What is the role of reassessment laparoscopy in the management of gynecologic cancers in 1995?

The Role of Surgery in the Management of Epithelial Ovarian Cancer

Background

Epithelial ovarian cancer is the most deadly gynecologic cancer in the United States. Multiple modalities of therapy are utilized in the management of the disease. The role of surgery remains important in the treatment of this disease and is described herein.

Methods

Medline and PubMed were utilized to search the English language medical literature up to March 2010. A broad range of studies and quality of data were analyzed, including prospective studies, case control analyses, and meta-analyses. When possible, the highest level of evidence was reviewed and presented.

Results

For the medically fit patient, optimal cytoreductive surgery positively impacts survival. For some highly selected patients, there is a role for a minimally invasive approach. In the recurrent setting, factors such as interval to recurrence and the distribution of disease will determine the utility of secondary cytoreductive surgery. A subgroup of patients may benefit from palliative surgical procedures in the recurrent setting.

Conclusions

Despite advances in the use of chemotherapy and biologic agents, surgery remains an important modality in the diagnosis and treatment of ovarian cancer.

Feasibility and accuracy of second-look laparoscopy after gastrectomy for gastric cancer

BACKGROUND

A better method for detecting early peritoneal progression is needed. This study evaluated the feasibility and accuracy of second-look laparoscopy for patients with gastric cancer treated using systemic chemotherapy after gastrectomy.

METHODS

Second-look laparoscopy was conducted for patients who had no clinical evidence of distant metastases but had peritoneal metastases or positive peritoneal cytology results without visible metastatic disease at initial surgery, patients who underwent systemic chemotherapy over a 6-month period after surgery, and patients who had no clinical evidence of disease based on imaging study after completion of primary chemotherapy.

RESULTS

Between November 2004 and April 2008, 21 patients underwent second-look laparoscopy. At the initial surgery, 13 of these patients underwent total gastrectomy and 8 patients underwent distal gastrectomy. One or two sheets of adhesion barrier were received by 18 patients. The median interval between initial surgery and second-look laparoscopy was 9.8 months (range, 6.6-17.5 months). All second-look procedures were completed laparoscopically, and no patients required conversion to laparotomy. None of the 21 patients experienced postlaparoscopy complications. Whereas 12 patients showed no pathologic evidence of disease, 9 patients showed disease at second-look laparoscopy. There was a significant difference in median survival between the groups with negative and positive results (p = 0.017). The median survival for the negative group has not been determined. All the patients in the positive group received further chemotherapy while showing a good performance status (PS). Six patients were PS 0, and 3 patients were PS 1. The median survival time for this group was 10.1 months.

CONCLUSIONS

Second-look laparoscopy was a safe and promising approach to reassessment of peritoneal disease for patients with gastric cancer. The incidence of complications was low, particularly in this group of patients, all of whom had undergone prior gastrectomy.

Role of surgery in ovarian carcinoma

Surgery plays a critical role in the optimal management of all stages of ovarian carcinoma. In apparent early-stage ovarian cancer, a comprehensive surgical evaluation allows stratification of patients into low- and high-risk categories. Low-risk patients may be candidates for fertility-sparing surgery and can safely avoid chemotherapy and be observed. Treatment of patients with high-risk early- or advanced-stage ovarian cancer usually requires a combined modality approach. Although it is well known that epithelial ovarian cancer is moderately chemosensitive, what distinguishes it most from other metastatic solid tumors is that surgical cytoreduction of tumor volume is highly correlated with prolongation of patient survival. Procedures such as radical pelvic surgery, bowel resection, and aggressive upper abdominal surgery are commonly required to achieve optimal cytoreduction. Women who develop recurrent disease may be eligible for a secondary cytoreductive surgery or may require a surgical intervention to palliate disease-related symptoms. For women at high risk of ovarian cancer, prophylactic bilateral salpingo-oophorectomy significantly reduces the incidence of this disease. The purpose of this article is to provide a comprehensive review of the surgical management of ovarian carcinoma. The roles of primary, interval, and secondary cytoreductive surgeries; second-look procedures; and palliative surgery are reviewed. The indications for fertility-sparing and minimally invasive surgery as well as the current guidelines for prophylactic surgery in high-risk mutation carriers are also discussed.

