Laparoscopic Approach to Gynecologic Malignancy

Tumor Manipulation, Tissue Extraction, and Port-Site Metastasis

Port-site metastases (PSMs) occur in approximately 1% of patients who have undergone laparoscopic procedures for a malignant disease. Ninety-five percent of patients have simultaneous carcinomatosis or metastases to other sites at the time of PSM diagnosis. The incidence of PSM after laparoscopy for cervical and endometrial cancer is less than 0.5%, and most of the time it is also associated with carcinomatosis. Abdominal wall metastases are not limited to laparoscopy and are observed with similar frequency in laparotomy procedures.

The exact mechanism of how PSMs occur is still not completely understood. Theories involve the exfoliation and spread of tumor cells by laparoscopic instruments; direct implantation at the trocar site by frequent changes of instruments; direct implantation from the passage of the specimen; the impact of aerosolization of cancer cells by the pneumoperitoneum, which when released can create a “chimney effect” that causes an increase in the passage of tumor cells at port sites; and preferential growth of malignant cells at areas of laparoscopic peritoneal perforation. Local immune reaction and tissue trauma have also been proposed as causes of PSMs in experimental models.

Several rules should be followed to avoid PSM, including avoiding tumor manipulation and unprotected tumor extraction. One should aim to remove lymph nodes or other potentially malignant tissue through the trocars with an endoscopic bag. Zivanovic and colleagues published findings from the largest series of PSMs, including 1694 patients with malignant intraabdominal conditions. PSMs were documented in 20 patients (1.18%). Of these, 15 had a diagnosis of epithelial ovarian or fallopian tube carcinoma. Nineteen of 20 patients (95%) had simultaneous carcinomatosis or metastases to other sites at the time of PSM.

Video 25.8 shows several techniques used for tissue extraction in order to avoid rupture. The incision used for extraction must have an adequate length; it is a common mistake to create a small incision and then use excessive traction, which can cause rupture of the bag and potential spillage of the tissue. Frequently, enlarging the incision 1 or 2 cm is enough to allow easy extraction and also saves time.

The chimney effect is also considered a possible cause of PSM. This refers to the increase in the number of tumor cells at the port sites caused by leakage of gas along the trocars. It is possible that gas turbulence favors the embolization of exfoliated tumor cells during dissection to the trocar sites. The gas-containing tumor cells can leak during the procedure between the port cannula and the abdominal wall and also at the end of the procedure if the gas is evacuated through the port incision after the trocar has been removed. Therefore we recommend that surgeons evacuate the gas and fluids before pulling out the ports.

Based on experimental models, port-site lavage with povidone-iodine has been suggested as a method to reduce PSM. Using colon cancer cells in a rat model, Eshraghi and colleagues showed that irrigation of the port site with 5-fluorouracil significantly decreased the incidence (30% vs. 81%) of metastases. In another study, Neuhaus and colleagues randomly allocated rats into five groups: (1) control (no intraperitoneal instillation), (2) intraperitoneal normal saline, (3) intraperitoneal povidone-iodine solution, (4) intraperitoneal methotrexate, and (5) intramuscular methotrexate. A significant reduction in tumor implantation and PSMs was observed in all treatment groups. No study in which port-site lavage was used with humans is available to date.

Ramirez and colleagues have suggested a series of preventive measures to reduce PSM ( Box 25.1 ).

Trocar Placement

In a prospective randomized trial comparing Veress needle use, direct trocar insertion (DTI), and open technique, minor complications occurred in 36 (6%) of 595 consecutive procedures: extraperitoneal insufflation (n = 6 in the Veress needle group only); site bleeding (n = 2 in the Veress needle group, n = 2 in the DTI group, and n = 1 in the open technique group); port-site infection (n = 5 in the Veress needle group and n = 6 in open technique group); and omental injury (n = 6 in the Veress group and n = 3 in the DTI group). Failed entry occurred in four patients in the Veress needle group and one patient in the DTI group. Mean times of entry were 212.4, 71.4, and 161.7 seconds for the Veress needle, DIT, and open technique groups, respectively. Among major complications, one bowel injury resulted from the Veress needle technique. As result, DTI and open technique entry presented a lower risk of minor complications and were faster compared with the Veress needle technique.

