Cancer Surgery is traditionally radical by nature as it aims to excise not only the tumour, but also the adjacent tissues and regional lymph nodes draining the diseased organ.
Indeed, radical surgery is the mainstay of treatment which heralds good cure rates for many solid tumours, including cancer of the uterine cervix, corpus uteri, ovary and vulva.
Minimally invasive surgery with laparoscopy was first introduced at the turn of 20 th century in gynaecological practice and was popularised in the 1970s for infertility treatment. It has since been widely adopted in all fields of surgical practice, mainly in treating benign diseases.
The advantage of minimally invasive surgery over conventional open surgery is overwhelming: the excellent view of operative field and the precision of surgical dissection, excision and haemostasis are beyond the imagination of non-laparoscopic surgeons and physicians. This is translated into lesser post-operative pain and faster recovery and resumption of daily activities in patients.
Laparoscopic surgery has been introduced into the treatment of women’s cancers cautiously over the last two decades. The success of these surgeries was compared with traditional open surgeries to assess the completeness of tumour excision, lymph node clearance and tumour control in terms of tumour recurrence rate and 5-year patient survival rate.
At SGH and NCC, we introduced laparascopic pelvic lymph node dissection and laparoscopic-assisted total hysterectomy and bilateral salpingo-oophorectomy for uterine cancer in 1993.
Comparing 40 patients treated with minimally invasive surgery with 40 patients treated by open surgery, we found that the average number of lymph nodes cleared was 32.5 and 31.8 respectively. Surgical excision was complete for all the patients in both groups of patients. There is no difference in cancer relapse rate or 5-year survival rate between the two groups of patients.
Minimally invasive surgery took, on average, 65 minutes longer but the mean hospital stay was 3 days shorter than open surgery. Our experience compares favourably to reports from other major cancer centres abroad. The role of minimally invasive surgery for uterine cancer is now well established and should be offered to all suitable patients.
Cancer of the uterine cervix is traditionally treated with radical hysterectomy with parametrial resection and pelvic lymphadenectomy. It is feasible to perform the same operation by minimally invasive surgery.
Ovarian cancer carries a different biological course from cancer of the cervix and uterine corpus. It is important to avoid spillage of tumour cells intra-operatively. Furthermore, the incidence of laporascopic port site metastasis is higher in ovarian cancer compared to other cancers. The role of minimally invasive surgery is thus limited.
However, laparoscopic surgery has a well-established role in completing the staging surgery in women who had been treated for ovarian cancer with inadequate staging, in second look procedure to assess the pelvis and peritoneal cavity for surgico-pathological completeness of tumour response to treatment, and for insertion of intra-peritoneal catheter for consolidation chemotherapy.
Minimally invasive surgery allows the necessary radical surgical approach to women’s cancer treatment to be carried out with lesser pain and faster recovery. It is a significant contribution to contemporary management of women’s cancers.
Tay Sun Kuie
Clinical Associate Professor & Senior Consultant
Obstetrician and Gynaecologist
Singapore General Hospital
& National Cancer Centre, Singapore.
