Laproscopy in gynecology oncology

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Laproscopy in gynecology oncology

  1. 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. 2. CLINICAL SERVICES FOR GYNECOLOGICAL CANCER SURGERY Robotic Laparoscopy Open
  3. 3. LAPAROSCOPY
  4. 4. LAPAROSCOPY IN GYNECOLOGIC ONCOLOGY „ Laparoscopically assisted vaginal hysterectomy „ Total simple and radical hysterectomy „ Pelvic and aortic node dissection „ Omentectomy „ Advanced bowel surgery
  5. 5. ADVANTAGE „ Improvement of vision „ Precision of dissection „ Reduce in preoperative morbidity „ Reduce hospital stay „ Patient’s satisfaction
  6. 6. ADDITIONAL BENEFIT „ Less adhesion „ Less bowel complication if radiation required
  7. 7. LAPAROSCOPY IN ENDOMETRIAL CANCER „ Childers 1992 „ Ghezzi ( small RCT) „ Obermair……………………..
  8. 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. 9. REASONS FOR THIS INCREASE….. „ Result of the ever-growing number of reports attesting to its technical feasibility, safety, and practicality
  10. 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. 11. REASONS OF UNACCEPTABILITY FOR SOME… „ Lacking of level I evidence
  12. 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. 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. 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. 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. 16. LAPAROSCOPY IN OBESE WOMEN WITH ENDOMETRIAL CANCER „ Eltabbakh : BMI: 28-60 „ Succ. rate 88 %
  17. 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. 18. SAUDI ARABIA LAPAROSCOPIC EXPERIENCE( KAUH) SEP 2011-AUG 2012 „ Endometrial cancer(20) 1- 50 % Robotic 2- 10 % laparoscopy 3- 40 % open
  19. 19. LAPAROSCOPIC IN OVARIAN CANCER „ Childers „ Tozzi „ Chi „ Leblanc „ Abu- Rustum „ Litell
  20. 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. 21. LAPAROSCOPIC IN EARLY OVARIAN CANCER „ 300 patients reported „ Case serious (9-42 patients) „ Low rate of conversion and reasonable intraoperative complication
  22. 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. 23. OMENTECTOMY
  24. 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. 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. 26. LAPAROSCOPY IN CERVICAL CANCER „ Daniel Dargent „ Spirtos „ Abu-Rustum „ Nezhat
  27. 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. 28. LAPAROSCOPY IN CERVICAL CANCER „ More than 400 LRH reported „ Concerned: Cure rate Radicallity Number of L. Node removed
  29. 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. 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. 31. SAUDI ARABIA LAPAROSCOPIC EXPERIENCE( KAUH) SEP 2011-AUG 2012 „ Cervical cancer(8) 50 % robotic 50 % open
  32. 32. LAPAROSCOPY IN PELVIC AND PARA- AORTIC LYMPH NODE DISSECTION „ Deniel Dargent 1989 „ Querleu „ Nezhat 1992 „ Scibner
  33. 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. 34. LAPAROSCOPY IN PELVIC EXENTERATION „ Plante „ Roy „ Kohler
  35. 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. 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

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