A Cochrane review including 46 randomized controlled trials (7389 patients) evaluated 13 laparoscopic entry techniques. The study failed to show evidence to recommend one laparoscopic entry technique over another. Even techniques such as the use of radially expanding trocars versus non-expanding trocars, or direct-vision entry versus open-entry, did not have significant differences in terms of complications. There was a significantly higher risk of failed entry in the group in which the abdominal wall was lifted before Veress needle insertion than in the not-lifted group (odds ratio [OR], 4.44; 95% confidence interval [CI], 2.16–9.13; n = 150). The studies had small numbers and excluded many patients with previous abdominal procedures and women with a high BMI. Some might suggest that the open technique should be used in the case of previous incision in the vicinity of the first trocar site. In patients with a midline vertical incision, surgeons should consider the Palmer point in the left upper quadrant. All auxiliary trocar insertion must be performed under direct visualization.

The chapter authors’ standard trocar placement (also known as French positioning) is as follows: a 10- to 11-mm port is inserted in the umbilicus, and two 5-mm ports are placed approximately 2 cm medial and cranial to the anterior superior iliac spine. A third 5-mm port is inserted 8 to 10 cm below the umbilical one on the midline ( Fig. 25.3 ). For paraaortic lymphadenectomy, a 10-mm suprapubic trocar can be used, and the umbilical port is usually inserted in the cranial part of the umbilicus ( Fig. 25.4 ). Additional ports should be considered if standard port placement does not provide adequate access to the site of interest.

The use of very low suprapubic port placement for cosmetic reasons is discouraged, as is use of only two ports for manipulation, because these practices are not ergonomic and can compromise the safety of the procedure as traction and countertraction will be compromised. In women with a large uterus (>500 g), when vision is impaired because the large volume of the uterus blocks the camera, the camera trocar may be placed 3 to 5 cm more cranial than the usual position in the umbilicus. Trocar fixation with sutures is advised to avoid frequent accidental removal and re-insertion, especially for prolonged procedures.

There are several techniques for removing the trocars. One may opt to remove the trocars after the abdomen has been deflated; others prefer to remove the trocars while the abdomen is still insufflated. Removal while the abdomen is insufflated allows for visualization of the trocars as they are removed and will help in showing whether there is any evidence of bleeding from the sites. Removal after the abdomen has been deflated offers the advantage of avoiding the chimney effect, which in the setting of cancer may contribute to the development of PSMs.

Abdominal Exploration ( Video 25.1 )

As in all oncologic surgical procedures, the first step is always complete abdominal cavity exploration. Clockwise inspection is recommended, starting with the pelvis and following with the appendix, cecum, right colon, right liver and diaphragm, left liver and diaphragm, stomach, and left colon and finally the sigmoid. One should then perform inspection of the terminal ileum, jejunum, mesentery, omentum, and finally the transverse colon and its mesentery. For pelvic procedures, the patient is placed in the Trendelenburg position, and the bowel is mobilized into the upper abdomen.

If peritoneal disease is found during this first inspection, then a more extensive evaluation must be performed, including the lesser sac, hepatic hilum, and cranial surfaces of the liver and spleen; comprehensive mesenteric inspection; and inspection of any other peritoneal surface that might contain peritoneal implants. This can be accomplished by using a 45-degree scope and extra port insertion for better organ mobilization. Patient positioning is also an important factor that allows full abdominal exploration.

Total Laparoscopic Hysterectomy ( Video 25.2 )

Total hysterectomy (simple hysterectomy) is the most frequently performed procedure for gynecologic malignancies. Several studies and meta-analyses have shown that laparoscopic hysterectomy, with or without other staging procedures, is as safe as the open approach in terms of complications and oncologic outcomes. Laparoscopic hysterectomy has some advantages over abdominal hysterectomy, including more rapid recovery, fewer febrile episodes, and fewer wound or abdominal wall infections, but these are offset by a longer operating time.

Exposure of the Retroperitoneum

The operation starts with the sealing and cutting of the round ligament midway from the uterus and the pelvic side wall. The former helps to expose the round ligament by using traction, and the uterus is retracted contralaterally by the second assistant with the uterine manipulator. The anterior leaf of the broad ligament is opened until it reaches the uterus. Traction is used to dissect the posterior leaf of the broad ligament. The ureter is then identified on the medial leaf of the broad ligament. The ureter may be identified transperitoneally or retroperitoneally. An incision is then made in the posterior leaf of the board ligament close to the infundibulopelvic (IP) ligament, above the ureter, creating a window ( Fig. 25.5 ).

