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INTRODUCTION

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Minimally invasive surgery is currently considered a safe and viable option in the management of most gynecologic malignancies. Compared to standard laparotomy, laparoscopic or robotic surgery is associated with lower blood loss and transfusion rates, lower intraoperative complication rates, decreased analgesic requirements in the immediate postoperative period, shorter length of hospitalization, lower postoperative complication rates, quicker return of bowel function, and improved short-term quality of life.

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This chapter provides an overview of the standard laparoscopic procedures and robotic surgery. Details on the preoperative evaluation and postoperative care of patients undergoing the procedures described and specific steps for the more commonly performed procedures are provided. Because the anatomical dissections are the same as for open procedures (see Chapters 25 and 26), the illustrations and figures are limited to those aspects specific to the minimally invasive surgical approach.

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LAPAROSCOPIC SURGERY

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Cervical Cancer

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Laparoscopic Radical Hysterectomy
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Procedure Overview
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Since the initial publications by Nezhat et al1 and Canis et al,2 several retrospective studies have documented the safety and feasibility of total laparoscopic radical hysterectomy (TLRH), with a major complication rate of just 5%.3 In a study by Frumovitz et al,4 the authors compared 35 women who had undergone TLRH to 54 women who had open radical hysterectomy (ORH) and found significantly less blood loss, shorter length of hospital stay, and increased operative time for the TLRH group. Transfusion rates were low in both groups (15% for ORH vs. 11% for TLRH). Intraoperative and postoperative noninfectious complications were the same for both groups, but the ORH group had a significantly higher postoperative infectious complication rate than the TLRH group (53% vs. 18%, respectively). These complications included postoperative febrile morbidity, wound cellulitis, urinary tract infections, pneumonia, and intra-abdominal abscesses.

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In evaluating oncologic outcomes, it appears that there is equivalency between TLRH and ORH. In their large series of 295 women who underwent TLRH, Chen et al3 reported overall disease-free survival rates of 95% for women with stage IA disease and 96% for women with stage IB disease.

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Box 31-1 Master Surgeon's Corner

  • Proper patient positioning with steep Trendelenburg will facilitate pelvic exposure and dissection.

  • Develop the avascular paravesical and pararectal spaces early in the course of operation to facilitate exposure to the parametria for ureteral dissection.

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Preoperative Management
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Patients with early-stage cervical cancer scheduled for a radical hysterectomy should routinely undergo a chest x-ray and blood type and cross. The use of other imaging modalities such as computed tomography (CT) or magnetic resonance imaging (MRI) scans is not recommended, unless there is evidence to suspect metastatic disease.

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All patients should undergo bowel preparation 1 day prior to surgery and receive antibiotic prophylaxis on the day of surgery. The choice of bowel preparation used ...

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