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Laproscopy in gynecology oncology
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  • 1. LAPAROSCOPY IN GYNECOLOGY ONCOLOGY KHALID SAIT Professor Director of Gynecology Oncology Unit Chairman of Scientific chair of prof.Abdullah Hussain Basalamah for Gynecological cancer Faculty of Medicine King Abdulaziz University Hospital
  • 2. CLINICAL SERVICES FOR GYNECOLOGICAL CANCER SURGERY Robotic Laparoscopy Open
  • 3. LAPAROSCOPY
  • 4. LAPAROSCOPY IN GYNECOLOGIC ONCOLOGY „ Laparoscopically assisted vaginal hysterectomy „ Total simple and radical hysterectomy „ Pelvic and aortic node dissection „ Omentectomy „ Advanced bowel surgery
  • 5. ADVANTAGE „ Improvement of vision „ Precision of dissection „ Reduce in preoperative morbidity „ Reduce hospital stay „ Patient’s satisfaction
  • 6. ADDITIONAL BENEFIT „ Less adhesion „ Less bowel complication if radiation required
  • 7. LAPAROSCOPY IN ENDOMETRIAL CANCER „ Childers 1992 „ Ghezzi ( small RCT) „ Obermair……………………..
  • 8. SURVEY OF MEMBERS OF SGO „ 47 % of responders advocated the use of laparoscopy for surgical staging of endometrial cancer in 2004 „ 87% of responders advocated the use of laparoscopy for surgical staging of endometrial cancer in 2009
  • 9. REASONS FOR THIS INCREASE….. „ Result of the ever-growing number of reports attesting to its technical feasibility, safety, and practicality
  • 10. IMPORTANT POINT „ Learning curve „ Select the best candidates „ Size of the uterus less than 8 cm to avoid marcellation and dissmination of cancer „ Proper equipment and patient position
  • 11. REASONS OF UNACCEPTABILITY FOR SOME… „ Lacking of level I evidence
  • 12. LAPAROSCOPY IN ENDOMETRIAL CANCER „  LAP -2 ( with nodes) „  2413 Eligible patients „  Multi-institutional RCT „  Open vs Laparoscopy assistant „  Result : „  Laparoscopy is feasible with longer operative times, comparable complications and shorter hospital stay „  Better quality of life at 6 weeks, but same at 6 month( apart from body image ) „  Conversion rate 25 %
  • 13. LAPAROSCOPY IN ENDOMETRIAL CANCER „  LACE trial ( Stage I Australian randomized trial ) ( with node depends on …..) „  Result: „  Open surgery : 142 „  Laparoscopy : 190 „  Significantly greater improvement in quality of life in laparoscopy group In early and late stage of recovery and Intraoperative adverse effect were similar „  Post operative severe adverse effect were more in open surgery „  Conversion rate 3.8 %
  • 14. LAPAROSCOPY IN ENDOMETRIAL CANCER „  Netherlands study ( no nodes) „  RCT „  OPEN : 94 „  Laparoscopy: 185 „  Less major complication in laparoscopy „  No different over time in the quality of life in both group „  In laparoscopy group: less blood loss, less pain medication, shorter hospital stay and faster recovery „  Conversion rate: 4.3 %
  • 15. MOST IMPORTANT GOAL OF CANCER SURGERY „ Cancer free survival „ Data still immature „ Retrospective…. „ RCT ( three studies) follow up were 38 – 79 months ---sample size were not sufficient to provide adequate statistical power to reveal modest but meaningful difference in survival
  • 16. LAPAROSCOPY IN OBESE WOMEN WITH ENDOMETRIAL CANCER „ Eltabbakh : BMI: 28-60 „ Succ. rate 88 %
  • 17. OBESITY AND LAPAROSCOPY IN ENDOMETRIAL CANCER „  Trocher placement is challenging „  Bleeding from abdominal wall vessels „  Restricted operative field( fat , bowel) „  Difficult to achieve pneumoperotinum to elevate ant. Abd. wall „  Difficult to place patient in steep trendelburg because of ventilation consideration „  Difficulty in doing para-ortic node „  Conversion rate 7.5-36%( BMI >35)
