Introduction
The original robot-assisted hysterectomy was first published in the World Journal of Surgery in 2001. Nearly 4 years later, the US Food and Drug Administration (FDA) approved the use of the da Vinci Surgical System for gynecologic procedures in 2005. Following this approval, the number of robotic-assisted surgeries in gynecologic oncology has increased dramatically. Minimally invasive surgery in the field of gynecology offers known benefits in most cases, including decreased postoperative pain, shorter hospital stays, and quicker return to daily functions. Additionally, the introduction of robotic-assisted surgery in gynecology has resulted in more patients being able to undergo minimally invasive surgery with lower rates of conversion to laparotomy when compared to conventional laparoscopy.
Robotic-assisted surgery has also taken on an increased role in the field of gynecologic oncology over the past decade as an effort to mitigate the limitations of laparoscopic surgery. With advantages of three-dimensional stereoscopic vision, tremor canceling software, and wristed instruments with improved dexterity, robotic-assisted surgery has allowed gynecologic oncology surgeons to perform more complex and increasingly radical procedures. These include ovarian cancer cytoreductive surgeries with upper abdominal disease as well as total pelvic exenterations.
Robotic-assisted surgery in ovarian cancer and upper abdominal debulking
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
Steps may vary based on location of tumor and indicated procedures.
- 1.
Place patient in dorsal standard lithotomy position with legs in Allen stirrups and both arms extended less than 90 degrees
- 2.
Prep abdominal area first, followed by the pelvic region and vagina
Transperitoneal
- 1.
Access and insufflation, port placement
- 2.
Thorough exploration of pelvis and upper abdomen, obtain pelvic washings
Trans/retroperitoneal
- 1.
Dissect pelvic sidewalls, identify ureters bilaterally
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Ligate infundibulopelvic ligament at least 2 cm distal to ovary and/or tumor
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Transect round ligament, dissect broad ligament anterior and posterior to level of cardinal ligament
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Develop vesicouterine flap to separate bladder from uterus
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Ligate uterine arteries bilaterally and transect cardinal ligament
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Ligate uterosacral ligaments
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Transect colpotomy
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Insert Endocatch bag through the vaginal opening and remove specimens through colpotomy opening (or through abdomen, if too large)
- 9.
Place pneumo-occluder in vagina
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Perform peritoneal biopsies, pelvic and para-aortic lymphadenectomy, and omentectomy
- 11.
Remove additional specimens through vagina
- 12.
Proceed with upper abdominal procedures as indicated by disease spread
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Closure of vaginal cuff
- 14.
Ports removed and closure
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
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Robotic instruments
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Fenestrated bipolar forceps/bipolar Maryland grasper
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Monopolar scissors
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ProGrasp forceps
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Large needle holders ×2
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Diamond forceps
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Potts scissors
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Vessel sealer
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Sutures
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Vicryl 3-0 SH
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Vicryl 2-0 SH
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V-Loc barbed suture 2-0 SH
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AirSeal insufflator
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Laparoscopic scissors, suction device, graspers, Hem-o-lok clip appliers
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Staplers
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Endo GIA 60 3.5 & DLU
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Endo GIA 80 3.5 & DLU
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TA 60 3.5 & DLU
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CEEA 28 & 31
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- 6.
Cystoscopy equipment
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8.5 × 90 cm single J ureteral stents
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5 Fr whistle tip ureteral catheters
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- 7.
Jackson Pratt drain and bulbs
- 8.
Laparotomy tray readily available in operating room
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
Hysterectomy with bilateral salpingo-oophorectomy
The retroperitoneal space is dissected and the ureters are identified bilaterally. A plane is created with the external iliac laterally and ureter medially. A window is then created along the peritoneum to allow isolation and ligation of the infundibulopelvic ligament with the vessel sealer (see Fig. 40.2 A). Posterior skeletonization of the uterine vessels should then be performed. The round ligament is transected as the vesicouterine flap is developed. The uterine vessels are then skeletonized and ligated (see Fig. 40.2 B). This allows for exposure to complete the vesicouterine flap. It is important to confirm that the uterine manipulator cup is in the correct anatomical location surrounding the cervix. The colpotomy is then transected. Bilateral uterosacral ligaments are transected as the colpotomy is carried through (see Fig. 40.2 C). It is important to avoid excessive cauterization as it is necessary to retain fresh tissue for proper healing of the vaginal cuff. The specimens are then placed in an Endocatch bag and delivered vaginally if possible. The pneumo-occluder should be placed immediately while the vaginal edges are held tight to prevent spread of air. The colpotomy closure is completed either with a Vicryl suture or V-loc barbed suture. At least 1 cm of vaginal mucosa should be incorporated.
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).
Omentectomy
The patient should be placed in semilithotomy or reverse Trendelenburg position based on exposure. The location of the robotic camera and instruments could be switched to provide the most efficient resection. The accessory port could also serve as a laparoscopic port for a vessel sealing device by the assistant. With alternating caudal and ventral retraction of the omentum, the supracolic omentectomy is performed with ligation and dissection beginning laterally, then along the transverse colon inferiorly and stomach superiorly. The short gastric vessels are identified and avoided. The omentectomy should be carried through laterally with completion at the left gastroepiploic artery and hilum of the spleen.
