Pedro F. Escobar

Laparoendoscopic single-site surgery (LESS) in gynecologic oncology: Technique and initial report

OBJECTIVES Recent reports suggest that laparoendoscopic single-site surgery (LESS), also known as single-port surgery, is technically feasible in treating a variety of disease processes. The purpose of this study was to assess the feasibility of LESS for the surgical treatment of various gynecologic cancers or precancerous conditions through both laparoscopic and robotic-assisted approaches. METHODS A single institution retrospective review of patients treated with LESS on the gynecologic oncology service in 2009 was performed. Patients underwent surgery through a single 2-3 cm umbilical incision with a multi-channel SILS port for laparoscopic cases or a single-channel Gelport for robotic cases on the daVinci Surgical System. RESULTS Thirteen patients had LESS surgery performed, nine done laparoscopically and four robotically. Procedures included endometrial cancer staging (n=1), ovarian cancer staging (n=1), retroperitoneal pelvic lymph node dissection (n=1), risk-reducing extrafascial hysterectomy/bilateral salpingo-oophorectomy (BSO, n=2) and BSO alone (n=5), and an ovarian cystectomy (n=1) and BSO (n=2) for complex adnexal masses. Median patient age and BMI were 47 years and 28, respectively. Median operating time was 65 min. All procedures were successfully performed via a single incision and no post-operative complications occurred. The majority of patients required no narcotics post-operatively. CONCLUSION We present the first series of laparoendoscopic single-site surgery for the treatment of various gynecologic oncology conditions. LESS is feasible in select patients by laparoscopic or robotic-assisted techniques. Further studies are needed to better define the ideal gynecologic procedures for single-site surgery and to assess the benefits of LESS compared with more conventional minimally invasive approaches.

Novel Robotic da Vinci Instruments for Laparoendoscopic Single-site Surgery

OBJECTIVES To describe novel robotic laparoendoscopic single-site surgery (R-LESS) instruments, and present the initial laboratory experience in urology. METHODS The VeSPA surgical instruments (Intuitive Surgical, Sunnyvale, CA) were designed to be used with the DaVinci Si surgical system. A multichannel port and curved cannulae were inserted through a single 3.5-cm umbilical incision. The port allowed 1 scope, 2 robotic instruments, and a 5- to 12-mm assistant instrument. Four pyeloplasties (right 2, left 2), 4 partial nephrectomies (right 2, left 2), and 8 nephrectomies (right 4, left 4) were performed in 4 female farm pigs (mean weight, 34.5 kg). Technical feasibility and efficiency were assessed in addition to perioperative outcomes. RESULTS All 16 R-LESS procedures were performed successfully without the addition of laparoscopic ports or open conversion. Mean total operative time was 110 minutes (range, 82-127), and mean blood loss was 20 mL (range, 10-100). Mean warm ischemia time for partial nephrectomy was 14.8 minutes (range, 12-20). There were no intraoperative complications. No robotic system failures occurred, and robotic instrument clashing was found to be minimal. One needle driver malfunctioned and assistant movement was limited. CONCLUSIONS R-LESS kidney surgery using the VeSPA instruments is feasible and efficient in the porcine model. The system offers a wide range of motion, instrument and scope stability, improved ergonomics, and minimal instrument clashing. Although preliminary experience is encouraging, further refinements are expected to optimize urological applications of this robotic technology.

Robotic-assisted laparoendoscopic single-site surgery in gynecology: initial report and technique.

Robotic surgery has greatly improved surgeon dexterity and ergonomics but has substantially increased the number and size of ports required. The typical robotic surgical procedure will use three 8-mm ports and two 12-mm ports. Single-port laparoscopy, also known as Laparo-Endoscopic Single Site (LESS) surgery, is an attempt to further enhance cosmetic benefits and reduce morbidity of minimally invasive surgery.We present our initial clinical experience and technique with robotic-assisted single-port surgery in gynecology.

