Faculty Bibliography

OBJECTIVES: To describe our experience with laparoscopic primary or interval tumor debulking in patients with presumed advanced ovarian, fallopian tube, or peritoneal cancers. METHODS: This is a retrospective analysis of a prospective case series. Women with presumed advanced (FIGO stage IIC or greater) ovarian, fallopian tube, or primary peritoneal cancers deemed appropriate candidates for laparoscopic debulking by the primary surgeon(s) were recruited. RESULTS: The study comprised 32 patients who underwent laparoscopic evaluation. Seventeen underwent total laparoscopic primary or interval cytoreduction, with 88.2% optimal cytoreduction. Eleven underwent diagnostic laparoscopy and conversion to laparotomy for cytoreduction, with 72.7% optimal cytoreduction. Four patients had biopsies, limited cytoreduction, or both. In the laparoscopy group, 9 patients have no evidence of disease (NED), 6 are alive with disease (AWD), and 2 have died of disease (DOD), with mean follow-up time of 19.7 months. In the laparotomy group, 3 patients are NED, 5 are AWD, and 3 are DOD, with mean follow-up of 25.8 months. Estimated blood loss and length of hospital stay were less for the laparoscopy group (P=0.008 and P=0.03), while operating time and complication rates were not different. Median time to recurrence was 31.7 months for the laparoscopy group and 21.5 months for the laparotomy group (P=0.3). CONCLUSIONS: Laparoscopy can be used for diagnosis, triage, and debulking of patients with advanced ovarian, fallopian tube, or primary peritoneal cancer and is technically feasible in a well-selected population

OBJECTIVE:To analyze the feasibility, safety, advantages, and disadvantages of using robotic technology for gynecologic surgeries in a large group of patients. DESIGN/METHODS:Retrospective study (Canadian Task Force classification II-3). SETTING/METHODS:Tertiary endoscopic referral centers. PATIENT(S)/METHODS:Eighty-seven patients requiring laparoscopic treatments for benign gynecologic conditions. INTERVENTION(S)/METHODS:Charts reviewed from robotic-assisted gynecologic operative laparoscopies. MAIN OUTCOME MEASURE(S)/METHODS:Length of surgery, time for robot assembly and disassembly, rate of conversion to laparotomies, and complications. RESULT(S)/RESULTS:Between January 2006 and August 2007, 137 robotically assisted gynecologic procedures were performed in 87 patients. The da Vinci Surgical System was used. The average length of the surgeries was 205 minutes (60-420 minutes). Assembly of the robot lasted 16 minutes (10-27 minutes) when disassembly took 2.5 minutes (2-6 minutes). There were no conversions to laparotomy. There were three complications. CONCLUSION(S)/CONCLUSIONS:Robotic-assisted technology, in its present state, is enabling more surgeons to perform endoscopic surgery. Its advantages are 3D Vision and a faster learning curve for suturing and operating while sitting. It's an exciting enabling technology with a great future.

OBJECTIVE: To evaluate the role of laparoscopy for staging of early ovarian cancers. STUDY DESIGN: Case series conducted at the University Hospital with 36 patients who had presumed early-stage adnexal cancers. Laparoscopic staging/restaging was performed. RESULTS: Cases included 20 invasive epithelial tumors, 11 borderline tumors, and 5 nonepithelial tumors. Mean number of peritoneal biopsies, paraaortic nodes, and pelvic nodes were 6, 12.23, and 14.84, respectively. Eighty-three percent of the patients had laparoscopic omentectomy. On final pathology, 7 patients were upstaged. Postoperative complications included 1 small bowel obstruction, 2 pelvic lymphoceles, and 1 lymphocele cyst. Mean duration of follow-up is 55.9 months. Three patients had recurrences. All patients are alive without evidence of the disease. CONCLUSION: This represents 1 of the largest series and longest follow-ups of laparoscopic staging for early-stage adnexal tumors. Laparoscopic staging of these cancers appears to be feasible and comprehensive without compromising survival when performed by gynecologic oncologists experienced with advanced laparoscopy.

BACKGROUND AND OBJECTIVES: Natural orifice transluminal endoscopic surgery involves the introduction of instruments through a natural orifice into the peritoneal cavity to perform diagnostic and therapeutic surgical interventions. We report the utilization of the vaginal opening at the time of laparoscopic-assisted vaginal hysterectomy or total laparoscopic hysterectomy as a natural orifice for appendectomy. METHODS: We reviewed cases of 42 patients who underwent total laparoscopic hysterectomy or laparoscopic-assisted vaginal hysterectomy followed by appendectomy, performed by applying a stapler and removing the appendix transvaginally. By using a small-diameter laparoscope, the appendix was mobilized, especially in patients with adhesions, endometriosis, or retrocecal appendix, to facilitate transvaginal access with the stapler. RESULTS: All procedures were performed successfully without intraoperative or major postoperative complications. The appendectomy portion of the procedure took approximately 5 minutes to 10 minutes. Appendiceal pathology included serosal adhesions (14), fibrous obliteration of the lumen (12), endometriosis (4), serositis (2), and carcinoid tumor (1), among others. CONCLUSIONS: Appendectomy performed with an endoscopic stapler introduced transvaginally for amputation and retrieval following total laparoscopic hysterectomy or laparoscopically assisted vaginal hysterectomy appears to be a safe and effective modification of established techniques with acceptable outcomes.

