Extreme Laparoscopy: Expanding the Surgical Horizon ...GALAXY CARE LAPAROSCOPY INSTITUTE ,PUNE , INDIA Disclosures No financial relationships to disclose OBJECTIVES… To evaluate

Sponsored by

AAGLAdvancing Minimally Invasive Gynecology Worldwide

Extreme Laparoscopy: Expanding the

Surgical Horizon (Didactic)

PROGRAM CHAIR

Arnaud Wattiez, MD

Christophe Pomel, MD Shailesh P. Puntambekar, MD David B. Redwine, MD

Professional Education Information Target Audience Educational activities are developed to meet the needs of surgical gynecologists in practice and in training, as well as, other allied healthcare professionals in the field of gynecology. Accreditation AAGL is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AAGL designates this live activity for a maximum of 3.75 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. DISCLOSURE OF RELEVANT FINANCIAL RELATIONSHIPS As a provider accredited by the Accreditation Council for Continuing Medical Education, AAGL must ensure balance, independence, and objectivity in all CME activities to promote improvements in health care and not proprietary interests of a commercial interest. The provider controls all decisions related to identification of CME needs, determination of educational objectives, selection and presentation of content, selection of all persons and organizations that will be in a position to control the content, selection of educational methods, and evaluation of the activity. Course chairs, planning committee members, presenters, authors, moderators, panel members, and others in a position to control the content of this activity are required to disclose relevant financial relationships with commercial interests related to the subject matter of this educational activity. Learners are able to assess the potential for commercial bias in information when complete disclosure, resolution of conflicts of interest, and acknowledgment of commercial support are provided prior to the activity. Informed learners are the final safeguards in assuring that a CME activity is independent from commercial support. We believe this mechanism contributes to the transparency and accountability of CME.

Table of Contents

Course Description ........................................................................................................................................ 1 Disclosure ...................................................................................................................................................... 3 What Does Extreme Laparoscopy Mean? A. Wattiez ..................................................................................................................................................... 5 Extreme Attitude Toward Organs S.P. Puntambekar ......................................................................................................................................... 8 Extreme Dissection D.B. Redwine .............................................................................................................................................. 17 Extreme Situation in Oncology C. Pomel ..................................................................................................................................................... 20 “Extreme” as a Philosophy A. Wattiez ................................................................................................................................................... 29 What Is Behind My Extreme Attitude? S.P. Puntambekar ....................................................................................................................................... 34 What Is Behind My Extreme Attitude? D.B. Redwine .............................................................................................................................................. 39 What Is Behind My Extreme Attitude? C. Pomel ..................................................................................................................................................... 46 Cultural and Linguistics Competency ......................................................................................................... 50

PG 111 Extreme Laparoscopy: Expanding the Surgical Horizon (Didactic)

Arnaud Wattiez, Chair

Faculty: Christophe Pomel, Shailesh P. Puntambekar, David B. Redwine

Course Description

Surgery should never be unpredictable and surgeons are exposed to constraints that should be

respected, understood and overcome. There is no place for uncertainty and that is why every single

action that may reduce the amount of uncertainty is paramount in surgery. The surgical act is a

succession and/or a series of basic actions. These basic actions do not require particularly complex skills

but when put together they create sophisticated surgical actions. These surgical actions can be called

“emergent” because they overcome the complexity of the original entity. It is relatively easy to reach an

average level in any type of surgery, but if one wishes to expand his surgical horizon, he must

understand that only surgical emergence is an art form as it is closely linked to the surgeon’s capacity,

ability, intelligence, vision and willpower.

Laparoscopy has come to the point where anything seems possible in the hands of certain people.

However, surgery cannot be guided by the surgeon’s ego and that is why improving one’s surgical skills

is such an important issue. This course has been developed to demonstrate the knowledge required and

the path to follow to become an “extreme” surgeon.

Learning Objectives

At the conclusion of this course, the participant will be able to: 1) Use the learning process to understand the power of endoscopic surgery; 2) master the theory of laparoscopic surgical rules; 3) identify the key steps of laparoscopic surgery; 4) recognize extreme situations; 5) explain the surgical basics required to face extreme situation; and 6) review the special training required to broaden your skills.

Course Outline 1:30 Welcome, Introductions and Course Overview A. Wattiez 1:35 What Does Extreme Laparoscopy Mean? A. Wattiez 2:00 Extreme Attitude Toward Organs S.P. Puntambekar 2:25 Extreme Dissection D.B. Redwine 2:50 Extreme Situation in Oncology C. Pomel 3:15 Questions & Answers All Faculty

1

3:25 Break 3:40 “Extreme” as a Philosophy A. Wattiez 4:05 What Is Behind My Extreme Attitude? S.P. Puntambekar 4:30 What Is Behind My Extreme Attitude? D.B. Redwine 4:55 What Is Behind My Extreme Attitude? C. Pomel 5:20 Questions & Answers All Faculty 5:30 Course Evaluation

2

PLANNER DISCLOSURE The following members of AAGL have been involved in the educational planning of this workshop and have no conflict of interest to disclose (in alphabetical order by last name). Art Arellano, Professional Education Manager, AAGL* Viviane F. Connor Consultant: Conceptus Incorporated Frank D. Loffer, Executive Vice President/Medical Director, AAGL* Linda Michels, Executive Director, AAGL* Jonathan Solnik Other: Lecturer ‐ Olympus, Lecturer ‐ Karl Storz Endoscopy‐America SCIENTIFIC PROGRAM COMMITTEE Arnold P. Advincula Consultant: CooperSurgical, Ethicon Women's Health & Urology, Intuitve Surgical Other: Royalties ‐ CooperSurgical Linda Bradley Grants/Research Support: Elsevier Consultant: Bayer Healthcare Corp., Conceptus Incorporated, Ferring Pharmaceuticals Speaker's Bureau: Bayer Healthcare Corp., Conceptus Incorporated, Ferring Pharm Keith Isaacson Consultant: Karl Storz Endoscopy Rosanne M. Kho Other: Honorarium ‐ Ethicon Endo‐Surgery C.Y. Liu* Javier Magrina* Ceana H. Nezhat Consultant: Intuitve Surgical, Lumenis, Karl Storz Endoscopy‐America Speaker's Bureau: Conceptus Incorporated, Ethicon Women's Health & Urology William H. Parker Grants/Research Support: Ethicon Women's Health & Urology Consultant: Ethicon Women's Health & Urology Craig J. Sobolewski Consultant: Covidien, CareFusion, TransEnterix Stock Shareholder: TransEnterix Speaker's Bureau: Covidien, Abbott Laboratories Other: Proctor ‐ Intuitve Surgical FACULTY DISCLOSURE The following have agreed to provide verbal disclosure of their relationships prior to their presentations. They have also agreed to support their presentations and clinical recommendations with the “best available evidence” from medical literature (in alphabetical order by last name). Arnaud Wattiez Consultant: VECTEC, Karl Storz Germany Christophe Pomel* Shailesh P. Puntambekar* David B. Redwine* Stephanie N. Morris* Asterisk (*) denotes no financial relationships to disclose.

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EXTREME LAPAROSCOPY....what does it means?

A. WATTIEZ

Disclosure

Consultant Karl Storz Gmbh

Consultant Vectec

• Objective1. To present the philosophy of extreme laparoscopy from a

different point of view.

d ll l b i i i d 2. To draw a parallel between extreme situations in surgery and other real situations in life.

Video• Learning points of course & video:1. To properly understand the definition of extreme laparoscopy

2. To recognize the extreme situations and review their management

3. To understand the advantages & power of endoscopic surgery

4. To master the theory of laparoscopic strategy & surgical rules

5. To review the special training required to broaden your skills

Extreme laparoscopy

• Definition • Management• Training

Extreme laparoscopy

.......a misunderstanding?

definition

4

video

•Understand

Management

think!

Principles

•Strategy & Rules

•Excellence

•Training

• Are you aware of the power of the scope?

StrategyStrategy

“To apply certain sequences in a certain order with the goal to achieve a task”

training

5

Is that enough?Is that enough?

The Philosophy of Extreme The Philosophy of Extreme

•think different!

Conclusions• Extreme laparoscopy is a relative concept and its definition must not be

misunderstood

• No matter the difficulty of the situation, surgery should never be unpredictable

• Mastering the principles of surgery & proper training are fundamental when dealing with extreme situations

• Technology can not replace dissection as the pivot of surgery

• Training in laparoscopical surgery must be progressive & continuous

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EXTREME ATTITUDE TOWARD ORGANS

DR SHAILESH PUNTAMBEKARDR .SHAILESH PUNTAMBEKARMD

ASSOCIATE PROFESSORMEDICAL DIRECTOR

GALAXY CARE LAPAROSCOPY INSTITUTE ,PUNE , INDIA

Disclosures

No financial relationships to disclose

OBJECTIVES…

To evaluate the feasibility of various types of laparoscopic exenterative surgeries in oncology.