Laparoendoscopic single-site surgery (LESS) in gynecology: a multi-institutional evaluation

OBJECTIVE The study objectives were to determine the surgical outcomes of a large series of gynecology patients treated with laparoendoscopic single-site surgery (LESS). STUDY DESIGN This was a retrospective, multi-institutional analysis of gynecology patients treated with LESS in 2009. Patients underwent surgery via a single 1.5- to 2.5-cm umbilical incision with a multichannel single port. RESULTS A total of 74 women underwent LESS. Procedures were performed for benign pelvic masses (n = 39), endometrial hyperplasia (n = 9), endometrial (n = 15) and ovarian (n = 6) cancers, and nongynecologic malignancies (n = 5). Median patient age and body mass index were 47 years and 28, respectively. A Pearson product-moment correlation coefficient was computed and demonstrated a significant linear relationship between the operating time and number of cases for cancer staging (r = -0.71; n = 26; P < .001) and nonstaging (r = -0.78; n = 48; P < .002) procedures. Perioperative complications were low (3%). CONCLUSION LESS is feasible, safe, and reproducible in gynecology patients with benign and cancerous conditions. Operative times are reasonable and can be decreased with experience.

Hypoxia Enhances Lysophosphatidic Acid Responsiveness in Ovarian Cancer Cells and Lysophosphatidic Acid Induces Ovarian Tumor Metastasis In vivo

Lysophosphatidic acid (LPA) is elevated in ascites of ovarian cancer patients and stimulates growth and other activities of ovarian cancer cells in vitro. Tissue hypoxia is a critical factor for tumor aggressiveness and metastasis in cancers. We tested whether the ascites of ovarian cancer is hypoxic and whether hypoxia influences the effects of LPA on ovarian cancer cells. We found that ovarian ascitic fluids were hypoxic in vivo. Enhanced cellular responsiveness to LPA, including migration and/or invasion of ovarian cancer cells, was observed under hypoxic conditions. This enhancement could be completely blocked by geldanamycin or a small interfering RNA targeting hypoxia-inducible factor 1 alpha (HIF1 alpha). LPA-induced cell migration required cytosolic phospholipase A(2) (cPLA(2)) and LPA stimulates cPLA(2) phosphorylation in a HIF1 alpha-dependent manner under hypoxia conditions. Furthermore, we show for the first time that exogenous LPA enhances tumor metastasis in an orthotopic ovarian cancer model and HIF alpha expression in tumors. 17-Dimethylaminoethylamino-17-demethoxygeldanamycin (an inhibitor of the heat shock protein 90) effectively blocked LPA-induced tumor metastasis in vivo. Together, our data indicate that hypoxic conditions are likely to be pathologically important for ovarian cancer development. HIF1 alpha plays a critical role in enhancing and/or sensitizing the role of LPA on cell migration and invasion under hypoxic conditions, where cPLA(2) is required for LPA-induced cell migration.

Laparoendoscopic single-site (LESS) surgery in patients with benign adnexal disease

OBJECTIVE To present our initial experience in laparoscopic surgery for benign adnexal disease performed exclusively through an umbilical incision using a single three-channel port and flexible laparoscopic instrumentation. DESIGN Case report. SETTING Tertiary-care referral center. PATIENT(S) Since November, 2008, we have performed single-port laparoscopic surgery in nine patients diagnosed with benign adnexal disease. Patients with adnexal masses or endometriosis and a body mass index of <35 kg/m(2) were selected. INTERVENTION(S) Laparoendoscopic single-site (LESS) surgery. In each case, a multichannel port was inserted into the peritoneum through a 1.5-2.0-centimeter umbilical incision. MAIN OUTCOME MEASURES Feasibility, postoperative pain score, age, BMI, estimated blood loss. RESULT(S) Eight of nine cases were completed successfully, without conversion to a standard laparoscopic approach or to laparotomy. An additional 3 mm extraumbilical port was required in one patient with stage 4 endometriosis. Seven out of nine patients had earlier abdominal surgery. The operative blood loss ranged from minimal to 75 mL. Duration of hospital stay was <24 hours in all cases. Minimal use of postoperative narcotics was required, and no intraoperative complications occurred. CONCLUSION(S) The LESS surgery for benign adnexal disease is feasible in patients with or without earlier surgery. Additional investigation is needed to evaluate the safety and long-term outcomes of this new approach.

Laparoendoscopic single-site surgery in gynecology: review of literature and available technology.

