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Novel technique for the complete staging of endometrial cancer by single-port laparoscopy
Gynecologic Oncology 140 (2016) 369–371
Contents lists available at ScienceDirect
Gynecologic Oncology journal homepage: www.elsevier.com/locate/ygyno
Surgical Film
Novel technique for the complete staging of endometrial cancer by single-port laparoscopy Ignacio Zapardiel ⁎, Estefanía Moreno, Antonio Piñera, Javier De Santiago Gynecologic Oncology Unit, La Paz University Hospital — IdiPAZ, Madrid, Spain
H I G H L I G H T S • Surgical staging using single-port laparoscopy for endometrial cancer is feasible. • Single-port could be an alternative for pelvic and para-aortic nodal dissection. • Longer learning curve could be the weakest aspect of the surgical technique.
a r t i c l e
i n f o
Article history: Received 2 November 2015 Received in revised form 12 December 2015 Accepted 14 December 2015 Available online 17 December 2015 Keywords: Endometrial cancer Laparoscopy Single-port Surgical staging
a b s t r a c t Objective. Our aim was to evaluate the feasibility of a novel technique using single-port laparoscopy for the complete surgical staging of endometrial cancer. Methods. Total hysterectomy, bilateral salpingo-oophorectomy, pelvic lymphadenectomy and para-aortic lymphadenectomy was performed using a single-port device in two steps: first, a retroperitoneal para-aortic dissection was conducted, followed by a transperitoneal pelvic lymphadenectomy and a total hysterectomy. Conventional laparoscopic instruments were used in all cases. Perioperative details were collected. Results. Four consecutive patients with endometrial cancer underwent single-port laparoscopic staging procedure. All cases were high-risk endometrial cancers (two FIGO stage IA and two IB). Histologic types included three adenocarcinomas and one carcinosarcoma. The median operating time was 280 min (ranged 240– 320 min), and the median length of stay was 3.5 days (ranged 3–6 days). No complications or conversion to conventional multiport laparoscopy were reported. Conclusions. Single-port laparoscopic surgical staging for endometrial cancer is a feasible procedure, even when the procedure included a para-aortic lymph node dissection. © 2015 Elsevier Inc. All rights reserved.
1. Introduction
2. Material and methods
Endometrial cancer is the most common malignancy of the female genital tract. Hysterectomy, bilateral salpingo-oophorectomy, and pelvic and/or para-aortic lymph node dissection are the standard procedures performed in early-stage cases of (intermediate–high risk cases) endometrial cancer [1]. Laparoscopic surgery is the most appropriate route for this type of surgery, compared to laparotomy. The use of single-port surgical devices has increased in the management of gynecologic diseases, even for the most advanced procedures such as para-aortic lymphadenectomy [1–3]. The objective of our study was to evaluate the feasibility of a novel technique using single-port laparoscopy for the complete surgical staging of endometrial cancer.
We performed a novel laparoscopic single-port technique in four consecutive cases of endometrial cancer at our institution. All surgeries were performed by the same surgeon and with the same surgical technique. In all cases, sentinel node biopsy was performed. The day prior to surgery 99 m-technetium (148 MBq in 4 ml) was injected pericervically in two quadrants. At the beginning of the procedure, 4 ml (10 mg) of indocyanine green was injected in the same fashion as 99 m-technetium. We used a 10 mm 30 degree laparoscope and regular laparoscopic instruments in all cases and for the whole procedure. The surgery began with a 10 mm trocar placed at the umbilicus after CO2 insufflation of the abdominal cavity by Veress needle up to 15 mm Hg. Exploration of the abdominal cavity was needed in order to identify peritoneal malignant dissemination. A RUMI (Cooper Surgical Inc., CT, USA) uterine manipulator was inserted in the uterus.
⁎ Corresponding author at: Gynecologic Oncology Unit, La Paz University Hospital — IdiPAZ, Paseo Castellana 261, 28046 Madrid, Spain. E-mail address: [email protected] (I. Zapardiel).
http://dx.doi.org/10.1016/j.ygyno.2015.12.014 0090-8258/© 2015 Elsevier Inc. All rights reserved.
