ΜΕΤΑΠΤΥΧΙΑΚΟ ΠΡΟΓΡΑΜΜΑ ΣΠΟΥΔΩΝ: ‘‘ΕΛΑΧΙΣΤΑ ΕΠΕΜΒΑΤΙΚΗ ΧΕΙΡΟΥΡΓΙΚΗ, ΡΟΜΠΟΤΙΚΗ ΧΕΙΡΟΥΡΓΙΚΗ ΚΑΙ ΤΗΛΕΧΕΙΡΟΥΡΓΙΚΗ’’ ΕΘΝΙΚΟ ΚΑΙ ΚΑΠΟΔΙΣΤΡΙΑΚΟ ΠΑΝΕΠΙΣΤΗΜΙΟ ΑΘΗΝΩΝ ΙΑΤΡΙΚΗ ΣΧΟΛΗ ΔΙΠΛΩΜΑΤΙΚΗ ΕΡΓΑΣΙΑ ΘΕΜΑ: MINIMALLY-INVASIVE LYMPHADENECTOMY IN OVARIAN CANCER ΜΕΤΑΠΤΥΧΙΑΚΗ ΦΟΙΤΗΤΡΙΑ : ΚΑΡΑΧΑΛΙΟΥ ΧΡΙΣΤΙΝΑ ΑΜ : 20130758 ΑΘΗΝΑ, ΔΕΚΕΜΒΡΙΟΣ 2016 ΠΡΑΚΤΙΚΟ ΚΡΙΣΕΩΣ ΤΗΣ ΣΥΝΕΔΡΙΑΣΗΣ ΤΗΣ ΤΡΙΜΕΛΟΥΣ ΕΠΙΤΡΟΠΗΣ ΓΙΑ ΤΗΝ ΑΞΙΟΛΟΓΗΣΗ ΤΗΣ ΔΙΠΛΩΜΑΤΙΚΗΣ ΕΡΓΑΣΙΑΣ Της Μεταπτυχιακής Φοιτήτριας Καραχάλιου Χριστίνας Εξεταστική Επιτροπή • Αλέξανδρος Παπαλάμπρος, Λέκτορας Χειρουργικής ( Επιβλέπων ) • Χρήστος Π. Τσιγκρής, Ομότιμος Καθηγητής Χειρουργικής & Επιστημονικός Υπεύθυνος του Π.Μ.Σ. • Θεόδωρος Διαμαντής, Καθηγητής Χειρουργικής Η Τριμελής Εξεταστική Επιτροπή η οποία ορίσθηκε από την ΓΣΕΣ της Ιατρικής Σχολής του Παν, Αθηνών Συνεδρίαση της ....ης ..........................20..... για την αξιολόγηση και εξέταση της υποψηφίου κας Καραχάλιου Χριστίνας, συνεδρίασε σήμερα .../.../..... Η Επιτροπή διαπίστωσε ότι η Διπλωματική Εργασία της Κας Καραχάλιου Χριστίνας με τίτλο : «MINIMALLY-INVASIVE LYMPHADENECTOMY IN OVARIAN CANCER» είναι πρωτότυπη, επιστημονικά και τεχνικά άρτια και η βιβλιογραφική πληροφορία ολοκληρωμένη και εμπεριστατωμένη. Η εξεταστική επιτροπή αφού έλαβε υπ' όψιν το περιεχόμενο της εργασίας και τη συμβολή της στην επιστήμη, με ψήφους ............................. προτείνει την απονομή του Μεταπτυχιακού Διπλώματος Ειδίκευσης ( Master's Degree ), στον παραπάνω Μεταπτυχιακό Φοιτητή. Στην ψηφοφορία για την βαθμολογία ο υποψήφιος έλαβε για τον βαθμό ‹‹ ΑΡΙΣΤΑ ›› ψήφους ..................., για τον βαθμό ‹‹ ΛΙΑΝ ΚΑΛΩΣ ›› ψήφους ........................, και για τον βαθμό ‹‹ ΚΑΛΩΣ ›› ψήφους ........................ Κατά συνέπεια, απονέμεται ο βαθμός ‹‹ ..........................................››. Τα μέλη της Εξεταστικής Επιτροπής • Αλέξανδρος Παπαλάμπρος ( Επιβλέπων ) ( Υπογραφή ) • Χρήστος Π. Τσιγκρής ( Υπογραφή ) • Θεόδωρος Διαμαντής ( Υπογραφή ) 2 The procedure of developing a study is always creative and educational. Nevertheless, it requires a lot of time and patience both of the writer and the people around him. In my case I owe gratitude to those who stood by me during this effort. I would like to thank my family, my teachers, my colleagues and above all Ilias Gkizis who gave me precious advice to accomplish and complete this task. 3 TABLE OF CONTENTS INTRODUCTION.......................................................................................................6 PART I 1. OVARIAN CANCER..............................................................................................7 2. INCIDENCE AND EPIDEMIOLOGY............................................................. 8 3. OVARIAN TUMORS..............................................................................................9 3.1 EPITHELIAL OVARIAN TUMORS..................................................................9 3.2 FALLOPIAN TUBE CANCER.........................................................................10 3.3 OVARIAN GERM CELL TUMORS................................................................10 3.4 OVARIAN STROMAL TUMORS....................................................................11 4. DIAGNOSIS...........................................................................................................12 5. STAGING OF OVARIAN CANCER...................................................................13 6. MANAGEMENT...................................................................................................16 7. LYMPHATIC SYSTEM........................................................................................18 8. OVARIAN CANCER AND LYMPHADENECTOMY.........................................................................................21 8.1 LYMPHADENECTOMY FOR EARLY OVARIAN CANCER......................22 8.2 LYMPHADENECTOMY FOR ADVANCED OVARIAN CANCER.............24 PART II MINIMALLY-INVASIVE LYMPHADENECTOMY IN OVARIAN CANCER 9. MINIMALLY-INVASIVE SURGERY.................................................................................................................28 9.1 INTRODUCTION............................................................................................28 9.2 BENEFITS OF MINIMALLY-INVASIVE PROCEDURES...........................29 10. LAPAROSCOPIC LYMPHADENECTOMY...................................................30 10.1 LAPAROSCOPIC PROCEDURE..............................................................32 10.2 LAPAROSCOPIC PELVIC LYMPHADENECTOMY............................36 4 10.3 LAPAROSCOPIC PARA-AORTIC LYMPHADENECTOMY...............43 10.3.1 ANATOMY AND SURGICAL PROCEDURES FOR PARA-AORTIC LYMPHADENECTOMY..........................................43 10.3.2 APPROACHES....................................................................................43 