ROBOTIC ASSISTED SURGICAL PROCEDURES
Robotic assisted surgery, one of the methods of minimal invasive surgery, utilizes sophisticated technology through which commands given by the surgeon through a computer console are relayed to robotic devices on patient console. Robotic assisted surgery known as Da Vinci Robotic Assisted Surgical system can also be defined as robotic assisted laparoscopic surgery. Similar to laparoscopic surgery, the procedure is carried out through small canals, called ports, made with small incisions within scope of robotic assisted surgery. Commands given on console of the surgeon are simultaneously relayed to Da Vinci robotic device located at console of the patient, which is equipped with high resolution 3 dimensional optical imaging system. Gynecological surgeries that are done utilizing robotic assisted surgical method can be performed successfully.
Sentinel lymph node sampling
Endometrial and cervical cancers can spread (metastasize) to lymph nodes. If you imagined lymph nodes as a system of interconnected chain, metastasis initially takes place in the lymph node. Lymphatic vessels and lymph nodes can be visualized by administering various agents (indocyanine green (ICG), methylene blue, etc.) at the beginning of the surgery in cases of endometrial and cervical cancers. Sentinel lymph node (the first lymph node of lymphatic chain) can be detected and excised using laparoscopic method and whether metastasis is present can be determined during the surgery. Thus, the method can enable avoiding complications secondary to total excision of lymph nodes.
LAPAROSCOPIC SURGERY PROCEDURES
MINIMALLY INVASIVE SURGERY
Laparoscopic surgery, also known as minimally invasive surgery, is performed by making small incisions (usually measuring between 0.3 - 1.5 cm in size) under anesthesia. It is a modern surgical method used for diagnostic and therapeutic purposes, which allows visualizing the abdominal cavity and, when necessary, enables treatment. Its use in gynecologic surgeries has gradually become more common recently, including gynecological cancers. Its main advantages over open method surgeries include; less bleeding during surgery, smaller scars, lower risk of surgical wound infections, lower risk of hernia at surgical wound site, less pain, faster recovery and better aesthetic results.
Method
After surgery is decided, the patients are examined to see whether laparoscopic surgery is viable. Surgical preparations are done for suitable patients. Intra-abdominal cavity is inflated with carbon dioxide while the patient is under anesthesia. Intra-abdominal organs are clearly visualized with a fiber optic telescope equipped with a light at the tip, called laparoscope, which is inserted into the body through an incision made on the abdomen. Thus, the surgeon can clearly examine the related site, using a monitor. Depending on the surgical procedure to be performed, adequate number of other laparoscopic tools are placed into the abdominal cavity with small incisions and trocars. The entire procedure is tracked on a high resolution monitor. Postoperative healing process is shorter in the case of laparoscopic surgery thanks to smaller wounds and patients require less pain killer medication since the procedure does not cause as much pain. Risks for wound site infections and potential future hernia at wound site are also lower.
Status of laparoscopy in gynecologic surgeries
Gynecological surgeries are safely performed using laparoscopic method with modern technology. The most commonly performed operations are; ovarian cyst surgery, myomectomy (excising myoma), hysterectomy (excising the uterus), tube ligation (tying fallopian tubes) and endometriosis surgery. The method is often used for diagnostic purposes such as investigating abdominal or inguinal pain, diagnosis of pelvic inflammatory disease (PID), diagnosis of ovarian cysts and checking whether fallopian tubes are intact. Hysterectomies planned due to uterine myomas, adenomyosis, treatment-resistant abnormal bleeding, endometriosis and prolapsed uterus can also be safely carried out with laparoscopic surgery method.
