Keywords hysterectomy - cervical cancer - single-site robotic laparoscopy - lymphadenectomy
- robotics - laparoendoscopic single-site surgery
Palavras-chave histerectomia - câncer do colo do útero - laparoscopia robótica de sítio único - linfadenectomia
- robótica - cirurgia laparoendoscópica de sítio único
Introduction
Laparoscopic and robotic surgeries for cervical cancer are becoming the standard surgical
treatment in most oncologic centers around the world. These procedures have several
advantages compared with laparotomic surgeries, including improved quality of life
and better surgical outcomes.[1 ]
Most minimally invasive surgeries, laparoscopic or robotic, are already being performed
by a multiport approach, which is responsible for some risks, such as pain, bleeding,
hernia, or infection associated with multiple incisions.[2 ]
The concept of laparoendoscopic single-port surgery emerged as a procedure less invasive
than multiport laparoscopy, and it was recently incorporated by robotic surgery. Robotic
single-site surgery has many advantages compared with the multiport approach,[3 ]
[4 ]
[5 ]
[6 ] but its safety and feasibility are still being investigated in radical oncologic
surgeries.
Case Report
Patient: a 42-year-old, multiparous, two previous C-section patient was diagnosed,
by cold-knife cone biopsy, with a Federation of Gynecology and Obstetrics (FIGO) stage
IB1 cervical adenosquamous cell carcinoma. The body mass index was 21.3. The physical
examination showed no visible residual disease. The magnetic resonance imaging examination
showed a cervical tumor of 1.8 cm, without any radiologic signs of deep invasion or
lymph node enlargement. The patient underwent a robotic single-site radical hysterectomy
and sentinel lymph node mapping using indocyanine green followed by complete pelvic
lymph node dissection.
Surgical technique: The patient under combined anesthesia was placed in the semidorsal
lithotomy position and then drapped. After bladder catheterization, a speculum was
placed for cervical visualization, and 1 mg indocyanine green was injected into the
cervix (0.5 mg/ml at 3 and 9 hours; [Fig. 1 ]) in order for the sentinel lymph node mapping to be detected by SPY fluorescence
image (SPY System; Novadaq Technologies, Concord, ON, Canada). Cervical dilatation
was performed, and a Clermont Ferrant uterine manipulator (Karl Storz GmbH & Co. KG,
Tuttlingen, Germany) was fixed onto the cervix. The access was performed through the
umbilicus, in the midline. A 2.5 cm incision was made using all the umbilical scar
length, opening the peritoneal cavity and double-checking the security of this entrance.
The single-site port was inserted into the abdominal cavity using an atraumatic forceps,
and the arrow drawn on the port was set in the direction of the target organ (uterus
and pelvic nodes; [Fig. 2 ]). The pneumoperitoneum was low flow inflated at a pressure of 15 mmHg. The trendelemburg
position was applied, and the bowel was placed with a laparoscopic grasper through
the assistant place. The da Vinci® Xi System (Intuitive Surgical, Sunnyvale, CA) was
docked between the patient's legs. A 3D 8.5 mm endoscope was used in the camera arm,
and a monopolar hook and a bipolar Maryland forceps were used on the right and left
hands respectively. Adhesiolysis from the epiploon and anterior abdominal wall was
performed to improve the vision and surgical field. The near-infrared (NIR) image
SPY highlighted in fluorescent green three retroperitoneal nodules, two on the right
and one on the left. On the right side, one nodule was located in the bifurcation
of the external and internal iliac arteries, and the other was medial of the right
common iliac artery lateral to the left common iliac vein. On left side we identified
three sentinel nodes between internal and external iliac arteries. The three sentinel
lymph nodes were collected ([Fig. 3 ]) for pathological ultrastaging. No frozen section was realized. The t-lift® device
(Vectec, Hauterive, France) was used for bilateral ovary suspension. The posterior
U-cut, a Puntambekar et al[7 ] technique, was performed to expose both ureters. A bilateral salpingectomy followed
for the anterior peritoneum and bladder dissection from the uterus on the caudal direction.