370
I. Zapardiel et al. / Gynecologic Oncology 140 (2016) 369–371
After that, the Triport device (Olympus Iberia S.A.U., Barcelona, Spain) was placed by means of a 2 cm incision in the lower-left quadrant of the abdominal wall. Specifically, it was positioned in the joint of external and medial third part of the imaginary line linking the umbilicus with the anterior–superior iliac spine. The subcutaneous tissue was dissected, the fascia and underlying muscular wall were opened to reach the parietal peritoneum. A blunt dissection of the parietal peritoneum was performed under direct laparoscopic vision with one finger. Then, the single-port device was placed extraperitoneally. The surgical technique included two steps: first, a para-aortic extraperitoneal lymphadenectomy; and second, a transperitoneal pelvic lymphadenectomy and total hysterectomy with bilateral salpingo-oophorectomy, using the single-port device in the same position. 2.1. Extraperitoneal step Once the single-port device had been placed as explained above, the intraabdominal cavity was deflated and CO2 was insufflated through the Triport device (Olympus Iberia S.A.U., Barcelona, Spain) in order to create the retroperitoneal cavity. The retroperitoneum was dissected identifying the main structures including the left iliopsoas muscle, the left common iliac artery and the left ureter on the roof of the space. The dissection was extended towards the left renal vein identifying the aorta and inferior mesenteric artery. Then, the retroperitoneal space was extended to the right side identifying the left common iliac vein and the aortic bifurcation, the inferior vena cava, the right common iliac artery, and the right gonadal vein and ureter. Finally, para-aortic lymphadenectomy was conducted up to the level of the left renal vein using the Thunderbeat (Olympus Iberia S.A.U., Barcelona, Spain) sealing device and a ROBI Kelly bipolar instrument (Karl Storz GmbH, Tuttlingen, Germany), while preserving the inferior mesenteric artery as described somewhere else [3]. Finally, the specimen was removed in a protected endoscopic bag.
3. Results Patients' baseline characteristics are shown in Table 1. All patients underwent single-port laparoscopy surgery including total simple hysterectomy, bilateral salpingo-oophorectomy and pelvic and para-aortic lymph node dissection. The median age of the patients was 72 years (ranged 55–74 years), and median body mass index (BMI) was 26.9 kg/m2 (ranged 20.1– 29.3 kg/m2). Pathologic report revealed adenocarcinoma in 3 cases (75%) and carcinosarcoma in 1 case (25%). The median tumoral size was 21 mm (ranged 8–38 mm). The median operating time was 263 min (ranged 240–320 min). The median pelvic and para-aortic lymph nodes removed were 11.5 nodes (ranged 8–18 nodes) and 22 nodes (ranged 13–28 nodes), respectively. All lymph nodes retrieved were negative but one pelvic presented micrometastasis. No intraoperative or postoperative complications were found, and no additional ports were used. There were no conversions to laparotomy. All patients were discharged without any incidence after a median hospital stay of 3.5 days (ranged 3–6 days). A video of the surgical technique can be found in the Supplemental Material (Supplemental Digital Content 1).
2.2. Transperitoneal step A peritoneal window was opened where the single-port device was inserted in order to re-locate it intraperitoneally. The intraperitoneal cavity was insufflated and a bilateral pelvic lymphadenectomy was performed in a standard fashion using the Thunderbeat device (Olympus Iberia S.A.U., Barcelona, Spain) through the single-port device placed at the left side of the pelvis. The obturator nerve was identified and preserved; cranial and caudal limits were iliac common vessels and circumflex vein, respectively. The specimen was placed in an endoscopic bag. An extrafascial simple hysterectomy with bilateral salpingooophorectomy was performed. The specimens were delivered through the vagina. The vaginal cuff was closed laparoscopically using a 0 Vicryl suture on a CT-1 needle (Ethicon Inc., NJ, USA) in an extracorporeal interrupted knotting fashion. Abdominal fascias were closed in both abdominal incisions by means of the same suture with interrupted stitches. Skin closure was performed using a 3-0 Monocryl suture (Ethicon Inc., NJ, USA) in a subcuticular fashion.
