Advanced laparoscopic procedures are increasingly being used as an alternative for laparotomy in gynecologic surgery.1–5 A meta-analysis of 27 prospective randomized trials has proven the benefits of laparoscopic compared with abdominal gynecologic surgery: decreased pain, decreased surgical site infections, decreased hospital stay, quicker return to activity, and less postoperative adhesions.6 Although originally more costly, with increasing experience, the length of laparoscopic procedures has shortened resulting in costs similar to laparotomy.7
Advanced laparoscopic procedures are also increasingly being used as an alternative for laparotomy in gynecologic oncology surgery. Laparoscopic and robotic radical hysterectomy is becoming more widely used for the treatment of cervical cancer.1,2 Laparoscopic staging of early ovarian cancer, laparoscopic secondary cytoreductive surgery for recurrent ovarian cancer,4 and laparoscopic-assisted cytoreduction for primary advanced ovarian cancer have been described.5
Laparoscopic-assisted vaginal hysterectomy with lymphadenectomy is becoming a standard treatment for endometrial cancer.8 Recently, the Gynecologic Oncology Group reported the results from LAP2, a prospective randomized trail comparing laparoscopy and laparotomy for surgical staging of uterine cancer.8 Consistent with the mentioned meta-analysis, laparoscopy resulted in statistically significantly less complications (14% compared with 21%) and hospital stay (2 compared with 4 days). Interestingly, in patients randomized to laparoscopy, there was a high conversion rate to laparotomy, 26% overall and 57% in patients with a body mass index (BMI, calculated as weight (kg)/[height (m)]2) of more than 40. The main reason for conversion was obesity (approximately 60%). The next two most common reasons were metastatic disease (16%) and bleeding (11%).
It is our practice that all patients with primary endometrial adenocarcinoma undergo attempted laparoscopic staging regardless of age, BMI, uterine size, prior surgery, and so on. The purpose of this report is to estimate our conversion rate of laparoscopic staging of primary endometrial adenocarcinoma.
Over a 5-year period (2005–2010), all patients undergoing major gynecologic surgery by the senior author were entered into a prospective surgical database. Demographics were obtained and entered preoperatively, surgical outcomes were entered immediately postoperatively, and follow-up was entered for the first 30 days.
Over this 5-year period, there were 235 cases of primary endometrial adenocarcinoma without clinical evidence of advanced disease that would preclude surgical staging. All patients underwent attempted laparoscopic-assisted vaginal hysterectomy and complete pelvic lymphadenectomy regardless of age, BMI, uterine size, and prior surgery. No patients were excluded. No surgeries were performed robotically.
All patients underwent a preoperative bowel preparation with one bottle of magnesium citrate, received a single dose of prophylactic antibiotics, pneumatic compression stockings, and early ambulation. Unless contraindicated, all patients received 30 mg ketorolac (Toradol) intravenously at the completion of surgery, 2–5 mg morphine intravenously every 2 hours as needed, and one to two tablets 5/325 mg oxycodone/acetaminophen (Percocet) orally every 6 hours as needed for analgesia. On postoperative day 1, patients were given bowel stimulation with 30 mL of milk of magnesia, started on a general diet, and were discharged when fluid intake was adequate. Patients were followed up in the office at 1 and 4 weeks after surgery.
All procedures were performed under general endotracheal anesthesia. An orogastric tube was inserted and removed at the end of surgery. The patient was positioned in the dorsolithotomy position with legs in Allen stirrups and placed in maximal Trendelenburg position (approximately 30°). A gel pad is placed under the buttocks to prevent the patient from gravitating toward the head of the table. A four-port (5-mm) transperitoneal approach was used: periumbilical, right and left lower quadrant, and left upper quadrant. Round ligaments, infundibulopelvic ligaments, uterine vessels, cardinal and uterosacral ligaments were excised with the PlasmaKinetic cutting forceps. The laparoscopic 5-mm Argon-Beam Coagulator was used to perform the lymphadenectomy. The Argon-Beam Coagulator was used at a setting of 80 W and an argon gas flow setting at 4 L/min. All lymph bearing tissue was removed from the entire common iliac artery, external iliac artery and vein, and internal iliac artery anterior to the obturator nerve. If metastatic or suspicious pelvic nodes were identified, an aortic lymphadenectomy was performed to at least the level of the inferior mesenteric artery. Grade, suspected deep myometrial invasion, or cervical involvement did not influence the decision to perform aortic lymphadenectomy if there were no suspicious pelvic lymph nodes. Vaginal hysterectomy was then performed. Surgical assistance was provided by a senior and junior gynecologic residents.
When adequate Trendelenburg position could not be safely maintained, the procedure was converted to a vaginal hysterectomy with transvaginal application of a laparoscopic bipolar cutting forceps as previously reported.9 Staging lymphadenectomy was not performed. If vaginal hysterectomy was unsuccessful, surgery was converted to a Maylard laparotomy.
Penn State Milton S. Hershey Medical Center Institutional Review Board approval was obtained.
Of the 235 patients, mean age was 59 years (range, 33–81 years), 91% were white, 87% had medical comorbidities, and 74% had prior abdominal or pelvic surgery. Mean BMI was 39 (range, 22–77) and 85 patients (36%) had a BMI higher than 40.
