Laparoscopic cytoreduction for primary advanced ovarian cancer

Case report: Minimally invasive primary debulking surgery for advanced stage epithelial ovarian cancer

The surgical management of advanced ovarian cancer has historically emphasized an open technique, but advances in minimally invasive surgery (MIS) have led to its increasing use in ovarian cancer. Most research has focused on the utility of MIS in the interval debulking setting. Here, we present a case of a 38-year-old patient with incidentally diagnosed advanced stage ovarian cancer. We describe the robotic surgery techniques used to achieve complete primary cytoreduction, including resection of disease on the diaphragm. The patient has completed standard adjuvant chemotherapy and maintenance treatment and remains without evidence of disease for more than 2 years. This case details the techniques utilized to achieve complete cytoreduction including trocar placement, robotic instrument preference, and rotation of the robotic boom. This patient has had successful perioperative and oncologic outcomes, and her case highlights the role for minimally invasive primary debulking surgery for select patients with advanced ovarian cancer.

Outcomes of Laparoscopic Optimal Interval Cytoreduction Surgery (LOICS) in Patients with Advanced Ovarian Cancers Having Low Burden Disease

Laparoscopy has been increasingly utilised for cytoreduction surgery in patients with early ovarian cancers. The present study tries to assess the feasibility of laparoscopic interval cytoreduction surgery (LOICS) in patients with advanced ovarian cancer (AOC) having low burden residual disease. A retrospective study of was done of AOC's who underwent LOICS between 2010 and 2014. Epithelial ovarian cancer patients who underwent interval cytoreduction surgery were included and analysed for short-term and long-term outcomes. In all, 36 patients with stage III ovarian cancers were included in the analysis. Twenty-two (61.1%) were grade 3 and 14 (38.8%) were grade 2, and no patient had grade 1 tumour. Stage wise majority were stage IIIC (94.4%) followed by 2 (5.5%) in stage IIIA. There was 1 postoperative complication (2.5%) and no intraoperative complications. Median time to discharge and to start chemotherapy was 5 days and 23 days respectively. After a median follow-up of 60 months, 3 patients (8.3%) were lost to follow-up and the remaining 33 patients were analysed for survival outcomes. The overall survival (OS) and recurrence-free survival (RFS) were 58.3% and 36.1% respectively. The median RFS and OS were 24 months and 51 months, respectively. Most recurrences involved the peritoneum (82.6%), and 5 patients (21.7%) had nodal recurrence alone. Laparoscopic optimal interval cytoreduction is feasible in patients with advanced ovarian cancers provided the disease burden permits optimal surgery, especially in centres with expertise in complex laparoscopic procedures.

Clinical Utility of Preoperative Assessment in Ovarian Cancer Cytoreduction

Ovarian cancer is the deadliest gynecologic cancer, in part due to late presentation. Many women have vague early symptoms and present with disseminated disease. Cytoreductive surgery can be extensive, involving multiple organ systems. Novel therapies and recent clinical trials have provided evidence that, compared to primary cytoreduction, neoadjuvant chemotherapy has equivalent survival outcomes with less morbidity. There is increasing need for validated tools and mechanisms for clinicians to determine the optimal management of ovarian cancer patients.

Minimally invasive hysterectomy at a university teaching hospital

BACKGROUND AND OBJECTIVES

To evaluate the feasibility of a minimally invasive approach for hysterectomy for benign disease at a university teaching hospital.

METHODS

Five hundred thirty-seven consecutive patients underwent hysterectomy for benign disease at Penn State Milton S. Hershey Medical Center in 2010. No cases were excluded. Minimally invasive approaches included total vaginal hysterectomy, laparoscopy-assisted vaginal hysterectomy, total laparoscopic hysterectomy, and laparoscopic supracervical hysterectomy. All surgeries were completed with the resident as the primary surgeon or first assistant.

RESULTS

The median age was 45 years, the median body mass index was 30 kg/m2, the median estimated uterine size was 11 cm, and 22% of patients had a prior cesarean section. Of the 537 hysterectomies, 526 (98%) were started with a minimally invasive approach and 517 (96%) were completed in that fashion; thus only 9 conversions (2%) were required. Of the cases in which a minimally invasive approach was used, 16% were vaginal and 84% were laparoscopic. The median operative time was 86 minutes, the median blood loss was 95 mL, the median hospital stay was 1 day, and the median uterine weight was 199 g. For the minimally invasive hysterectomies, there was a 5% major complication rate.

CONCLUSION

Our residency training institution completed 96% of 537 hysterectomies using a minimally invasive approach while maintaining an acceptable operative time, amount of blood loss, hospital stay, and complication rate. Thus our study supports that a minimally invasive approach for hysterectomy for benign disease at an academic resident teaching facility is feasible.

Laparoscopy-assisted supracervical hysterectomy for ovarian cancer: cervical recurrence

Background and Objectives:

The purpose of our study is to evaluate the incidence of cervical recurrence after laparoscopic supracervical hysterectomy for ovarian cancer debulking or staging.

Methods:

From a prospective surgical database, we identified 51 cases of laparoscopic supracervical hysterectomy for ovarian cancer debulking or staging. No cases were excluded.

