Robotic surgery for radical procedures: Ovarian cancer, upper abdominal debulking, and pelvic exenteration

Introduction

The combination of surgery and chemotherapy remains the hallmark of management for ovarian cancer. Minimally invasive interval cytoreductive surgery following neoadjuvant chemotherapy in advanced stage epithelial ovarian cancer has been increasing over the past decade, from roughly 11% in 2010 to 21% in 2016. However, the ideal role for robotic-assisted surgery in ovarian cancer has remained a topic of debate.

In high-grade serous ovarian, fallopian tube, and primary peritoneal cancers, the standard of care is surgical staging, including total hysterectomy, bilateral salpingo-oophorectomy, evaluation of all peritoneal surfaces, washings, omentectomy, pelvic and para-aortic lymphadenectomy, resection of suspicious lesions, and biopsies of normal peritoneal surfaces—referred to as a Type I debulking. A Type II debulking entails a Type I debulking plus one additional major procedure such as bowel resection, full-thickness diaphragm resection, liver resection, and porta hepatis or liver resection. A Type III debulking includes patients with two or more major procedures.

The literature surrounding robotic-assisted debulking surgery in patients with advanced ovarian cancer is scarce and limited to small series. Initially, a major reason that the robot wasn’t widely utilized for ovarian cancer surgery was the inability to access all four abdominal quadrants simultaneously. Especially with the early da Vinci S and Si Surgical Systems, multiple dockings and patient bed adjustments were required throughout the surgery—which substantially added to the operative time. The introduction of the Xi Surgical System corrected for several of these limitations with the ability to change camera arm ports, synchronization of the bed and the robotic surgical system, and 180 degrees rotation of the robotic boom. However, other concerns exist including the lack of haptic feedback which can make it difficult to differentiate tumors from normal tissue. The inability to handle tissue within the upper abdomen raises the question of whether minimally invasive cytoreduction can yield the same rates of complete gross resection as compared to an open approach.

The Gynecologic Oncology Group (GOG) currently defines optimal cytoreduction as residual disease that is ≤1 cm in maximum tumor diameter and complete cytoreduction as no grossly visible disease at completion of surgery. Suboptimal cytoreduction is defined as residual tumor nodules greater than 1 cm in diameter. The greatest survival benefit is seen in patients who achieve removal of all macroscopic disease. Therefore, the goal of any cytoreductive surgery should be to obtain complete gross resection (R0). The success of R0 depends on various factors, including bowel involvement, extent of disease, and patient selection. It is important to consider these factors in determining the appropriate surgical modality as well.

The 2019 International Mission study by Fagotti et al. followed 127 patients diagnosed with advanced epithelial ovarian cancer after neoadjuvant chemotherapy undergoing minimally invasive interval cytoreductive surgery. They found minimally invasive cytoreductive surgery was associated with a 96% rate of R0 resection and an intraoperative complication rate of 4.7%. The authors concluded that minimally invasive surgery may be considered for patients with advanced ovarian cancer who have undergone neoadjuvant chemotherapy, when surgery is limited to low-complexity standard cytoreductive procedures.

In a 2013 retrospective review of 89 patients with ovarian cancer, 63 patients had undergone robotic-assisted surgery. The robotic-assisted surgery cohort was associated with longer operative time, less blood loss, and shorter hospital stay on average as compared to the laparotomy cohort. Major complication rates, lymphadenectomy yields, recurrence outcomes, and survival outcomes were similar between the two surgical approaches. The use of neoadjuvant chemotherapy was three times more frequent in the robotic-assisted cohort as compared to the laparotomy cohort; additionally, residual disease rates in the robotic-assisted cohort were higher as compared to the laparotomy cohort (73% vs. 50%, P = .88).

Another small retrospective case-control series evaluating 25 patients with ovarian cancer undergoing robotic-assisted surgery found less blood loss and fewer intraoperative complications in the robotic-assisted cohort. However, the patients undergoing robotic-assisted surgery had a mean operating time 138 minutes longer and an overall survival 11 months shorter when compared to the laparotomy cohort. ^, These studies—as well as similar reports in the literature—demonstrate that robotic-assisted surgery can be a safe, feasible approach for ovarian cancer management when patients are properly selected.