Laparoscopy after previous laparotomy

Following the abdominal surgery, extensive adhesions often occur and they can cause difficulties during laparoscopic operations. However, previous laparotomy is not considered to be a contraindication for laparoscopy. The aim of this study is to present that an insertion of Veres needle in the region of umbilicus is a safe method for creating a pneumoperitoneum for laparoscopic operations after previous laparotomy. In the last three years, we have performed 144 laparoscopic operations in patients that previously underwent one or two laparotomies. Pathology of digestive system, genital organs, Cesarean Section or abdominal war injuries were the most common causes of previous laparotomy. During those operations or during entering into abdominal cavity we have not experienced any complications, while in 7 patients we performed conversion to laparotomy following the diagnostic laparoscopy. In all patients an insertion of Veres needle and trocar insertion in the umbilical region was performed, namely a technique of closed laparoscopy. Not even in one patient adhesions in the region of umbilicus were found, and no abdominal organs were injured.

Transperitoneal laparoscopic pelvic and paraaortic lymphadenectomy in gynecologic cancers

Laparoscopy, a minimally invasive surgery, may benefit select patients more than traditional abdominal approaches. The benefits of this procedure include low morbidity, shorter length of hospital stay, less blood loss, no significant increase in complications, and a shorter postoperative recovery period; this allows patients to begin adjuvant therapy more quickly. Laparoscopy has been used in gynecologic oncology since the early 1990s and has continued to grow and develop. Complex gynecologic oncology procedures can be performed with a low rate of complication and a low rate of conversion to laparotomy. The literature supports the fact that laparoscopy can be performed with short-term benefit with no increase in morbidity. Although the data are limited and emerging, the risk of cancer recurrence does not appear to increase because of this minimal access approach. Currently, advanced laparoscopic techniques are used to evaluate and treat cervical, endometrial, and ovarian malignancies. Specifically, transperitoneal laparoscopic lymphadenectomy including pelvic and paraaortic nodes is a feasible and efficacious procedure in the management of certain gynecologic malignancies.

Bowel injury as a complication of laparoscopy

BACKGROUND

Bowel injury is a rare but serious complication of laparoscopic surgery. This review examines the incidence, location, time of diagnosis, causative instruments, management and mortality of laparoscopy-induced bowel injury.

METHODS

The review was carried out using the MeSH browser within PubMed. The keywords used were 'laparoscopy/adverse effects' and 'bowel perforation'. Additional articles were sourced from references within the studies found in the PubMed search.

RESULTS

The incidence of laparoscopy-induced gastrointestinal injury was 0.13 per cent (430 of 329 935) and of bowel perforation 0.22 per cent (66 of 29 532). The small intestine was most frequently injured (55.8 per cent), followed by the large intestine (38.6 per cent). In at least 66.8 per cent of bowel injuries the diagnosis was made during the laparoscopy or within 24 h thereafter. A trocar or Veress needle caused the most bowel injuries (41.8 per cent), followed by a coagulator or laser (25.6 per cent). In 68.9 per cent of instances of bowel injury, adhesions or a previous laparotomy were noted. Management was mainly by laparotomy (78.6 per cent). The mortality rate associated with laparoscopy-induced bowel injury was 3.6 per cent.

CONCLUSION

At 0.13 per cent, the incidence of laparoscopy-induced bowel injury is small and such injury is usually discovered during the operation. Nevertheless, laparoscopy-induced bowel injury is associated with a high mortality rate of 3.6 per cent.

Ten-year experience with laparoscopy on a gynecologic oncology service: analysis of risk factors for complications and conversion to laparotomy

OBJECTIVE

The purpose of this study was to analyze our initial 10-year experience with laparoscopy and to determine risk factors for complications and conversions to laparotomy for technical difficulty.

