1. LAPAROSCOPIC RADICAL HYSTERECTOMY AND BILATERAL PELVIC LYMPHADENECTOMY; OUR INSTITUTIONAL EXPERIENCE
DR ASHUTOSH GUPTA
ASSOCIATE PROFESSOR
SURGICAL ONCOLOGY
REGIONAL CANCER CENTRE, RAIPUR.
INDIA

2. Brief about surgical management of ca cervix
Our experience with laparoscopic radical hysterectomy
Video –laparoscopic radical hysterectomy

3. DISEASE BURDEN
Carcinoma cervix is the second most common malignancy in women worldwide
It is the leading cause of cancer-related death for women in developing countries.
In India, 200 women die each day due to Cervical cancer.

4. Cervical Cancer – Disease Burden
New Cervical Cancer Cases
Deaths due to Cervical cancer
India ~1,32,000
World ~ 4,93,000
India ~ 74,000
World ~ 2,73,000
India ~27%
India ~27%
India - 27%
India’s population is approximately 1/6th of the world burden but the disease burden in India is more than 25%( 1/4th)
Rest of World - 73%
Rest of World - 73%
Rest of World - 73%
India ~27% of new
Cervical Cancer cases in world
India ~27% of deaths
due to Cervical Cancer in world

5. CLINICAL PRESENTATION AND WORK UP
Asymptomatic(preclinical) / postcoital bleeding / bleeding in between menstrual cycles/Discharge- watery, offensive, blood stained
Histological evidence Pap smear, Biopsy, Colposcopy, Endocervical curettage.
Staging
Abdomino-pelvic USG
CT/MRI – loco regional staging
PET SCAN – nodal and distant metastasis
CYSTOSCOPY/COLONOSCOPY- if symptoms present or involvement suspected.

6. TREATMENT OPTIONS Surgery Chemotherapy Radiotherapy
Some combination of above
Doing nothing – the hardest option

7. Surgery: General considerations
Patients with FIGO stage I to IIA

8. Surgery: General considerations
Operable growth: smaller tumour, not fixed to pelvic wall and no distant metastasis.
Those who are physically able to tolerate an aggressive surgical procedure.
Those who wish to avoid the long term complications of radiation therapy.

9. Surgery: General considerations
Radio resistant growth.
Typical candidates include young patients who desire ovarian preservation.
Retention of a functional of a non-irradiated vagina.
Women with pelvic masses, pelvic infections, chronic salpingitis, extensive bowel adhesions from previous peritonitis, endometriosis.

10. SIMPLE HYSTERECTOMY (TYPE I)
Also known as extrafascial hysterectomy or simple hysterectomy, removes the uterus and cervix but does not require excision of parametrium and paracolpium.
It is appropriately selected for benign gynaecologic pathology, pre-invasive cervical disease and stage IA1 cervical cancer.

11. MODIFIED RADICAL HYSTERECTOMY (TYPE II)
Modified radical hysterectomy removes the cervix, proximal vagina and parametrial and paravaginal tissue.
This hysterectomy is well suited for tumour with 3-5 mm depth of invasion and smaller stage IB tumours.

12. RADICAL HYSTERECTOMY (TYPE III)
Requires greater resection of the parametrium, and excision extends to the pelvic sidewall.
The ureters are completely dissected from their bed and the bladder and rectum are mobilised to permit this more extensive removal of tissue. In addition at least 2 to 3 cm of proximal vagina is removed.
This procedure is performed for larger IB lesions and for patients with relative contraindications to radiation such as diabetes, pelvic inflammatory disease, hypertension, collagen vascular disease or adnexal mass.

13. RADICAL HYSTERECTOMY

14. COMPLICATION
Acute- Ureterovaginal fistua (1-2%), Vesicovaginal fistula (1%), ileus (1%), Sepsis
Subacute - Postoperative bladder dysfunction, ureteric fistula, urinary retention, Lymphocyst formation
Chronic - Bladder hypotonia, Bladder atony, Ureteric stricture: rare

15. ADVANTAGE OF MIS

16. MIS
LAPAROSCOPIC
ROBOTICS

17. DEFINITION
Minimal access surgery is the marriage of modern technology and surgical innovation that aims to accomplish surgical therapeutic goals with minimal somatic and psychological trauma.

18. PRINCIPLE DIFFERENCES BETWEEN LAPAROSCOPIC AND OPEN SURGERY
FOR THE PATIENTS
Post operative pain related to size of the incision.
Less handling of intestine results in less or no disturbance of normal bowel function.
Avoidance of the trauma of the abdominal wall injury by the incision allows rapid return to normal activity.
No incision allows early return to more strenuous activity.

