Laparoscopic surgery for gynaecological cancers in obese women

Effect of two different modalities of hysterectomy on wound infection and wound dehiscence in obese patients

This research intended to investigate the influence of the operation of both kinds of hysterectomies in the risk of wound infection and the degree of wound dehiscence. Both of them were open field and laparoscope. In this research, we looked into four databases: PubMed, Web of Science, Embase and Cochrane Library. Research was conducted on various operative methods for hysterectomy in obese patients between 2000 and October 2023. Two independent investigators performed an independent review of the data, established the inclusion and exclusion criteria, and managed the results with Endnote software. It also evaluated the quality of the included literature. Finally, the data were analysed with RevMan 5.3. This study involved 874 cases, 387 cases received laparoscopy and 487 cases received open access operation. Our findings indicate that there is a significant reduction in the rate of post-operative wound infection among those who have received laparoscopy compared with who have received open surgical procedures (odds ratio [OR], 0.04; 95% confidence interval [CI], 0.01-0.15; p < 0.001); There was no statistical difference between the rate of post-operative wound dehiscence and those who received laparotomy compared with those who received open surgical procedures (OR, 0.33; 95% CI, 0.10-1.11; p = 0.07); The estimated amount of blood lost during the operation was less in the laparoscopy group compared with the open procedure (mean difference, -123.72; 95% CI, -215.16 to -32.28; p = 0.008). Generally speaking, the application of laparoscopy to overweight women who have had a hysterectomy results in a reduction in the expected amount of bleeding during surgery and a reduction in the risk of post-operative wound infections.

Robot-assisted laparoscopic pelvic floor surgery: Review

Minimally invasive surgical techniques have become more common in pelvic floor reconstructive urogynaecological surgery, specifically, robotic-assisted pelvic floor surgery. Female pelvic floor anatomy is complex, and some repairs require highly experienced surgical skills that can be gained more easily using robotic-assisted surgery. A common application of the robotic platform in urogynaecological surgeries includes sacrocolpopexy, which has become the gold standard approach in the last decade for the correction of apical prolapse. Additional procedures include sacrohysteropexy, sacrocervicopexy, fistula repair, and complex procedures involving the bladder and other pelvic organs. Despite its increasing use and clear benefit in our field, data in the literature and, in particular, randomised controlled trials are sparse. This review provides an update, incorporating recently published literature and our personal experience in that field.

Analysis of Hysterectomy Trends in the Last 5 Years at a Tertiary Center

Objectives

This study aimed to assess trends by evaluating the types and complications of hysterectomies performed for benign gynecological reasons at our clinic, which is one of the largest hospitals in Turkey.

Materials and Methods

Hysterectomies performed for benign reasons at our gynecology and obstetrics clinic between January 1, 2015 and December 31, 2020 were retrospectively reviewed and included in the analysis. Of the 4288 patients who had undergone hysterectomy, 888 patients were excluded some reasons. The data of the remaining 3400 patients were analyzed.

Results

For the 3400 patients, the hysterectomy methods performed were as follows: Total Abdominal Hysterectomy (TAH (60%, n = 2055), Total Laparoscopic Hysterectomy (TLH), (27%, n = 948), Vaginal Hysterectomy (VH), (8.9%, n = 302), Conversion from laparoscopy to laparotomy (L / S > LT). (1.4%, n = 49), Robotic hysterectomy (RH), (1%, n = 33), and Subtotal hysterectomy (SH), (0.4%, n = 13). The length of hospital stay was statistically significantly lower in the TLH group than in the TAH group (P < 0.05). A statistically significant and moderate correlation was noted between the length of hospital stay and the duration of operation (r: 0.68 P = 0.00).

Conclusion

The ratio of TLH group among hysterectomy modalities has increased over the years. There are many factors that affect the surgeon's decision in determining the hysterectomy method. TLH is the first option in patients who are not suitable for vaginal hysterectomy.

Laparoscopic para-aortic lymphadenectomy: Technique and surgical outcomes

OBJECTIVE

Pelvic and para-aortic lymph node dissection is an important part of staging surgery. Aim of this study is to evaluate perioperative outcomes of patients, who underwent laparoscopic para-aortic lymphadenectomy for gynecological cancer in a single center over a period of 7 years, based on body mass index (BMI), and to present the surgical technique in steps.