The objective of this article was to review the published literature on laparoendoscopic single-site surgery (LESS) in gynecology and to present current advances in instruments used in LESS surgery. Inasmuch as LESS surgery is relatively new, the current literature on use of this technique in gynecology is somewhat limited. Sixteen articles were available for the literature review: 10 case series, 2 comparative studies, 3 case reports, and 1 surgical technique demonstration. In recent years, however, improvements in traditional laparoscopic techniques and availability of more advanced instruments has made single-incision laparoscopy more feasible and safer for the patient. There is increasing interest in LESS surgery both as an alternative to traditional laparoscopy and as an adjunct to robotic surgery when performing complicated procedures through a single incision. Although LESS surgery provides another option in the arena of minimally invasive gynecologic surgery, the ultimate role of this approach remains to be determined.

Robotic Surgery in Gynecology: An Updated Systematic Review

The introduction of da Vinci Robotic Surgery to the field of Gynecology has resulted in large changes in surgical management. The robotic platform allows less experienced laparoscopic surgeons to perform more complex procedures. In general gynecology and reproductive gynecology, the robot is being increasingly used for procedures such as hysterectomies, myomectomies, adnexal surgery, and tubal anastomosis. Among urogynecology the robot is being utilized for sacrocolopexies. In the field of gynecologic oncology, the robot is being increasingly used for hysterectomies and lymphadenectomies in oncologic diseases. Despite the rapid and widespread adoption of robotic surgery in gynecology, there are no randomized trials comparing its efficacy and safety to other traditional surgical approaches. Our aim is to update previously published reviews with a focus on only comparative observational studies. We determined that, with the right amount of training and skill, along with appropriate patient selection, robotic surgery can be highly advantageous. Patients will likely have less blood loss, less post-operative pain, faster recoveries, and fewer complications compared to open surgery and potentially even laparoscopy. However, until larger, well-designed observational studies or randomized control trials are completed which report long-term outcomes, we cannot definitively state the superiority of robotic surgery over other surgical methods.

Lysophosphatidic acid downregulates tissue inhibitor of metalloproteinases, which are negatively involved in lysophosphatidic acid-induced cell invasion

Ovarian cancer is a highly metastatic disease. Lysophosphatidic acid (LPA) levels are elevated in ascites from ovarian cancer patients, but its potential role in ovarian cancer metastasis has just begun to be revealed. In this work, we show that LPA stimulates invasion of primary ovarian cancer cells, but not ovarian epithelial or borderline ovarian tumor cells, although these benign cells indeed respond to LPA in cell migration. We have found that LPA downregulates tissue inhibitor of metalloproteinases (TIMPs). TIMP2 and TIMP3 play functional role in LPA-induced invasion as negative regulators. Gi protein, phosphatidylinositol-3 kinase (PI3K), p38 mitogen-activated protein kinase (MAPK), cytosolic phospholipase A2 and urokinase type plasminogen activator (uPA) are required for LPA-induced cells invasion. TIMP3 may affect two independent downstream targets, vascular endothelial growth factor receptor and p38 MAPK. In vivo, LPA stimulates tumor metastasis in an orthotopic ovarian tumor model, which can be inhibited by a PI3K inhibitor, LY294002. In summary, LPA is likely a key component for promoting ovarian metastasis in vivo. LPA downregulates TIMP3, which may have targets other than metalloproteinases. Our in vivo metastasis mouse model is useful for studying the efficacy of therapeutic regimes of ovarian cancer.

First 100 early endometrial cancer cases treated with laparoendoscopic single-site surgery: a multicentric retrospective study

OBJECTIVE We sought to assess feasibility and perioperative outcomes for laparoendoscopic single-site surgery (LESS) in early endometrial cancer. STUDY DESIGN This was a retrospective multicentric study of 100 early endometrial cancer cases undergoing LESS from July 2009 through July 2011. RESULTS All patients underwent total hysterectomy and bilateral salpingo-oophorectomy by LESS. Pelvic and paraaortic lymphadenectomy were performed in 48 and 27 patients, respectively. A median of 16 pelvic lymph nodes (range, 1-33) and 7 paraaortic lymph nodes (range, 2-28) were retrieved. Both median operative time (129 minutes; range, 45-321) and estimated blood loss (70 mL; range, 10-500) were greater when staging lymphadenectomy was performed (P values = .001). Four intraoperative and 4 postoperative complications were observed. Conversion to standard laparoscopy and laparotomy was necessary for completion of 1 case each. Patients responded positively regarding cosmetic result and minimal postoperative pain control. CONCLUSION LESS further minimizes the invasive nature of surgery and is feasible for treatment of early-stage endometrial cancer.