The role of Minimally Invasive Laparoscopic Surgery (MILS)in patients with cervical cancer has become more clearly defined over the past two years months. Initially, thoughts of how to incorporate MILS in treatment focused on those patients with advanced disease (Stage II-IV).

Advanced Disease

The importance of identifying the presence of lymph node metastases, especially aortic lymph node metastases, has been well established. In 1978, Dr. Samuel Ballon of the Women's Cancer Center published data demonstrating that, when identified, these patients could be cured if the radiation fields were extended to include the aortic lymph nodes. Obviously, if the lymph nodes are not biopsied, the presence or absence of disease cannot be accurately determined.

CT scan and MRI have proven to be inadequate in determining lymph node involvement. Thus, historically, biopsies of the lymph nodes required either an exploratory laparotomy or, preferentially, an extraperitoneal laparotomy as described by Dr. Ballon et al. The advantages of the extraperitoneal laparotomy include fewer complications as the peritoneal cavity is not entered and adhesion formation is minimized.

Initial laparoscopic approaches were performed transperitoneally and, for the most part, continue to be performed in this fashion as much of the evidence in our literature suggests adhesion formation is decreased when surgical procedures are performed laparoscopically. Because of this, the need to use a retroperitoneal approach may not be as important when having surgery performed using a traditional incision.

At the Women's Cancer Center, we are currently working with Dr. Carlos Gracia to develop a balloon dissection technique to perform laparoscopic retroperitoneal aortic and pelvic lymphadenectomy. A video of this technique will soon be available.

The use of MILS in patients with early invasive cervical cancer has been developed at the Women's Cancer Center. John B. Schlaerth, MD authored protocol 9207 for the Gynecology Oncology Group (GOG). This protocol was developed to test the feasibility of performing a therapeutic lymph node dissection in patients with early cervical cancer.

To test the adequacy of the lymph node dissection patients first underwent a laparoscopic lymph node dissection followed by an exploratory laparotomy. This study is presently undergoing statistical analysis and the results will be published by the GOG. Using our initial experiences as a spring board, our group moved forward, applying MILS surgical techniques not only to pelvic and aortic lymph node dissection, but also to the successful performance of the radical (Type III) hysterectomy.

The results of this effort were recently published in the American Journal of Obstetrics and Gynecology, available by request for your review. We believe that for selected patients MILS can be performed safely with shorter hospitalizations, more rapid recovery, and without compromising the basic principles of oncologic surgery.

The role of laparoscopic surgery in ovarian cancer can be explained best by determining the reasons for the surgery. For the purpose of this discussion we will break down the indication for MILS and ovarian cancer into three categories.

Patients with "early-stage ovarian cancer" more often have incorrectly staged cancer. Simply examining the abdomen is not enough to make an adequate assessment of the spread of the disease. Young et al, first reported that approximately 30% of patients thought to have stage I ovarian cancer were incorrectly assessed. Patients were found to have unsuspected involvement in one or more areas. The more usual locations were the diaphragm, the omentum, and the lymph nodes. These patients, after undergoing operative reassessment, required further treatment, i.e. chemotherapy. Research at Georgetown University also found that ovarian cancer patients often had incomplete surgical staging.

For the most part, patients with incomplete surgical staging are forced to make decisions regarding potentially toxic therapy with incomplete information. Until recently, the only means to completely stage a patient was to reoperate with the obvious morbidity and recovery time associated with it.

The GOG has opened Protocol 9042 designed to study the feasibility of completing surgical staging using MILS. The physicians at Women's Cancer Center have coauthored this protocol and have significant experience in performing these procedures. In patients who are preoperatively suspected of having early stage ovarian cancer, complete surgery is now possible using MILS techniques. All peritoneal surfaces can be inspected, the omentum can be removed, as can the pelvic and aortic lymph nodes and reproductive organs if so indicated by the intraoperative findings. When a diagnosis is unclear, obviously laparoscopy offers the patient, as well as the physician, a means to to make a more accurate diagnosis prior to committing to a final treatment plan.

Reassessment laparotomy refers to a reoperation following initial surgery (maximal surgical effort) and chemotherapy. The goal of this operation is to determine a patient's disease status. Based on this information, a patient and her physician can make a decision either to discontinue therapy or perhaps to undergo radiation therapy. Many physicians state that a second-look surgery is controversial, but no prospective randomized study has ever been completed in this country that supports such a position. In fact, our analysis of the literature finds that in virtually every series of second look operations, a group of patients has been identified with persistent disease and therefore benefitted from additional therapy. A bibliography of these studies is available.

One of the obvious downsides associated with reassessment surgery is the morbidity associated with the exploratory laparotomy. Most likely the morbidity associated with the procedure can be decreased by using MILS. There have been no prospective studies designed to evaluate the feasibility of performing this procedure and the Women's Cancer Center strongly believes that this should be done as a cooperative group effort similar to the other studies being undertaken by the GOG. Efforts are being made to complete this study. Until this is done, patients and their physicians will have to individually discuss the risks of laparoscopy including possible limitations of the procedure that are not obvious at this time.