That laparoscopic exenterative surgeries canThat laparoscopic exenterative surgeries can be achieved safely with comparable oncological results.

Use of anatomical landmarks while performing these procedures.

INTRODUCTION...Exenteration is an established procedure for treatment of gynecological cancers.

Since June 2003 till September 2012‐ 92 patients underwent different types of pelvic exenterations at our institute‐

‐82 patients underwent laparoscopic procedure while 10 were done Robotically.

40

50

60

70

Ca Endometrium n‐2

Ca Vagina n‐1

DISTRIBUTION OF CANCER CASES

0

10

20

30

A E P E T P E

64

9 11

Ca Ovary n‐5

Ca Cervix n‐84

OUR STATISTICS…

OPERATION AE PE TPE TOTAL

Laparoscopic 60 11 11 82

Robotic 9 0 1 10

Total 69 11 12 92

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LAPAROSCOPIC ANTERIOR EXENTERATION

• 60 women who underwent LAE at our institute between June 2003 to

September 2012 were retrospectively analysed .

TOTAL CASES 60 Primary surgery(n‐25)

Secondary surgery post CT/RT(n‐35)

Cervix 15 30

Ovary 8 5

Vagina 1 ‐

Uterus 1 ‐

• Anterior Exenteration‐ resection of uterus with urinary bladder


PRESENT STUDY Lap. Anterior Exenteration(n‐60)

Median surgical duration 180 mins(160‐200)

Median blood loss 220 ml

Mean hospital stay 6 days

Intra op blood tranfusion 0

Median followup 30 months

Immediate mortality 0


• Type of urinary diversion important

• Earlier diversions ‐ureterosigmoidostomy ‐has high complication rate.

• Since last few years Ileal conduit and Indiana• Since last few years ‐Ileal conduit and Indiana pouch.

• 2 cases with Mainz II.

TYPES OF URINARY DIVERSIONS(LAPAROSCOPIC)

NO OF PATIENTS (n‐60)

Ureterosigmoidostomy 38

LAPAROSCOPIC ANTERIOR EXENTERATION-TYPES OF URINARY DIVERSIONS

Mainz II 2

Ileal conduit 15

Indiana pouch 5

Neo ‐bladder 0

8

Recurrence rate in Lap. Anterior Exenteration

• In our series, 33 patients of recurrence in 3 years.

‐Out of these patients ,10 patients had primary surgery and 23 patients had surgery post CT/RT .

Variable Number of patients with recurrence (n‐33)

Primary surgery 10

Secondary surgery(post CT/RT) 23


• Earliest recurrence seen 6 months following surgery.

• Patients who developed recurrence in 3 years , 80% had distant metastasis and 20% had local & distant

disease. Variable No. of patients (n‐33)

Distant recurrence 26 (80%)

Local and distant recurrence 7 (20%)

Lymph node involvement 33 (100%)

Surgical margins 3 (9%)


All the patients with recurrence had nodal metastasis at the time of surgery

3 of the patients with recurrence had surgical margins positivemargins positive.

80% of patients were free of local symptoms post surgery.

Survival ratesurvival solely dependant on

‐ negative nodal status

‐ tumour free marginsPRESENTSTUDY(N‐60)

No. of patients Primarysurgery

Secondary surgery

Percentage

3 year survival rate

27 21 6 45%

5 year survival rate

15 9 6 25%

Survival rate of Lap. Anterior Exenteration

• 3‐year survival‐ 27 patients

• disease free‐21 patients

• Disease free survival after 3 years ‐ 35%.

Conclusion

All 6 patients with recurrent disease were having nodal involvement. Hence nodal status is important prognostic factor for survival.

Survival is much better when primary surgery.

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Conclusion

5‐year survival ‐25%

Results comparable to our open cases , other world series.

M j it h i t i th th l l Majority having systemic recurrence rather than lacal .

Quality of life post‐surgery directly related to surgical expertise.

Hurdles perceived in feasiblilty of laparoscopy

Multi organ involvement requiring extensive dissection

Technical feasibility of a urinary diversion

LAPAROSCOPIC POSTERIOR EXENTERATION

11 patients who underwent LPE for advanced gynecological malignant disease studied.

laparoscopic surgery beneficial in carefully selected patients following R 0 resectionselected patients following R‐0 resection.

Posterior exenteration

10


OUR STUDY (2010)(N‐10)

No. of patients

Primary surgery 7

S d 3Secondary surgery 3

Temporary stoma 7

Permanent stoma 3

Reference - The J of minimal invasive gynecology ,2010


INCLUSION CRITERIA EXCLUSION CRITERIA

OVARIAN CANCER INVOLVING THE POUCH OF DOUGLAS

EXTRA PELVIC SPREAD

POST RADIATION CERVICAL CANCERRECURRENCE LOCALISED POSTERIORLY

DISTANT METASTASIS INCLUDING PARAAORTIC NODES

CA CERVIX WITH RVF INVOLVEMENT OF URINARY BLADDER

CA VAGINA WITH RECTAL INVOLEMENT INVOLVEMENT OF URETERS

LIMB OEDEMA AND SCIATIC PAIN

MEDICALLY UNFIT



Operative data (our data 2010)(n‐10)

Median

Age 54 yrs

Operative time 220min

Blood loss 360 ml360 ml

Length of hospital stay 9days

No of blood transfusion 1.3

Median follow‐up 26 months

Lymph node yield in cervical and vaginal cancers

18



Variable Primary surgery Secondary surgery

No. of patients 3 2

Tumor size,mean ,cm 5.5 4

Pathologic characteristics of cervical carcinoma

No. of nodes harvested,mean

22 16

No.of positive nodes,mean 8 3

Margins positive 1 0

Recurrence 1 0

Reference - The J of minimal invasive gynecology


Major morbidity after LPE 30%

Complications (our data 2010)(n‐10)

No. of patients(%)

Delayed bladder recovery 4(40)Delayed bladder recovery 4(40)

Surgical site infection 1(10)

Anastomatic leak 1(10)

Pronged ileus 1(10)



• Morbidity in open series 40% to 60%

• In our series ‐surgical site infection ‐1

‐anastomatic leak ‐1‐managed conservatively.

• Successful colostomy reversal ‐in 6 patients.

• No 30‐day operative mortality

• No major intra‐op complications

• No conversions.

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CONCLUSION

disease free survival in LPE ‐ 80%.

‐after median follow‐up of 26 months –

‐9 out of 11 patients were alive

8 i f f di‐8 patients were free of disease

Survival is much better in cancer cervix than in cancer ovary

POSTERIOR EXENTERATION‐CONCLUSION

Restoration of complete anatomy is possible.

LPE has a good 5 year survival rate, but cases are few.

i i i i dDespite extensive experience in LRH and anterior and total pelvic exenteration, only 11 patients were eligible to undergo LPE during study.

TOTAL PELVIC EXENTERATION

• We have successfully performed laparoscopic TPE 11 cases

• in 1 patient ‐robotic TPE

i i d i• no patients required conversions to open surgery.

• relief from local symptoms was dramatic and was documented in all patients.

Lap. Total Pelvic Exenterations

Our series ‐ 11 patients• Median operative time 200 min.• Average blood loss 400 ml• postop. hospital stay 6 days

6 patients have completed one year follow –up and are disease free.

• Compared to a total of 600 cases of Lap radical hysterectomies, 10% were of LAE, 1.5 % were of LPE, and 1% were of TPE .

• This is because of stringent criteria in selection of cases for exenteration procedure.

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Complications of Laparoscopic Exenteration

Complications No. of patients(n‐81)

Bleeding 2

Ureteric injury 3j y

Intestinal leak 4

Wound infection 1

Prolonged ileus 8

Complications of Exenteration

Bleeding

ureteric injuryj y

intestinal leak

wound infection

ileus

no major complication

COMPARISON OF OUR OPERATIVE DATA

PRESENT STUDY(n‐81)

LAP. ANTERIOR EXENTERATION

(N‐60)

LAP. POSTERIOR EXENTERATION

(N‐11)

LAP. TOTAL EXENTERATION

(N‐11)

Median surgical duration

180 mins (160‐200) 220 mins (180‐430) 230+/‐15 mins

Median blood loss 220 200 250

Mean hospital stay 6 7 7

Intra op blood transfusion

0 1.3 5

Median follow up 30 26 24

Immediate mortality 0 0 0

Our 5 year Survival Rate of LPE ,LAE and TPE

60%

70%

80%

0%

10%

20%

30%

40%

50%

Anterior Exenteration (N‐69)Posterior Exenteration (N‐11)Total Exenteration (N‐12)

25%

80%

0%

SURVIVAL

• Survival rate in LPE is better as compared to LAE .

