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San Doctor Autumn 2018 The benefits of robotic San surgery in the management of endometrial cancer Doctor A/PROF FELIX CHAN MBBS MRACOG FRANZCOG CGO Associate Professor Felix Chan is a certified gynaecological oncologist and is currently the Head of the Centre for Robotic Surgery in Gynaecology at Sydney Adventist Hospital. He is also and the Director of Gynaecological Oncology for South Western Sydney Area Health District. A/Prof Chan specialises in advanced laparoscopic, robotic, vaginal and open surgery for the treatment of gynaecologic malignancies and complex gynaecological problems. He was a nominee for Australian of the Year in 2009, 2011 and 2012 and is also AUTUMN 2018 a member of the NSW Doctor’s Orchestra. P: 1300 227 428 In Australia, the incidence of endometrial cancer is resection of recurrent tumours becomes technically rising, due to the ageing population and increased possible. prevalence of obesity. Endometrial cancer can Robotic-assisted reconstructive surgery such as ileal be caused by genetic factors as found in Lynch conduit and continent urinary reservoir, become Syndrome or as a result of increased exogenous and feasible. In addition, complex surgery requiring endogenous oestrogen. a team of surgeons can be carried out efficiently After a confirmed diagnosis based on histology, the without any change of patient position. use of pre-operative imaging such as a CT scans aims Simulation and procedure specific modules allow to assess the extent of the disease. gynaecological surgeons to acquire and maintain Surgery not only removes the origin of the disease, their skills through their surgical career. it also relieves symptoms and defines the extent of Training and teaching can be standardised and the disease. Adjuvant therapy such as chemotherapy allow progression of surgical skill development from and radiotherapy can be recommended to a patient registrars, to specialist consultant. to avoid over, or under-treatment. This article aims to describe the current trends in surgical treatment of Task performance and the learning curve for endometrial cancer. acquisition of skills were found to be superior with the robotics system when compared with Robotic-assisted technology conventional laparoscopy in a laboratory setting. Currently, Intuitive Surgical’s da Vinci robot remains When the viewing condition specifically between the the only surgical system performing robotic surgery two systems was evaluated, the three-dimensional in Australia. It has evolved extensively over the features provided an advantage. last ten years with surgeons now able to control a high definition three-dimensional camera system Endometrial cancer with a wristed instrument that has seven degrees Surgery is the cornerstone in the treatment of of movement. This results in intuitive surgical endometrial cancer, with removal of the uterus and movement, fewer tremors and improved stability, the adnexae along with inspection of the peritoneal precision and reproducibility. Furthermore, the cavity and staging of the disease by removal of surgeon sits at a console to operate, which minimises pelvic and, in some cases, para-aortic lymph nodes surgical fatigue and improves ergonomics. Improved and omentum. Traditionally, the surgical treatment tissue magnification allows the surgeon to visualise of endometrial cancer has been performed by vital structures and avoid unnecessary trauma or laparotomy. injuries. However, a randomised trial of comprehensive staging in more than 2500 women with endometrial cancer comparing laparotomy to laparoscopy, published in 2009 by the Gynaecological Oncology Group, concluded that laparoscopy was safe for endometrial cancer patients1. The study demonstrated a decrease in serious complications, less use of antibiotics and shorter hospital stay and was further supported by a meta-analysis on four randomised controlled trials including 339 patients2. Accordingly, the number of women with endometrial cancer treated by MIS has since increased dramatically from 9% in 2006 to the current 90% years and within this frame, robotic assisted surgery (RAS) Figure 1. Sentinal node removed after injection of ICG using has become the preferred surgical modality by JACARANDA LODGE da Vinci Xi Firefly Cancer Support Centre gynaecological oncologists in the USA3. As the surgeon controls three surgical instruments In 2008, Boggess et al. compared the three in addition to a camera, they can operate with very modalities and found that RAS had lower estimated little assistance, and therefore do not have to rely on blood loss and larger lymph node yield. Transfusions an assistant’s expertise. The latest da Vinci Xi allows were administered less frequently with RAS and multiple quadrants surgery. postoperative complications like