This document discusses the use of laparoscopy in gynecologic oncology. It notes that laparoscopy can be used for procedures like hysterectomy, node dissection, and bowel surgery. Studies show laparoscopy provides benefits like improved vision, less morbidity, shorter hospital stays, and better patient satisfaction compared to open surgery. However, laparoscopy requires a learning curve and is still being evaluated for oncologic outcomes in some cancers. The document reviews evidence for laparoscopy in endometrial, ovarian, and cervical cancers. It concludes laparoscopy is feasible and effective for gynecologic oncology when performed by trained specialists, though more research is still needed.

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 %

32. SAUDI ARABIA LAPAROSCOPIC
EXPERIENCE( KAUH) SEP 2011-AUG 2012
„ Cervical cancer(8)
50 % robotic
50 % open

33. LAPAROSCOPY IN PELVIC AND PARA-
AORTIC LYMPH NODE DISSECTION
„ Deniel Dargent 1989
„ Querleu
„ Nezhat 1992
„ Scibner

35. 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%

37. LAPAROSCOPY IN PELVIC EXENTERATION
„ Plante
„ Roy
„ Kohler

38. TEACHING LAPAROSCOPY
ONCO-GYNECOLOGY
„ Learning curve is a real concern
„ Pelvic node: need 7 cases under supervision
„ Para aortic node need 15 cases

39. 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