LAPAROSCOPY ROLE IN

GYNECOLOGY- ONCOLOGY

Dr. Ratih Krisna, Sp.O.G, Subsp. Urogin Re

Divisi Uroginekologi Rekonstruksi

Departemen Obstetri dan Ginekologi
FK Unsri – RSMH Palembang
 CONTENTS
Introduction
History
Overview Procedure
Use as a Diagnostic Tool
Use as a Therapeutic Modality
Contraindications
Risk Factors
Complications
Role in Gynecolocy- Oncology
Summary And Conclusion
 LAPAROSCOPY
Minimally
Bandaid Keyhole
Invasive
surgery surgery
Surgery (MIS)

a fibre-optic instrument is inserted the

abdominal wall
A modern
surgical permit small-scale surgery with help of
procedure pneumoperitoneum.
performed far from their location &
small incisions (usually 0.5–1.5 cm)
 HISTORY OF LAPAROSCOPIC
SURGERY

Dr. Hans Christian Jacobaeus

A Swedish Surgeon
the first to publish a description of
laparothorakoskopie was in
humans in 1910.
He used air pneumoperitonea cystoscope
to evaluate the peritoneal cavity of
tuberculosis patients with ascites.

Litynski GS. Laparoscopy--the early attempts: spotlighting Georg

Kelling and Hans Christian Jacobaeus.JSLS. 1997. 1:83-5.
HISTORY OF LAPAROSCOPIC
SURGERY

Dr. Janos Veress

A Hungarian Internist
Developed a spring-loaded needle
with an inner stylet that
automatically converted the sharp
cutting edge to a rounded end.
The Veress needle is still used today to
create a pneumoperitoneum
 HISTORY OF LAPAROSCOPIC
SURGERY
Dr. Palmer
 1961: the first laparoscopic
retrieval of oocytes
 1974: he described the point 3 cm
below the last rib in the left mid-
clavicular line
Palmer's point is often used today for left
upper quadrant laparoscopic entry.
He pioneered:
Intra-abdominal
electrocoagulati Puncture of Lysis of pelvic
on of bleeding ovarian cysts adhesions.
sites

Palmer R. Safety in laparoscopy. J Reprod Med. 1974 Jul. 13(1):1-5.

 HISTORY OF LAPAROSCOPIC
SURGERY

1982: the introduction of the solid

state video camera for laparoscopy

Both laparoscopist and assistants

simultaneously view the
operative field on a video
screen.
By end of decade, laparoscopy
accepted as a safe and effective
surgical approach
 HISTORY OF LAPAROSCOPIC
SURGERY
Routinely used by gynecologists to perform a multitude of
procedures

Hysterectomies

Incontinence
procedures

The diagnosis and

treatment of
gynecologic
malignancies.
 LAPAROSCOPY –
CONTRAINDICATIONS

Generalized Hypovolemic Severe Cardiac

Peritonitis Shock Disease

Multiple
Hemoglobin
Uterine Size > Previous
Less Than 7
12 Wks. Abdominal
G/Dl
Procedures

Extreme Body
Weight
 LAPAROSCOPY – RISK FACTORS

Patient related risk factors

Previous
Obesity Age abdominal
surgery

Anesthetic risk factors

Time since last Pulmonary

Heart disease
oral intake disease
 LAPAROSCOPY – PATIENT
RELATED RISK FACTORS

Obesity Age

Placement of
Laparoscopy more Older patients:
laparoscopic instruments
difficult and potentially increased risk of having
becomes much more
more risky concomitant disease
difficult
processes that affect their
perioperative morbidity
and mortality
Restricted operative field
secondary to
Bleeding from abdominal retroperitoneal fat
wall vessels deposits and increased
bowel excursion into the
operative field
 LAPAROSCOPY – PATIENT
RELATED RISK FACTORS

Previous abdominal surgery

Risk of adhesions

◉ Adhesion of omentum and/or bowel to the anterior

abdominal wall after previous abdominal surgery
>20%.