A) TRANSPERITONEAL...................................................................44 B) EXTRAPERITONEAL...................................................................55 11. SINGLE-PORT LAPAROENDOSCOPY SURGERY.....................................63 12. ROBOTIC-ASSISTED LYMPHADENECTOMY...........................................71 12.1 ROBOTIC PELVIC LYMPHADENECTOMY.............................................71 12.2 ROBOTIC TRANSPERITONEAL INFRARENAL AORTIC LYMPHADENECTOMY...............................................................76 12.3 ROBOTIC EXTRAPERITONEAL AORTIC LYMPHADENECTOMY.....84 12.4 ROBOTIC SINGLE-PORT LYMPHADENECTOMY.................................92 DISCUSSION.............................................................................................................97 CONCLUSION........................................................................................................105 ABSTRACT.............................................................................................................106 ΠΕΡΙΛΗΨΗ.............................................................................................................107 REFERENCES........................................................................................................108 5 INTRODUCTION Ovarian cancer metastases disseminate via lymphatic system. The metastases occur in the pelvic nodes and also in the aortic nodes.The upper aortic infra-renal lymph nodes are of special concern because of the direct drainage from the left ovarian vein to the left renal vein and the right ovarian vein to infra-renal vena cava. Because of the high incidence of lymphatic metastasis, bilateral pelvic and aortic lymphadenectomy is indicated in all ovarian cancers. In early stage ovarian cancer, systematic lymph node dissection is required in order to perform accurate clinical staging and to select an adequate adjuvant chemotherapy. For advanced cancer with minimal tumour residuals of up to 10mm, systematic lymphadenectomy will produce a significant benefit in progression- free survival, and may improve the 5- year overall survival. Laparotomy remained for years the prevailing method for the management of ovarian cancer, including pelvic and para-aortic lymphadenectomy. Although, minimally-invasive surgery has been dramatically increased in the recent years and has been widely adopted in gynecological procedures, providing a few of benefits. The aim of this study is to present and understand all the available minimally-invasive techiques that have been reported for pelvic and para-aortic lymphadenectomy in ovarian cancer and successfully end up to the most feasible, minimal invasive, efficient and most economic. The parameters which will be analyzed is the operative time, the estimated intraoperative blood loss, the postoperative pain, the length of hospital stay, the number of lymph nodes yielded and the complication rates. 6 PART I 1. OVARIAN CANCER Ovarian cancer begins in the ovaries. Ovaries are reproductive glands found only in females. The ovaries produce eggs (ova) for reproduction. The eggs travel through the fallopian tubes into the uterus where the fertilized egg implants and develops into a fetus. The ovaries are also the main source of the female hormones estrogen and progesterone. One ovary is on each side of the uterus in the pelvis. Picture 1. (http://www.medicinenet.com/ovarian_cancer/article.htm) The ovaries are made up of 3 main kinds of cells. Each type of cell can develop into a different type of tumor: Epithelial tumors start from the cells that cover the outer surface of the ovary. Most ovarian tumors are epithelial cell tumors. Germ cell tumors start from the cells that produce the eggs (ova). Stromal tumors start from structural tissue cells that hold the ovary together and produce the female hormones estrogen and progesterone. Most of these tumors are benign (non-cancerous) and never spread beyond the ovary. Benign tumors can be treated by removing either the ovary or the part of the ovary that contains the tumor. Malignant (cancerous) or low malignant potential ovarian tumors can spread (metastasize) to other parts of the body and can be fatal. 7 2. INCIDENCE AND EPIDEMIOLOGY The estimated number of new ovarian cancer cases in Europe in 2012 was 65 538 with 42 704 deaths [1]. There is variation in the incidence rate across the continent with a higher incidence in northern European countries. In the USA, there were 20 400 newly diagnosed cases and 14 400 deaths in 2009 [2]. Ovarian cancer is the fifth most common type of cancer in women and the fourth most common cause of cancer death in women. The estimated lifetime risk for a woman developing ovarian cancer is about 1 in 54. Ovarian