stay „ Conversion rate close to zero %
  • 31.
  • 32. SAUDI ARABIA LAPAROSCOPIC EXPERIENCE( KAUH) SEP 2011-AUG 2012 „ Cervical cancer(8) 50 % robotic 50 % open
  • 33. LAPAROSCOPY IN PELVIC AND PARA- AORTIC LYMPH NODE DISSECTION „ Deniel Dargent 1989 „ Querleu „ Nezhat 1992 „ Scibner
  • 34.
  • 35. LAPAROSCOPIC NODE DISSECTION „ Trans peritoneal node dissection „ Several RCT showed that number of node count not significantly different from open „ Learning curve „ Conversion rate 12-18%
  • 36.
  • 37. LAPAROSCOPY IN PELVIC EXENTERATION „ Plante „ Roy „ Kohler
  • 38. TEACHING LAPAROSCOPY ONCO-GYNECOLOGY „ Learning curve is a real concern „ Pelvic node: need 7 cases under supervision „ Para aortic node need 15 cases
  • 39. CONCLUSION „ Operative technique in gynecologic oncology have been adapted to lend themselves to laparoscopic approach „ The operative technique are feasible , safe and effective „ There is will and desire by gynecological oncologist to offer minimal invasive surgery options to their patients, while in the same time patient demand is also on the rise