METHODS

Data of patients who underwent para-aortic lymphadenectomy at gynecological oncology department of a tertiary center in between March 2013 and July 2020 were analyzed retrospectively. Patients were evaluated in two groups according to their BMI (< 30 kg/m² as non-obese and ≥ 30 kg/m² as obese groups). Surgical technique is described in steps. Perioperative outcomes of the two groups were evaluated.

RESULTS

A total of 230 patients were included in the study. BMI was ≥30 at 58.46 % of the patients. Peri-operative features were not significantly affected by the patient's BMI with the presented surgical technique, however, collected para-aortic lymph node numbers were higher in the group with BMI < 30, though sufficient number of lymph nodes were achieved in both groups.

CONCLUSION

Although some technical difficulties may be encountered, laparoscopic para-aortic lymphadenectomy is feasable in gynecologic oncological surgery independent of BMI. However, surgical experience is important.

A Comparison of Laparoscopies and Laparotomies for Radical Hysterectomy in Stage IA1-IB1 Cervical Cancer Patients: A Single Team With 18 Years of Experience

Objective

To investigate the safety and efficacy of abdominal radical hysterectomy (ARH) and laparoscopic radical hysterectomy (LRH) in managing early-stage cervical cancer.

Methods

This retrospective study comprised patients with FIGO stage IA1 with lymphovascular space invasion (LVSI), IA2, and IB1 cervical cancer who underwent radical hysterectomy performed by a single gynecologic oncology team at Peking Union Medical College Hospital from 2000–2018. The clinicopathological characteristics, surgical outcomes, and survival outcomes were compared between the two groups.

Results

The ARH and LRH groups consisted of 84 and 172 patients, respectively. The 5-year progression-free survival (PFS) rates were 89.3 and 95.9% in the ARH and LRH groups (P = 0.122, adjusted HR = 0.449, 95% CI: 0.162–1.239), respectively, while the 5-year overall survival (OS) rates were 95.2 and 98.8%, respectively (P = 0.578, adjusted HR = 0.650, 95% CI: 0.143–2.961). The presence of more than two comorbidities led to poor OS (P = 0.011). For patients with a BMI greater than 24 kg/m², LRH was associated with better PFS (P = 0.039). Compared with ARH, LRH was associated with a shorter operation time (248.8 vs. 176.9 min, P < 0.001), less blood loss (670.2 vs. 200.9 ml, P < 0.001), and lower postoperative ileus rates (2.4% vs. 0%, P = 0.042). No significant differences were observed in PFS and OS between 2006–2012, 2013–2015, and 2016–2018 in the LRH group (P = 0.126 and P = 0.583).

Conclusion

Compared with ARH, LRH yields similar survival and improved surgical outcomes in patients with early-stage cervical cancer. LRH is not inferior to ARH for select cervical cancer patients treated by a single team with adequate laparoscopy experience.

Robotic surgery for gynecologic cancers: indications, techniques and controversies

Minimally invasive surgery for gynecologic cancers is associated with fewer postoperative complications including less blood loss and quicker recovery time compared to traditional laparotomy. The robotic platform has allowed patients access to minimally invasive surgery due to its increased utilization by gynecologic oncologists. Many surgeons have embraced the robotic platform due to its technological advances over traditional laparoscopy including high-definition 3D optics, wristed instrumentation, camera stability and improved ergonomics. While robotic surgery continues as a mainstay in the management of gynecologic cancers, it remains controversial in regards to its cost effectiveness and more recently, its long-term impact on clinical and oncologic outcomes. A strong component of the justification of this surgical platform is based on extrapolated data from traditional laparoscopy despite limited prospective randomized trials for robotic-assisted surgery. In this review, we highlight the use of robotic surgery in the management of gynecologic cancers in special populations: fertility sparing patients, the morbidly obese, the elderly, and patients with a favorable response to neoadjuvant chemotherapy.