The uterine artery was coagulated with a bipolar Maryland forceps close to the internal
iliac artery, and the parametrial anterior dissection was performed bilaterally with
ureteral tunnelization until the bladder. Hypogastric nerves were identified bilaterally
and saved. A Querleu/Morrow type C1 radical hysterectomy was performed. A bilateral
pelvic lymph node dissection was performed using only bipolar and monopolar energy
from the ForceTriad platform (Covidien; Medtronic, Minneapolis, MN, US). No vessel
sealing or ultrasonic energy was used. All surgical specimens were extracted from
the abdominal cavity through the vagina, without any bag. A careful hemostasis was
performed before the vaginal cuff closure. The vaginal cuff closure was started internally,
but was aborted due to the absence of the single-site needle driver, and was done
vaginally with Caprofyl 2–0 (Caprofyl®, Ethicon Inc, Bridgewater, NJ, US). The robot
was undocked, and the single-site port was taken out. The umbilical incision was sutured
in planes with number 2 prolene thread on the aponeurosis, and monocryl 4–0 (Ethicon,
Cornelia, Georgia, US) under the skin ([Fig. 4 ]).
Fig. 1 Cervical injection of indocyanine green (1 ml on each side).
Fig. 2 Single-site port. The five-lumen port provides access for two single-site instruments:
the 8.5 mm 3DHD endoscope, a 5/10 mm accessory port, and an insufflation adapter.
Fig. 3 Sentinel lymph node mapping with indocyanine green.
Fig. 4 Umbilicus at the end of the surgery.
Pathological examination: The uterus weighed 85 g and measured 8.8 × 5.0 × 3.2 cm.
There was bilateral parametrial and vaginal cuff. The gross examination of the specimen
revealed an ulcer in the periorificial cervical area ([Fig. 5 ]). The histological examination revealed a histological grade 2 cervical adenosquamous
carcinoma measuring 3.0 × 2.1 × 1.8 cm associated with multifocal lymphovascular space
invasion. The maximum level of infiltration of the cervical wall was 0.7 cm (54% thickness).
The parametrial and vaginal cuff as well as the surgical margins were free of neoplasia.
There was an intraparametrial lymph node with metastasis. The three sentinel lymph
nodes and the pelvic lymph nodes dissected (8 to the left pelvic chain and 9 to the
right) were free, totalizing a nodal status of 1/21.
Fig. 5 Surgical specimen: uterus and vaginal margins.
Evolution: The patient recovered very well, and was discharged from the hospital after
24 hours.
Discussion
Cervical cancer remains highly prevalent worldwide, particularly in lower- and middle-income
economies. The standard treatment for early-stage cervical cancer is radical hysterectomy,
which, although effective, is associated with serious morbidities. A systematic review
and meta-analysis was conducted to compare the intraoperative and postoperative complications
of robotic radical hysterectomy and other surgical methods. Robotic surgery is superior
to abdominal surgery, with lower blood loss, shorter hospital stay, lower febrile
morbidity, and lower wound-related complications.[8 ] Robotic and laparoscopic surgeries are comparable in the same study. The laparoendoscopic
single-site access reduces postoperative pain and analgesia use compared with the
multiport conventional laparoscopy in a benign disease.[9 ] Although laparoendoscopic radical hysterectomy with pelvic lymphadenectomy appears
safe and feasible,[10 ] it has not gained wide acceptance due to a lack of flexibility inside the cavity.
The robotic approach for single-site procedures has the potential advantage of better
surgeon comfort.