• Because of physiologically weaker cervicovescical fascia cancerous cells tends tocervicovescical fascia ,cancerous cells tends to invade bladder more frequently compared to rectum.

Comparison of 5 year Survival Rates Of pelvic exenteration

30%

40%

50%

60%

70%

60% 54%

0%

10%

20%

30% 54%41% 44% 45%

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Robotic Exenteration

• With the advent of da vinci robotic system, many surgeries that would have been done with an abdominal incision are now being performed with minimal invasive techniques using DRS.

• In our institute,since 2009 we performed 10 cases of pelvic exenteration with robotic approach.pp

• Recently we performed first robotic total pelvic exenteration, Our data shows..

• All patients who underwent robotic exenteration were underwent chemoradiations before surgery.

• We have only 3 year survival data of these patients, as we started using robot since 2009.

Robotic Exenteration PRESENT STUDY

(N‐10)ROBOTIC ANTERIOR EXENTERATION

(n‐9)

ROBOTIC TOTAL EXENTERATION

(n‐1)

Median surgical duration 120 mins 150 mins

Median blood loss 100 ml 150 ml

Intra op blood transfusion 0 0

Mean hospital stay 5 5

Immediate post op mortality 0 0

Comparison of world Laparoscopic series

Author(year)

No ofpts

Surgical method

Mean time of procedure

Blood loss Hospital stay

Follow‐up 5 year Survival

Ferennscild(2009)

69 Open exenteration

448 mins 6300 ml 17 days 45%

Maggion(2005)

106 Open exenteration

490 mins 1240 ml 21 days 52%

PRESENTSTUDY

92 LAP.‐82ROBOTIC ‐ 10

180 MINS 200 ML 7 DAYS 26 (16 ‐54 )months 60%

Ferron et al (2006)

7 Laparoscopy‐assisted pelvicexenteration:

6.5 hours less than 500 ml 27 days 14 months2 pts free of disease1 pt local reccurenceexenteration:

2 pts total3 pts anterior2 pts posterior

1 pt local reccurence4 pts died (3 weremetastatic)

Uzan et al (2006)

5 LaparoscopicPelvicexenteration:2 pts total1 pts posterior2 pts anterior

4.5‐9 hours 370 ml 3 pts died (3 weremetastatic)4 pts alive for 11 and 15 months

Ferron et al (2006)

5 Laparoscopy‐assisted pelvicexenteration:1 pts total2 pts anterior

6 hours(range 4.5‐9 h)

less than 500 ml 27 days(13‐33 days)

3‐16 months3 pts free of disease2 pts growing metastatis1 pt died after 8 months

LAPAROSCOPIC ANTERIOR EXENTERATION(VIDEO)

LAPAROSCOPIC POSTERIOR EXENTERATION(VIDEO)( ) Laparoscopic Total Exenteration(VIDEO)

14

Robotic Vault excision

Summary

• Exenteration is supposedly a very extensive procedure but it has a definite role in the treatment of cancer cervix

• It gives a distinct chance (20%) of cure to the• It gives a distinct chance (20%) of cure to the patient

• Its offers excellent palliation

References

• Netters Atlas of Anatomy

• J.Pelvic Surgery Sep2002

• Journal of Gynecologic Oncology. 102(2006)513‐516.

• Journalof Minimally Invasive Gynecology 14 682‐• Journalof Minimally Invasive Gynecology. 14, 682‐689 July 2006.

• Journal of Minimal Invasive Gynaecology

• J.of Biomedical Sci, March 2009

15

Extreme dissectionExtreme dissectionWhat surgical horizons?What surgical horizons?

David B. Redwine, M.D.Bend, OregonDavid B. Redwine, M.D.Bend, Oregon

PG Course 11141st Global CongressLas Vegas, NVNovember 5, 2012


The painted hills, John Day, Oregon The painted hills, John Day, Oregon

DisclosureDisclosure

I have no financial relationships to discloseI have no financial relationships to disclosedisclose.disclose.

ObjectiveObjective

ObjectivesObjectives

Demonstrate unusual and difficult dissections in the surgical treatment of endometriosisDemonstrate unusual and difficult dissections in the surgical treatment of endometriosisin the surgical treatment of endometriosisin the surgical treatment of endometriosis

Describe the rationale behind such dissectionsDescribe the rationale behind such dissections

As a resultAs a result

Attendees may augment their surgical skill set for better surgical care of their patientsAttendees may augment their surgical skill set for better surgical care of their patients

Extreme dissection

Most often required in excision of endometriosisMost often required in excision of endometriosis

S i l t t t f d t i iS i l t t t f d t i iSurgical treatment of endometriosis demands complete freedom within the abdominal and thoracic cavities

Surgical treatment of endometriosis demands complete freedom within the abdominal and thoracic cavities

Surgical treatment of endometriosis is excellent training for everything elseSurgical treatment of endometriosis is excellent training for everything else

Extreme dissection

Surgical treatment of endometriosis is excellent training for everything else

angiolysis

Surgical treatment of endometriosis is excellent training for everything else

angiolysisangiolysis

neurolysis

intestinal resections

urological resections

diaphragmatic resections

angiolysis

neurolysis

intestinal resections

urological resections

diaphragmatic resections

Did I missany organsystems?

Did I missany organsystems?

Extreme dissection

If you can excise endometriosis anywhere laparoscopically, you can treat anything everywhere laparoscopically

If you can excise endometriosis anywhere laparoscopically, you can treat anything everywhere laparoscopicallyy p p yy p p y

If you can’t excise endometriosis laparoscopically, learn how to do it at laparotomy.

If you can’t excise endometriosis laparoscopically, learn how to do it at laparotomy.

16

Extreme dissectionImportant principles of severe endometriosis:Important principles of severe endometriosis:

Ovarian endometriosis carries a higher risk of:Ovarian endometriosis carries a higher risk of:- more extensive pelvic involvement- intestinal involvement- more extensive pelvic involvement- intestinal involvementPositive scans of endometriomas are misleading – there is more disease!Positive scans of endometriomas are misleading – there is more disease!If you plan to treat only ovarian disease, you will leave a lot of disease behindIf you plan to treat only ovarian disease, you will leave a lot of disease behind

Extreme dissectionImportant principles of severe endometriosis:Important principles of severe endometriosis:

Obliteration of the cul de sac:Obliteration of the cul de sac:

M h th dh i blM h th dh i blMuch more than an adhesive problemMuch more than an adhesive problem

Signifies invasive disease of the uterosacral ligaments, cul-de-sac and anterior rectum

Signifies invasive disease of the uterosacral ligaments, cul-de-sac and anterior rectum

Some type of rectal surgery in >70%Some type of rectal surgery in >70%

Extreme dissection

Three examplesThree examples

Di h ti d t i iDi h ti d t i i

Umbilical endometriosisUmbilical endometriosis

Diaphragmatic endometriosisDiaphragmatic endometriosis

Intestinal endometriosisIntestinal endometriosis

Schematic of obliterated cul de sac dissection

Redwine DB, J ReprodMed, 1992

Extreme dissectionRectosigmoidresectionRectosigmoidresection

Ultimate nerve sparingUltimate nerve sparing

mesenterymesentery

Extreme dissectionDiaphragmatic resectionDiaphragmatic resection

headhead

Symptomatic disease is always on posterior diaphragm behind liverSymptomatic disease is always on posterior diaphragm behind liver

Umbilical portUmbilical port

Right costal marginRight costal margin

headhead

feetfeet

17


Do pelvic, intestinal surgery first

Left lateral decubitus positionLeft lateral decubitus position

Allows liver to fall away from diaphragmAllows liver to fall away from diaphragm


full thickness resection requiredfull thickness resection required

~ 5 mm ~ 8 - 10 mm

END OF STORYEND OF STORYEND OF STORYEND OF STORY

ReferencesRedwine DB. Conservative laparoscopic excision of endometriosis by sharp dissection: life table analysis of reoperation and persistent or recurrent disease. Fertil Steril 1991; 56:628-34.

