Innovative laparoscopic surgery in gynecologic oncology

Prospective, randomized comparison of the use of FloShield Air System® versus the reference technique (water + povidone-iodine solution) during gynecologic endoscopic surgery to evaluate the operative lens vision quality

BACKGROUND

The FloShield Air System^® is a new device for laparoscopic surgery that utilizes a continuous dry CO₂ gas flow over the scope to defog the lens and protect it from condensation, debris and smoke. We set out to compare the performance and efficiency of the device in terms of operative lens vision quality (OLVQ) with the reference technique (water + povidone-iodine (PVI) solution) during gynecologic laparoscopic surgery.

MATERIALS AND METHODS

We conducted a single-center randomized prospective study between March and June 2016 (Trials Database Registration NCT02702531) including 53 patients undergoing gynecologic laparoscopic surgery with water + PVI solution and 51 patients who underwent surgical procedures with the FloShield Air System. The primary outcome measure was the number of laparoscope removals during surgery. Secondary outcome measures were the time to clean, assessment of the quality of vision, the correlation between the laparoscopic surgical complexity and outcomes, and cost effectiveness.

RESULTS

Overall, the mean patient age was 43.2 years (range 22-86) and body mass index 24.8 (range 16.8-42.7). The mean number of endoscope removals during surgery was 7.0 (range 0-37) in the water + PVI solution arm and 2.8 (range 0-12) in the FloShield Air System^® arm. The number of removals was significantly lower in the FloShield arm (p < 0.001). No difference in time to clean, quality of vision, level of laparoscopic procedure complexity, or cost was observed between the groups.

CONSLUSIONS

The FloShield Air System^® resulted in fewer laparoscopic lens removals than the water + PVI solution solution, but that there was no difference in quality of vision, cleaning time or cost, especially for the more complex surgery.

Risk factors for robotic gynecologic procedures requiring conversion to other surgical procedures

OBJECTIVE

To determine the incidence of, and risk factors for, conversion from robotic gynecologic procedures to other procedure types.

METHODS

A retrospective cohort study included data from women who underwent any robotic gynecologic procedures between January 1, 2011 and December 31, 2012 at a tertiary care referral center in the USA. Demographic data, perioperative data, and surgeon experience (monthly case volume) data were retrieved; potential risk factors were compared between robotic procedures that were converted to other procedures and those completed as robotic procedures.

RESULTS

There were 942 robotic procedures during the study period. Conversion from robotic to any other type of procedure was recorded for 47 (5.0%, 95% confidence interval 3.8-6.6) procedures and robotic-to-open-surgery conversion occurred in 16 (1.7%, 95% confidence interval 1.0-2.7) procedures. Conversion from robotic surgery to another approach was associated with higher body mass index (P<0.001), previous laparotomy (P=0.042), and surgeons having a lower monthly robotic surgical case volume (P=0.011). Asthma (P=0.008), intra-operative bowel injury (P<0.001), intra-operative vascular injury (P=0.003), and single-port robotic surgery (P=0.034) were associated with increased odds of requiring conversion from robotic procedures.

CONCLUSION

The overall incidence of conversion from robotic surgery to laparotomy was low. Higher body mass index, previous laparotomy, history of asthma, using a single-port approach, and surgeon case volume were associated with the risk of conversion.

Feasibility of laparoscopic extraperitoneal pelvic lymphadenectomy in gynecologic malignancies

OBJECTIVE

The aim of this study is to evaluate the feasibility of laparoscopic extraperitoneal pelvic lymphadenectomy (LEPL) in gynecologic malignancies.

METHODS

Twenty-nine women with cervical, ovarian or endometrial cancer underwent laparoscopic extraperitoneal pelvic lymphadenectomy between July 2008 and December 2010. The operating time, nodal yield, blood loss and complications were recorded.

RESULTS

The number of patients with cervical, ovarian and endometrial carcinoma was 14, 3 and 12, respectively. The median age of patients was 48.9±12.6 years. The median body mass index was 25.6±4.8. Conversion to the transperitoneal laparoscopic approach was necessary in 6 patients for peritoneal tears causing CO(2) gas leakage. Among the remaining 23 patients, the median operating time for laparoscopic extraperitoneal pelvic lymphadenectomy was 69 min (range 50-126 min), and the median estimated blood loss was 20 ml (range 5-105 ml). The median total number of resected nodes was 26 (range 14-42), and complications related to the procedure were rare.

CONCLUSIONS

Laparoscopic extraperitoneal pelvic lymphadenectomy is a feasible and safe procedure. It can be used in gynecologic malignancies.

Robotic surgery for cervical cancer

The development of robotic technology has facilitated the application of minimally invasive techniques for the treatment and evaluation of patients with early, advanced, and recurrent cervical cancer. The application of robotic technology for selected patients with cervical cancer and the data available in the literature are addressed in the present review paper. The robotic radical hysterectomy technique developed at the Mayo Clinic Arizona is presented with data comparing 27 patients who underwent the robotic procedure with 2 matched groups of patients treated by laparoscopic (N = 31), and laparotomic radical hysterectomy (N = 35). A few other studies confirmed the feasibility and safety of robotic radical hysterectomy and comparisons to either to the laparoscopic or open approach were discussed. Based on data from the literature, minimally invasive techniques including laparoscopy and robotics are preferable to laparotomy for patients requiring radical hysterectomy, with some advantages noted for robotics over laparoscopy. A prospective randomised trial is currently being performed under the auspices of the American Association of Gyneoclogic Laparoscopists comparing minimally invasive radical hysterectomy (laparoscopy or robotics) with laparotomy. For early cervical cancer radical parametrectomy and fertility preserving trachelectomy have been performed using robotic technology and been shown to be feasible, safe, and easier to perform when compared to the laparoscopic approach. Similar benefits have been noted in the treatment of advanced and recurrent cervical cancer where complex procedures such as extraperitoneal paraortic lymphadenectomy and pelvic exenteration have been required.

CONCLUSION

Robotic technology better facilitates the surgical approach as compared to laparoscopy for technically challenging operations performed to treat primary, early or advanced, and recurrent cervical cancer. Although patient advantages are similar or slightly improved with robotics, there are multiple advantages for surgeons.