Diaphragm resection
The diaphragm resection method will depend on the location of the suspected lesion. If dorsomedial on the right diaphragm, a suprahepatic resection is most common with division of the falciform and coronary ligaments. If dorsolateral along the right diaphragm, an infrahepatic procedure will likely be utilized. For superficial diaphragm tumors, a peritoneal stripping is adequate. If there is any suspicion for invasion, a plane is created between the peritoneum and muscular layer for further evaluation. A full-thickness resection with electrocautery is utilized for any evidence of invasion into the diaphragm muscle. The recommended maximum level of power setting for a peritonectomy is 15 watts versus a maximum of 35 watts for full-thickness resections. Careful attention must be paid to avoid damage to the phrenic nerve (C3–5).
The resection should then undergo closure with a 2-0 delayed absorbable suture. Prior to the last stitch, a catheter—placed on suction—should be introduced into the pleural side to expand the lung and remove fluid/debris. The catheter is then removed while positive pressure is administered before closure. We recommend a bubble test to rule out defects as well as a postoperative chest x-ray.
In a 2006 retrospective series of 59 advanced ovarian cancer patients who underwent a diaphragm peritonectomy or resection at a single institution, more than half of the patients developed ipsilateral pleural effusions. Most were managed conservatively without a chest tube or thoracentesis. The use of prolonged chest tube placement at the time of diaphragmatic peritonectomy or resection should be determined on a case-by-case basis.
Liver/porta hepatis resection
We recommend a multidisciplinary approach with the assistance of a hepatobiliary surgery team depending on the location of the metastasis and surgeon experience. Superficial lesions can be resected first with demarcation using a monopolar hook. The liver lesion is then fully resected from the parenchyma using monopolar energy or a saline bipolar device for hemostasis. Robotic-assisted surgery is also an acceptable modality for a local recurrence of disease within the porta hepatis ( Fig. 40.4 ).
Splenectomy
The lesser sac is first entered with an incision along the gastrocolic omentum ( Fig. 40.5 A); attention should be paid to avoid transection of the short gastric vessels. The splenic artery should be identified at this time. The gastrosplenic ligament should then undergo division followed by dissection of the lienorenal ligament (splenorenal ligament) (see Fig. 40.5 B). The splenic artery and splenic vein should then be skeletonized and isolated. The splenic artery should be divided first using an Endo GIA 2.5 mm stapler (see Fig. 40.5 C). Next, the splenic vein should be divided in similar fashion. The remaining portion of the lienorenal ligament should be dissected to release the remainder of the spleen (see Fig. 40.5 D).
Postoperative care
Patients with epithelial ovarian cancer commonly differ from many other surgical patients. Patients with ovarian cancer often have advanced stage disease at the time of diagnosis, and they often have a high burden of abdominal distension and impairment of gastrointestinal function, as well as malnutrition. In addition, postoperative morbidity can be particularly high among this patient population, given long operating times and excess fluid shifts. Because of this, special attention toward a specifically tailored postoperative course must be considered.
We recommend postoperative management aimed at stress reduction and preservation of the patient’s organ function. The multimodal bundle referred to as ERAS (enhanced recovery after surgery) has demonstrated strategies that reduce postoperative morbidity and hasten recovery. These include early resumption of feeding postoperatively, early ambulation, weight-directed fluid management, and early orogastric tube removal. Venous thromboembolism prophylaxis should be initiated preoperatively and continued postoperatively; extended chemoprophylaxis should be prescribed to patients who meet high-risk American College of Chest Physicians criteria.
In order to avoid vaginal cuff dehiscence, we recommend patients refrain from vaginal intercourse, tampon use, or douching for 6 to 8 weeks. The majority of patients with epithelial ovarian cancer will benefit from postoperative chemotherapy, typically started within two to 4 weeks after surgery. Data suggest that a delay of greater than approximately 1 month in instituting chemotherapy may be associated with worse outcomes. ,
Following a splenectomy, patients are at an increased risk of encapsulated organisms—which are more resilient to phagocytosis. The pneumococcal 13-valent conjugate vaccine (PCV13—Prevnar 13), Haemophilus influenzae type B vaccine, meningococcal vaccine, and meningococcal serogroup B vaccine must all be administered within the first 14 days of splenectomy. At 2 months’ follow-up after the initial vaccination, the patent should receive the pneumococcal polysaccharide vaccine (PPSV23—Pneumovax 23), meningococcal vaccine, and meningococcal serogroup B vaccine. Long-term care includes a pneumococcal polysaccharide vaccine revaccination 5 years after the first dose, a meningococcal vaccine revaccination every 5 years, and a meningococcal serogroup B vaccine 1 year after the primary series followed by revaccination every 2 to 3 years afterward ( Table 40.1 ). Without the appropriate vaccinations, asplenia can place patients at risk of severe sepsis with significant rates of mortality. It should be noted that a white blood cell count greater than 15 × 10(3)/μL and a platelet count/white blood cell count ratio of less than 20 are highly associated with sepsis and should warrant further workup as this is not part of the physiologic response to splenectomy.
