Page 24 - Journal of Laparoscopic Surgery

Jayasree Santhosh

Childers et al and Spirtos et al in the United States demonstrated A randomized control study from Turkey—out of
the adequacy and safety in small single-institution studies. 10-13 52 patients, 26 underwent laparotomy and the remaining
There are isolated reports of surgical staging with micro- 26 underwent laparoscopic staging surgery. No significant
laparoscopy also. difference existed between the demographic characteristics of
Inspite of its advantages, the limitations of laparoscopy the two groups. The mean number of harvested lymph nodes
which includes counterintuitive motion, nonwristed was 18.2 in the laparoscopic group and 21.1 in the laparotomy
instrumentation and heavy reliance on skilled surgical assistance group (p > 0.05). Pelvic lymph node metastases were detected
contributed to a difficult and long learning curve. Comprehensive in 7.7% of the patients in the laparoscopy group and 15.4% in
laparoscopic surgical staging is more difficult in the morbidly the laparotomy group and the difference was not significant.
obese and with other patient factors, such as associated Operative morbidity was higher in the laparotomy group mainly
comorbidities, adhesive disease, large uteri, fatty mesentery. because of postoperative wound infection and the patients in
Since, the da Vinci surgical system was approved for gynecology the laparotomy group had a longer hospital stay. They
in April 2005, the role of robotic-assisted surgery in gynecologic concluded that the lymph node detection rates do not differ. 16
oncology continues to evolve. A retrospective cohort study compares the adverse event
The main concerns with the advent of minimal access rates between laparoscopic versus open surgery. A total of 107,
surgery in surgical staging were adequacy of lymphadenec- who underwent surgical staging for endometrial cancer were
tomy, intraoperative and postoperative complications, long- compared to 269 age and body mass index matched women.
term survival, quality of life, feasibility in elderly and obese, Laparotomies had higher rates of cellulitis (16 vs 7%; p = 0.018)
learning curve and cost involved. and open wound infection (9 vs 2%; p = 0.02). Laparoscopy
group had significantly higher sensory peripheral nerve deficit
Adequacy of Surgical Staging and (5 vs 0%; p = 0.008) and lymphedema (7 vs 1%; p = 0.003). 17
Operative Complications After analyzing four randomized control trials, Suzanna
Granado et al from Spain have concluded that the short-term
A large randomized control trial comparing laparotomy and results of laparoscopic surgery are better than laparotomy and
laparoscopy in surgical staging of carcinoma endometrium was long-term results are comparable. 18
done by gynecologic oncology study group (LAP 2 study). Robotic surgical staging of carcinoma endometrium was
A total of 1,682 laparoscopy patients and 909 laparotomy started from 2003 onward. Several studies are published to date
patients were included in the analysis of short-term surgical assessing the surgical adequacy and complications of robotic-
outcomes. Laparoscopy was completed without conversion in assisted staging as well as it is compared with laparoscopic
1,248 patients (74.2%). Conversion from laparoscopy to staging and conventional laparotomy. Lowe et al have published
laparotomy was secondary to poor visibility in 246 patients a multi-institutional data of all patients who underwent robotic
(14.6%), metastatic cancer in 69 patients (4.1%), bleeding in staging for endometrial carcinoma. A total of 405 patients who
49 patients (2.9%) and other causes in 70 patients (4.2%). underwent surgery in the period from April 2003 to January
Laparoscopy had fewer, moderate to severe postoperative 2009 were included. Mean BMI was 32.4. A total of 55% had
adverse events than laparotomy (14 vs 21% respectively; prior abdominal surgery. Mean operating time was 170.5 minutes.
p < 0.0001) but similar rates of intraoperative complications, Mean estimated blood loss was 87.5 ml. Mean lymph node
despite having a significantly longer operative time (median, count was 15.5. Mean hospital stay was 1.8 days. Conversion
204 vs 130 minutes, respectively; p < 0.001). Hospitalization of to laparotomy was done in 6.7% of patients. Postoperative
more than 2 days was significantly lower in laparoscopy versus complications were reported in 14.6%. 19
laparotomy patients (52 vs 94% respectively; p < 0.0001). Pelvic A prospective analysis of 80 patients who underwent robotic
and para-aortic nodes were not removed in 8% of laparoscopy staging is reported from European Institute of Oncology, Milan,
patients and 4% of laparotomy patients (p < 0.0001). No Italy. They concluded that for endometrial cancer, open surgical
difference in overall detection of advanced stage (stage IIIA, procedures decreased from 78 to 35% and their preliminary data
IIIC or IVB) was seen (17% of laparoscopy patients vs 17% of confirm that surgical robotic staging for early-stage endometrial
laparotomy patients; p < 0.841). 14 cancer is feasible and safe. Age, obesity and previous surgery
Holub Z et al report a prospective multicentric study in do not seem to be contraindications. 20
three oncolaparoscopic centers. A total of 221 patients who Dan SA et al have reported a prospective case-control
had laparoscopic surgery were compared with 45 patients who study comparing robotic surgery with laparotomy. A total of
had laparotomy. Difference in surgical complications was 118 patients underwent robotic staging and were compared
insignificant. Blood loss was comparable. Mean hospital stay with 131 patients who had laparotomy and staging. Lymph node
was significantly less for the laparoscopy group (p < 0.0001). yield was comparable (p = 0.11). Blood loss was significantly
Operating time was significantly more for the laparoscopy group. more in the laparotomy group (66.6 and 197.6 ml, p < 0.001).
Recurrence and disease-free survival was comparable. 15 Length of hospital stay was significantly longer in the

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