4. Discussion Our study shows that single-port laparoscopic surgery seems to be a feasible technique in early stage endometrial cancer. In spite of our findings, single-port laparoscopic surgery has only been recently used in single procedures such as hysterectomy or paraaortic lymphadenectomy [3], but not for complete staging within the same surgical setting. There is little evidence available on the learning curve for para-aortic dissection by single-port. Nevertheless, our experience is consistent
Table 1 Baseline patients' characteristics. Cases
1
2
3
4
Age (years) BMI (kg/m2) Operative time (minutes) Hospital stay (days) Tumor histology FIGO stage–grade Pelvic/para-aortic lymph nodes removed Positive pelvic/para-aortic lymph nodes
55 20.11 280 3 Carcinosarcoma IA-G3 8/21 0/0
74 29.30 240 6 Endometrioid adenocarcinoma IA-G3 10/13 0/0
74 28.25 320 4 Endometrioid adenocarcinoma IB-G2 18/23 1/0
70 25.63 245 3 Endometrioid adenocarcinoma IB-G3 13/28 0/0
I. Zapardiel et al. / Gynecologic Oncology 140 (2016) 369–371
with that of Gouy S et al. [2] after ten procedures, the surgical time decreased and the surgeon's confidence increased. Our experience suggests that it is not necessary to use additional laparoscopic ports or laparotomic route in this procedure, even if the operating time was slightly longer than that of conventional laparoscopy [1,4]. Fanfani published his experience on 20 early stage endometrial cancer patients which were treated with single-port surgery [4]. However, extrafascial hysterectomy was performed in all patients but no lymphadenectomy was conducted, reporting an average surgical time of 105 min. Similarly to our initial experience, the use of additional laparoscopic ports or laparotomic conversion was not required [4]. In addition, patients showed high rates of satisfaction with the aesthetic results and with the postoperative pain control. In conclusion, our surgical staging technique using single-port laparoscopy for endometrial cancer is a feasible strategy and could become an alternative to traditional laparoscopic technique. Nevertheless, additional information is needed on the learning curve for the technique as well as on the long-term clinical benefits.
371
Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ygyno.2015.12.014. Conflicts of interest All authors declare no conflicts of interest. References [1] J.Y. Park, D.Y. Kim, D.S. Suh, et al., Laparoendoscopic single-site versus conventional laparoscopic surgical staging for early-stage endometrial cancer, Int. J. Gynecol. Cancer 24 (2014) 358–363. [2] S. Gouy, C. Uzan, S. Scherier, et al., Single-port laparoscopy and extraperitoneal paraaortic lymphadenectomy for locally advanced cervical cancer: assessment after 52 consecutive patients, Surg. Endosc. 28 (1) (2014) 249–256. [3] S. Iacoponi, J. De Santiago, M.D. Diestro, et al., Single-port laparoscopic extraperitoneal para-aortic lymphadenectomy, Int. J. Gynecol. Cancer 23 (9) (2013) 1712–1716. [4] F. Fanfani, C. Rossitto, M.L. Gagliardi, et al., Total laparoendoscopic single-site surgery (LESS) hysterectomy in low risk early endometrial cancer: a pilot study, Surg. Endosc. 26 (2012) 41–46.
Contents lists available at ScienceDirect
Gynecologic Oncology journal homepage: www.elsevier.com/locate/ygyno
Surgical Film
Novel technique for the complete staging of endometrial cancer by single-port laparoscopy Ignacio Zapardiel ⁎, Estefanía Moreno, Antonio Piñera, Javier De Santiago Gynecologic Oncology Unit, La Paz University Hospital — IdiPAZ, Madrid, Spain
H I G H L I G H T S • Surgical staging using single-port laparoscopy for endometrial cancer is feasible. • Single-port could be an alternative for pelvic and para-aortic nodal dissection. • Longer learning curve could be the weakest aspect of the surgical technique.
a r t i c l e
i n f o
Article history: Received 2 November 2015 Received in revised form 12 December 2015 Accepted 14 December 2015 Available online 17 December 2015 Keywords: Endometrial cancer Laparoscopy Single-port Surgical staging
a b s t r a c t Objective. Our aim was to evaluate the feasibility of a novel technique using single-port laparoscopy for the complete surgical staging of endometrial cancer. Methods. Total hysterectomy, bilateral salpingo-oophorectomy, pelvic lymphadenectomy and para-aortic lymphadenectomy was performed using a single-port device in two steps: first, a retroperitoneal para-aortic dissection was conducted, followed by a transperitoneal pelvic lymphadenectomy and a total hysterectomy. Conventional laparoscopic instruments were used in all cases. Perioperative details were collected. Results. Four consecutive patients with endometrial cancer underwent single-port laparoscopic staging procedure. All cases were high-risk endometrial cancers (two FIGO stage IA and two IB). Histologic types included three adenocarcinomas and one carcinosarcoma. The median operating time was 280 min (ranged 240– 320 min), and the median length of stay was 3.5 days (ranged 3–6 days). No complications or conversion to conventional multiport laparoscopy were reported. Conclusions. Single-port laparoscopic surgical staging for endometrial cancer is a feasible procedure, even when the procedure included a para-aortic lymph node dissection. © 2015 Elsevier Inc. All rights reserved.