Comparison of Perioperative and Oncologic Outcomes with Laparotomy, and Laparoscopic or Robotic Surgery for Women with Endometrial Cancer

PURPOSE

To compare perioperative outcomes and oncologic outcomes in endometrial cancer patients treated with laparotomy, and laparoscopic or robotic surgery.

MATERIALS AND METHODS

Endometrial cancer patients who underwent primary surgery from January 2011 to December 2014 were retrospectively reviewed. Perioperative outcomes, including estimated blood loss (EBL), operation time, number of lymph nodes retrieved, and intra and postoperative complications, were reviewed. Recovery time, disease free survival (DFS) and overall survival (OS) were compared.

RESULTS

Of the total of 218 patients, 143 underwent laparotomy, 47 laparoscopy, and 28 robotic surgery. The laparotomy group had the highest EBL (300, 200, 200 ml, p<0.05) while the robotic group had the longest operative time (302 min) as compared with laparoscopy (180 min) and laparotomy (125 min) (p<0.05). Intra and postoperative complications were not different with any of the surgical approaches. No significant difference in number of lymph nodes retrieved was identified. The longest hospital stay was reported in the laparotomy group (four days) but there was no difference between the laparoscopy (three days) and robotic (three days) groups. Recovery was significantly faster in robotic group than laparotomy group (14 and 28 days, p=0.003). No significant difference in DFS and OS at 21 months of median follow up time was observed among the three groups.

CONCLUSIONS

Minimally invasive surgery has more favorable outcomes, including lower blood loss, shorter hospital stay, and faster recovery time than laparotomy. It also has equivalent perioperative complications and short term oncologic outcomes. MIS is feasible as an alternative option to surgery of endometrial cancer.

Robotic versus laparoscopic versus open surgery in morbidly obese endometrial cancer patients - a comparative analysis of total charges and complication rates

OBJECTIVE

To compare the complications and charges of robotic vs. laparoscopic vs. open surgeries in morbidly obese patients treated for endometrial cancer.

METHODS

Data were obtained from the Nationwide Inpatient Sample from 2011. Chi-squared, Wilcoxon rank sum two-sample tests, and multivariate analyses were used for statistical analyses.

RESULTS

Of 1087 morbidly obese (BMI ≥40kg/m(2)) endometrial cancer patients (median age: 59years, range: 22 to 89), 567 (52%) had open surgery (OS), 98 (9%) laparoscopic (LS), and 422 (39%) robotic surgery (RS). 23% of OS, 13% of LS, and 8% of RS patients experienced an intraoperative or postoperative complication including: blood transfusions, mechanical ventilation, urinary tract injury, gastrointestinal injury, wound debridement, infection, venous thromboembolism, and lymphedema (p<0.0001). RS and LS patients were less likely to receive blood transfusions compared to OS (5% and 6% vs. 14%, respectively; p<0.0001). The median lengths of hospitalization for OS, LS, and RS patients were 4, 1, and 1days, respectively (p<0.0001). Median total charges associated with OS, LS, and RS were $39,281, $40,997, and $45,030 (p=0.037), respectively.

CONCLUSIONS

In morbidly obese endometrial cancer patients, minimally invasive robotic or laparoscopic surgeries were associated with fewer complications and less days of hospitalization relative to open surgery. Compared to laparoscopic approach, robotic surgeries had comparable rates of complications but higher charges.

The role of laparoscopy in the surgical treatment of endometrial cancer

Introduction

Endometrial carcinoma is one of the most common neoplasms in gynecological oncology and the most common genital cancer in women in developed countries. The 5-year overall survival rate depends on the FIGO stage. For patients with stage I endometrial cancer it is estimated as 80%. Traditionally, the main treatment of endometrial cancer consists of total abdominal hysterectomy with bilateral salpingo-oophorectomy and, in some histological or clinical stages, with additional pelvic lymphadenectomy. The main surgical approach so far for women with endometrial cancer has been laparotomy. However, in the last decades there have been many reports stating that the survival rate in such cases is similar after laparoscopy and laparotomy. Some researchers claim that laparoscopy is as effective as laparotomy, and it might be much more precise than laparotomy thanks to its special optic system.

Aim

To establish the method of choice for treatment of stage I endometrial cancer.