Redwine DB. Laparoscopic en bloc resection for treatment of the obliterated cul de sac in endometriosis. J Reprod Med 1992;37:695-8.

Redwine DB. Ovarian endometriosis: A marker for more severe pelvic and intestinal

Redwine DB. Conservative laparoscopic excision of endometriosis by sharp dissection: life table analysis of reoperation and persistent or recurrent disease. Fertil Steril 1991; 56:628-34.

Redwine DB. Laparoscopic en bloc resection for treatment of the obliterated cul de sac in endometriosis. J Reprod Med 1992;37:695-8.

Redwine DB. Ovarian endometriosis: A marker for more severe pelvic and intestinal pdisease. Fertil Steril 1999;73:310-5.

Redwine DB, Wright J. Laparoscopic treatment of obliteration of the cul de sac in endometriosis: Long term followup. Fertil Steril 2001;76:358-65.

Peireira R, Zanatta A, Redwine DB. The feasibility of laparoscopic bowel resection performed by a gynecologist to treat endometriosis. Curr Opin Obstet Gynecol 2010, 22:344 – 53.

pdisease. Fertil Steril 1999;73:310-5.

Redwine DB, Wright J. Laparoscopic treatment of obliteration of the cul de sac in endometriosis: Long term followup. Fertil Steril 2001;76:358-65.

Peireira R, Zanatta A, Redwine DB. The feasibility of laparoscopic bowel resection performed by a gynecologist to treat endometriosis. Curr Opin Obstet Gynecol 2010, 22:344 – 53.

18

Extreme Situation in Oncology

Professor Christophe Pomel

Professor in Oncology and General SurgeryJean Perrin Cancer Centre, France

Faculty of MedicineAuvergne University , Clermont‐Ferrand, France

INSERM UNIT 990

I have no financial relationships to disclosedisclose

Laparotomy / laparoscopy and

extreme situation in surgical oncology

Gynaecologist oncologist surgeons have to deal with dramatic amount of variety

of disease And various anatomical areas

From the top of the diaphragm till the vulva

Size of the Mass/TumourAnd also nature of the tissue are extremely variable in the

field of GYNAECOLOGIC MALIGNANCIES.

19

With One objectiveCLean the disease / O residual tumour Furthermore dissection after

‐chemo‐radiation

chemotherapy alone is sometime‐chemotherapy alone is sometime extremely difficut

Operation in early stages is very different than operating on pre-irradiated tissue.

The majority of laparoscopy procedures in oncology are for early stage disease

Patients benefits:Patients benefits:

--less blood loss.less blood loss.--less scar.less scar.less painless pain--less pain.less pain.

--Short hospital stay.Short hospital stay.--quick recovery.quick recovery.

« the laparoscopic approach to radical prostatectomy has become widespread

with several technical variations»

Trabulsi, GuillonneauLaparoscopic radical prostatectomy J Urol 2005Laparoscopic radical prostatectomy.J Urol. 2005 Apr;173(4):1072-9. Review. 1000 cases…

･Zheng SB, Liu CX, Xu YW.Laparoscopic radical cystectomy and sigmoid colon orthotopic neobladder reconstruction: report of 26 cases

20

Three randomized studies of colo-rectal cancer treated by laparoscopy without

compromising survival

Ka Lau Leung et al. Scopy VS Tomy

Lancet 2004; 363: 1187-91

(203 versus 200)

Lacy AM et alLacy AM et al.

Lancet 2002; 359: 2224-29 (111 versus 108)

Clinical Outcomes of Surgical Therapy Study Group.N Engl J Med. 2004 May 13;350(20):2050-9.

872 patientes de 48 institutions!!!

Because the laparoscopy was use in the anterior part of the pelvis by the urologist, the posterior part by the

l t l t t d tcolorectal surgeons, we started to perform laparoscopic pelvic

exenteration in 2002

We started doing pelvic exenterations in 2002.

All patients were operated after failure of chemo rad treatmentof chemo-rad treatment

- abdominal MRI- thoracic Scan- TEP Scan

The procedure

Confection of the ileal loop conduit

21

22

•Pomel C and Castaigne D.•Laparoscopic hand assisted Miami Pouch following laparoscopic anterior pelvic exenteration.•Gynecol Oncol. 2004 May; 93 (2): 543-545 Posterior exenteration with illeal diversion.

C. Pomel, R. Rouzier, M. Pocard, A. Thoury, L. Sideris, P. Morice et al.Laparoscopic total pelvic exenteration for cervical cancer relapseGynecol Oncol, 91 (3) (2003), pp. 616–618

G. Ferron, D. Querleu, P. Martel, B. Letourneur, M. Soulié Laparoscopy-assisted vaginal pelvic exenterationGynecol Oncol, 100 (3) (2006), pp. 551–555

G. Ferron, T.Y. Lim, C. Pomel, M. Soulie, D. Querleu Creation of the miami pouch during laparoscopic-assisted pelvic exenteration: the initial experienceInt J Gynecol Cancer, 19 (3) (2009), pp. 466–470

E. Lambaudie, F. Narducci, E. Leblanc, M. Bannier, G. Houvenaeghel Robotically-assisted laparoscopic anterior pelvic exenteration for recurrent cervical cancer: report of three first casesGynecol Oncol, 116 (3) (2010), pp. 582–583

A. Martinez, T. Filleron, L. Vitse, D. Querleu, E. Mery, G. Balague et al.Laparoscopic pelvic exenteration for gynaecological malignancy: is there any advantage?Gynecol Oncol, 120 (3) (2011), pp. 374–379

Laparoscopic pelvic exenteration for advanced pelvic cancers: A review of 16 casesShailesh Puntambekar et al.Gynecol Oncol. 2006 Sep;102(3):513-6. Epub 2006 Feb 28

23

before…

after…

1 No technique limits with laparoscopy for cervical cancer treatment whatever the stage.

2 They are still ergonomic and volume limits.

Tumor of more than 10 cm

Laparosocpy and pelvic exenterations

Previous large abdominal surgery with strength adherences.

Obesity (BMI>31)

Vaginal reconstruction and the use of laparoscopy

???

LIMITATIONS OF LAPAROSCOPY

G Ferron et al, GOF January 2012, 43–47

The need of plastic surgery in exenteration ...


Isolated pelvic perfusion S Bonvalot (Gustave Roussy Institute)


Vascular resection for gynaecological malignancies

-Vena cava


-Internal iliac vessels

-Common and/or Extenal iliac vessels

24

Vascular resection for cervical cancer relapse

Inferior cavectomy

Inferior C-+avectomy

Vascular resection for ovarian cancer relapse

Lateral extension of resection: Okabaiashy

Vascular resection for ovarian cancer relapse

Lateral extension of resection:

25

LEER

Resection of common and external iliac vessels

Ileo‐ureteric plasty

OVARIAN CANCER The need of upper abdomen expertise

26

HIPEC and ovarian cancer

?

Sugarbaker and colleagues7 cases of laparoscopic intra-peritoneal hyperhermic chemotherapy

EJSO: sept 2006

Gynaecologist oncologist surgeons are always touching the boundaries of other speciality…

They are in facts dealing with

…General surgery, urology, colorectal surgery, vascular

CONCLUSIONS

g y, gy, g y,surgery, plastic surgery and … medical oncologist…

It is still an utopia to consider that all Gyn Onc cancer can be treated by full laparoscopic approach

27

The Philosophy of Extreme

A. Wattiez, M. Puga, J. Albornoz, E. Faller A. Wattiez, M. Puga, J. Albornoz, E. Faller

Disclosure• Consultant: VECTEC, Karl Storz Germany

What is extreme?What is extreme?

definition

P ti i ti t di t ti i t i Participating or tending to participate in a very dangerous or difficult task

Video 1 Para ver esta película, debedisponer de QuickTime™ y de

un descompresor .

28

definition

Participating or tending to participate in a very dangerous or difficult sport

Being in or attaining the greatest or highest degree

definition

highest degree

• Understand

......to reach the limit

• Strategy & Rules

• Training

To Understand

think!

Laparoscopy is more than just another surgical route....

29

Vision is powerVision is power

ErgonomyErgon = Work Nomos = Law

Strategy & Rules Strategy

Why?• Keep your assitant

• Improve Vision

Para ver esta película, debedisponer de QuickTime™ y de

un descompresor H.264.

• Improve surgical performance

• Save Time

30

g

g

Train hard

Do not underestimate training!

definition

Extending far beyond the norm

.......To push the limits.......To push the limits

HOW?Fantasy

Courage

Innovation

Conviction

PerseverancePerseverance

Humility

......but

if you don’t try you’ll never know!