Salpingectomy and/or Adnexectomy

If the ovaries are going to be preserved, then the mesosalpinx is cut throughout the utero-ovarian ligament to avoid ischemia of the ovary. At this point, the utero-ovarian ligament is sealed and cut (see Fig. 25.5 ). Care must be taken not to cut the utero-ovarian ligament in close proximity to the uterus. In this area the vessels are tortuous, and if the transection is made too close to the uterus, there may be significant bleeding from the uterus.

In the setting of performing adnexectomy, the IP ligament is placed under traction by the first assistant while the surgeon coagulates and cuts it. Hemostasis of the distal end of the IP ligament is as important as that at the proximal end because backflow in the uterus is a common cause of bleeding during surgical procedures.

Posterior Leaf and Uterosacral Ligament Section

The posterior leaf of the broad ligament is dissected medially until the uterosacral ligament is reached, while the second assistant pushes the uterus anteriorly and laterally and the first assistant holds the round ligament ( Fig. 25.6 ). The same steps are repeated on the opposite side.

Vesicouterine Space Dissection

Vesicouterine space dissection begins with the second assistant pushing the uterus centrally. The first assistant grasps the bladder with atraumatic forceps. It is important at this point that careful attention be paid to the traction that is placed on the bladder peritoneum because excessive traction may cause an accidental cystotomy. The assistant uses anterior traction to expose the vesicovaginal fold while the surgeon cuts the peritoneum along its junction to the uterus, connecting the two previously dissected anterior leaves of the broad ligament.

The vesicovaginal space is gently dissected approximately 1 cm distal to the cervicovaginal junction. A colpotomy delineator, usually present on the manipulator, can be used to help with this step. Patients who have had previous cesarean deliveries are usually at risk for bladder injury at this point, and extra caution is advised.

Transection of Uterine Vessels

The uterine pedicles must be isolated to allow effective coagulation. However, the vessels should not be individually dissected because this is a common cause of bleeding. The uterine vessels are coagulated along their junction to the cervix and cut ( Fig. 25.7 ). Then the pericervical fascia is incised at the same level of the coagulated uterine pedicles to enter the fascial plane. The paracervical vessels and the insertion of the uterosacral ligament are coagulated and transected until the surgeon has a full vaginal circumference accessible for cutting.

Colpotomy and Uterine Extraction

The vaginal junction of the cervix can be appreciated while the assistant pushes the valve and uterus to the contralateral side; the surgeon is able to cut the vagina by using monopolar energy. The use of cutting energy is advised in order to minimize tissue trauma and to allow better vaginal healing. Air leakage is avoided by using a vaginal occluder with the manipulator. Air leakage must be controlled to avoid unintentional lesions of the rectum during posterior colpotomy.

The uterus is extracted vaginally if size permits. Usually, a uterus up to 350 g is easily extracted through the vagina. Morcellation is not advised in patients with gynecologic tumors; it can be considered when it is not feasible to remove the uterus intact, but it must be performed by using an extraction bag.

Vaginal Cuff Suture

Usually the vaginal vault is sutured with separate zero monofilament absorbable sutures; however, suture techniques and materials vary among the surgeons. Vaginal cuff closure may be one of the most challenging steps during laparoscopic hysterectomy. There are several techniques and tools that may be used to perform vaginal cuff closure, and all are effective provided proper technique is used. We prefer to use barbed sutures because these allow for faster and easier closure. In addition, they may also reduce the rate of vaginal cuff dehiscence (VCD).

Laparoscopic Radical Hysterectomy

Nezhat and colleagues first described the laparoscopic radical hysterectomy in 1992. The indications for laparoscopic radical hysterectomy are the same as for the open approach. The most common indication for radical hysterectomy is the diagnosis of cervical cancer stage IA1 with lymphovascular space invasion or IA2 to IB1 and selected cases of IIA1 disease. For tumors smaller than 2 cm, the type B radical hysterectomy (Querleu and Morrow classification ) is considered adequate. It also can be used in endometrial cancer with stromal invasion of the cervix. For cervical cancers larger than 2 cm, the type C1 radical hysterectomy is the preferred approach.

Retrospective studies have shown that compared with the open approach, laparoscopic radical hysterectomy reduces operative blood loss, postoperative infectious morbidity, and postoperative length of stay, but it is associated with increased operative time. Surgical time for laparoscopic radical hysterectomy has ranged from 92 to 344 minutes. The conversion rate is approximately 1.5%. The Laparoscopic Approach to Cervical Cancer (LACC) study is an ongoing phase 3 prospective randomized clinical trial comparing open with laparoscopic or robotic radical hysterectomy in the management of patients with early-stage cervical cancer. The end points of the study include progression-free and overall survival, feasibility of lymphatic mapping, and quality-of-life outcomes. The study has stopped recruiting recently, and its results are pending. Despite the lack of large randomized studies, it is suggested that the recurrence rate is equivalent to that of the open technique.