Material and methods

Comparing the preliminary results from data collected during surgical procedures performed at the First Department of Obstetrics and Gynecology of the Medical Centre of Postgraduate Education in Warsaw and the Department of Obstetrics and Gynecology of the Rural Hospital in Garwolin.

Results

Laparoscopy is as effective as laparotomy, and it might be much more precise than laparotomy.

Conclusions

Taking into consideration all the above arguments, if an experienced endoscopic surgeon and proper laparoscopic equipment are available, laparoscopy might become the method of choice for treatment of stage I endometrial cancer.

Total laparoscopic hysterectomy in obese and morbidly obese women

BACKGROUND

The study aimed at estimating the effect of body mass index (BMI), used to classify non-obese, obese, and morbidly obese patients, on clinical outcomes in total laparoscopic hysterectomy (TLH) cases.

METHODS

This retrospective cohort study included 153 patients who underwent TLH for benign, premalignant, or malignant conditions between August 2010 and June 2013. Patients were divided into 3 groups according to BMI, and the following variables were analyzed: operation time, conversion rate, blood loss, total complications, and length of hospital stay.

RESULTS

The mean BMI was 33.5 kg/m(2) (range, 22-61). Forty-four patients were non-obese (BMI <30), 73 were obese (30≤ BMI <40), and 36 were morbidly obese (BMI ≥40). In 138 patients (90.2%), hysterectomy was performed using an endoscopic technique. The rate of conversion to laparotomy (9.8%; 95% confidence interval (CI), 5.1-14.5), blood loss (70.5 ml; range, 10-700), total complications (5.9%), and length of hospital stay (2.9 d; range, 1-8) did not vary according to BMI. Operation time was longer in obese (p = 0.003) and morbidly obese (0.002) patients than in non-obese patients.

CONCLUSION

TLH could be considered a safe and feasible alternative to abdominal hysterectomy in obese and morbidly obese patients.

Surgical management of early endometrial cancer: an update and proposal of a therapeutic algorithm

In the last few years technical improvements have produced a dramatic shift from traditional open surgery towards a minimally invasive approach for the management of early endometrial cancer. Advancement in minimally invasive surgical approaches has allowed extensive staging procedures to be performed with significantly reduced patient morbidity. Debate is ongoing regarding the choice of a minimally invasive approach that has the most effective benefit for the patients, the surgeon, and the healthcare system as a whole.

Surgical treatment of women with presumed early endometrial cancer should take into account the features of endometrial disease and the general surgical risk of the patient. Women with endometrial cancer are often aged, obese, and with cardiovascular and metabolic comorbidities that increase the risk of peri-operative complications, so it is important to tailor the extent and the radicalness of surgery in order to decrease morbidity and mortality potentially derivable from unnecessary procedures. In this regard women with negative nodes derive no benefit from unnecessary lymphadenectomy, but may develop short- and long-term morbidity related to this procedure. Preoperative and intraoperative techniques could be critical tools for tailoring the extent and the radicalness of surgery in the management of women with presumed early endometrial cancer. In this review we will discuss updates in surgical management of early endometrial cancer and also the role of preoperative and intraoperative evaluation of lymph node status in influencing surgical options, with the aim of proposing a management algorithm based on the literature and our experience.

Influence of Morbid Obesity on Surgical Outcomes in Robotic-Assisted Gynecologic Surgery