Risk of bowel injury

◉ As laparoscopy requires the insertion of sharp

instruments into the abdominal cavity → that previous
surgery would increase the risk of bowel injury
 LAPAROSCOPY – PRE-OP WORK-UP

Complete
Pregnancy
blood cell Urinalysis ECG
test
count

Other
In patients with known health problems: A thorough preoperative
other laboratory tests (liver function tests medical evaluation (appropriate
or electrolyte evaluations) laboratory studies)

Imaging studies:

Chest radiography Barium enema

Intravenous pyelograph or kidney ultrasound
 LAPAROSCOPY – POSSIBLE
COMPLICATIONS

Laparoscopic
procedures have unique
risks, related to: Injury to
abdominal
organs
Methods used for the Pneumoperito
placement of abdominal wall neum related
ports complications

Pneumoperitoneum required Blood

vessel
for laparoscopy injury
 LAPAROSCOPY COMPLICATIONS –
PNEUMOPERITONEUM
failure of introducing verres
needle correctly into the
peritoneal cavity
Extra-peritoneal
It not checking the negative emphysema
pressure on the machine

Compromise Gas may extend to

cardiac function the mediastinum

Pneumo-mentum increase
anesthesia-  Aspiration
related risks  Increased difficulty
Increased
intra-abdominal ventilating the patient
pressures
 LAPAROSCOPY COMPLICATIONS –
ABDOMINAL ORGANS

Injury to GI
Abdominal
Organs
Bladder Injury
if the intestine is distended
or adherent to the abdominal
wall (prevented by good
intestinal preparation) and
prevented by emptying the putting the patient on the
bladder telendelenburg position
 LAPAROSCOPY COMPLICATIONS –
BLOOD VESSEL INJURY

Pelvic, omental and Prevented by

mesentric blood introducing the verres
vessel injury needle in an angle.

Blood vessel
injury:
Potentially massive
blood loss may occur
 LAPAROSCOPY – RISK VS BENEFIT

characteristics of both minor

A hybrid surgical approach
and major surgery

To patients: seem to be The small

minor surgery incisions

An intra-abdominal Relatively small

procedure: amount of
postoperative
All intraoperative and pain
postoperative risks of laparotomy
Short
Infection & injury to adjacent convalescent
intra-abdominal structures period.
 BENEFIT OF LAPAROSCOPY
SURGERY
Image magnification Fewer injuries in
to visualize challenging areas
Improved dissection
metastatic or (the retro
recurrent disease peritoneum)

No need
for an
Decreased bleeding
Shorter hospital stay Faster recovery. incisional
from small vessels
hernia
repair.

Postoperative Radiation
Less postoperative chemotherapy or complications from
complications radiation can be bowel adhesions are
initiated earlier minimized.
 LAPAROSCOPY – IN ONCOLOGIC
PROCEDURES

Laparoscopy has also been

For second-look procedures used for staging:
following surgical and chemo
treatment of malignancy. peritoneal washes with
biopsy

partial omentectomy

Laparoscopically assisted pelvic and periaortic

radical vaginal hysterectomy lymphadenectomy

Ghezzi F, Cromi A, Uccella S, Siesto G, Zefiro F, Bolis P.

Incorporating Laparoscopy in the Practice of a Gynecologic
Oncology Service: Actual Impact Beyond Clinical Trials Data. Ann
Surg Oncol. 2009 May 21.
 LAPAROSCOPIC CERVICAL CANCER

Also used for

In early stadium cervical pelvic
cancer: exterentation
and ovarian
transposition
Lymphadenectomy

Laparoscopy assisted radical

vaginal hysterectomy

Laparoscopy radical
hysterectomy

Laparoscopy vaginal
trachelectomy
 LAPAROSCOPY – IN CERVICAL
CANCER
Laparoscopic vaginal radical
hysterectomy
The scottish a safe and effective
intercollegiate guidelines alternative
network, 2008: → conventional abdominal
radical hysterectomy to treat
FIGO stage IB1 cervical
cancer

sufficient evidence on the

the national institute for effectiveness and safety
health and clinical
laparoscopic radical
excellence in the uk, hysterectomy
2010
→ treat early-stage cervical
cancer
 LAPAROSCOPY – IN CERVICAL
CANCER
There are no significant differences between the findings in these studies and
outcomes after open surgery

Current and Future Status of Laparoscopy in Gynecologic Oncology

 LAPAROSCOPY – IN
ENDOMETRICAL CANCER
Benefits generally:

fewer
Shorter hospital
perioperative less loss of blood fewer transfusions
times as
complications

