I. Indications and contraindications of laparoscopic surgery for gynecologic tumors.
1. Indications for laparoscopic surgery of gynecologic tumors
(1) Cervical cancer: cervical cancer before stage IIa is suitable for surgical treatment under laparoscopy, including total hysterectomy, extensive hysterectomy (type III) and pelvic and abdominal lymph node dissection to achieve the treatment purpose. For young patients before stage Ib2 who need to preserve their reproductive function, laparoscopic pelvic lymph node dissection plus transvaginal radical hysterectomy can be performed. For patients with stage IIb or higher, laparoscopic retroperitoneal lymph node dissection biopsy can be utilized to guide the scope of radiotherapy delivery.
(2) Endometrial cancer: The purpose of surgery for endometrial cancer is surgical-pathological staging and treatment of the disease. The literature reports that surgical-pathological staging and therapeutic surgery can be completed laparoscopically for endometrial cancer before stage IIb, including stage IIb patients, and for patients with clinical stage III, laparoscopic Lymph node sampling or dissection is performed by transabdominal route and retroperitoneal route.
(3) Vaginal cancer: generally for patients with local infiltration before stage IIa. For patients located in the upper middle third of the vagina, sampling laparoscopic extensive total hysterectomy and total vaginal resection plus pelvic lymph node dissection is performed. Meanwhile, for patients with stage I vaginal cancer, local vaginal resection with preservation of reproductive function plus laparoscopic pelvic lymph node dissection can be used, which can also achieve good results.
(4) Ovarian cancer: it is generally applicable to early ovarian epithelial carcinoma and germ cell tumor before stage IIc. Laparoscopic full-stage ovarian surgery is a more difficult type of surgery and the most controversial one. To date, the vast majority of gynecologic oncologists do not advocate laparoscopic surgery, so in any case, when adnexal tumors are found to be malignant, the following conditions must be met to perform exploratory surgery for ovarian cancer.
(i) Tumor diameter of 10 cm.
② no obvious metastases in other parts or organs of the abdominal cavity.
③The operator has sufficient skills to complete the whole operation.
Secondary exploration and cytoreductive surgery for ovarian cancer is suitable for patients with elevated CA125 after chemotherapy with or without intra-abdominal lesions. Different strategies can be used depending on the results of surgical exploration, and lesion removal can be completed laparoscopically for single or isolated 5 cm lesions, while biopsy can be completed for diffuse lesions. Also cases with extensive intra-abdominal recurrence can be evaluated to assess the need for further open tumor cytoreduction.
2. Contraindications of laparoscopic surgery for gynecologic tumors
(1) Advanced gynecologic tumors: patients with stage IIb or above cervical cancer or cervical cancer lymph node metastases fused and encircling important blood vessels, endometrial cancer and ovarian cancer with extensive abdominal metastases and/or extensive infiltration of tumor and surrounding tissues are not suitable for laparoscopic surgery.
(2) Others: severe abdominal adhesions, severe obesity and poor heart function are relative contraindications to surgery; poor general condition, which cannot be corrected despite preoperative treatment; serious heart, lung, liver and kidney diseases, which cannot tolerate surgery and anesthesia are contraindications to surgery.
Principles of laparoscopic surgery for gynecological tumors.
1, the scope of gynecologic tumor hysterectomy: laparoscopic surgery for gynecologic malignant tumors still adopts the classification criteria and assessment measures of open surgery, i.e., the classic Piver’s five staging categories are used.
2. Basic principles of surgery: laparoscopic surgery must follow the principles of traditional open surgery for radical tumor treatment, including.
(1) Emphasis on the whole block resection of tumor and surrounding tissues.
(2) tumor-free technique of tumor operation.
(3) adequate incision margins.
(4) thorough pelvic and abdominal lymphatic dissection.
3. Principle of intermediate open surgery: During laparoscopic surgery, those who really need open surgery for patient safety reasons, or those who find that the tumor cannot be resected under laparoscopy or the tumor margins are not sufficient, should be promptly intermediate open surgery.
4. Pay attention to protect the incision and abdominal cavity irrigation: attention should be paid to protect the incision when the specimen is removed to prevent tumor cells from planting in the incision. After surgery, lavage of the abdominal cavity should be performed to remove free cancer cells in the abdominal cavity as much as possible. Distilled water, 5-fluoropyrimidine (5-FU) or cisplatin can be used as lavage solution. Intraoperative intraperitoneal chemotherapy can be preferred when patient and equipment conditions permit.