A MEDLINE search was conducted using the keywords 'laparoscopy ovarian cancer,' 'laparoscopy and borderline ovarian tumors,' 'advanced stage ovarian cancer,' 'laparoscopic cytoreduction ovarian cancer,' 'laparoscopy intraperitoneal catheter,' 'port-site metastases,' and 'carbon dioxide pneumoperitoneum.' The publications were further limited to English-language articles, those addressing adnexal mass management, early stage ovarian cancer, and advanced stage ovarian cancer treatments. The articles were divided into 4 broad categories: adnexal masses, low malignant potential tumors, early stage ovarian cancer, and advanced ovarian cancer. For each category, a further subdivision into case reports, case series, and finally cohorts was developed and summarized. Additional articles were obtained based on the bibliographic cross-reference of the initial articles reviewed. The current literature defining the role of laparoscopy in the diagnosis and treatment of ovarian cancer is limited to case reports, case series, and cohort studies. However, these limited studies suggest equal efficacy of laparoscopy compared with laparotomy in both early and advanced stage ovarian cancer

Laparoscopy was used for a second-look assessment in ovarian cancer patients back in the 1970s. However, it is only with the advent of new developments in equipment in the late 1980s and early 1990s along with the vision of pioneers in laparoscopic surgery that has made operative laparoscopy in gynecologic oncology feasible. Laparoscopy has multiple benefits in the cancer patients, including image magnification to visualize metastatic or recurrent disease and improved dissection in challenging areas such as the paravesical and pararectal spaces. There is limited bleeding from small vessels because of the pressure from pneumoperitoneum, decreased hospital stay, and rapid recovery. Postoperative chemotherapy or radiation can be initiated earlier, and radiation complications from bowel adhesions are minimized. Significant progress has been made in the last 2 decades in gynecologic malignancy. In this study, the application of laparoscopy in cervical, endometrial, and ovarian cancer will be presented

The objectives of this article were to review the published scientific literature about robotics and its application to gynecologic oncology to date and to summarize findings of this advanced computerenhanced laparoscopic technique. Relevant sources were identified by a search of PUBMED from January 1950 to January 2009 using the key words Robot or Robotics and Cervical cancer, Endometrial cancer, Gynecologic oncology, and Ovarian cancer. Appropriate case reports, case series, retrospective studies, prospective trials, and review articles were selected. A total of 38 articles were identified on the subject, and 27 were included in the study. The data for gynecologic cancer show comparable results between robotic and laparoscopic surgery for estimated blood loss, operative time, length of hospital stay, and complications. Overall, there were more wound complications with the laparotomy approach compared with laparoscopy and robotic-assisted laparoscopy. There were more lymphocysts, lymphoceles, and lymphedema in the robotic-assisted laparoscopic group compared with the laparoscopy and laparotomy groups in patients with cervical cancer. Infectious and lung-related morbidity, postoperative ileus, and bleeding or clot formation were more commonly reported in the laparotomy group compared with the other 2 cohorts in patients with endometrial cancer. Computer-enhanced technology may enable more surgeons to convert laparotomies to laparoscopic surgery with its associated benefits. It seems that in the hands of experienced laparoscopic surgeons, final outcomes are the same with or without use of the robot. There is good evidence that robotic surgery facilitates laparoscopic surgery, with equivalent if not better operative time and comparable surgical outcomes, shorter hospital stay, and fewer major complications than with surgeries using the laparotomy approach

OBJECTIVE:To present a case of successful laparoscopic resection of adrenal endometriosis. DESIGN/METHODS:Case report. SETTING/METHODS:University Hospital. PATIENT(S)/METHODS:Forty-eight-year-old woman with left-sided abdominal and flank pain. INTERVENTION(S)/METHODS:Laparoscopic radical adrenalectomy. MAIN OUTCOME MEASURE(S)/METHODS:Diagnosis and surgical approach to adrenal endometriosis. RESULT(S)/RESULTS:There have been two case reports of adrenal endometriosis. Based on a search of Medline and Google for "adrenal endometriosis," this is the first known successful laparoscopic resection of adrenal endometriosis. CONCLUSION(S)/CONCLUSIONS:We report the first case of successful laparoscopic adrenalectomy for the treatment of endometriosis.