Mean blood loss was 162 mL (range, 25–1850 mL), mean operating time was 2 hours (range, 1–4 hours 20 minutes), and mean hospital stay was 1 day (range, 1–4 days). Forty-two patients underwent aortic lymphadenectomy because of suspicious pelvic nodes.
Six patients (3%) developed perioperative morbidity: congestive heart failure, pulmonary embolus, urinary retention, urinary tract infection, ileus, and intraoperative hemorrhage requiring transfusion.
Fifty-four percent of tumors were low risk (stage 1A or B, grade 1 or 2), 36% were intermediate risk (stage 1, grade 3 or stage 1C or stage 2), and 10% were stage 3C secondary to nodal metastasis. Mean and median pelvic lymph node count was 10 and 13, respectively (range, 5–22) and mean and median aortic lymph node count was eight and nine, respectively (range, 6–11).
There were six conversions (3%; 95% confidence interval, 1–5%) to laparotomy or vaginal hysterectomy, all occurring in patients with a BMI of more than 40; mean BMI of conversions was 66 (range, 55–77). All conversions were secondary to inadequate visualization because of inability to maintain adequate Trendelenburg position. Five of six conversions to vaginal hysterectomy were successful. The single conversion to laparotomy was the result of a 10-cm anterior vaginal leiomyoma, which precluded transvaginal entry into the anterior cul de sac. Surgery was completed through a Maylard laparotomy. There were no conversions because of bleeding.
Recently, the Gynecologic Oncology Group reported the results from LAP2, comparing laparoscopy and laparotomy for surgical staging of uterine cancer.8 This class 1 trial producing level A evidence was prospective, randomized, multiinstitutional, and involved 2,616 patients. Laparoscopy staging resulted in statistically significantly less complications (14% compared with 21%) and hospital stay (2 compared with 4 days). When the data are mature, if survival is similar for laparoscopy compared with laparotomy, it is our opinion that laparoscopic staging will become the recommended approach because of significantly less morbidity. Laparoscopic compared with robotic staging will need to be compared.
Interestingly, there was a high rate of conversion to laparotomy in patients randomized to laparoscopy (26% of the total patients and 57% of the patients with BMI greater than 40). The main reason for conversion was obesity (approximately 60%). In our study, although there was a higher BMI (39 compared with 28 in LAP2), conversions to laparotomy or vaginal hysterectomy occurred in 3% of the total patients and 7% of the patients with BMI of more than 40, one-tenth the rate of LAP2. Importantly, similar to the laparoscopic arm of the LAP2 trial, in our study, all patients underwent attempted laparoscopic staging regardless of age, BMI, uterine size, prior surgery, and so on. No patients were excluded. It is our opinion that the much higher conversion rate in the LAP2 trial is secondary to the laparoscopic “learning curve.” During the time of the LAP2 trial (1996–2005), nationally only 8% of surgical staging of uterine cancer was performed laparoscopically.10 In an analysis of the learning curve for robotic surgical staging of uterine cancer, proficiency was not achieved until after 20 cases were completed.11 The senior author has been performing more than 100 laparoscopic lymphadenectomies per year for the past 10 years.
Our technique of lymphadenectomy varies from the LAP2 trial in that we remove all lymph-bearing tissue from the entire common iliac artery and not just the distal half of the common iliac artery like in the LAP2 trial. However, we do not routinely perform an aortic lymphadenectomy unless metastatic or suspicious pelvic nodes are identified because only 1% of patients without pelvic nodal metastasis will have aortic metastasis.12 In our study, none of the conversions to laparotomy were the result of inability to perform aortic lymphadenectomy. In our trial, nodal metastasis was detected in 10% of patients, which is similar to the 9% detection rate in the LAP2 trial. Mean BMI of patients undergoing aortic lymphadenectomy was 31.
In a PubMed literature search, we were able to locate several studies on laparoscopic staging of uterine cancer.13–17 All five studies reported a 5–6% conversion to laparotomy. Compared with our study, these five studies had fewer patients (median of 73) and a much lower BMI (median of 26). Importantly, unlike our study, these five studies had multiple exclusion criteria for laparoscopic staging: clinical suspicion of disease outside the uterus, poor uterine mobility, prior surgery, cardiopulmonary disease, BMI more than 35, prior pelvic or abdominal radiation, uterine diameter more than 10 cm, and uterus more than 12 weeks. Likewise, Eisenkop18 reported a 5% conversion to laparotomy but had a 15% exclusion rate. Because the mentioned studies used multiple exclusion criteria, it is not possible to make a direct comparison of conversion rates, although one would expect that exclusion criteria for laparoscopic staging would result in lower conversion rates from laparoscopy to laparotomy.
In conclusion, of 235 consecutive cases of attempted laparoscopic staging for primary endometrial adenocarcinoma, conversion to laparotomy or vaginal hysterectomy occurred in 3% of the total patients and 7% of the patients with BMI of more than 40. We believe our low conversion rate is the result of laparoscopic experience and the high conversion rate in the LAP2 trial is secondary to the laparoscopic “learning curve.”
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