There are no current guidelines to determine ideal patients to undergo minimally invasive cytoreductive surgery. At this time, it is reasonable to consider robotic-assisted cytoreductive surgery for staging, for patients with a robust response to neoadjuvant chemotherapy when surgery is limited to low-complexity additional procedures, and for localized recurrences.

Key steps

Patient considerations, indications, contraindications

Contraindications that pertain to open cytoreductive surgery should be similar to robotic-assisted cytoreductive surgery. These include patient age, comorbidities, high likelihood of suboptimal resection, extensive small bowel involvement, and goals of patient care. In addition to these, contraindications specific to robotic-assisted cytoreductive surgery include underlying cardiopulmonary issues that may preclude the patient from undergoing a steep Trendelenburg position for an extended period, as well as inadequate surgeon experience on the robotic console that may reduce the probability of achieving R0.

The selected surgical modality must balance the potential benefits of decreased hospital stay and quicker return to baseline functional status with the potential drawbacks of increased operative time. The decision for robotic-assisted cytoreductive surgery should only be considered if the surgeon believes the probability of achieving R0 is similar to that of laparotomy for each individual case. If during robotic-assisted cytoreductive surgery the surgeon feels the open approach may improve the patient’s chances of complete resection, it is always reasonable to convert to laparotomy. It is important to counsel patients appropriately on the risk of conversion.

Special equipment

Patient positioning/port placement

Abdominal pelvic port placement for the da Vinci Robotic System should utilize all four arms with the addition of an assistant port. For the pelvic approach ( Fig. 40.1 A) the camera port (CP) is placed midline at the umbilicus or 1 to 2. Port #1 is placed 8 cm lateral right of the umbilicus. Port #2 is placed 8 cm lateral left of the umbilicus. Port #3 is placed 8 cm superior-lateral to Port #1 around the right lower quadrant. The assistant port is placed in the left upper quadrant 4 cm superior-lateral to port #2. The patient is placed in the dorsolithotomy position with steep Trendelenburg. The legs should be placed in Allen stirrups. The robot should be docked at the patient’s right or left hip to allow assistant access between the legs to the vagina and perineum.

For the upper abdominal approach ( Fig. 40.2 A), the CP is placed in the same location as the pelvic placement. Several of the same port locations could be continued. The accessory port is utilized on the left side of the abdomen 8 cm from the umbilicus. Port #1 should be placed in the left upper quadrant superior to the level of the accessory port. Port #3 should be placed to the right of the umbilicus and port #2 in the right lower quadrant. With the da Vinci Xi, the boom can be rotated 180 degrees. The robot may need to be moved toward the patient’s upper shoulder/head region to allow for optimal efficiency in movement (see Fig. 40.2 B).

Stages of the procedure

Pelvic and para-aortic lymph node dissection

Once the round ligament is transected and the paravesical space is developed, the obliterated umbilical artery should be identified and retracted medially. The obturator vein and nerve should be identified posteriorly and the ureter should be identified medially with the internal iliac artery laterally. Further dissection along the avascular planes distally into the sidewall is commonly required. It is important to identify the genitofemoral nerve to prevent transection. The distal limit of the pelvic lymph node dissection should be the landmark of the deep circumflex iliac vein. The obturator nodes can be found between the obliterated umbilical artery and external iliac vein ( Fig. 40.3 A). Completing the pelvic lymph node dissection may require further dissection of nodes between the obturator vein/obturator nerve and external iliac vessels.

The para-aortic lymph node dissection begins with a dissection between the ureter and internal iliac artery, which is then traced superiorly along the adventitia toward the aorta. The common iliac vessels should be identified and the ureter laterally. The major vessels should be further isolated with dissection through avascular planes. Using careful blunt dissection and precise electrocautery of smaller vessels, dissection and skeletonization of the lymphatic tissue should take place along the aorta. It is important to identify the inferior mesenteric artery, ovarian vessels, and renal vessels as they branch from the aorta (see Fig. 40.3 B).