Status of laparoscopy in gynecologic cancers
Thanks to technological advancements and improved laparoscopic devices, minimally invasive methods have been becoming more common in treatment of endometrial (uterine wall) and cervical cancers. Laparoscopic surgery also has a role in treatment of ovarian cancer. Endometrial cancer is the most common gynecological cancer. The uterus, ovaries and, if required, lymph nodes are excised within scope of the standard treatment. Laparoscopic surgery is frequently and safely utilized in surgical staging and treatment of endometrial cancer. Chance of early diagnosis in cervical cancer has increased thanks to efficient screening policies of the present day. Cervical cancer is treated with radical hysterectomy when diagnosed early. For younger patients, ovaries are not excised but suspended outside of the pelvis in order to spare them from harms of radiotherapy. This surgery is called “ovarian transposition.” Both radical hysterectomy and ovarian transposition can be performed with laparoscopic method. However, an article published on a prestigious medical journal suggested that, compared to hysterectomy with open method, radical hysterectomy performed with minimally invasive methods are associated with lower disease-free survival rates and shorter total survival. Once this information in the literature is presented to patients and advantages as well as disadvantages of laparoscopic surgery performed with open method are re-assessed, a joint decision is made for the method to be utilized. When the patient prefers open surgery method at our clinic, instead of mid-line (incising the abdomen vertically on the mid-line), incision is made at a slightly lower location than pfannenstiel incision (location for cesarean section incisions) for better aesthetic results with open surgery method. Whether radical hysterectomy for treatment of cervical cancer is performed with laparoscopic method or open method, nerves running throughout the abdomen are preserved. Since nerves extending to the urinary bladder and to the organs at close proximity are preserved, risk for postoperative complications (difficulty urinating, inability urinating, etc.) are significantly lower.
Whether laparoscopic surgery is viable for a patient is determined through detailed preoperative assessments and imaging tests performed for endometrial and cervical cancers. Thus, the best method for the patient is selected.
Mini-laparoscopic surgery
Mini-laparoscopy is a surgical method in which tools measuring smaller in diameter compared to traditional laparoscopic tools are used. While laparoscope measuring 10 mm in diameter and auxiliary laparoscopic tools measuring 5 mm are used in traditional laparoscopy; laparoscope measuring 5 mm in diameter and auxiliary mini-laparoscopic tools measuring 3 to 3.5 mm in diameter are utilized within scope of mini-laparoscopy at our clinic. Thanks to these tools, wounds are rather small and aesthetic outcomes are fairly good. All gynecologic surgeries can safely be performed with mini-laparoscopy, including cancer surgeries performed with traditional laparoscopy.
OTHER INTERVENTIONS
CYTOREDUCTIVE SURGERY AND HYPERTHERMIC CHEMOTHERAPY
GENERAL OVERVIEW ON OVARIAN CANCER
Ovarian cancer is the second most prevalent cancer in Turkey among cancers of female reproductive organs. It is most frequently seen in women between ages of 50 to 65, however, younger or older women can be affected as well. Lifelong risk of developing ovarian cancer for a woman is approximately 1.4 percent.
There are several cancer types that can originate from ovaries; the most prevalent one is named as epithelial ovarian cancer (“epithelium” is a type of cells which cover the surface of the ovaries). These ovarian cancers require to be treated with advanced level cytoreductive surgery, through which surgical treatment is performed until no visible tumoral tissue remains. Other cancer types exist, which originate from other cells located in the ovaries. While the group of germ cell ovarian cancers usually manifest in childhood and adolescence; group of cancers originating from sex cord-stromal cells are adulthood diseases. Yet, the group of ovarian tumors is rare, which require different treatment schematics. The type of ovarian cancer whose treatment will be elaborated in the following section is epithelial ovarian cancer (cancer of ovarian surface).
RISK FACTORS
Certain factors increase the risk of developing ovarian cancer, for example:
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Having no history of pregnancy,
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Menarch at early age (when menstrual cycles start) or late menopausal age,
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Familial history of ovarian, breast or endometrial (uterine) cancer, especially in cases of specific genetic abnormality of BRCA1 or BRCA2 mutation.Familial history of the genetic condition called Lynch syndrome (hereditary non-polyposis colorectal cancer [HNPCC]).
SIGNS AND SYMPTOMS OF OVARIAN CANCER
Ovarian cancer often does not cause symptoms in early stages. Symptoms may be seen in later stages including but not limited to irritation in inguinal or abdominal regions, increased volume or distention in the abdomen, loss of appetite, sensation of fullness after consuming low amount of food, in other words early satiety.
For some women, suspicion on ovarian cancer rises when a mass lesion or a lump is palpated at a routine pelvic examination. Although, detecting a mass lesion does not necessarily mean ovarian cancer has developed. There is wide range of cases which lead to mass lesions but are not cancers (ovarian cysts, benign tumors, etc.).
Ovarian mass lesion may be coincidentally detected in certain women in light of an imaging study (ultrasound, computed tomography [CT] or magnetic resonance imaging [MRI]) performed for another reason.
However, most women are diagnosed in later stages since ovarian cancer does not cause symptoms or due to non-specific early symptoms. By this stage, more significant symptoms may develop such as abdominal pain (distention), nausea or loss of appetite.