Surgery is 75% cerebral and 25% manualSurgery is 75% cerebral and 25% manual

31

Surgery cannot be unpredictable .....

Dissection is the Pivot step of surgery• Surgery is a succession and/or an addition of basicactions.

• These single actions are not very «smart», but they acttogether or interact to create sophisticated surgicalactions.


un descompresor .


un descompresor .

•These surgical actions can be named «emergent»because they transcend the complexity of their originalentity.

•Only«the surgical emergence» is an art, because itstightly depends on the surgeon’s capacity.

video

Thank you for your attention!Thank you for your attention!

A. WATTIEZ / A. VÁZQUEZ / S. MAIA / J. ALCOCER

32

What Is Behind My Extreme Attitude

DR SHAILESH PUNTAMBEKARDR .SHAILESH PUNTAMBEKARMD

ASSOCIATE PROFESSORMEDICAL DIRECTOR

GALAXY CARE LAPAROSCOPY INSTITUTE ,PUNE , INDIA

Disclosure

• I have no financial relationships to disclose.

Going back to roots

Basic training as surgeon.

Trained as a cancer surgeon at Tata Memorial i l b i f 989 993Hospital,Mumbai from 1989‐1993.

Mindset

• One sees what the mind wants to see

• The famous TMH philosophy‐

India

• Cancer Cervix is still the numero uno among female cancers

• Large number of cancer cervix patients

i i l• No screening system in place yet

• Radiation facilities available at few centers

• State of art facilities available in big cities

Indian scenario:• Ca cervix kills one Indian every 7 minutes.

• Three‐quarters of the world's burden of cervical cancer falls on developing countries such as India.

• Late presentation is predominantly due to both inadequate knowledge and lack of effectiveinadequate knowledge and lack of effective screening, especially in rural areas.

• In developing countries more than three‐fourths of these cancers are diagnosed in advanced stages with poor prospects for long‐term survival and cure.

33

Surgical Philosophy

• Screening and diagnostic facilities poor

• Less awareness for the disease

• Many patients presented in advanced stage of h dithe disease

Surgical Philosophy

• Chemotherapy and radiation therapy second options

• Anterior CT+RT was not available

di l h h h• Hence Radical surgery was the chosen path

Surgical practices

• Thus exenterative procedures were very common

• This was duly followed in my practice after passing outpassing out

• Thus in 12 years of open surgical practice‐more than 60 exenterations done

Evolution of laparoscopic radical hysterectomy

• The philosophy and the surgical skills were already developed before embarking on laparoscopy.

• In 2004 first laparoscopic radical• In 2004 ,first laparoscopic radical hysterectomy was done by us.

• Opposition to this procedure came from most established centers doing open radical hysterectomies

• Two things that my Guru taught me‐

‐”Surgery takes place in the mind and is just executed on the table!”

”S i b i i‐”Science progresses more by opposition than by appreciation!”

The urge to match the outcome to that of open surgery and make laparoscopic radical hysterectomy a duplicable procedure‐

BIRTH OF PUNE TECHNIQUE!BIRTH OF PUNE TECHNIQUE!

34

A new Era

• Gone are days of” big surgeons –big incisions”

• Current philosophy‐ “big surgeons‐small incisions”

i id h h ld f• Innovations ride on the shoulders of technology.

• Next three years‐

• Completed more than 250 lap radical hysterectomies

i f h b i h• Downstaging of the tumor by anterior chemo‐radiation‐more patients in operable stages

• Patients with central recurrences after completing chemo‐radiation were referred

Reaching a plateau

After doing a considerable no of lap radical hysterectomies‐

• The confidence levels increased

• An excellent trained team was in placeAn excellent trained team was in place

• Advanced optics and energy sources available

• Better understanding of lap anatomy‐ like the only structures to be preserved were the ureters and the external iliac vessles.

<Picture anatomy>

Indian Scenario

• Radical surgeries being done@ TMH

• Open surgical experience

• With large numbers‐ standardization of l i h i dlaparoscopic techniques and steps

• Natural progression to the next step‐exenterative procedures

• First laparoscopic exenteration‐an anterior exenteration

WORLD SCENARIO

• Involvement of contiguous organs‐a contraindication for laparoscopy.

• Serosal involvement‐ contraindication for laparoscopylaparoscopy.

• Postchemo/radiotherapy‐ patients presented with resectable diseases.

35

The world scene

• By 2005‐ only two case reports of laparoscopic exenteration available in literature‐

‐by Pommel et al

Pomel C, Rouzier R, PocardM, Thoury A, Sideris L, Morice P et al. Laparoscopic total pelvic exenteration for cervical cancer relapses. Gynecol Oncol 2003; 91: 616-618

World Scene

• Increased importance to quality of life

• Demanding patients

• Technological advances‐better i i b iinstrumentation, energy sources, better optics

The next summit

• High volumes and experience of open exenterative procedures‐

‐the idea of laparoscopic exenterations was bornborn.

• We started with anterior exenterations‐graduating to

‐ posterior exenterations

‐ Total pelvic exenterations

• After successfully completing a good number of laparoscopic exenterations, the robotic exenterations followed with equal success

The confidence and competence

• Surgical confidence is

‐directly proportional to surgical competence

‐inversely proportional to complications.inversely proportional to complications.

• As the competence grew

‐ the confidence grew

‐the complications reduced

• Alexander Brunschwig gave the the world message to do anterior exenterations

• Pune brought the laparoscopic exenteration to the world live telesurgery @ the AAGLthe world – live telesurgery @ the AAGL annual conference in 2010

36

Which is the next summit

• The ideal urinary diversion

• Natural orifice surgery

• ?single port surgery

The mission

• What America believes in‐

‐reproducibility

• Thus what starts as anecdotal grows into a i d d dseries and as more and more centers adapt

the procedure‐ will be an accepted procedure!

References

• Netters Atlas of Anatomy

• J.Pelvic Surgery Sep2002

• Journal of Gynecologic Oncology. 102(2006)513‐516.

• Journalof Minimally Invasive Gynecology 14 682‐• Journalof Minimally Invasive Gynecology. 14, 682‐689 July 2006.

• Journal of Minimal Invasive Gynaecology

• J.of Biomedical Sci, March 2009

37

What is behind my extreme attitude?

David B. Redwine, M.D.Bend, OregonDavid B. Redwine, M.D.Bend, Oregon



DisclosureDisclosure

I have no financial relationships to discloseI have no financial relationships to disclosedisclose.disclose.

ObejectiveObejective

ObjectivesObjectives

Describe the journey I’ve taken to become an über surgeonDescribe the journey I’ve taken to become an über surgeonüber surgeon über surgeon

Explain why I undertook this journeyExplain why I undertook this journey

As a resultAs a result

Attendees may decide whether to take such a journey for themselvesAttendees may decide whether to take such a journey for themselves


Simplicity of treating endometriosisSimplicity of treating endometriosis

1. Woman has disease1. Woman has disease

2 Disease causes pain ? infertility2 Disease causes pain ? infertility2. Disease causes pain, ? infertility2. Disease causes pain, ? infertility

3. No medicine eradicates disease3. No medicine eradicates disease

4. Surgeon removes disease4. Surgeon removes disease

What could be more simple?What could be more simple?


CorollariesCorollaries

Medicine treats only symptomsMedicine treats only symptoms

Surgery treats the diseaseSurgery treats the diseaseSurgery treats the diseaseSurgery treats the disease

Medical therapy is a cliché “Why don’t doctors treat the disease instead of just the symptoms?” The Public at Large

Medical therapy is a cliché “Why don’t doctors treat the disease instead of just the symptoms?” The Public at Large


Lupron treatment of endometriosisLupron treatment of endometriosis

By one year after stopping treatment:By one year after stopping treatment:

62% have not returned to baseline E262% have not returned to baseline E2

50% have E2 < 10050% have E2 < 100

12.5% have E2 < 2012.5% have E2 < 20

Is long-term ‘improvement’ at expense of ovarian function?Is long-term ‘improvement’ at expense of ovarian function?