STUDY DESIGN

We reviewed the charts of all laparoscopic procedures from January 1991 through December 2000 and divided the procedures into 4 levels on the basis of the degree of difficulty: level I, diagnostic; level II, procedures on the uterus and/or adnexa; level III, second look operations for malignancy; and level IV, lymphadenectomies/other complex procedures. Complications were graded from 1 (mild) to 5 (death). Standard univariate and multivariate analyses were performed.

RESULTS

We identified 1451 evaluable procedures. The number of complications was as follows: grades 1 to 5, 129 complications (9%); grades 3 to 5, 36 complications (2.5%). On multivariate analysis, older age ( P = .03), previous radiation ( P = .03), and malignancy ( P = .006) were associated with an increased risk of complications grades 3 to 5. Complication rates for grades 3 to 5 for patients with malignancy versus benign disease was 4% versus 1%, respectively. Technical difficulty led to conversion to laparotomy in 105 cases (7%). Previous abdominal surgery ( P < .001) significantly increased the rate of conversion to laparotomy; more complex, higher procedure levels were associated with a significant decrease in conversions ( P = .005).

CONCLUSION

Both simple and complex laparoscopic procedures can be performed by a gynecologic oncology service with a low rate of complications and conversions to laparotomy. Older age, malignancy, previous radiation therapy, and previous abdominal surgery were identified as significant risk factors for complications and/or conversion and should be taken into account in patient selection, preoperative counseling, and surgical planning.

Laparoscopic training and practice in gynecologic oncology among Society of Gynecologic Oncologists members and fellows-in-training

OBJECTIVE

To determine the proportion of Society of Gynecologic Oncologists (SGO) members performing laparoscopic procedures and to determine SGO members' and fellows' opinions regarding indications for and the adequacy of training in laparoscopy.

METHODS

Surveys were mailed to SGO members and fellows-in-training in December 2002. Anonymous responses were collected by mail or through a Web site. The survey was mailed twice and was estimated to take 5 min to complete. The data were analyzed using frequency distributions and nonparametric tests.

RESULTS

Three hundred thirty-six SGO members (45%) and fifty-seven fellows (49%) responded. Among SGO members, 272 (84%) currently performed laparoscopic surgeries. Reasons cited for performing laparoscopy were decreased length of hospital stay (74%), improved patient quality of life (57%), patient preference (48%), improved cosmesis (46%), and better visualization (18%). Among those who did not perform laparoscopy, 50% cited increased operating time as their main reason. When asked to indicate the laparoscopic procedure most commonly performed in their practice, 69% reported diagnosis of an adnexal mass; 11%, prophylactic bilateral salpingo-oophorectomies; and 10%, laparoscopically assisted vaginal hysterectomy and lymph node staging for uterine cancer. Only 3% of SGO respondents performed more than 50% of their procedures laparoscopically, and all respondents reported converting from laparoscopy to laparotomy less than 25% of the time. Most respondents had limited laparoscopic training during their fellowships: 39% received none, and 46% received limited (less than five procedures per month) training. Nevertheless, 78% of SGO respondents rated their laparoscopic skills as either very good or good. Among fellows, only 25% believed they were receiving very good or good laparoscopic training. Eighty percent of SGO respondents believe that at least six procedures per month were necessary for adequate training, yet only 33% of fellows performed that many procedures.

CONCLUSIONS

Most SGO respondents used laparoscopy for selective indications, and most developed their laparoscopic skills after their fellowship training. SGO respondents believed laparoscopic instruction is an important part of training, but most fellows perceived their laparoscopic training as inadequate.

Surgical advances in the treatment of ovarian cancer

Surgical intervention remains a key component in the diagnosis and management of epithelial ovarian carcinomas. Although the parameters defining "optimal" tumor cytoreduction continue to evolve, data validate the concept of complete operative tumor resection to no visible residual disease in all stages of ovarian cancer to prolong disease-free and overall survival. In select patients, recurrent disease also may be managed with surgical cytoreduction. At the other end of the spectrum, prophylactic bilateral salpingo-oophorectomy has been shown conclusively to reduce the risk of ovarian cancer in women at high risk. Although BRCA1-associated and BRCA2-associated gynecologic cancer syndromes do not seem to include uterine malignancies, the role of hysterectomy to remove the fallopian tube completely is controversial. Finally, new data support the concept of conservative, fertility-sparing surgery in a select group of women with early-stage disease. Although laparoscopy may be feasible in staging women with disease apparently limited to an ovary, further studies are necessary before it can be considered routinely as an alternative to standard laparotomy.