19. PRINCIPLE DIFFERENCES BETWEEN LAPAROSCOPIC AND OPEN SURGERY
FOR THE HOSPITAL
Initial capital costs to establish laparoscopic surgery in the order of 10 – 20 lakhs.
But overall costs reduces by shortening of hospital stay.

20. PRINCIPLE DIFFERENCES BETWEEN LAPAROSCOPIC AND OPEN SURGERY
FOR THE SURGEON
Magnified view often better than obtained via an incision allows precise dissection.
Altered (but not absent) tactile response.
Two dimensional view (flat view).
Usually (not always) long operating time.
Need to develop entirely different operating technique/ long learning curve.

21. AIM
To study the outcome, feasibility, morbidity and safety of total radical hysterectomy and bilateral pelvic lymphadenectomy at our institution.
50 patients of Carcinoma Cervix and Endometrium according to International Federation of Gynaecology and Obstetrics (FIGO) stages were studied.
Patients were followed up for 6 months.

22. INTRODUCTION
Radical hysterectomy with pelvic lymphadenectomy was developed for the treatment of cervical cancer in early Due to high morbidity related to the open surgery, laparoscopy was introduced in late twentieth century.
Canis et al and Nezhat et al.

23. There are many studies worldwide which have proven its worth in terms of patient safety and feasibility of the laparoscopic procedure without compromising oncologic principles.

24. MATERIALS AND METHODS
A total of 50 patients of Carcinoma Cervix and Endometrium according to International Federation of Gynaecology and Obstetrics (FIGO) stage were selected and enrolled for the study from August 2014 to August 2016.
Preoperative MRI was done for all the patients to rule out adjacent organ involvement and non-regional lymph node metastasis.

25. Para-aortic lymph nodes were assessed both preoperatively with MRI and intra-operatively for carcinoma Endometrium and none of the patient required para-aortic nodal dissection in the current series.
All the patients of Carcinoma Cervix underwent standard type 3 radical hysterectomy.

26. All the patients had standard mechanical bowel preparation and preoperative antibiotic prophylaxis and were operated under general anesthesia.
A Foleys catheter was placed in urinary bladder before the procedure was started.

27. A 10-mm camera port at the umbilicus and a 10-mm working port at Mcburney’s point were inserted.
Two 5-mm ports were inserted at left mid-clavicular point para-rectally and left iliac region, respectively. Surgeon stood on the right side of the patient.

29. RESULTS
A total of 50 patients underwent laparoscopic radical hysterectomy at our institution. None of the patients needed conversion to laparotomy.
Mean age of the patients was 54.2 years (range 45–67 years).
The mean weight was 58.3 kg (range 45–126 kg) and mean BMI was 22.1 for the patients in the present study.

30. A total of 38 patients had Carcinoma Cervix
24 patients had stage IB1 and
14 patients had stage IA2
12 patients had Carcinoma Endometrium
eight patients had stage IB and
four patients had stage II

31. Among 38 patients of Carcinoma Cervix,
six of them had adenocarcinoma whereas
other 32 had squamous cell carcinoma.

32. Mean operative time recorded in our series was 166 min (range 120–210 min).
Carcinoma cervix- 175 min (range 140–210 min)
Carcinoma endometrium- 150 min (range 120–165 min)

33. The average blood loss calculated was 212 ml (range 150–320 ml).
None of the patient required intra-operative blood transfusion.

34. Surgical margins of the specimen were free from tumour infiltration for all the patients.
Vaginal cuff margin of seven patients was less than 1 cm whereas rest of the patients had margin of more than 2 cm.

35. Four out of 38 patients of carcinoma cervix were shown to have microscopic parametrium involvement in pathological specimen.

36. Average growth size for carcinoma cervix stage IB1 was 2
Average growth size for carcinoma cervix stage IB1 was 2.34 cm (range 1.60–3.40 cm).

37. Median lymph node yield was 14 (range 10–21) and six patients had lymph node positive disease.

38. Patients were shifted to surgical ICU for 24 h postoperatively and monitored intensively.
Patients were started on oral diet gradually from postoperative day one.
Mean duration of hospital stay was three days.

39. COMPLICATIONS There were no port related complications.
There were no superficial surgical site infections.
11 patients developed retention of urine and required repeat catheterisation after 7 days and bladder training and were managed conservatively.