M84-042M84-042

38



M92-878M92-878

12 months Rx

Norethindrone lessened but did not eliminate this racial differenceNorethindrone lessened but did not eliminate this racial difference


Lupron-only x 6 months treatment of endometriosisLupron-only x 6 months treatment of endometriosisPlacebo rate with Lupron: 5% - 14%, depending on symptomPlacebo rate with Lupron: 5% - 14%, depending on symptom

M86-031M86-031

46% require narcotics during time of peak Lupron efficacy46% require narcotics during time of peak Lupron efficacy

100% of patients completing Rx require OTC or narcotic meds during treatment100% of patients completing Rx require OTC or narcotic meds during treatment

Dropout rate due to side effects: 9.4%Dropout rate due to side effects: 9.4%


Lupron-only x 6 months treatment of endometriosisLupron-only x 6 months treatment of endometriosis

The symptom responding best is dysmenorrhea, a uterine symptomThe symptom responding best is dysmenorrhea, a uterine symptom

M86-031, M86-039M86-031, M86-039

Between 42% and 73% of patients still had pelvic pain or tenderness at final check during maximum Lupron effect M86-031, M86-039

Between 42% and 73% of patients still had pelvic pain or tenderness at final check during maximum Lupron effect M86-031, M86-039



Many other major ‘data management problems’Many other major ‘data management problems’

M84-042M86-031M86-039M90-471M91-601M92-878M97-777M86-050

M84-042M86-031M86-039M90-471M91-601M92-878M97-777M86-050

Original proprietary studies which brought Lupron to market.Original proprietary studies which brought Lupron to market.

Now under federal court seal atrequest of Abbott Labs.Now under federal court seal atrequest of Abbott Labs.

WHY?WHY?

The “D” is silent

DISTRIBUTION RESTRICTEDDISTRIBUTION RESTRICTEDDISTRIBUTION RESTRICTEDDISTRIBUTION RESTRICTED


“Ablation” of endometriosis“Ablation” of endometriosis

Vascular adhesions Carbon

Persistent endometriosis

39


“Ablation” of endometriosis“Ablation” of endometriosis

No follow-up in reoperated patientsNo follow-up in reoperated patients

No path reportNo path report

Illogical for treatment of deep endometriosisIllogical for treatment of deep endometriosis

Can’t always treat superficial endometriosisCan’t always treat superficial endometriosis

no evidence of efficacy in eradication or reduction of disease – symptoms only

no evidence of efficacy in eradication or reduction of disease – symptoms only

“Ablation” can’t treat deep or intestinal endometriosis safely

Superficial endometriosis

Obturator Obturator

Fibrosis around nerve

Fibrosis around nerve

nervenerve

Nodule ofendometriosisNodule ofendometriosis

? I thought you said it was superficial? I thought you said it was superficial

Ablation of endometriosis

Converts all disease into superficial disease in the

surgeon’s mind

Converts all disease into superficial disease in the

surgeon’s mindsurgeon s mindsurgeon s mind

Excision reveals the truthExcision reveals the truth

In the beginning . . .

Before danazolBefore danazol

Before GnRH agonistsBefore GnRH agonists

Before progestinsBefore progestins

Before birth control pills

Before aromatase inhibitorsBefore aromatase inhibitors

Before anti-angiogenicsBefore anti-angiogenics

Before laserBefore laser

Before electrocoagulationBefore electrocoagulation

There was excision. There was excision. And it was good.And it was good.

HOW GOOD?HOW GOOD?HOW GOOD?HOW GOOD?

40

Let’s talk about “CURE”

Cure (n): 1. a complete or permanent solution or Cure (n): 1. a complete or permanent solution or remedy2. a process or method of curing remedy2. a process or method of curing

How to prove cure of endometriosis?

Symptom relief? Symptom relief?

Pregnancy in infertile women? Pregnancy in infertile women?

NO Pain symptoms can be due to non-endometriotic syndromes.Absence of symptoms doesn’t prove absence of disease.

NO Pain symptoms can be due to non-endometriotic syndromes.Absence of symptoms doesn’t prove absence of disease.

Reoperation after medical/surgical treatment? Reoperation after medical/surgical treatment?

NO Infertility can be due to non-endometriotic issues.Successful pregnancy doesn’t prove absence of disease.

NO Infertility can be due to non-endometriotic issues.Successful pregnancy doesn’t prove absence of disease.

YESReoperation is the only way to judge if disease is present or absent YESReoperation is the only way to judge if disease is present or absent

CURE = absence of disease at reoperationCURE = absence of disease at reoperation

Absence of endometriosisat reoperation:

If not CURE, then what should we call it? If not CURE, then what should we call it?

Remission? Remission? NO - endometriosis is supposed to recur with the next menses NO - endometriosis is supposed to recur with the next menses pppp

Occult endometriosis? Occult endometriosis? NO - you can’t diagnose endometriosis by its absenceNO - you can’t diagnose endometriosis by its absence

Occult advanced cancer? Occult advanced cancer? NO - this makes as much sense as diagnosing endometriosis by its absenceNO - this makes as much sense as diagnosing endometriosis by its absence

Recurrence after LAPEX

11 359359 00 00 359.0 359.0 1010 0.028 0.028 33 0.008 0.008 0.028 0.028 0.008 0.008 1.67 1.67 1.331.3322 349349 1717 00 340.5 340.5 1111 0.0320.032 55 0.015 0.015 0.059 0.059 0.023 0.023 1.40 1.40 2.202.2033 321321 00 1515 313.5 313.5 99 0.0290.029 55 0.016 0.016 0.086 0.086 0.038 0.038 2.80 2.80 2.402.4044 297297 11 3030 281.5 281.5 1111 0.039 0.039 44 0.014 0.014 0.122 0.122 0.052 0.052 1.75 1.75 2.502.5055 255255 00 2727 241.5 241.5 33 0.0120.012 22 0.008 0.008 0.133 0.133 0.060 0.060 2.50 2.50 3.003.0066 225225 00 2222 214.0214.0 77 0.0330.033 11 0.005 0.005 0.161 0.161 0.064 0.064 2.00 2.00 4.004.0077 196196 00 1111 190.5190.5 44 0.0210.021 33 0.016 0.016 0.179 0.179 0.079 0.079 2.67 2.67 3.003.0088 181181 11 1818 171.5171.5 88 0.0470.047 44 0.023 0.023 0.217 0.217 0.101 0.101 2.00 2.00 2.502.5099 154154 00 2222 143.0143.0 55 0.0350.035 22 0.014 0.014 0.2450.245 0.113 0.113 1.001.00 1.001.00

1010 127127 11 1616 118.5118.5 33 0.025 0.025 22 0.0170.017 0.2640.264 0.1280.128 1.50 1.50 2.002.001111 107107 00 1818 98.098.0 55 0.051 0.051 22 0.0200.020 0.3000.300 0.146 0.146 1.00 1.00 1.001.001212 8484 11 1616 75.575.5 11 0.013 0.013 11 0.0130.013 0.3100.310 0.157 0.157 3.00 3.00 1.001.001313 6666 00 2424 54 054 0 00 0 0000 000 00 0 0000 000 0 3100 310 0 1570 157 0 000 00 0 000 00

Column 11: Cumulative persistence/recurrence rateColumn 11: Cumulative persistence/recurrence rate

0.60.6

0.50.5

Redwine, DB. Fertil Steril 1991;56:628-34.

Wheeler, MalinakWheeler, Malinak1313 6666 00 2424 54.054.0 00 0.000 0.000 00 0.000 0.000 0.310 0.310 0.157 0.157 0.000.00 0.000.001414 4242 11 99 37.037.0 00 0.000 0.000 00 0.000 0.000 0.310 0.310 0.157 0.157 0.00 0.00 0.000.001515 3232 00 44 30.030.0 00 0.000 0.000 00 0.000 0.000 0.310 0.310 0.157 0.157 0.000.00 0.000.001616 2828 00 22 27.027.0 11 0.037 0.037 00 0.000 0.000 0.336 0.336 0.157 0.157 0.00 0.00 0.000.001717 2525 00 55 22.522.5 11 0.044 0.044 11 0.044 0.044 0.366 0.366 0.194 0.194 1.00 1.00 1.001.001818 1919 00 44 17.017.0 00 0.000 0.000 00 0.000 0.000 0.3660.366 0.194 0.194 0.000.00 0.000.001919 1515 00 11 14.514.5 00 0.000 0.000 00 0.000 0.000 0.366 0.366 0.194 0.194 0.00 0.00 0.000.002020 1414 11 11 13.013.0 00 0.000 0.000 00 0.000 0.000 0.3660.366 0.194 0.194 0.00 0.00 0.000.002121 1212 00 33 10.510.5 00 0.000 0.000 00 0.000 0.000 0.366 0.366 0.194 0.194 0.000.00 0.000.002222 99 00 11 8.58.5 00 0.000 0.000 00 0.000 0.000 0.37 0.37 0.19 0.19 0.00 0.00 0.000.002323 88 00 00 8.08.0 00 0.0000.000 00 0.000 0.000 0.37 0.37 0.19 0.19 0.00 0.00 0.000.0024 24 88 00 11 7.57.5 00 0.0000.000 00 0.000 0.000 0.37 0.37 0.19 0.19 0.00 0.00 0.000.002525 77 00 00 7.0 7.0 00 0.000 0.000 00 0.000 0.000 0.37 0.37 0.19 0.19 0.000.00 0.000.002626 77 00 00 7.07.0 22 0.286 0.286 00 0.000 0.000 0.55 0.55 0.19 0.19 0.00 0.00 0.000.00