Laparoscopic Type A Radical Hysterectomy (Extrafascial Hysterectomy)

The steps of this procedure are the same as those for a simple hysterectomy until the paracervix transection. The position of the ureters is determined by palpation or direct visualization (after opening of the ureteral tunnels) without freeing the ureters from their attachments to the broad ligaments. The uterine vessels are coagulated and cut between the ureter and the cervix. After the transection of the uterine vessels, the uterosacral ligaments are transected at the same level. Then the pericervical and perivaginal tissues are coagulated and cut to allow complete extrafascial resection of the cervix.

The vaginal section is performed in the same manner as for total hysterectomy, except for the inclusion of a small cuff, usually less than 10 mm, of the vagina. The uterus is extracted vaginally, and hemostasis of the pericervical tissue is performed by using bipolar energy. Vaginal closure is performed as in total hysterectomy, and oophoropexy can be performed if needed. The operation concludes with cavity inspection for abnormal secretion or bleeding, followed by irrigation of the remaining pelvic cavity.

Laparoscopic Type B Radical Hysterectomy ( Video 25.3 )

The type B radical hysterectomy is also called a modified radical hysterectomy. The operation starts with the sealing and cutting of the round ligament at the point where this enters the inguinal canal. This step is performed while the uterus is mobilized contralaterally by using the uterine manipulator. The peritoneum along the lateral aspect of the external iliac artery is incised. This peritoneal opening is extended proximally along the artery and the IP ligament but lateral to these structures. Gas infiltration of connective tissue helps in visualizing the dissection of this space. The paravesical space is opened by gentle blunt dissection with the use of divergent forces until the umbilical artery is identified and mobilized medially ( Fig. 25.8 ). This is an avascular space, and bleeding should not occur during dissection of the paravesical space. Once the dissection is performed deeper into the paravesical space, the obturator nerve and vessels can be identified on the lateral aspect of the dissection. With continuation of the dissection approximately 1 to 2 cm deeper, the levator ani muscle is reached. The limits in this avascular space are the obturator internus muscle laterally, the bladder medially, the pubis symphysis anteriorly, and the cardinal ligament posteriorly.

Traction of the IP ligament at the level where it crosses the iliac artery exposes the artery, and the ureter is identified approximately 1 to 2 cm posterior to this plane. The pararectal space is then developed by placing medial traction on the ureter while dissecting between it and the internal iliac artery ( Fig. 25.9 ).

At the point where the uterine artery emerges, the dissection is performed more deeply (1–2 cm), and the hypogastric nerve branches can be observed on the medial aspect ( Fig. 25.10 ) of the dissection and the deep uterine vein crossing anteriorly. Avoiding any bleeding during this step is essential to allow proper visualization of the nerve. During the type B radical hysterectomy it is not necessary to perform extensive dissection of the hypogastric nerve. However, isolation and separation of the hypogastric nerve can be performed very similarly to the open approach for nerve-sparing radical hysterectomy, as described by Shingo Fujii. Detaching the hypogastric nerve branches from the posterior leaf of the broad ligament ( Fig. 25.11 ) will allow division of the pararectal space laterally (Latzko space) and medially (Okabayashi space). The pararectal space limits are the internal iliac artery and levator ani laterally, the rectum medially, the sacrum posteriorly, and the paracervix anteriorly.

Pelvic Lymphadenectomy

Currently, we perform a sentinel lymph node dissection followed by a complete pelvic lymphadenectomy for cervical cancer. However, this approach may change soon because of the recent evidence in favor of a change to sentinel lymph node biopsy only. We prefer to perform these procedures before the radical hysterectomy because the uterine manipulation helps to expose the paravesical and pararectal spaces and the lymphatic tissue. Also, in the event of grossly positive nodes or nodes suspicious for metastatic disease, one can then send these nodes for frozen section evaluation; if confirmed to be positive, then one may abort the radical hysterectomy. Some surgeons prefer to perform the hysterectomy first. Usually, those surgeons do not use manipulation, and hysterectomy provides better exposure of the pelvic side wall for the lymphadenectomy.