Page 26 - Journal of Laparoscopic Surgery

Jayasree Santhosh

(p < 0.003) and return to work (p < 0.04) over the 6-week significantly longer operative time, more pelvic lymph nodes
postsurgery period, as compared with laparotomy patients. removed, a smaller drop in postoperative hematocrit, less pain
However, the differences in BI and return to work between medication, and a shorter hospital stay (194.8 vs 137.7 minutes,
groups were modest, and the adjusted FACT-G scores did not p < 0.001; 11.3 vs 5.3, p < 0.001; 3.9 vs 5.4, p = 0.029; 32.3 vs
meet the minimally important difference (MID) between the two 124.1 mg, p < 0.001; and 2.5 vs 5.6 days, p < 0.001 respectively).
surgical arms over 6 weeks. By 6 months, except for better BI in There was a trend toward earlier resumption of full activity and
laparoscopy patients (p < 0.001), the difference in QoL between return to work among women who underwent laparoscopy
the two surgical techniques was not statistically significant. 29 (23.2 vs 45.0 days, p = 0.073, and 35.3 vs 67.0 days, p = 0.055
A two-stage randomized controlled trial, comparing total respectively).
laparoscopic hysterectomy (TLH) with total abdominal They concluded that most obese women with early stage
hysterectomy (TAH) for stage I endometrial cancer (LACE), endometrial cancer can be safely managed through laparoscopy
began in 2005. The primary objective of stage 1 was to assess with excellent surgical outcome, shorter hospitalization and less
whether TLH results in equivalent or improved quality of life postoperative pain than those managed through laparotomy. 34
(QoL) up to 6 months after surgery compared with TAH. A total Seamon et al have done a case-control study comparing
of 361 patients were enrolled from 19 centers. QoL improvements robotic surgery and laparotomy in obese women. A total of
from baseline during early and later phases of recovery and the 109 patients underwent surgery with the intent of robotic staging
adverse event profile, favor TLH compared with TAH for and were matched to 191 laparotomy patients. The mean BMI
treatment of stage I endometrial cancer. 30 was 40 for each group. The robotic conversion rate was 15.6%
[95% confidence interval (CI) 9.5-24.2%]. Ninety-two completed
Feasibility in Elderly and Obese robotic patients were compared with 162 matched laparotomy
patients. The two groups were comparable regarding total lymph
Melissa KF et al have done a retrospective analysis on 60 node count (25 ± 13 compared with 24 ± 12, p = 0.45) and the
patients aged above 65 years and 69 patients less than 65 years percentage of patients undergoing adequate lymphadenectomy
who underwent surgical staging of carcinoma endometrium by (85% compared with 91%, p = 0.16) and adequate pelvic
laparoscopic and robotic hysterectomy. They concluded that (90% compared with 95%, p = 0.16) and aortic lymphadenectomy
minimal access surgery is feasible and safe in elderly women. 31 (76% compared with 79%, p = 0.70) for robotic and laparotomy
Sribner et al have reported that age is not a contraindication patients respectively, but there was limited power to detect this
for laparoscopic surgery. Transvaginal hysterectomy remains difference. The blood transfusion rate [2% compared with 9%,
a proven option for women with serious comorbidities. 32 odds ratio (OR) 0.22, 95% CI 0.05-0.97, p = 0.046], the number of
A review article published from North Carolina School of nights in the hospital (1 compared with 3, p < 0.001),
Medicine, Obesity–Physiologic Changes and Challenges in complications (11% compared with 27%, OR 0.29, 95% CI 0.13-
Laparoscopy concludes that with thorough preparation and 0.65, p = 0.003), and wound problems (2% compared with 17%,
careful preoperative evaluation, laparoscopy can be performed OR 0.10, 95% CI 0.02-0.43, p = 0.002) were reduced for robotic
safely and is the preferred surgical method in obese patients. 33 surgery. In obese women with endometrial cancer, robotic
Gamal H et al compared laparoscopy and laparotomy in a comprehensive surgical staging is feasible. Importantly, obesity
cohort of obese women with carcinoma endometrium. may not compromise the ability to adequately stage patients
Prospective study over 2 years applying laparoscopic surgery robotically. 35
to all women with clinical stage I endometrial cancer and body Laparoscopic and robotic-assisted staging seem to be
mass indices (BMIs) between 28.0 and 60.0 who can tolerate promising in the management of obese and elderly women with
such surgery. Controls were women with clinical stage I carcinoma endometrium.
endometrial cancer and similar BMIs who underwent laparotomy
in the previous 2 years. Both groups were compared in their Learning Curve
characteristics, surgical outcome, cost and hospital stay and A retrospective review of cases by Terry et al suggests that in
interviewed regarding time to recovery, recall of postoperative the laparoscopic staging of carcinoma endometrium, the
pain control, and overall satisfaction with their management. operating time and hospital stay decrease after 50 cases and
Forty out of 42 obese women had laparoscopic surgery. The continue to drop till 125 cases. While the ability to detect
procedure was converted to laparotomy in 3 (7.5%) patients. metastatic disease and rate of major complications appear
Laparoscopic surgery was thus successful in 88.1% of all obese unrelated to operator experience, the conversion rate to
women. There was no significant difference between women laparotomy decreased with operator experience. 36
who underwent laparoscopy and those who underwent There are two articles that report the learning curve for
laparotomy in patient characteristics, proportion of women who robotic hysterectomy with pelvic and para-aortic node
underwent lymphadenectomy, complications, total cost, dissection for endometrial cancer staging. Seamon et al have
patients’ recall of postoperative pain and patients’ satisfaction reported number of cases to gain proficiency (approximately
with management. Women who underwent laparoscopy had a 20 cases). 37

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