2727++ 55 00 00 5.05.0 00 0.000 0.000 00 0.000 0.000 0.55 0.55 0.190.19 0.000.00 0.00 0.00

23 23 8181 3535

1 2 3 4 5 6 7 8 9 10 11 12 16 17 21 22 26+1 2 3 4 5 6 7 8 9 10 11 12 16 17 21 22 26+Quarters post op

0.40.4

0.30.3

0.20.2

0.10.1

0.00.0 *

*

* ** ******

* RedwineRedwine**

*

***

* * *

Endometriosis: conservative excision at laparotomy

““ . . . recurrence is not . . . recurrence is not frequent, and frequent, and curecure . . . . . . by conservative surgery by conservative surgery

““ . . . recurrence is not . . . recurrence is not frequent, and frequent, and curecure . . . . . . by conservative surgery by conservative surgery y g yy g yis usual.is usual.””

y g yy g yis usual.is usual.””

Joe Vincent Meigs (1892 Joe Vincent Meigs (1892 -- 1963)1963)Joe Vincent Meigs (1892 Joe Vincent Meigs (1892 -- 1963)1963)

J. V. MeigsJ. V. MeigsObstet Gynecol 2:46,1953Obstet Gynecol 2:46,1953J. V. MeigsJ. V. MeigsObstet Gynecol 2:46,1953Obstet Gynecol 2:46,1953

Published CURE rates following excisionPublished CURE rates following excision

As judged among reoperated patients:As judged among reoperated patients:As judged among reoperated patients:As judged among reoperated patients:

66%66% cured by laparotomy excisioncured by laparotomy excision

Wheeler, Malinak. Contr Obstet Gynecol 1987;16:13Wheeler, Malinak. Contr Obstet Gynecol 1987;16:13--2121

66%66% cured by laparotomy excisioncured by laparotomy excision

Wheeler, Malinak. Contr Obstet Gynecol 1987;16:13Wheeler, Malinak. Contr Obstet Gynecol 1987;16:13--2121

57%57% cured by laparoscopy excision*cured by laparoscopy excision*

Redwine DB. Fertil Steril 1991; 56:628Redwine DB. Fertil Steril 1991; 56:628--3434

57%57% cured by laparoscopy excision*cured by laparoscopy excision*

Redwine DB. Fertil Steril 1991; 56:628Redwine DB. Fertil Steril 1991; 56:628--343457%57% cured by laparoscopy excisioncured by laparoscopy excision57%57% cured by laparoscopy excisioncured by laparoscopy excision

(No post op medical therapy routinely in any series)(No post op medical therapy routinely in any series)(No post op medical therapy routinely in any series)(No post op medical therapy routinely in any series)

56% cured by laparoscopy excision

Abbott et al. Fertil Steril 2004;82:878 - 84


Abbott et al. Fertil Steril 2004;82:878 - 84

* DISEASE REDUCTION IN MOST OF THE OTHERS* DISEASE REDUCTION IN MOST OF THE OTHERS

57%57% cured by laparoscopy excisioncured by laparoscopy excision

Varol et al. JAAGL 2003:10;182Varol et al. JAAGL 2003:10;182--99

57%57% cured by laparoscopy excisioncured by laparoscopy excision

Varol et al. JAAGL 2003:10;182Varol et al. JAAGL 2003:10;182--99


Roman JD, JMIG 2010;17:42 - 6.


Roman JD, JMIG 2010;17:42 - 6.

41

Evidence-based medicine:

1. Bad1. Bad

2. Not good

3. Good

4. Pretty darn good

5. Darn good

Excision of endometriosis is 5. Darn good!

Excision of endometriosis is 5. Darn good!

EXCISION IS THE ONLY THERAPY

EXCISION IS THE ONLY THERAPY

PROVEN TO CURE ENDOMETRIOSIS

PROVEN TO CURE ENDOMETRIOSIS. .

Excision of endometriosis -the gold standard Endometriosis surgeon

Has to be able to treat disease anywhere

PelvisBowelPelvisBowelBowelBladderUreterDiaphragmThoraxUmbilicusSkinProstate

BowelBladderUreterDiaphragmThoraxUmbilicusSkinProstate

Endometriosis surgery

individual über-surgeon

vs

individual über-surgeon

vs

multi-disciplinary teammulti-disciplinary team

What is best for the patient?What is best for the patient?


Individual surgeon – surgical privileges required

Bowel

Urological

Individual surgeon – surgical privileges required

Bowel

UrologicalUrological

Gyn

Diaphragmatic

Urological

Gyn

Diaphragmatic

42


Individual surgeon – advantagesIndividual surgeon – advantages

M i i i l t thM i i i l t th

Focused, highly specialized skill set is developedFocused, highly specialized skill set is developed

Less need for preop scansLess need for preop scans

Less need for coordination of officesLess need for coordination of offices

Maximum experience is always at the operating tableMaximum experience is always at the operating table


Individual surgeon – disadvantages

Surgery can be exhausting

Sense of isolation

ff

Individual surgeon – disadvantages

Surgery can be exhausting

Sense of isolation

ffDifficult to gain credentials

Politically incorrect

Difficult to gain credentials

Politically incorrect


Multi-disciplinary team – advantages

General non-gyn skill set is available

Generic experience in non-gyncases

Multi-disciplinary team – advantages

General non-gyn skill set is available

Generic experience in non-gyncasescases

Other specialties usually available for pre- or intra-operative consult

Politically correct thing to do

Safe for the surgeons

cases

Other specialties usually available for pre- or intra-operative consult

Politically correct thing to do

Safe for the surgeonsIs it best for the patient?Is it best for the patient?

Endometriosis surgeryAd-hoc multi-disciplinary team – disadvantagesAd-hoc multi-disciplinary team – disadvantages

A general surgeon may want to do an intestinal diversion for seromuscular lacerationA general surgeon may want to do an intestinal diversion for seromuscular laceration

When simple suture repair is bestWhen simple suture repair is best

The care you planned for your patient can be hijackedThe care you planned for your patient can be hijacked

Others may want to remove the pelvic organs and leave the endometriosis inOthers may want to remove the pelvic organs and leave the endometriosis in

A urologist may just want to do a psoas hitchA urologist may just want to do a psoas hitchWhen segmental resection/anastomosis is bestWhen segmental resection/anastomosis is best

When removal of all endometriosis is bestWhen removal of all endometriosis is best


Best for the patient:

Excision of all disease by a dedicated multi-disciplinary team

or

Best for the patient:

Excision of all disease by a dedicated multi-disciplinary team

oror

by an Über-surgeon

or

by an Über-surgeon

If not by laparoscopy, then by laparotomyIf not by laparoscopy, then by laparotomy


Phrases to avoid:Phrases to avoid:

“Let’s not do such aggressive surgery, it will cause adhesions which might cause infertility.”“Let’s not do such aggressive surgery, it will cause adhesions which might cause infertility.”

Initial laparoscopic view

43

Endometriosis surgeryPhrases to avoid:Phrases to avoid:“Let’s not do such aggressive surgery, it may cause injury. After all – PRIMUM NON NOCERE (Hippocrates)”

“Let’s not do such aggressive surgery, it may cause injury. After all – PRIMUM NON NOCERE (Hippocrates)”

What I actually said was:“The physician must . . . have What I actually said was:“The physician must . . . have

Hippocrates 460 BC – 370 BCHippocrates 460 BC – 370 BC

p ytwo special objects in view with regard to diseases, namely, to do good or to do no harm.”

p ytwo special objects in view with regard to diseases, namely, to do good or to do no harm.”

Redwine, GooglingEndometriosis: The lost centuries 2012

Redwine, GooglingEndometriosis: The lost centuries 2012


Phrases to avoid:Phrases to avoid:“It’s not really necessary to do all that aggressive surgery when good medical treatment is available.”“It’s not really necessary to do all that aggressive surgery when good medical treatment is available.”

