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Role of Robotic surgery in Gynaecological Cancers

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written by Dr. Yogesh Kulkarni

Introduction

Approximately, more than 150000 women are diagnosed with Gynaecological cancers in India every year. Three most common cancers diagnosed in women are cervical, ovarian and endometrium (body of uterus). Traditionally, the treatment included major abdominal surger y with removal of the uterus/ adnexal/parametrium and nodes.

When we look at surgery in broader perspective, surgery is essentially an injury caused with a specific intent and fixed end points. The only way surgery can evolve, is by reducing the morbidity caused by the surgery. Evolution in cancer treatment is in sync with evolution in surgical techniques. Over the years the focus has shifted from radical surgeries to organ preserving surgeries for cancer and from open surgeries to minimally invasive surgeries, wherever possible. The whole theme and the guiding force and the direction of this change is to improve quality of life of patients undergoing treatment for cancer.

Surgical approach in Gynaecology

Gynaecology as a specialty is at the forefront of adapting minimally invasive surgery in practice. In fact, as early as late 70s and early 80s laparoscopy was widely used by gynecologists for diagnosis and for certain therapeutic procedures like tubal ligation, cyst aspiration. But there are obvious difficulties in adapting laparoscopy particularly for complex cancer surgeries. This has made use of laparoscopy in complex cancer procedures very limited. In fact, the statistics suggest that not more that 20% – 30% of complex procedures are done laparoscopically. This is where there is a need for technology which can overcome challenges and difficulties of conventional laparoscopy.

Da Vinci Robotic System : The game changer

This should be seen as next step in laparoscopy and a piece of technology, which as of today comes closet to satisfying both the surgeon and the patient. It offers the surgeon a system without the drawback of conventional laparoscopy.

Where can robotic surgery be used in Gynaecological cancers?

  • Surgery for endometrial (body of uterus) cancer
  • Radical hysterectomy (Wertheim’s) for cervical cancer
  • Pelvic Exentration
  • Restaging surgery
  • Radical Trachelectomy
  • Groin node dissection for Vulval cancers

Surgery is not widely used except in a few cases. Most common indications at our center are endometrial cancer and cervical cancer.

Robotic Surgery for Endometrial (Body of uterus ) cancers

This is at our center as well as world wide is the most common indication for the use of robotic surgery in Gyneacological cancers

Why should it be used in Endometrial cancers ?

Majority of patients with endometrial cancers are obese with comorbiditiies like diabetes/ hypertension/ heart disease. There are no great surgical solutions in obese women. Open surgery is associated with significant postoperative morbidity and delayed recovery. This may also delay postoperative treatment like radiation and chemotherapy if required. Regular laparoscopy is extremely difficult in morbidly obese patients with very high conversion rate 25% (which means 1out of 4 patients has to be converted to open surgery)

In comparison, robotic surgery is ideal for endometrial cancer cases. As the tenting effect of the arms help maintain the pneumoperitoneum and also the conversion rates are significantly less than laparoscopy (5-10%). The paraortic Lymphadenectomy which is the most difficult part of the surgery can be safely and effectively managed by robotic system. Also on all the other comparable parameters of cancer surgery like blood loss, lymph node count, postoperative stay, postoperative pain and recurrence rates, robotic surgery is equivalent or better than conventional surgery or laparoscopy. So all patients of endometrial carcinoma should be offered robotic surgery.

Robotic surgery for Cervical cancer ( Radical hysterectomy – Wertheim’s operation )

Radical hysterectomy (Wertheim’s) is the standard surgery offered for women with early stage cervical cancer. This is one of the most complex pelvic surgeries which includes removal of uterus with the surrounding tissues, complete dissection of ureters, removal of vaginal cuff and Lymphadenectomy. The ureteric dissection part is the most crucial component of a Wertheim’s operation which determines the adequacy of the clearance. Robotic system with the Endowrist instruments helps immensely in this part of the operation. Again like endometrial parameters and recurrence rates, robotic assisted surgery is as safe and effective as conventional/ laparoscopic surgery.

Is robotic surgery safe for Gynaecological Cancer patients?

According the current data that is available, robotic assisted surgery is equivalent to conventional open/Laparoscopic surgery in terms of adequacy of dissection, lymph node retrieval and complications. The conversion rates are actually less with robotic surgery than laparoscopic surgery. Available data suggests that, Robotic surgery can be safely recommended to all suitable women with Gynaecological cancers.

KDAH Experience

Total Number of Surgeries51
Lymph nodes retrievedNumber: 16-18
Blood lossAverage: 75-100 ml
ConversionsOne
MorbidityTwo : one DVT and one intestinal obstruction
Hospital stayAverage: 4 days
TransfusionsOne

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