Early physician experience with laparoscopically assisted vaginal hysterectomy and rates of surgical complications and conversion to laparotomy

OBJECTIVE

Our purpose was to determine whether the rates of conversion to laparotomy and surgical complication rate decrease with increasing physician experience with laparoscopically assisted vaginal hysterectomies (LAVH) in a large population-based administrative database.

STUDY DESIGN

We queried the North Carolina Medical Commission Database for all LAVHs performed in the state from January 1, 1988, through September 30, 1994. Conversion to laparotomy and the surgical complication rate were analyzed by use of logistic regression controlling for patient age, socioeconomic level, academic setting, and indication for surgery. Physician experience was assessed by sequentially assigning case numbers for each LAVH by attending physician. A surgical complication was defined as any International Classification of Disease, 9th Revision, code for intraoperative organ injury, excessive blood loss, blood transfusion, or wound infection.

RESULTS

Six hundred two attending physicians performed 3,728 LAVHs during the observation period. The median number of LAVHs performed by each attending physician was 2, range 1-107, mean 6.2 +/- 10.1. The mean age of the patients was 39.4 +/- 9.2 years. The mean number of days hospitalized was 2.8 +/- 1.6. A concurrent bilateral salpingo-oophorectomy was performed in 46.4% of the LAVHs. Only 1% were performed for malignancy. There was one reported death. A total of 10.3% of the patients were from a low socioeconomic level. Nine percent were performed at an academic center. Overall, there was a 21.5% rate of conversion to laparotomy and a 12.1% surgical complication rate. The rate of conversion to laparotomy significantly decreased with increasing physician experience (P <.0001) and retained its significance even after patient age, socioeconomic level, indication for surgery, academic setting, and surgical complication were controlled. However, no decrease in the surgical complication rate was observed with increasing physician experience.

CONCLUSION

As the number of LAVHs performed by an individual physician increases, the rate of conversion to laparotomy decreases. However, no significant increase or decrease in the complication rate was observed with increasing operator experience.

Laparoscopic entry: a literature review and analysis of techniques and complications of primary port entry

OBJECTIVE

To obtain consensus as to the optimal form of entry technique for access to the peritoneal cavity.

DESIGN

A meta-analysis of all relevant English language studies of laparoscopic entry complications.

MAIN OUTCOME MEASURES

Incidence of bowel and major vascular injuries.

RESULTS

Bowel injuries occur in 0.7/1,000 and major vascular injuries in 0.4/1,000. The overall incidence of major injuries at time of entry is 1.1/1,000. The direct entry technique is associated with a significantly reduced major injury incidence of 0.5/1,000, when compared to both open and Veress entry produces (1.1 and 0.9/1,000 respectively, p = 0.0005). Entry-related bowel injuries are reported more often following general surgical laparoscopies than with gynaecological procedures (p = 0.001). No such difference is seen in the incidence of vascular injuries (p = 0.987). Open entry is statistically more likely to be associated with bowel injury than either Veress needle or direct entry However, open entry appears to minimise vascular injury at time of entry.

CONCLUSIONS

There remains no clear evidence as to the optimal form of laparoscopic entry in the low-risk patient. However, direct entry may be an under-utilised and safe alternative to the Veress needle and open entry technique.

The role of laparoscopy in second-look evaluations for ovarian cancer

BACKGROUND

The aim of this study was to evaluate the accuracy and safety of laparoscopic second-look operations in patients with ovarian cancer.

METHODS

We retrospectively reviewed the medical records of all patients who have undergone laparoscopic second-look procedures for ovarian cancer at our institution.

