Laparoscopic Surgery in Endometrial Cancer
Laparoscopic Surgery in Endometrial Cancer
Maliheh Arab, MD Diploma course, March 2018
Comparison of complications and advantages of laparoscopy and laparotomy in endometrial cancer
In a study of 465 patients undergoing laparoscopy and laparotomy, no significant difference was observed between the two methods in terms of intra or post operative complications. In another study however, laparoscopy reported to be associated with fewer perioperative complications to that of open surgery. Another study states intraoperative complications of laparoscopy to be higher than laparotomy but a lower rate of postoperative complications via laparoscopy . Laparoscopy has been reported to have benefits over laparotomy that include lower rate of hemorrhages, fewer days of hospitalization and fewer complications during the procedure, that s why even the elderly presented with endometrial cancer can benefit from this method. Possible postoperative complications in people receiving laparoscopy include infections in the chest and around surgical wounds, thrombosis, fever, hemorrhage, lymphocele and urinary tract injuries. It seems laparotomy is associated with a greater risk of infection because of a more exposed surgical site and an increased risk of thrombosis and embolism because of a longer postoperative bed rest of laparoscopy. Xu et al. managed to reduce the risk of urological injury during laparoscopic surgery by filling the bladder with saline to improve visualization of bladder and by careful observation of ureter course reduce risk of accidental harm to these structures.
Studies on laparoscopic and laparotomic approaches show a significant difference in post operational hospital stay, that is, the hospital stay in the laparoscopic method is much lower than the laparotomic one. The rate of patients needed more than 2 days of hospitalization in a study was lower in laparoscopic surgery compared to laparotomy (%52 versus %94). Some studies carried out Studies on hospital stay discrepancies between laparoscopic and robotic approach in older patients and other different age groups did not find a meaningful difference. It appears that robotic and laparoscopic surgery are more efficient methods in many aspects such as days of hospitalization, blood loss and need for blood transfusion when compared to laparotomy and less blood loss and conversion to laparotomy compared to laparoscopy , But as today, laparotomy has shown to have a shorter surgery time than robotic and laparoscopic surgery. Malur et al. studied 37 endometrial cancer patients who underwent laparoscopy and compared them to 33 patients who had laparotomy and found patients in the first group to have shorter days of hospitalization , blood loss and blood transfusion rate. Another study in comparison of laparoscopy with laparotomy in patients with endometrial cancer confirmed less blood loss (145 versus 501 ml) and hospital stay (2.3 versus 5.5 days) in laparoscopy group with no difference in number of lymph nodes removed(21.3 versus 21.9).
Blood transfusion and blood loss
In a study by Volpi et al. on 77 patients with stage I-III endometrial cancer , the patients underwent laparoscopic surgery didn't need transfusions and in a study by Scibner et al., patients in the laparoscopy group received more blood transfusions than in the laparotomy group but Bogani et el. who studied differences between laparoscopy and laparotomy in women over 75 years found no great difference in blood transfusion rate in the two groups. Ghezzi et al. in their study on a same
subject found a higher blood transfusion rate in patients undergoing laparotomy. It is of importance that studies on different age groups undergoing laparoscopy do not show a notable difference in transfusion rates. A study reported that 10.7% of patients undergoing laparoscopic surgery needed blood transfusion whereas the rate was 14.5% in patients undergoing laparotomy.
Comparison of operation time of laparoscopy versus laparotomy
According to various studies, laparoscopic surgery in endometrial cancer tends to take longer than laparotomy. Scribner et al. reported a longer surgery time for laparoscopic surgery compared to laparotomy in older than 65 years old patients with endometrial cancer. Frigerio et al. reported an average surgery time of 220 min (range of 80- 375) for laparoscopy and 175 min (range of 70- 360) for laparotomy, whereas Zullo found an average of 196.7 for laparoscopy and 135.3 for laparotomy. The part of learning curve and experience is very important in achievement of a shorter operative time. In a study of laparoscopic approach in endometrial cancer compared with historical controls of open surgery, the operative time was longer with a mean of 190 minutes, blood loss was less (278.3 ml) , hospital stay was shorter, pain medication was less.
Conversion of laparoscopy to laparotomy
Main reasons resulting in conversion to laparotomy in the case of starting surgery by laparoscopy are as followed: gastrointestinal tract trauma, high stage endometrial cancer (extrauterine extension of tumor), large uterus, extensive adhesion preventive for completion of operation by laparoscopy and excessive bleeding. GOG ĹAP2 trial also showed metastases, haemorrhage and limited visual field contribute to conversion to laparotomy , However, the main reason for laparotomy conversion in women with endometrial cancer is excessive weight . In a study by Palomba et al., it was declared that the probability of conversion to laparotomy in patients with endometrial cancer is associated with the stage of endometrial carcinoma, that is, the more progressed the carcinoma is, the higher the risk of conversion to laparotomy will be and the overall conversion rate of laparoscopy in their study was 13.2%. Conversion to laparotomy in a laparoscopic surgery increases risk of complications that according to Jung et al. is related to the incision of laparotomy. The two factors contributing significantly to a lower rate of conversion to laparotomy in a laparoscopic surgery for endometrial cancer include younger age and lower BMI that explains zero cases of conversions in Lee et al. s study. Other effective parameters contributing to fewer conversions to laparotomy are expert surgeon and incorporation of ĹeeeHuang poin .
Comparison of endometrial cancer lymphadenectomy in laparoscopy with laparotomy Lymphadenectomy accounts for an important part of surgery in endometrial cancer both in laparoscopy and laparotomy. Studies show different results comparing the two methods. Some studies report no difference in number of obtained lymph nodes between laparoscopy and laparotomy and some studies show more number of nodes in laparotomy which might be due to more para-aortic nodes in laparotomy group. Kohler et el. Investigated the feasibility of laparoscopic lymphadenectomy in 650 patients with gynecologic cancers. Of 66 patients who had lymphadenectomy procedure, an average 26.7 lymph nodes (15.4 pelvic and 9.6 para-aortic) were obtained from with the time of 56 and 63 minutes for pelvic and para-aortic lymph nodes, respectively. In a more detailed investigation, number of pelvic lymph nodes obtained from the women underwent laparoscopy tends to be higher than the ones performing laparotomy (11.0 _ 5.1 pelvic lymph nodes vs. 7.0 _ 4.6 pelvic lymph nodes ; P < 0.001) , whereas number of para-aortic lymph nodes removed did not differ much in the two surgical approaches (2.5 _ 1.9 paraaortic lymph nodes vs. 3.5 _ 2.6 para-aortic lymph nodes ; P <0.148). In other studies however, number of yielded lymph nodes were higher in laparoscopy compared to laparotomy and that may be due to pneumoperitoneum resulting in a positive pressure making pelvic lymphadenectomy easier . In another study of 295 patients with endometrial cancer stage I or II, laparoscopy appeared to be a better procedure in harvesting lymph nodes rather than laparotomy that is 27.4 in laparoscopy versus 23.9 in laparotomy.
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