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Minimally Invasive
Laparoscopic Surgery (MILS)

Overview
Eligibility & Quetelet Index Scores
Detailed Discussions
Video: Laparoscopic Hysterectomy, Aortic & Pelvic Lymph Node Dissection

Overview

The physicians at the Women's Cancer Center have helped pioneer the use of Minimally Invasive Laparoscopic Surgery (MILS) for the treatment of patients with gynecological malignancies. MILS offers select patients the opportunity to have 1)complete surgical staging without the morbidity associated with traditional surgical staging and 2) interval surgical staging if the initial surgery did not include adequate evaluation of the abdominal cavity and/or the pelvic and aortic lymph nodes. Similar surgical techniques can be applied to patients with uterine sarcomas.

MILS, in our opinion, is less morbid because the incisions made are significantly smaller than those associated with traditional surgery. Figure M1 demonstrates the obvious differences. It is not surprising that patients undergoing MILS require less pain medication than those who undergo traditional surgery. This, combined with the fact that there is less manipulation of the intestines, most likely accounts for the early return of bowel function and therefore the earlier discharge home. Our recent publication in the American Journal of Obstetrics and Gynecology discusses in detail the shortened hospital stay associated with this procedure.

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Eligibility

Surgery on obese patients has an increased rate of complications. This is also true for MILS. To minimize potential complications, we normally only perform MILS in patients with an obesity or Quetelet index ‹30. The National Cancer Institute (NCI) imposed similar restrictions in early feasibility studies but has now increased the index to allow the MILS surgery with Quetelet indexes up to 35. However, it is currently our opinion that patients with endometrial cancer should not be denied the opportunity to undergo MILS based solely on the calculation of their Quetelet index.

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Quetelet Index

The Quetelet index is a formula defined by dividing weight in kilograms by the square of the height in meters. Often called QI, scores can be divided into certain ranges:

0 - 18.5    Weight is too low. 
18.6 - 25   Healthy weight range.
26 - 30     1st degree; Increased risk for 
                weight-related health problems.
31 plus     High risk for weight-related 
                health problems         

NOTE: To calculate your own Quetelet index, try our online calculator


If your Quetelet index is greater than 35, that does not mean you cannot have MILS. However, it may be more difficult to accomplish and this risk factor will need to be discussed in more detail during an office visit.

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Surgery

Approximately 90% of patients undergoing MILS will have their surgery completed successfully. The remaining 10% will have their surgery completed via a traditional incision. The three most common reasons to abandon a MILS procedure are 1) bleeding, 2) disease found outside the uterus requiring more extensive surgery than is either possible or reasonably performed using MILS, and 3) inadequate exposure either related to obesity or adhesions from a previous surgery.

With increasing expertise in the MILS procedure, both the length of surgery as well as days spent in the hospital by our patients have decreased. Currently, the vast majority of our patients are discharged home within 36 hours of undergoing surgery.

Detailed Discussions

To better understand the use and potential advantages of MILS for each type of cancer, please select one of the following:

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Minimally Invasive Laparoscopic Surgery in Endometrial Cancers or Uterine Sarcomas

Endometrial Cancer is the most frequently occurring gyencologic malignancy. Although it is commonly thought to be curable with hysterectomy alone, or in combination with radiation therapy, often complete knowledge as to how far the disease has spread is unknown. Surgical staging is needed to determine this information, including pelvic and aortic lymph node dissection.

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Minimally Invasive Laparoscopic Surgery
in Cervical and Vaginal Cancer

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.

Early Stages

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 applications of these techniques have far reaching consequences, especially to patients with cervical cancer who wish to preserve their ability to conceive. Dargent et al, described their experience performing radical trachelectomy and laparoscopic lymph node dissection.

At the Women's Cancer Center we have performed this procedure for over two years. Patients are advised that long term follow-up data regarding recurrence rates are not available at this time and, therefore, they need to be followed closely.

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Minimally Invasive Laparoscopic Surgery
and Ovarian Cancer

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.

MILS in Early Stage Ovarian Cancer

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.

MILS in Advanced Stage Ovarian Cancer

The role of MILS in patients with advanced ovarian cancer is less well defined. Traditionally, patients with obvious advanced ovarian cancer should undergo cytoreductive surgery with an attempt to reduce the tumor volume to as little as possible. The goal is to leave no visible tumor as those patients have been shown to have the longest median survivals.

However, some patients have disease that is distributed in such a manner as to make optimal cytoreductive surgery impossible. Most large studies show that approximately 20-25% of patients with advanced ovarian cancer will not have optimal cytoreductive surgery. For more information, request the article by Dr. Spirtos et al, Aortic and Pelvic Lymph Node Dissection in Ovarian Cancer.

It could be argued that these patients would benefit from a lesser initial operation (i.e. laparoscopy), followed by chemotherapy (3 cycles), then reoperation, hopefully with significantly less tumor present, allowing for a more complete cytoreductive effort. This approach for patients with advanced ovarian cancer is also being investigated by the GOG Protocol 158.

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MILS in Reassessment Surgery

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.

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Summary of MILS in Gynecology Oncology

In May of 1992, the Women's Cancer Center made a decision that Minimally Invasive Laparoscopic Surgery (MILS) techniques should be evaluated and, if promising, incorporated into the practice of gynecologic oncology. Clearly, great strides have been made in this field and MILS techniques are now offered as dictated by the preferences of the individual patient. However, it is important that the patient understand that these procedures should be performed by a qualified gynecologic oncologist who has experience in the proposed procedure either using traditional surgical methods or MILS.

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