RESULTS

From July 1993 to December 1998, 150 patients underwent laparoscopic second-look operations. The mean age of patients was 53 years (range, 25-78 years). The majority of patients (87%) had Stage III or IV disease at initial surgery; the remainder were Stage II or unstaged. Eighty-two patients (54%) had had optimal cytoreduction at the time of their initial surgery. All patients had completed primary chemotherapy and were clinically disease-free based on imaging studies and CA-125 levels at the time of second look. Sixty-nine patients (46%) were found to have pathologically negative second looks; thus, the rate of positive second-look evaluations was 54%. The rate of conversion to laparotomy was 18/150 (12%). In 3 cases this was secondary to bowel injury; one patient sustained a bladder injury; the remainder of conversions to laparotomy were for secondary cytoreduction. There was only 1 case where the patient was found to have extensive adhesions and laparoscopy was abandoned. The overall rate of major complications was 2.7%.

CONCLUSIONS

In our experience, laparoscopy is a safe and accurate method of second-look assessment in patients with ovarian cancer. The incidence of complications is low, particularly in this group of patients, all of whom have undergone prior abdominal surgery. The rate of negative evaluations and the rate of recurrences in patients with negative second looks are equivalent to those described in studies of second-look assessment by laparotomy.

Laparoscopic surgery for gynecologic cancers

In conclusion, laparoscopic techniques are useful for the evaluation and treatment of selected gynecologic malignancies and provide major benefits to patients. The benefits, however, can be expected only from gynecologic oncologists well-versed in advanced laparoscopic techniques. Results must be interpreted cautiously, depending on the laparoscopic expertise of the reporting authors. Numerous questions remain unanswered, particularly those associated with long-term recurrences and survival. The use of laparoscopic procedures for gynecologic malignancies must be considered investigational until adequate long-term survival data are available.

High resolution imaging of endometriosis and ovarian carcinoma with optical coherence tomography: feasibility for laparoscopic-based imaging

High resolution imaging of gynaecological tissue offers the potential for identifying pathological changes at early stages when interventions are more effective. Optical coherence tomography (OCT) is a high resolution high speed optical imaging technology which is analogous to ultrasound B-mode imaging except reflections of light are detected rather than sound. The OCT technology is capable of being integrated with laparoscopy for real-time subsurface imaging. In this report, the feasibility of OCT for differentiating normal and pathologic laparoscopically-accessible gynaecologic tissue is demonstrated. Differentiation is based on architectural changes of in vitro tissue morphology. OCT has the potential to improve conventional laparoscopy by enabling subsurface imaging near the level of histopathology.

Second look for ovarian cancer: laparoscopy or Laparotomy? A prospective comparative study

OBJECTIVE

The objective of this study was to evaluate, for patients with ovarian cancer, the feasibility, reliability, and complications of a laparoscopic second look and to compare them with those of a second look by laparotomy.

METHODS

Twenty patients treated by initial surgery and adjuvant chemotherapy for ovarian carcinoma underwent a laparoscopic second look, immediately followed by a comparative laparotomy. All were in complete remission after chemotherapy. Both operations were performed according to a predefined checklist, identical for both surgical techniques and for each patient: after liberation of adhesions, an exhaustive intraperitoneal inspection was performed, with systematic peritoneal cytology and biopsies. Each patient therefore was her own control for the two techniques.

RESULTS

The positive predictive value of laparoscopy for the diagnosis of residual disease was 100% (6 of 6 cases), while the negative predictive value was 86% (2 false-negative cases out of 14). Because of the presence of postoperative adhesions, the rate of complete intraperitoneal investigation was 95% for laparotomy versus 41% for laparoscopy. The complication rate of laparoscopy requiring laparotomy was 5.3%.

CONCLUSIONS

After treatment of ovarian cancer, a laparoscopic second look appears to be less reliable than one performed by laparotomy. The presence of severe postoperative adhesions is the main obstacle to an exhaustive, reliable, and safe laparoscopic second look.

Laparoscopic bowel injury: incidence and clinical presentation

PURPOSE

Bowel injury is a potential complication of any abdominal or retroperitoneal surgical procedure. We determine the incidence and assess the sequelae of laparoscopic bowel injury, and identify signs and symptoms of an unrecognized injury.