  • 18. SAUDI ARABIA LAPAROSCOPIC EXPERIENCE( KAUH) SEP 2011-AUG 2012 „ Endometrial cancer(20) 1- 50 % Robotic 2- 10 % laparoscopy 3- 40 % open
  • 19. LAPAROSCOPIC IN OVARIAN CANCER „ Childers „ Tozzi „ Chi „ Leblanc „ Abu- Rustum „ Litell
  • 20. SURVEY OF MEMBERS OF SGO „ The use of laparoscopic for Early ovarian cancer in 2004 not considered „ 62 % of responders advocated the use of laparoscopic in early ovarian cancer in 2009
  • 21. LAPAROSCOPIC IN EARLY OVARIAN CANCER „ 300 patients reported „ Case serious (9-42 patients) „ Low rate of conversion and reasonable intraoperative complication
  • 22. LIMITATION IN LAPAROSCPY IN EARLY OVARIAN CANCER „ No RCT „ Lack of level I evidence in term of : rate of upstaging and number of node retrieved and survival „ Its rare, and has long life expectancy „ Need 1000 patients to demonstrate slimier oncologic out come Which is difficult to do …
  • 23. OMENTECTOMY
  • 24. LIMITATION IN LAPAROSCPY IN EARLY OVARIAN CANCER „ Not allow inspection of whole peritoneum, mesentery, behind the liver and high part of left diaphragm „ Port site mets. (2%) ??? „ Tumor rupture ( big topic to discuss…) …….largest review by Vergote of 6 international data base including 1545 pts. in which found that rupture is an independent predictor of disease free survival
  • 25. SAUDI ARABIA LAPAROSCOPIC EXPERIENCE( KAUH) SEP 2011-AUG 2012 „ Ovarian cancer Suspicious ovarian mass 100 % open „ Staging after initial oophorectomy for ovarian cancer ( 10 cases) 50% laparoscopy 50 % open
  • 26. LAPAROSCOPY IN CERVICAL CANCER „ Daniel Dargent „ Spirtos „ Abu-Rustum „ Nezhat
  • 27. SURVEY OF MEMBERS OF SGO „ 11 % of responders advocated the use of laparoscopic for cervical cancer in 2004 „ 38 % of responders advocated the use of laparoscopic for cervical cancer In 2009
  • 28. LAPAROSCOPY IN CERVICAL CANCER „ More than 400 LRH reported „ Concerned: Cure rate Radicallity Number of L. Node removed
  • 29. LIMITATION OF LAPAROSCOPY IN CERVICAL CANCER „ No RCT „ One serious of 139 patients , median follow up 92 months Over all survival rate 92.8 % and progress free survival 91 %
  • 30. LAPAROSCOPY IN CERVICAL CANCER (RH) „ Largest serious of 200 patients „ Median operative time 210-250 mints „ Less blood loss „ Shorter hospital stay „ Conversion rate close to zero %
  • 31. SAUDI ARABIA LAPAROSCOPIC EXPERIENCE( KAUH) SEP 2011-AUG 2012 „ Cervical cancer(8) 50 % robotic 50 % open
  • 32. LAPAROSCOPY IN PELVIC AND PARA- AORTIC LYMPH NODE DISSECTION „ Deniel Dargent 1989 „ Querleu „ Nezhat 1992 „ Scibner
  • 33. LAPAROSCOPIC NODE DISSECTION „ Trans peritoneal node dissection „ Several RCT showed that number of node count not significantly different from open „ Learning curve „ Conversion rate 12-18%
  • 34. LAPAROSCOPY IN PELVIC EXENTERATION „ Plante „ Roy „ Kohler
  • 35. TEACHING LAPAROSCOPY ONCO-GYNECOLOGY „ Learning curve is a real concern „ Pelvic node: need 7 cases under supervision „ Para aortic node need 15 cases
  • 36. CONCLUSION „ Operative technique in gynecologic oncology have been adapted to lend themselves to laparoscopic approach „ The operative technique are feasible , safe and effective „ There is will and desire by gynecological oncologist to offer minimal invasive surgery options to their patients, while in the same time patient demand is also on the rise