40. One patient developed colovaginal fistula diagnosed in the postoperative period. She was readmitted and investigated accordingly and another operative intervention was carried out for the same.

41. ADJUVANT THERAPY
14 patients of carcinoma cervix received adjuvant therapy.
7 patients of carcinoma endometrium received adjuvant therapy.

42. CARCINOMA CERVIX High risk patients- 1. Lymph node metastasis.
2. microscopic parametrium involvement.
3. close vaginal margin (less than 1 cm).
There were 8 high risk patients in our study.

43. Intermediate risk patients-
1.Deep stromal invasion.
2. Growth size more than 3 cms.
3. Lymphovascular invasion.
There were 6 intermediate risk patients in our study.

44. Adjuvant chemotherapy every 3 weekly in the form of cisplatin and 5FU infusion for three cycles along with concurrent radiation of 50 Gy was given to all 8 high-risk patients .
Adjuvant radiotherapy of 50 Gy in 28 fractions was given to all intermediate risk patients.

45. CARCINOMA ENDOMETRIUM
Adjuvant radiotherapy was given to three patients of stage IB carcinoma endometrium who had intermediate and high grade endometrioid pathology and
all four patients of stage II.

46. FOLLOW UP All the patients were followed up for a period of 6 months.
All of them were recurrence-free till last follow-up.
Since the patients were followed up for relatively short period, calculation of long-term survival was not feasible but results are encouraging. Long-term follow-up will be presented shortly.

47. DISCUSSION
Major advantages of laparoscopic procedure are less postoperative pain, shorter hospital stay and shorter recovery time.
It has now been performed at various centers as their first choice for early carcinoma Cervix and Endometrium.

48. Taylor SE et al
Nine laparoscopic patients (3 stage IA2, 6 stage IB1) with 18 matched controls (6 and 12) were identified. Demographics for each group were similar. An average of vs.13.9 pelvic lymph nodes were removed.
Average operating time was vs minutes, and average estimated blood loss was vs mL.
Average length of stay was 2.9 vs. 5.5 days.
No transfusions or operative complications were noted in the laparoscopic group vs. 3 each in the open group.

49. Taylor SE et al
Conclusion-that Laparoscopy is a feasible alternative to laparotomy for early stage cervical cancer. Similar surgical outcomes are achieved with significantly less morbidity.
Intraoperative advantages are 10–15 times magnification and better access to deeper areas of pelvic cavity which leads to better visualisation of anatomical structure leading to lesser complication.
Although there is a learning curve in laparoscopy yet in the experienced hands it has superior results.

50. Ramirez et al
He performed this procedure in 20 patients of cervical and endometrial carcinoma.
The median number of resected pelvic lymph nodes was 13 (range, 9-26). One patient had nodal disease.
The surgical margins were free of disease in all cases.
The median blood loss was 200 ml (range, ml). Only 1 patient required an intraoperative blood transfusion.
The median length of hospital stay was 1 day (range, 1-5).

51. Ramirez et al
He concluded that laparoscopy can be performed safely with minimal blood loss and postoperative morbidity, and patients undergoing this procedure may be discharged after an overnight stay in the hospital.
Laparoscopic access has reduced the blood loss and need for intra-operative transfusion.
With the advent of better instruments like ligasure, bipolar electro coagulation and harmonic scalpels and better experience of the surgeon the need for blood transfusion has gradually reduced.

52. Puntambekar et al
The largest single- institution study. He included Two hundred forty-eight patients with International Federation of Gynecology and Obstetrics stage IA2 (n = 32) and IB1 (n = 216) of cancer of the cervix.
The median operative time was 92 minutes (range minutes). 
The median number of resected pelvic nodes was 18. The median blood loss was 165 mL. The median length of stay was 3 days.
There were no deaths in this series. Seventeen patients had complications within 2 months of surgery. Seven patients had recurrences after a median follow-up of 36 months.

53. Puntambekar et al
He concluded that it can be performed safely. It is an easily replicable technique. This procedure reduces the morbidity associated with abdominal radical hysterectomy.

54. CONCLUSION
Today laparoscopic radical hysterectomy a regular surgery performed worldwide.
The morbidity of the procedure is within acceptable limits and less than open counterpart maintaining the same oncologic outcome.

55. Hospital stay, pain and patients satisfaction were better.
Early recovery enabled the patient to go for timely postoperative adjuvant treatment.

56. Video – Laparoscopic Radical Hysterectomy