1. Introduction
2. Material and methods
Endometrial cancer is the most common malignancy of the female genital tract. Hysterectomy, bilateral salpingo-oophorectomy, and pelvic and/or para-aortic lymph node dissection are the standard procedures performed in early-stage cases of (intermediate–high risk cases) endometrial cancer [1]. Laparoscopic surgery is the most appropriate route for this type of surgery, compared to laparotomy. The use of single-port surgical devices has increased in the management of gynecologic diseases, even for the most advanced procedures such as para-aortic lymphadenectomy [1–3]. The objective of our study was to evaluate the feasibility of a novel technique using single-port laparoscopy for the complete surgical staging of endometrial cancer.
We performed a novel laparoscopic single-port technique in four consecutive cases of endometrial cancer at our institution. All surgeries were performed by the same surgeon and with the same surgical technique. In all cases, sentinel node biopsy was performed. The day prior to surgery 99 m-technetium (148 MBq in 4 ml) was injected pericervically in two quadrants. At the beginning of the procedure, 4 ml (10 mg) of indocyanine green was injected in the same fashion as 99 m-technetium. We used a 10 mm 30 degree laparoscope and regular laparoscopic instruments in all cases and for the whole procedure. The surgery began with a 10 mm trocar placed at the umbilicus after CO2 insufflation of the abdominal cavity by Veress needle up to 15 mm Hg. Exploration of the abdominal cavity was needed in order to identify peritoneal malignant dissemination. A RUMI (Cooper Surgical Inc., CT, USA) uterine manipulator was inserted in the uterus.
⁎ Corresponding author at: Gynecologic Oncology Unit, La Paz University Hospital — IdiPAZ, Paseo Castellana 261, 28046 Madrid, Spain. E-mail address: [email protected] (I. Zapardiel).
http://dx.doi.org/10.1016/j.ygyno.2015.12.014 0090-8258/© 2015 Elsevier Inc. All rights reserved.
370
I. Zapardiel et al. / Gynecologic Oncology 140 (2016) 369–371
After that, the Triport device (Olympus Iberia S.A.U., Barcelona, Spain) was placed by means of a 2 cm incision in the lower-left quadrant of the abdominal wall. Specifically, it was positioned in the joint of external and medial third part of the imaginary line linking the umbilicus with the anterior–superior iliac spine. The subcutaneous tissue was dissected, the fascia and underlying muscular wall were opened to reach the parietal peritoneum. A blunt dissection of the parietal peritoneum was performed under direct laparoscopic vision with one finger. Then, the single-port device was placed extraperitoneally. The surgical technique included two steps: first, a para-aortic extraperitoneal lymphadenectomy; and second, a transperitoneal pelvic lymphadenectomy and total hysterectomy with bilateral salpingo-oophorectomy, using the single-port device in the same position. 2.1. Extraperitoneal step Once the single-port device had been placed as explained above, the intraabdominal cavity was deflated and CO2 was insufflated through the Triport device (Olympus Iberia S.A.U., Barcelona, Spain) in order to create the retroperitoneal cavity. The retroperitoneum was dissected identifying the main structures including the left iliopsoas muscle, the left common iliac artery and the left ureter on the roof of the space. The dissection was extended towards the left renal vein identifying the aorta and inferior mesenteric artery. Then, the retroperitoneal space was extended to the right side identifying the left common iliac vein and the aortic bifurcation, the inferior vena cava, the right common iliac artery, and the right gonadal vein and ureter. Finally, para-aortic lymphadenectomy was conducted up to the level of the left renal vein using the Thunderbeat (Olympus Iberia S.A.U., Barcelona, Spain) sealing device and a ROBI Kelly bipolar instrument (Karl Storz GmbH, Tuttlingen, Germany), while preserving the inferior mesenteric artery as described somewhere else [3]. Finally, the specimen was removed in a protected endoscopic bag.
3. Results Patients' baseline characteristics are shown in Table 1. All patients underwent single-port laparoscopy surgery including total simple hysterectomy, bilateral salpingo-oophorectomy and pelvic and para-aortic lymph node dissection. The median age of the patients was 72 years (ranged 55–74 years), and median body mass index (BMI) was 26.9 kg/m2 (ranged 20.1– 29.3 kg/m2). Pathologic report revealed adenocarcinoma in 3 cases (75%) and carcinosarcoma in 1 case (25%). The median tumoral size was 21 mm (ranged 8–38 mm). The median operating time was 263 min (ranged 240–320 min). The median pelvic and para-aortic lymph nodes removed were 11.5 nodes (ranged 8–18 nodes) and 22 nodes (ranged 13–28 nodes), respectively. All lymph nodes retrieved were negative but one pelvic presented micrometastasis. No intraoperative or postoperative complications were found, and no additional ports were used. There were no conversions to laparotomy. All patients were discharged without any incidence after a median hospital stay of 3.5 days (ranged 3–6 days). A video of the surgical technique can be found in the Supplemental Material (Supplemental Digital Content 1).