Results:

From 2009 to 2012, 51 patients were identified. The median age was 62 years (range, 32–83 years), and the median body mass index was 29 kg/m² (range, 16–41 kg/m²). Medical comorbidities were present in 40 patients (78%), and 53% had prior abdominal surgery. The median operative time was 2 hours (range, 1–3.5 hours), and the median blood loss was 200 mL (range, 50–900 mL). The median length of stay was 1 day (range, 0–12 days). The stage was I in 12 patients, II in 6, and III/IV in 33. At a median follow-up time of 1.7 years (range, 0.3–2.6 years), 20 patients (39%) had recurrence of cancer, with a median time of recurrence of 1.1 years (range, 0.3–2.3 years). All recurrences were in the abdomen or pelvis except for 1 axillary node recurrence and 1 recurrence in the distal vagina. There were no recurrences in the remaining cervical stump. No patient had a postoperative vaginal cuff infection. Among the 104 cycles of intraperitoneal chemotherapy, there was no vaginal leakage of intraperitoneal chemotherapy.

Conclusion:

Laparoscopic supracervical hysterectomy for ovarian cancer debulking or staging does not result in cervical recurrence.

Effects of electrosurgery and vaginal closure technique on postoperative vaginal cuff dehiscence

BACKGROUND AND OBJECTIVES

The aim of our study is to evaluate the role of electrosurgery and vaginal closure technique in the development of postoperative vaginal cuff dehiscence.

METHODS

From prospective surgical databases, we identified 463 patients who underwent total laparoscopic hysterectomy (TLH) for benign disease and 147 patients who underwent laparoscopic-assisted vaginal hysterectomy (LAVH) for cancer. All TLHs and LAVHs were performed entirely by use of electrosurgery, including colpotomy. Colpotomy in the TLH group was performed with Harmonic Ace Curved Shears (Ethicon Endo-Surgery, Cincinnati, OH, USA), and in the LAVH group, it was performed with a monopolar electrosurgical pencil. The main surgical difference was vaginal cuff closure--laparoscopically in the TLH group and vaginally in the LAVH group.

RESULTS

Although patients in the LAVH group were at increased risk for poor healing (significantly older, higher body mass index, more medical comorbidities, higher blood loss, and longer operative time), there were no vaginal cuff dehiscences in the LAVH group compared with 17 vaginal cuff dehiscences (4%) in the TLH group (P = .02).

CONCLUSION

It does not appear that the increased vaginal cuff dehiscence rate associated with TLH is due to electrosurgery; rather, it is due to the vaginal closure technique.

Safety and Efficacy of Immediate Postoperative Feeding and Bowel Stimulation to Prevent Ileus After Major Gynecologic Surgical Procedures

Context: Postoperative ileus is a major complication of abdominal surgical procedures

Objective: To evaluate the incidence of ileus and gastrointestinal morbidity in patients who received immediate postoperative feeding and bowel stimulation after undergoing major gynecologic surgical procedures.

Methods: During a 5-year period, the authors tracked demographic, surgical outcome, and follow-up information for 707 patients who underwent major gynecologic operations. All patients received the same postoperative orders, including immediate feeding of a diet of choice and bowel stimulation with 30 mL of magnesium hydroxide (milk of magnesia) twice daily until bowel movements occurred.

Results: Of 707 patients, 6 (<1%) had postoperative ileus. No patients experienced postoperative bowel obstruction and 2 patients (0.3%) had postoperative intestinal leak. No serious adverse effects associated with bowel stimulation were reported.

Conclusion: Immediate postoperative feeding and bowel stimulation is a safe and effective approach to preventing ileus in patients who undergo major gynecologic surgical procedures.

Laparoscopic-assisted cytoreduction for primary advanced ovarian cancer: success, morbidity and survival

OBJECTIVE

The purpose of this paper is to evaluate laparoscopic-assisted cytoreduction for primary advanced ovarian cancer: feasibility, morbidity, response to chemotherapy and survival.

METHODS

All patients with presumed stage 3/4 primary ovarian cancer underwent attempted laparoscopic cytoreduction. All patients had CT evidence of omental metastasis and ascites. A five port (5-mm) transperitoneal approach was used. A bilateral salpingo-oophorectomy, supracervical hysterectomy and omentectomy were performed with the PlasmaKinetic (PK) cutting forceps. A laparoscopic 5-mm Argon-Beam Coagulator was used to coagulate tumor in the pelvis, abdominal peritoneum, intestinal mesentery, and diaphragm.

RESULTS

Twenty-three cases (92%) were successfully cytoreduced laparoscopically without conversion to laparotomy. Median operative time was 2.3h and median blood loss was 340 cc. All tumors were debulked to less than 2 cm and 36% had no residual disease. Median length of stay was 1 day. Median VAS pain score was 4-discomforting. Six patients (24%) had post-operative complications, none grades 3-4. Median overall survival is 3.5 years.

CONCLUSION

Laparoscopic-assisted cytoreduction for primary advanced ovarian cancer was successful, resulting in minimal morbidity, and acceptable survival.