A higher quality of life after laparoscopic hysterectomy compared to open abdominal

hysterectomy

1. Zullo F, Falbo A, Palomba S. Safety of laparoscopy vs. laparotomy in the surgical staging of endometrial cancer: a
systematic review and metaanalysis of randomized controlled trials. Am J Obstet Gynecol 2012;
207: 94–100
2 Galaal K, Bryant A, Fisher AD et al. Laparoscopy versus laparotomy for themanagement of early stage endometrial
cancer. Cochrane Database Syst Rev 2012; 9: CD006655
 LAPAROSCOPY – IN
ENDOMETRICAL CANCER
AGO recommendation
Examination of short-term postoperative
morbidity shows that laparoscopy is
superior to open surgery. The long-term
morbidity is the same For low-risk cases the oncologic
results for laparoscopic and open
surgery are comparable. The data
on high-risk cases is still insufficient
International guidelines, e.g. from the UK and France
support the use of laparoscopy to
treat endometrial cancer
They emphasize the importance of
special training and the fact that
surgeons must have advanced
laparoscopic skills
 LAPAROSCOPY – IN
ENDOMETRICAL CANCER
No statistically significant differences : perioperative morbidity blood transfusion rates
bladder lesions intestinal injuries and vascular injuries .
From an oncologic standpoint, there were no differences between laparoscopic and
open surgery with respect to disease-free interval and overall survival .
The 5-year survival rate was almost identical in both groups at 89.9% laparoscopy or
laparotomy treatment.

Galaal K, Bryant A, Fisher AD et al. Laparoscopy versus laparotomy for themanagement of early stage endometrial cancer. Cochrane Database
Syst Rev 2012; 9: CD006655
 LAPAROSCOPY – IN OVARIAN
CANCER
Publication from UK:
The study evaluated 35 patients with early-stage ovarian cancer operated
on using a laparoscopic approach
Disease-free survival
The overall The conversion was 94% after a
Survival
complication rate rate was 6% mean follow-up of 18
was 100%
was 14% (5/35) (2/35) months (range 3–
59).

The authors concluded:

Patients benefitted from a laparoscopic approch compared to laparotomy.

An Italian study group

After a mean follow-up of 30 months (range 10–74), overall survival was
100% and disease-free survival was 84%.

1. Brockbank EC, Harry V, Kolomainen D et al. Laparoscopic staging for apparent early stage ovarian or fallopian tube cancer. First case series from a UK cancer centre and systematic literature review. Eur J
Surg Oncol 2013; 39: 912–917
2.Montanari G, Di Donato N, Del Forno S et al. Laparoscopic management of early stage ovarian cancer: is it feasible, safe, and adequate? A retrospective study. Eur J Gynaecol Oncol 2013; 34: 415–418
 LAPAROSCOPY – IN OVARIAN
CANCER
Chi et al.
There were no significant differences Regard to the
number of resected
The complication
Operation times were longer with lymph nodes or
rates
laparoscopy (321 vs. 276 minutes) omental specimen
size
Blood loss and hospital times were
lower after laparoscopy

The retrospective comparative study of Lee

the complication rate after laparoscopic staging was significantly lower (7.7%) than
that of the laparotomy group (23.0%)

Koo et al
a recurrence rate of 8.3% in the laparoscopy group and 3.8% after laparotomy group.

1. Brockbank EC, Harry V, Kolomainen D et al. Laparoscopic staging for apparent early stage ovarian or fallopian tube cancer. First case series from a UK cancer centre and systematic literature review. Eur J
Surg Oncol 2013; 39: 912–917
2.Montanari G, Di Donato N, Del Forno S et al. Laparoscopic management of early stage ovarian cancer: is it feasible, safe, and adequate? A retrospective study. Eur J Gynaecol Oncol 2013; 34: 415–418
 LAPAROSCOPY – IN OVARIAN
CANCER
Laparoscopy was associated with a significantly lower postoperative
complication rate
Five-year disease-free survival and overall survival rates were not
affected by the surgical technique

Fagotti published, 2013

No complications were reported after laparoscopy (exploratory staging
laparoscopy).
R0 resection was achieved in 62.1% and reduction of the tumor to less than
1 cm in 22.5%.

A recent Cochrane analysis

the authors concluded that laparoscopy was a promising approach
1.Bogani G, Cromi A, Serati M et al. Laparoscopic and open abdominal staging for early-stage ovarian cancer: our experience, systematic review, and meta-analysis of comparative studies. Int J Gynecol Cancer
2014; 24: 1241–1249
2. Fagotti A, Vizzielli G, Fanfani F et al. Introduction of staging laparoscopy in the management of advanced epithelial ovarian, tubal and peritoneal cancer: impact on prognosis in a single institution experience.
 CONCLUSION

Laparoscopy has an
Laparoscopic radical
increasingly important role to
hysterectomy is an
play in gynecologic oncology
established alternative to
surgery. The benefits of
abdominal open radical
minimally invasive surgical
hysterectomy for the surgical
procedures are also manifest
treatment of cervical cancer.
for oncologic indications.

Operation times are usually

Benefits of laparoscopy
longer. Oncologic radicality
include less loss of blood,
and recurrence and survival
fewer transfusions and shorter
rates are comparable for both
hospital times.
approaches.
Thank You