Robotic laparoendoscopic single-site radical hysterectomy for uterine malignancies
is a very recent and innovative surgical procedure, wherein the surgeon operates exclusively
through a single skin incision within the umbilicus. This procedure evolved from laparoscopic
single-port and multiport robotic surgery, with many advantages. It is expected to
have lesser complications from multiple access and better cosmesis, like single-port
laparoscopy, but under more ergonomic conditions for the surgeon. The procedure has
been reported as feasible and safe in benign conditions, although there are only a
few cases reported with this approach for gynecologic cancers.[3 ]
[11 ]
[12 ]
[13 ]
[14 ] In a retrospective case-control study comparing robotic single-site to robotic multiport
hysterectomy in early-stage endometrial cancer, Corrado et al[14 ] found similar operative times, lower blood loss, lower hospital stay days, and lower
costs with the single-site approach.[14 ]
The single-site approach comes as an upgrade of the minimally invasive surgeries,
first of all, because of the cosmetic results. It is unquestionable that one umbilical
single incision looks better than two or more surgical wounds, and this is an important
factor for cancer patients and their self-esteems. Nevertheless, some technical issues
should be considered. Surgeons are obliged to deal with arched instruments that cross
through the single-site device reaching the cavity in an inverted position. Assistants
holding the camera must keep their arm in between the surgeon's hands, conflicting
with the first approach and causing image instability. Inside the cavity, the instruments
lack triangulation and flexibility. One by one, all of these few details compromise
the surgeon's capability, leading to a decrease in performance and an increase in
the risks.[15 ]
Robotic surgery improved surgical gestures such as camera stability, less tremors,
articulated instruments, and 3D visualization. Likewise, single-site robotic surgery
developed not only with previous robotic characteristics, like a superior range of
motion, but also by canceling the crossing effect of instruments. The software allows
the surgeon to control the ipsilateral device as seen on screen. The surgeon's ergonomy
is also improved. The doctor remains in a chair, with arms resting on a comfortable
support while controlling the instruments. The available single site for the da Vinci®
Xi System with lack of wrist movement represents a downgrade compared with the conventional
multiport robotic approach. An important detail is that it not only obliges the surgeon
to be experienced in classic laparoscopic gestures, but also requires that the whole
surgical team be extremely synchronized. A simple suction and irrigation procedure
requires a close collaboration between the console surgeon and the bedside assistant.
The latest da Vinci® Xi System was upgraded with articulated instruments, and brings
some advantages back. Several snake-like robots are currently under development. The
flexible architecture and multiple degrees of freedom make this concept the most suitable
one for robotic single-site surgeries.[16 ]
In the era of minimally invasive surgeries and significant advances in adjuvant therapies
and imaging methods, the role of systematic lymphadenectomies is under debate, and,
in many cancers, they have been replaced by less extensive procedures, such as sentinel
lymph node biopsy. There are increasing data to suggest that sentinel lymph node mapping
for cervical cancer is a sensitive tool in the detection of lymph node metastasis.[17 ] The traditional techniques of sentinel lymph node mapping use blue dyes (isosulfan
or methylene blue) and radiolabeled isotopes such as technetium 99 (Tc99) microsulfur
colloid, alone or in combination. These techniques can be challenging to master with
prolonged learning curves.[18 ] A new feasible technique was introduced (using indocyanine green and NIR imaging)
to detect the sentinel lymph node fluorescing dye. It has the accumulative benefits
of visibility (like from the blue dye) and of the penetration of the signal from the
intact tissue (from the nuclear tracer techniques) in a single modality.[17 ]
[19 ] Fluorescence imaging can be used in laparotomic, laparoscopic, and robotic surgeries.[17 ]
[19 ]
[20 ]
[21 ]
Conclusion
Single-site robotic radical hysterectomy is a feasible procedure in early-stage invasive
cervical cancer. In our case, indocyanine green mapping allowed us to identify sentinel
lymph nodes in both sides, all of them negative, as well as all the pelvic lymph nodes.
Although a positive intraparametrial microscopic lymph node was found, it was located
in the proximal parametrium, just beside the injection area. All resection margins
were free of neoplasia.
