Endoscopic surgical procedures for cervical cancer treatment: a literature review

Cervical cancer remains the leading cause of death by gynecologic cancer worldwide, comprising 15% of all cancers in women younger than 40 years. Standard treatments of invasive cancer in early stages are radical hysterectomy and pelvic radiotherapy, both of which are almost reliable by minimal invasive surgery, so as traditional laparoscopy and robotic-assisted surgery. Moreover, 45% of reproductive-age women are diagnosed with stage IB1 disease, making the fertility-sparing procedure, radical trachelectomy, a viable option for most patients for treatment of early-stage cervical cancer and maintenance of future fertility. This chapter focuses on emerging surgical techniques, including the laparoscopic and robotic approach, are improving perioperative outcomes for these patients. A manual and computer-aided search was carried out for all reviews related to this topic, randomized controlled trials, prospective observational studies, retrospective studies and case reports published between 1980 and 2012, assessing robotic surgery, Search strings were: laparoscopic surgery; robot or robot-assisted surgery; radical hysterectomy; cervical cancer, minimally invasive surgery. Robotic-assisted gynecologic surgery has increased worldwide, considering the number of scientific articles dedicated to it though few retrospective and prospective studies have demonstrated the feasibility of robotic-assisted surgery in radical hysterectomy. In general, robot-assisted gynecologic surgery is often associated with longer operating room time but generally similar clinical outcomes, decreased blood loss, and shorter hospital stay. Robotic-assisted procedures are not, however, without their limitations: the equipment is still very large, bulky, and expensive, the staff must be trained, specifically on draping and docking the apparatus to maintain efficient operative times. Functional limitations include lack of haptic feedback, limited vaginal access, limited instrumentation, and larger port incisions. Exchanging instruments becomes more cumbersome and requires a surgical assistant to change the instruments. Additionally, the current robotic instruments do not include endoscopic staplers or vessel sealing devices. Finally, laparoscopic radical hysterectomy is a feasible and safe procedure that is associated with fewer intraoperative and postoperative complications than abdominal radical hysterectomy. The role of robotic-assisted surgery is continuing to expand, but well-designed, prospective studies with well-defined clinical, long-term outcomes, including complications, cost, pain, return to normal activity, and quality of life, are needed to fully assess the value of this new technology in radical hysterectomy. Scientific literature has shown the feasibility of a radical resection by minimally invasive oncological surgery and documented an equivalent number of pelvic nodes harvested by laparoscopy and open surgery. Women with a tumor size 2 cm or smaller and stage IA1 with lymphovascular space involvement (LVSI), IA2, or IB1 disease may be offered fertility-sparing treatment after thorough evaluation by an oncologist trained in this management

Severe inflammatory reaction induced by peritoneal trauma is the key driving mechanism of postoperative adhesion formation

<p>Abstract</p> <p>Background</p> <p>Many factors have been put forward as a driving mechanism of surgery-triggered adhesion formation (AF). In this study, we underline the key role of specific surgical trauma related with open surgery (OS) and laparoscopic (LS) conditions in postoperative AF and we aimed to study peritoneal tissue inflammatory reaction (TIR), remodelling specific complications of open surgery (OS) versus LS and subsequently evaluating AF induced by these conditions.</p> <p>Methods</p> <p>A prospective randomized study was done in 80 anaesthetised female Wistar rats divided equally into 2 groups. Specific traumatic OS conditions were induced by midline incision line (MIL) extension and tissue drying and specific LS conditions were remodelled by intraperitoneal CO₂insufflation at the 10 cm of water. TIR was evaluated at the 24^th, 72^nd, 120^thand 168^thhour by scoring scale. Statistical analysis was performed by the non-parametric t test and two-way ANOVA using Bonferroni post-tests.</p> <p>Results</p> <p>More pronounced residual TIR was registered after OS than after LS. There were no significant TIR interactions though highly significant differences were observed between the OS and LS groups (p < 0.0001) with regard to surgical and time factors. The TIR change differences between the OS and LS groups were pronounced with postoperative time p < 0.05 at the 24^thand 72^nd; p < 0.01 - 120^thand p < 0.001 - 168^thhrs. Adhesion free wounds were observed in 20.0 and 31.0% of cases after creation of OS and LS conditions respectively; with no significant differences between these values (p > 0.05). However larger adhesion size (41.67 ± 33.63) was observed after OS in comparison with LS (20.31 ± 16.38). The upper-lower 95% confidential limits ranged from 60.29 to 23.04 and from 29.04 to 11.59 respectively after OS and LS groups with significant differences (p = 0.03). Analogous changes were observed in adhesion severity values. Subsequently, severe TIR parameters were followed by larger sizes of severe postoperative adhesions in the OS group than those observed in the LS group.</p> <p>Conclusions</p> <p>MIL extension and tissue drying seem to be the key factors in the pathogenesis of adhesion formation, triggering severe inflammatory reactions of the peritoneal tissue surrounding the MIL resulting in local and systemic consequences. CO₂insufflation however, led to moderate inflammation and less adhesion formation.</p

A surgical polypragmasy: Koninckx PR, Corona R, Timmerman D, Verguts J, Adamyan L. Peritoneal full-conditioning reduces postoperative adhesions and pain: a randomised controlled trial in deep endometriosis surgery. J Ovarian Res. 2013 Dec 11;6(1):90

[No abstract available