2.2. Transperitoneal step A peritoneal window was opened where the single-port device was inserted in order to re-locate it intraperitoneally. The intraperitoneal cavity was insufflated and a bilateral pelvic lymphadenectomy was performed in a standard fashion using the Thunderbeat device (Olympus Iberia S.A.U., Barcelona, Spain) through the single-port device placed at the left side of the pelvis. The obturator nerve was identified and preserved; cranial and caudal limits were iliac common vessels and circumflex vein, respectively. The specimen was placed in an endoscopic bag. An extrafascial simple hysterectomy with bilateral salpingooophorectomy was performed. The specimens were delivered through the vagina. The vaginal cuff was closed laparoscopically using a 0 Vicryl suture on a CT-1 needle (Ethicon Inc., NJ, USA) in an extracorporeal interrupted knotting fashion. Abdominal fascias were closed in both abdominal incisions by means of the same suture with interrupted stitches. Skin closure was performed using a 3-0 Monocryl suture (Ethicon Inc., NJ, USA) in a subcuticular fashion.
4. Discussion Our study shows that single-port laparoscopic surgery seems to be a feasible technique in early stage endometrial cancer. In spite of our findings, single-port laparoscopic surgery has only been recently used in single procedures such as hysterectomy or paraaortic lymphadenectomy [3], but not for complete staging within the same surgical setting. There is little evidence available on the learning curve for para-aortic dissection by single-port. Nevertheless, our experience is consistent
Table 1 Baseline patients' characteristics. Cases
1
2
3
4
Age (years) BMI (kg/m2) Operative time (minutes) Hospital stay (days) Tumor histology FIGO stage–grade Pelvic/para-aortic lymph nodes removed Positive pelvic/para-aortic lymph nodes
55 20.11 280 3 Carcinosarcoma IA-G3 8/21 0/0
74 29.30 240 6 Endometrioid adenocarcinoma IA-G3 10/13 0/0
74 28.25 320 4 Endometrioid adenocarcinoma IB-G2 18/23 1/0
70 25.63 245 3 Endometrioid adenocarcinoma IB-G3 13/28 0/0
I. Zapardiel et al. / Gynecologic Oncology 140 (2016) 369–371
with that of Gouy S et al. [2] after ten procedures, the surgical time decreased and the surgeon's confidence increased. Our experience suggests that it is not necessary to use additional laparoscopic ports or laparotomic route in this procedure, even if the operating time was slightly longer than that of conventional laparoscopy [1,4]. Fanfani published his experience on 20 early stage endometrial cancer patients which were treated with single-port surgery [4]. However, extrafascial hysterectomy was performed in all patients but no lymphadenectomy was conducted, reporting an average surgical time of 105 min. Similarly to our initial experience, the use of additional laparoscopic ports or laparotomic conversion was not required [4]. In addition, patients showed high rates of satisfaction with the aesthetic results and with the postoperative pain control. In conclusion, our surgical staging technique using single-port laparoscopy for endometrial cancer is a feasible strategy and could become an alternative to traditional laparoscopic technique. Nevertheless, additional information is needed on the learning curve for the technique as well as on the long-term clinical benefits.
371
Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ygyno.2015.12.014. Conflicts of interest All authors declare no conflicts of interest. References [1] J.Y. Park, D.Y. Kim, D.S. Suh, et al., Laparoendoscopic single-site versus conventional laparoscopic surgical staging for early-stage endometrial cancer, Int. J. Gynecol. Cancer 24 (2014) 358–363. [2] S. Gouy, C. Uzan, S. Scherier, et al., Single-port laparoscopy and extraperitoneal paraaortic lymphadenectomy for locally advanced cervical cancer: assessment after 52 consecutive patients, Surg. Endosc. 28 (1) (2014) 249–256. [3] S. Iacoponi, J. De Santiago, M.D. Diestro, et al., Single-port laparoscopic extraperitoneal para-aortic lymphadenectomy, Int. J. Gynecol. Cancer 23 (9) (2013) 1712–1716. [4] F. Fanfani, C. Rossitto, M.L. Gagliardi, et al., Total laparoendoscopic single-site surgery (LESS) hysterectomy in low risk early endometrial cancer: a pilot study, Surg. Endosc. 26 (2012) 41–46.