Objective: The aim of this research was to estimate the impact of body mass index (BMI) on surgical outcomes in patients undergoing robotic-assisted gynecologic surgery. Materials and Methods: This study was a retrospective review of prospectively collected cohort data for a consecutive series of patients undergoing gynecologic robotic surgery in a single institution. BMI, expressed as kg/m2, was abstracted from the medical charts of all patients undergoing robotic hysterectomy. Data on estimated blood loss (EBL), hemoglobin (Hb) drop, procedure time, length of hospital stay, uterine weight, pain-medication use, and complications were also extracted. Results: Two hundred and eighty-one patients underwent robotic operations. Types of procedures were total hysterectomy with or without adnexal excision, and total hysterectomies with lymphadenectomies. Eighty-four patients who were classified as morbidly obese (BMI>35) were compared with 197 patients who had a BMI of<35 (nonmorbidly obese). For patients with BMI<35, and BMI>35, the mean BMI was 27.1 and 42.5 kg/m2 (p<0.05), mean age was 49 and 50 (p=0.45), mean total operative time was 222 and 266 minutes (p<0.05), console time 115 and 142 minutes (p<0.05), closing time (from undocking until port-site fascia closure) was 30 and 41 minutes (p<0.05), EBL was 67 and 79 mL (p=0.27), Hb drop was 1.6 and 1.4 (p=0.28), uterine weight was 196.2 and 227 g (p=0.52), pain-medication use 93.7 and 111 mg of morphine (p=0.46), and mean length of stay was 1.42 and 1.43 days (0.9), all respectively. No statistically significant difference was noted between the 2 groups for EBL, Hb drop, LOS, uterine weight, pain-medication use, or complications. The only statistically significant difference was seen in operating times and included docking, console, closing, and procedure times. There were no perioperative mortalities. Morbidity occurred in 24 patients (8%). In the morbidly obese group, there were 6 complications (7%) and, in the nonmorbidly obese group, there were 18 complications (9%). Conclusions: Morbid obesity does not appear to be associated with an increased risk of morbidity in patients undergoing robotically assisted gynecologic surgery. Morbid obesity is associated with increased procedure time, but otherwise appears to have no difference in outcomes. Robotic surgery offered an ideal approach, allowing minimally invasive surgery in these technically challenging patients, with no significant increase in morbidity. J GYNECOL SURG 30:81).

Differences in Epidural and Analgesic Use in Patients with Apparent Stage I Endometrial Cancer Treated by Open versus Laparoscopic Surgery: Results from the Randomised LACE Trial

Objectives. We compared postoperative analgesic requirements between women with early stage endometrial cancer treated by total abdominal hysterectomy (TAH) or total laparoscopic hysterectomy (TLH). Methods. 760 patients with apparent stage I endometrial cancer were treated in the international, multicentre, prospective randomised trial (LACE) by TAH (n = 353) or TLH (n = 407) (2005–2010). Epidural, opioid, and nonopioid analgesic requirements were collected until ten months after surgery. Results. Baseline demographics and analgesic use were comparable between treatment arms. TAH patients were more likely to receive epidural analgesia than TLH patients (33% versus 0.5%, P < 0.001) during the early postoperative phase. Although opioid use was comparable in the TAH versus TLH groups during postoperative 0–2 days (99.7% versus 98.5%, P = 0.09), a significantly higher proportion of TAH patients required opioids 3–5 days (70% versus 22%, P < 0.0001), 6–14 days (35% versus 15%, P < 0.0001), and 15–60 days (15% versus 9%, P = 0.02) after surgery. Mean pain scores were significantly higher in the TAH versus TLH group one (2.48 versus 1.62, P < 0.0001) and four weeks (0.89 versus 0.63, P = 0.01) following surgery. Conclusion. Treatment of early stage endometrial cancer with TLH is associated with less frequent use of epidural, lower post-operative opioid requirements, and better pain scores than TAH.

Robotic surgical staging for obese patients with endometrial cancer

OBJECTIVE

To compare surgical outcomes for robotic vs laparotomy staging in obese endometrial cancer patients.

STUDY DESIGN

This was a retrospective cohort study of patients with body mass index ≥30 kg/m(2) staged in a community gynecologic oncology practice. Patients undergoing robotic staging were compared with historic laparotomy controls.

RESULTS

One hundred twenty-nine patients underwent robotic staging, compared with 110 laparotomy patients. The robotic cohort had fewer abdominal wound complications (13.9% vs 32.7%, P < .001), but more vaginal cuff complications (4.7% vs 0%, P = .032). Blood loss was lower in the robotic group (P < .001), as was length of stay (P < .001). Surgical times were longer in the robotic group (P < .001). There was no difference in terms of percentage of patients undergoing pelvic or paraaortic lymph node dissection.

CONCLUSION

Robotic staging for endometrial cancer is feasible in obese women, with fewer abdominal wound complications, but more vaginal cuff complications.