MATERIALS AND METHODS

Between July 1991 and June 1998 laparoscopic urological procedures were performed in 915 patients, of whom 8 had intraoperative bowel perforation or abrasion injuries. In addition, 2 cases of unrecognized bowel perforation referred from elsewhere were reviewed. A survey of the surgical and gynecological literature revealed 266 laparoscopic bowel perforation injuries in 205,969 laparoscopic cases.

RESULTS

In our series laparoscopic bowel perforation occurred in 0.2% of cases (2) and bowel abrasion occurred in 0.6% (6). The 6 bowel abrasion injuries were recognized intraoperatively and 5 were repaired immediately. In 4 cases, including 2 referred from elsewhere, perforation injuries were not recognized intraoperatively and they had an unusual presentation postoperatively. These patients had severe, single trocar site pain, abdominal distention, diarrhea and leukopenia followed by acute cardiopulmonary collapse secondary to sepsis within 96 hours of surgery. The combined incidence of bowel complications in the literature was 1.3/1,000 cases. Most injuries (69%) were not recognized at surgery. Of the injuries 58% were of small bowel, 32% were of colon and 50% were caused by electrocautery. Of the patients 80% required laparotomy to repair the bowel injuries.

CONCLUSIONS

Bowel injury following laparoscopic surgery is a rare complication that may have an unusual presentation and devastating sequelae. Any bowel injury, including serosal abrasions, should be treated at the time of recognition. Persistent focal pain in a trocar site with abdominal distention, diarrhea and leukopenia may be the first presenting signs and symptoms of an unrecognized laparoscopic bowel injury.

Gynecologic cancer and laparoscopy

Numerous technologic and surgical advances have led to the application of operative laparoscopic techniques to gynecologic cancers. Operative laparoscopy has been described in the surgical staging and treatment of patients with ovarian, cervical, and endometrial cancers. it seems to be a very promising approach with the potential to revolutionize numerous aspects of the management of gynecologic malignancies. Since 1996, the SGO has offered an operative laparoscopy course to all gynecologic oncology fellowship programs. Boike and colleagues report that faculty and fellows from 25 different fellowship programs have attended the 2-day course. In questionnaires filled out at the completion of the course, more than 85% of respondents believed that operative laparoscopic procedures were equivalent to open techniques and should be taught in fellowship programs. Despite the enthusiasm for the use of endoscopy in patients with gynecologic malignancies, its potential is unconfirmed and its hazards unknown. Reports regarding complications and long-term results are just now beginning to be published. More clinical data must be collected before the minimally invasive techniques can be accepted as new surgical standards. Ongoing prospective clinical trials will help to answer many of the questions regarding safety and efficacy. Pending the completion of additional trials, operative laparoscopy will remain a promising but unproven tool in the management of patients with gynecologic cancer.

The virtues and pitfalls of minimally invasive surgery for gynecological malignancies: an update

Operative laparoscopy is still jockeying for its place in the surgical management of gynecological malignancies. Its usefulness in staging these malignancies continues to be investigated, as does its ability to convert abdominal procedures to vaginal procedures. Recent articles also address the role of operative laparoscopy in less common procedures, as well as the curiosity of investigators to gain a better understanding of the 'consequences' of operative laparoscopy by using animal models. The reader is updated by a review of the reports published over the past year and a half.

The feasibility of open laparoscopy in gynecologic-oncologic patients

Gynecologic-oncologic patients are at increased risk for complications with closed laparoscopy. Open laparoscopy eliminates the steps of blind insufflation and trocar insertion. This study is the first large series of open laparoscopies to assess the feasibility and safety of the open laparoscopy technique in patients with gynecologic malignancies. We performed 90 open laparoscopies in 89 oncologic patients with previous major surgery (65%) and/or radiotherapy (17%) or a large omental cake (18%). Complications due to the laparoscopic access technique occurred in one patient (1%) for whom a laparotomy was performed for a small bowel perforation. The incidence of complications of the open laparoscopy technique (1%) is favorable compared to the complication rate of closed laparoscopy in gynecologic-oncologic patients. It is concluded that open laparoscopy is a safe and feasible technique in gynecologic-oncologic patients.