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Overview
The physicians at the Women's Cancer Center have helped pioneer the use of
Minimally Invasive Laparoscopic Surgery (MILS) for the treatment of patients
with gynecological malignancies. MILS offers select patients the opportunity to
have 1)complete surgical staging without the morbidity associated with
traditional surgical staging and 2) interval surgical staging if the initial
surgery did not include adequate evaluation of the abdominal cavity and/or the
pelvic and aortic lymph nodes. Similar surgical techniques can be applied to
patients with uterine sarcomas.
MILS, in our opinion, is less morbid because the incisions made are
significantly smaller than those associated with traditional surgery. Figure M1
demonstrates the obvious differences. It is not surprising that patients
undergoing MILS require less pain medication than those who undergo traditional
surgery. This, combined with the fact that there is less manipulation of the
intestines, most likely accounts for the early return of bowel function and
therefore the earlier discharge home. Our recent publication in the American
Journal of Obstetrics and Gynecology discusses in detail the shortened hospital
stay associated with this procedure.
Eligibility
Surgery on obese patients has an increased rate of complications. This is also
true for MILS. To minimize potential complications, we normally only perform
MILS in patients with an obesity or Quetelet index ‹30. The National Cancer
Institute (NCI) imposed similar restrictions in early feasibility studies but
has now increased the index to allow the MILS surgery with Quetelet indexes up
to 35. However, it is currently our opinion that patients with endometrial
cancer should not be denied the opportunity to undergo MILS based solely on the
calculation of their Quetelet index.
Quetelet Index
The Quetelet index is a formula defined by dividing weight in kilograms by the
square of the height in meters. Often called QI, scores can be divided into
certain ranges:
0 - 18.5 Weight is too low.
18.6 - 25 Healthy weight range.
26 - 30 1st degree; Increased risk for
weight-related health problems.
31 plus High risk for weight-related
health problems
NOTE: To calculate your own Quetelet index, try our online calculator
If your Quetelet index is greater than 35, that does not mean you cannot have
MILS. However, it may be more difficult to accomplish and this risk factor will
need to be discussed in more detail during an office visit.
Surgery
Approximately 90% of patients undergoing MILS will have their surgery completed
successfully. The remaining 10% will have their surgery completed via a
traditional incision. The three most common reasons to abandon a MILS procedure
are 1) bleeding, 2) disease found outside the uterus requiring more extensive
surgery than is either possible or reasonably performed using MILS, and 3)
inadequate exposure either related to obesity or adhesions from a previous
surgery.
With increasing expertise in the MILS procedure, both the length of surgery as
well as days spent in the hospital by our patients have decreased. Currently,
the vast majority of our patients are discharged home within 36 hours of
undergoing surgery.
Detailed Discussions
To better understand the use and potential advantages of MILS for each type of
cancer, please select one of the following:
* Endometrial Cancers and Uterine Sarcomas
* Cervical and Vaginal Cancers
* Ovarian Cancers
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Minimally Invasive Laparoscopic Surgery in Endometrial Cancers or Uterine
Sarcomas
Endometrial Cancer is the most frequently occurring gyencologic malignancy.
Although it is commonly thought to be curable with hysterectomy alone, or in
combination with radiation therapy, often complete knowledge as to how far the
disease has spread is unknown. Surgical staging is needed to determine this
information, including pelvic and aortic lymph node dissection.
Minimally Invasive Laparoscopic Surgery
in Cervical and Vaginal Cancer
The role of Minimally Invasive Laparoscopic Surgery (MILS)in patients with
cervical cancer has become more clearly defined over the past two years months.
Initially, thoughts of how to incorporate MILS in treatment focused on those
patients with advanced disease (Stage II-IV).
Advanced Disease
The importance of identifying the presence of lymph node metastases, especially
aortic lymph node metastases, has been well established. In 1978, Dr. Samuel
Ballon of the Women's Cancer Center published data demonstrating that, when
identified, these patients could be cured if the radiation fields were extended
to include the aortic lymph nodes. Obviously, if the lymph nodes are not
biopsied, the presence or absence of disease cannot be accurately determined.
CT scan and MRI have proven to be inadequate in determining lymph node
involvement. Thus, historically, biopsies of the lymph nodes required either an
exploratory laparotomy or, preferentially, an extraperitoneal laparotomy as
described by Dr. Ballon et al. The advantages of the extraperitoneal laparotomy
include fewer complications as the peritoneal cavity is not entered and adhesion
formation is minimized.
Initial laparoscopic approaches were performed transperitoneally and, for the
most part, continue to be performed in this fashion as much of the evidence in
our literature suggests adhesion formation is decreased when surgical procedures
are performed laparoscopically. Because of this, the need to use a
retroperitoneal approach may not be as important when having surgery performed
using a traditional incision.
At the Women's Cancer Center, we are currently working with Dr. Carlos Gracia to
develop a balloon dissection technique to perform laparoscopic retroperitoneal
aortic and pelvic lymphadenectomy. A video of this technique will soon be
available.
Early Stages
The use of MILS in patients with early invasive cervical cancer has been
developed at the Women's Cancer Center. John B. Schlaerth, MD authored protocol
9207 for the Gynecology Oncology Group (GOG). This protocol was developed to
test the feasibility of performing a therapeutic lymph node dissection in
patients with early cervical cancer.