DIAGNOSIS OF OVARIAN CANCER
If ovarian cancer is suspected based on symptoms and / or abnormal physical examination findings, imaging tests of abdomen and pelvis are often recommended as the first step of evaluation. Imaging tests may include ultrasound, computed tomography (CT) or magnetic resonance imaging (MRI) scans. These tests do not yield sufficient information to make final diagnosis of ovarian cancer; however they can provide critical information on location, size and spread of a possible cancer.
At our healthcare facility, we examine each patient with suspect of ovarian cancer before the operation with;
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Detailed physical examination and ultrasound,
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MRI scan for the entire abdominal region,
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Thorax tomography for lungs and chest region,
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Colonoscopy and gastroscopy, in order to rule out possible colonic or stomach tumors,
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Mammography and breast ultrasound, in order to detect possible breast diseases unless the patient has been recently examined,
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Blood work for analyzing CA 125, HE-4, CEA, CA19.9, CA 15.3 etc., which are tumor markers.
Note: Tumor markers (CA 125, HE-4, ROMA score) Although there is no definitive blood work to make final diagnosis on cancer, in the case of cancer suspect blood work called CA 125 and HE-4 can be performed and ROMA score can be applied, which evaluates risk of developing ovarian cancer.
Additionally, periodical follow up is recommended in case elevated CA 125 and HE-4 levels are detected after a woman is diagnosed with ovarian cancer. This helps physicians to evaluate effectiveness of treatments and to check the risk of recurrence of cancer after treatment.
Nevertheless, the only certain method for making final diagnosis of ovarian cancer is surgery. In certain cases (e.g. if surgery is not viable for the woman or if she is a candidate for chemotherapy prior to surgery) non-surgical procedures can be alternatively utilized. The procedure involves obtaining tissue or fluid from the abdomen or chest with a needle (biopsy, paracentesis or thoracentesis) for evaluation.
STAGING OVARIAN CANCER
Tumor is “staged” based on surgical findings, depending on size, spread and location of the cancer, as well as how aggressive the tumor is (can also be called “grade” of tumor). Correct staging at surgery is crucial to determine long-term result (prognosis) of the patient and whether additional postoperative treatment is viable.
Stage of ovarian cancer is designated with roman numerals (between I and IV) or letters (A, B or C). Generally, while stages I, II, III and IV refer to location of tumoral involvement; A, B and C sub-divisions define extent of tumoral involvement. Higher stage of the disease indicates more extensive tumoral involvement.
Early stage caner
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Stages I and II are considered to be early stage ovarian cancers. In Stage IA and IB diseases, cancer is limited to one or both of ovaries and capsule or membrane encompassing the ovaries is not ruptured secondary to progression of tumor.
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In stage IC disease, capsule of either ovary may have been ruptured or signs may be present suggesting cancer cells have started to spread into the pelvis (i.e. cancer cells are present in the fluid obtained from abdominal cavity during surgery).
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In stage II disease, tumor is involved with other pelvic organs such as uterus or fallopian tubes and early findings may be present, suggesting that cancer has spread into the pelvis.
Advanced stage disease
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Stages III and IV are considered to be advanced stage ovarian cancer: In stage III diseases, cancer has spread into abdominal cavity and/or abdominal lymph nodes without spread into distant areas.
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In stage IV disease, cancer has spread to other regions of the body, such as inside of the liver or lungs.
CYTOREDUCTIVE SURGERY
Surgical treatment is the most crucial and the initial stage for treating ovarian cancer. The most important principle of surgical treatment is to perform a surgery through which all tumoral tissues are patiently and diligently excised until no diseased tissue remains. Performing surgery until no diseased tissue remains is directly correlated with success of treating the disease. The surgery is known as “Cytoreductive Surgery.” First, all intra-abdominal organs and tissues are thoroughly screened for the surgery. All sites in which tumoral tissues may possibly be hidden are exposed in detail and these potentially hidden areas are explored. In the meantime, all aspects of peritoneum, the membrane that covers the stomach, omentum, which is located in the abdominal cavity and covers abdominal organs like a fatty cloth as well as lymph tissues at periphery of the uterus, ovaries, colon and small intestines, appendix, liver itself and upper and lower aspects, stomach, areas above, below and back of the stomach, spleen, pancreas, gall bladder, surface of bilateral hemidiaphragms and all abdominal major vessels (bilateral pelvic and para-aortic lymph nodes, porta hepatis and celiac lymph nodes) are diligently evaluated. All tissues that are suspected for being tumor tissue are excised. The procedure through which surgery is maintained after the specified evaluation is performed is known as primary cytoreductive surgery.