ileus and wound This is enabled through the use of cameras in all infections were diminished or similar to total ports, which allow the visualisation of the operative laparoscopic hysterectomy4. Recent data supports field from different vantage points (camera that quality of life after RAS for endometrial hopping), surgeon controlled surgical bed motion, cancer, with regard to fatigue, pain, constipation, and reduction of port distance to 6cm. Complex gastrointestinal symptoms, and appetite, was procedures including pelvic and left infra-renal returned to pre-operative levels five weeks para-aortic node dissection, omentectomy, bowel postoperatively5. resection, anterior and posterior exenteration and continued on page 4 The views and opinions expressed in the articles in this publication are those of the authors and are not necessarily shared by the editors or Adventist HealthCare Limited. The editors and Adventist HealthCare Limited do not accept responsibility for any errors or omissions in any article in this publication. Robotic coronary bypass and hybrid cardiac surgery An innovative approach combining the best of cardiac surgery and interventional cardiology DR LEVI BASSIN BSC (COMP) MBBS PHD FRACS Dr Levi Bassin is a consultant cardiothoracic surgeon at Sydney Adventist and Royal North Shore Hospitals with a special interest in mitral valve repair. Dr Bassin specialises in robotic, minimally invasive, and hybrid cardiac surgery including TAVI (Transcatheter Aortic Valve Implantation). P:02 9449 1559 E: [email protected] W: www.levibassin.com Figure 1. Robotic harvesting of the Left Internal Figure 2. Post op- Robotic Coronary Bypass Surgery Figure 3. Post op mini Aortic Valve Replacement (Right Mammary Artery (LIMA). (4cm Thoracotomy). Anterior Thoracotomy-RAT) and coronary stent. ROBOTIC CORONARY BYPASS SURGERY This is removed just prior to completing another major surgery. Conversely, we have The latest iterations of the da Vinci surgical the anastomosis. The pericardium is then recently had patients undergo a laparotomy robot have facilitated truly minimally invasive closed and the lung is reinflated. The wound for a Whipple’s procedure two weeks post coronary bypass surgery. The surgeon is closed and then an ultrasound guided robotic bypass surgery. This expedited recovery controls the robotic arms from a console a few catheter is placed in the chest wall to provide facilitates a superior cancer operation and metres away from the operative field. These a continuous infusion of local anaesthesia for minimises the chance of cancer metastasising instruments perfectly mimic the surgeon’s the first 48 hours. The patients are extubated or becoming inoperable whilst the patient hand movements as well as provide 10x in the operating theatre and transferred to recovers from a sternotomy. magnification in 3D. This means that coronary intensive care. Most patients can go home HYBRID CARDIAC SURGERY bypass surgery can be performed without a after approximately three days in hospital As technology has improved, cardiac surgery sternotomy with vastly improved recovery and and are back to their preoperative state 2-4 and interventional cardiology are converging minimal pain. weeks following surgery, compared with three with considerable overlap in the treatment months following a sternotomy (Figure 2). The left internal mammary artery (LIMA) of both coronary and valvular heart disease. to left anterior descending coronary artery In some patients, it is also possible to perform This is ideal for patients as there are now more (LAD) has the best long-term outcome of two bypasses using both mammary arteries to options for effective treatments with reduced any revascularisation procedure and has a graft to the LAD and circumflex. surgical trauma, pain and recovery time. proven survival benefit. Typically, a sternotomy Patients that are good candidates include: Hybrid cardiac surgery refers to a treatment is required, which patients are hesitant to • Those that have a significant single or double strategy that uses robotic or minimally undertake, and would prefer percutaneous vessel coronary disease invasive cardiac surgery in combination with coronary intervention (PCI) with intracoronary transcatheter techniques such as percutaneous • Those with triple vessel disease where the stents if feasible. coronary intervention (PCI) with the placement remaining stenoses will be treated with of intracoronary stents to achieve ‘the best For a robotic bypass operation, the patient is coronary stents (See Hybrid Cardiac Surgery) anaesthetised and the left lung is deflated. of both worlds’ – that is the durability and Carbon dioxide is insufflated under pressure • BMI < 35 survival benefit of cardiac surgery combined to increase exposure to
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