To test the adequacy of the lymph node dissection patients first underwent a
laparoscopic lymph node dissection followed by an exploratory laparotomy. This
study is presently undergoing statistical analysis and the results will be
published by the GOG. Using our initial experiences as a spring board, our group
moved forward, applying MILS surgical techniques not only to pelvic and aortic
lymph node dissection, but also to the successful performance of the radical
(Type III) hysterectomy.
The results of this effort were recently published in the American Journal of
Obstetrics and Gynecology, available by request for your review. We believe that
for selected patients MILS can be performed safely with shorter
hospitalizations, more rapid recovery, and without compromising the basic
principles of oncologic surgery.
The applications of these techniques have far reaching consequences, especially
to patients with cervical cancer who wish to preserve their ability to conceive.
Dargent et al, described their experience performing radical trachelectomy and
laparoscopic lymph node dissection.
At the Women's Cancer Center we have performed this procedure for over two
years. Patients are advised that long term follow-up data regarding recurrence
rates are not available at this time and, therefore, they need to be followed
closely.
Minimally Invasive Laparoscopic Surgery
and Ovarian Cancer
The role of laparoscopic surgery in ovarian cancer can be explained best by
determining the reasons for the surgery. For the purpose of this discussion we
will break down the indication for MILS and ovarian cancer into three
categories.
* MILS in early stage Ovarian Cancer
* MILS in advanced stage Ovarian Cancer
* MILS in reassessment surgery
MILS in Early Stage Ovarian Cancer
Patients with "early-stage ovarian cancer" more often have incorrectly staged
cancer. Simply examining the abdomen is not enough to make an adequate
assessment of the spread of the disease. Young et al, first reported that
approximately 30% of patients thought to have stage I ovarian cancer were
incorrectly assessed. Patients were found to have unsuspected involvement in one
or more areas. The more usual locations were the diaphragm, the omentum, and the
lymph nodes. These patients, after undergoing operative reassessment, required
further treatment, i.e. chemotherapy. Research at Georgetown University also
found that ovarian cancer patients often had incomplete surgical staging.
For the most part, patients with incomplete surgical staging are forced to make
decisions regarding potentially toxic therapy with incomplete information. Until
recently, the only means to completely stage a patient was to reoperate with the
obvious morbidity and recovery time associated with it.
The GOG has opened Protocol 9042 designed to study the feasibility of completing
surgical staging using MILS. The physicians at Women's Cancer Center have
coauthored this protocol and have significant experience in performing these
procedures. In patients who are preoperatively suspected of having early stage
ovarian cancer, complete surgery is now possible using MILS techniques. All
peritoneal surfaces can be inspected, the omentum can be removed, as can the
pelvic and aortic lymph nodes and reproductive organs if so indicated by the
intraoperative findings. When a diagnosis is unclear, obviously laparoscopy
offers the patient, as well as the physician, a means to to make a more accurate
diagnosis prior to committing to a final treatment plan.
MILS in Advanced Stage Ovarian Cancer
The role of MILS in patients with advanced ovarian cancer is less well defined.
Traditionally, patients with obvious advanced ovarian cancer should undergo
cytoreductive surgery with an attempt to reduce the tumor volume to as little as
possible. The goal is to leave no visible tumor as those patients have been
shown to have the longest median survivals.
However, some patients have disease that is distributed in such a manner as to
make optimal cytoreductive surgery impossible. Most large studies show that
approximately 20-25% of patients with advanced ovarian cancer will not have
optimal cytoreductive surgery. For more information, request the article by Dr.
Spirtos et al, Aortic and Pelvic Lymph Node Dissection in Ovarian Cancer.
It could be argued that these patients would benefit from a lesser initial
operation (i.e. laparoscopy), followed by chemotherapy (3 cycles), then
reoperation, hopefully with significantly less tumor present, allowing for a
more complete cytoreductive effort. This approach for patients with advanced
ovarian cancer is also being investigated by the GOG Protocol 158.
MILS in Reassessment Surgery
Reassessment laparotomy refers to a reoperation following initial surgery
(maximal surgical effort) and chemotherapy. The goal of this operation is to
determine a patient's disease status. Based on this information, a patient and
her physician can make a decision either to discontinue therapy or perhaps to
undergo radiation therapy. Many physicians state that a second-look surgery is
controversial, but no prospective randomized study has ever been completed in
this country that supports such a position. In fact, our analysis of the
literature finds that in virtually every series of second look operations, a
group of patients has been identified with persistent disease and therefore
benefitted from additional therapy. A bibliography of these studies is
available.
One of the obvious downsides associated with reassessment surgery is the
morbidity associated with the exploratory laparotomy. Most likely the morbidity
associated with the procedure can be decreased by using MILS. There have been no
prospective studies designed to evaluate the feasibility of performing this
procedure and the Women's Cancer Center strongly believes that this should be
done as a cooperative group effort similar to the other studies being undertaken
by the GOG. Efforts are being made to complete this study. Until this is done,
patients and their physicians will have to individually discuss the risks of
laparoscopy including possible limitations of the procedure that are not obvious
at this time.
Summary of MILS in Gynecology Oncology
In May of 1992, the Women's Cancer Center made a decision that Minimally
Invasive Laparoscopic Surgery (MILS) techniques should be evaluated and, if
promising, incorporated into the practice of gynecologic oncology. Clearly,
great strides have been made in this field and MILS techniques are now offered
as dictated by the preferences of the individual patient. However, it is
important that the patient understand that these procedures should be performed
by a qualified gynecologic oncologist who has experience in the proposed
procedure either using traditional surgical methods or MILS.
Source :
http://www.womenscancercenter.com/info/articles/mils.html