If excising the entire diseased tissue is not considered to be viable, biopsy sample may be obtained in order to diagnose the disease and surgery may be terminated. When that is the case, 3 cycles of chemotherapy is usually administered in order to alleviate the disease and enable surgical treatment. This type of treatment is known as neo-adjuvant chemotherapy and the following surgical treatment is known as interval cytoreduction surgery. At our healthcare facility, if such a case is suspected in light of preoperative imaging tests, we prefer starting surgery with closed method, which is called laparoscopy. Within scope of the procedure before switching to open surgery, we examine the intra-abdominal cavity by inserting a fine camera into the abdominal cavity through a small incision measuring half a centimeter in size. Thus, decisions can be made without opening the abdominal cavity.
At our healthcare center, we prefer primary cytoreductive surgery for the vast majority of our patients (95%). The main reason is our belief in more successful results achieved through this method. In light of researches, numerous studies can be found with supporting and conflicting results. The provisional evaluation of data collected from our patients suggests that this treatment method yields better results. These findings are currently prepared to be published in medical scientific literature.
The most important element in the success and superiority of primary cytoreductive surgery for ovarian cancer treatment is very carefully and patiently removing all tumors without leaving any diseased tissue. All tissues and organs affected by the tumor are exposed and swept in the surgery to achieve the goal. To this end, we perform total abdominal hysterectomy (removing uterus), bilateral salpingo-oophorectomy (removing bilateral ovaries), total infragastric omentectomy (removing entire omenetum), appendectomy (removing appendix), resection of colon and small intestines if necessary, splenectomy (removing spleen), distal pancreatectomy (removing pancreatic tail), cholecystectomy (removing gall bladder), total peritonectomy (removing entire abdominal membrane), peeling peritoneum of diaphragm, paracardiac lymph node dissection (removing lymph nodes that are close to heart) and, in case suspicious lymph nodes are detected, removing bilateral pelvic and paraaortic lymph nodes, porta hepatis and celiac lymph nodes. Presence of experienced surgeons who are competent in advanced surgical methods for tumors, such as gastroenterologic surgery, liver surgery, thoracic surgery and urologic surgery at a facility where these procedures are performed significantly helps with eliminating cases of inoperable tumors. Similarly, presence of an anesthesiologist who enables such surgeries to be performed and intensive care staff who are experienced in advanced surgery are crucial to obtain success. The most remarkable advantage our healthcare facility offers to surgeons and patients is availability of the mentioned facilities at our healthcare center. The rate of patients with no visible remaining tumor as a result of surgical treatment of ovarian cancer is nearly 94%. The success rate is one of the best among advanced surgical treatment facilities around the globe that perform this surgery.
HYPERTHERMIC INTRAPERITONEAL CHEMOTHERAPY (HIPEC)
Hyperthermic intraperitoneal chemotherapy (HIPEC) is among the treatments that are offered at our healthcare facility. Within scope of the treatment, fluid containing chemotherapy drug and warmed up to 42 Celsius degrees is circulated through abdominal cavity for 1 to 1.5 hours via tubes placed into the abdominal cavity after surgery is completed. A special device is required for the procedure. One of the advantages of the procedure is the ability to administer much higher dose of chemotherapy drugs into the abdominal cavity compared to that of administered through intravenous route. Even if dose of medication is high, systemic toxicity is minimal since it is only administered into the abdominal cavity. Moreover, since the procedure is performed at the end of the surgery and since all sites are thoroughly exposed for the surgery, the fluid can reach the entire abdominal cavity. Also, heat has directly lethal effect on cancer cells, which makes cancer cells more vulnerable to chemotherapy drugs.
Numerous researches have been conducted on hyperthermic intraperitoneal chemotherapy (HIPEC). These researches show that hyperthermic intraperitoneal chemotherapy (HIPEC) offers advantages both for the initial surgery and surgery that is performed due to recurring disease. Many researches on the topic are ongoing. However, HIPEC is still not the standard procedure for treatment of ovarian cancer. Thus, we thoroughly discuss possible side effects and benefits of the procedure with our patients and perform the procedure accordingly at our healthcare facility. We have an ongoing study on results of the procedure at our healthcare facility which we conduct with other healthcare centers that perform HIPEC in Turkey. We plan on presenting the related results in form of a scientific publication soon.