“We’ll clean up any residual disease with Lupron ”“We’ll clean up any residual disease with Lupron ”

Medicine treats only symptoms, not the diseaseMedicine treats only symptoms, not the disease

We ll clean up any residual disease with Lupron.We ll clean up any residual disease with Lupron.

“There are dense adhesions in the cul-de-sac. This patient must have had an STD.”“There are dense adhesions in the cul-de-sac. This patient must have had an STD.”

“If you would just get pregnant, it would help your disease a lot. Most women are cured by pregnancy.”“If you would just get pregnant, it would help your disease a lot. Most women are cured by pregnancy.”

Lupron no better than bcps - Vercellini et al, 1993; Guzick et al 2011Lupron no better than bcps - Vercellini et al, 1993; Guzick et al 2011

This is complete obliteration of CDS with invasive endometriosis!!This is complete obliteration of CDS with invasive endometriosis!!

Pregnancy does not eradicate endometriosisPregnancy does not eradicate endometriosis


Phrases to avoid:Phrases to avoid:“I’m sorry I can’t talk with you anymore now, I have to run and deliver a baby, and you know how babies are –they won’t wait. My nurse will explain what’s next.”

“I’m sorry I can’t talk with you anymore now, I have to run and deliver a baby, and you know how babies are –they won’t wait. My nurse will explain what’s next.”

Y ’t d it llY ’t d it ll

“We are going to do definitive surgery for your endometriosis. We’re going to remove your uterus, tubes and ovaries. The endometriosis will just shrivel up and go away.”

“We are going to do definitive surgery for your endometriosis. We’re going to remove your uterus, tubes and ovaries. The endometriosis will just shrivel up and go away.”

You can’t do it allYou can’t do it all

The uterus, tubes and ovaries are uncommonly involved by endometriosis. Most disease will be left behind. Sampson 1940, Redwine,

1987 Aromatase problem

The uterus, tubes and ovaries are uncommonly involved by endometriosis. Most disease will be left behind. Sampson 1940, Redwine,

1987 Aromatase problem


Endometriosis is the only benign disease which is Endometriosis is the only benign disease which is gtreated surgically by removal of something else.

gtreated surgically by removal of something else.

Redwine, 1994Redwine, 1994

ReferencesSampson JA.The development of the implantation theory for the origin of peritoneal endometriosis. Am J Obstet Gynecol 1940;40:549 – 57.

Redwine DB. The distribution of endometriosis in the pelvis by age groups and fertility. FertilSteril 1987;47:173-5.

Redwine DB. Endometriosis persisting after castration: Clinical characteristics and results of surgical management. Obstet Gynecol 1994;83:405-13.

Vercellini P et al. A GnRH agonist versus a low-dose oral contraceptive for pelvic pain associated with endometriosis Fertil Steril 1993;60:75 9

Sampson JA.The development of the implantation theory for the origin of peritoneal endometriosis. Am J Obstet Gynecol 1940;40:549 – 57.

Redwine DB. The distribution of endometriosis in the pelvis by age groups and fertility. FertilSteril 1987;47:173-5.

Redwine DB. Endometriosis persisting after castration: Clinical characteristics and results of surgical management. Obstet Gynecol 1994;83:405-13.

Vercellini P et al. A GnRH agonist versus a low-dose oral contraceptive for pelvic pain associated with endometriosis Fertil Steril 1993;60:75 9associated with endometriosis. Fertil Steril 1993;60:75-9.

Guzick DS et al. Randomized trial of leuprolide versus continuous oral contraceptives in the treatment of endometriosis-associated pelvic pain. Fertil Steril 2011;5:1568 – 73.

Redwine DB. Googling Endometriosis: The lost centuries. 2012 https://www.createspace.com/3949764

TAP/Abbott Laboratories. M84-042, M86-031, M86-039, M90-471, M91-601, M92-878, M97-777, M86-050 Under federal court seal

Redwine DB. Leuprolide: The “d” is silent. 2011 Restricted distribution.

associated with endometriosis. Fertil Steril 1993;60:75-9.

Guzick DS et al. Randomized trial of leuprolide versus continuous oral contraceptives in the treatment of endometriosis-associated pelvic pain. Fertil Steril 2011;5:1568 – 73.

Redwine DB. Googling Endometriosis: The lost centuries. 2012 https://www.createspace.com/3949764

TAP/Abbott Laboratories. M84-042, M86-031, M86-039, M90-471, M91-601, M92-878, M97-777, M86-050 Under federal court seal

Redwine DB. Leuprolide: The “d” is silent. 2011 Restricted distribution.

44

WHAT IS BEHIND MY EXTREME ATITUDE

Professor Christophe Pomel

Professor in Oncology and General SurgeryJean Perrin Cancer Centre, France

Faculty of MedicineAuvergne University , Clermont‐Ferrand, France

INSERM UNIT 990

I have no financial relationships to disclose.disclose.

Extreme attitude need the addition of

‐Multidisciplinary approach++

‐Quality control

Example of ovarian cancer

Only patient with complete resection can expect an acceptable 5 year overal survival rate.

Vergote I, Tropé CG, Amant F, Kristensen GB, Ehlen T, Johnson

N, et al. Neoadjuvant chemotherapy or primary surgery in stage

IIIC or IV ovarian cancer. N Engl J Med 2010;363:943—53.

Chi DS, Musa F, Dao F, Zivanovic O, Sonoda Y, Leitao MM, et al. An analysis of patients with bulky advanced stage ovarian, tubal, and peritoneal carcinoma treated with primary debulking sur‐ gery (PDS) during an identical time period as the randomized EORTC‐NCIC trial of PDS vs neoadjuvant chemotherapy (NACT).

Gynecol Oncol 2011

Complete surgery is the goalThe so called « optimal surgery » should be avoid.

This is also true for sarcoma, colorectal, etc…

Pomel C, Barton DP, McNeish I, Shepherd J. A statement for extensive primary cytoreductive surgery in advanced ovarian cancer. BJOG 2008;115:808—10.

Zapardiel I, Morrow CP. New terminology for cytoreduction in advanced ovarian cancer.Lancet Oncol 2011;12:214.

To reach that objective a various important technical surgical action are to be considered.

« agressivness and complexity of surgery must stay in keeping with both morbidity and quality of life issues»

45

Lymphadectomy / no lymphadenectomy (benedetti et al.) Complete / uncomplete

Quality of peritonectomies in all areas…Quality of posterior pelvic exenteration : « one block resection»

46

Quality control

Whatever extent of the disease and surgeon’s expertise, complete resection is not always possible

Preoperative assessment ++p

MRI, CT, PET, … laparoscopy ?

Quality Control

Patient’s status? Evaluation of resectabilityOncogeritry, anesthetic, nutrition…

Will both patient and family accept the surgery and consequences? Per and postoperative morbidity, lost of function and autonomy, nutrition…

Need for multidisciplinary approach with high level of expertise +++Radiologist, radiotherapist, medical oncologists, gyn onc…

Appropriate hospitalPer operative team, ITU…

‐ CA 125 = WHAT IS THE CUT OFF VALUE = 500 iu/ml 1000 iu/ml ?

‐ IN THE NEAR FUTURE : GENOMIC ANALYSIS BY DNA CHIPS ?

( Berchuck 2004)

Role of biology in the future ?Role of biology in the future ?Role of biology in the future ?Role of biology in the future ?

SUBOPTIMAL DEBULKING

NON RESECTABLE ?

Role of C.T. SCAN (ovarian cancer)Role of C.T. SCAN (ovarian cancer)Role of C.T. SCAN (ovarian cancer)Role of C.T. SCAN (ovarian cancer)

J Clin Oncol. 2007 Feb 1;25(4):384-9. Multi-institutional reciprocal validation study of computed tomography predictors of suboptimal primary cytoreduction in patients with advanced ovarian cancer.Axtell AE, Lee MH, Bristow RE, Dowdy SC, Cliby WA, Raman S, Weaver JP, Gabbay M, Ngo M, Lentz S, Cass I, Li AJ, Karlan BY, Holschneider CH.

CT ?CT ?CT ?CT ?

Résécable Non résécable

ROLE +++ of laparoscopy for preoperative assessment of peritoneal resectability

As HIPEC procedure…

Laterza et al. In Vivo. 2009 Jan-Feb;23(1):187-90.

47

Avantage of laparoscopy

1 Simple procedure

2 biopsies

PCI scopy = PCI tomy

-Small bowel-omentum-pelvis -Anterior part of the diaphragm-Parieto-colic gutters

Pitfalls of laparoscopy

PCI scopy < PCI tomy

-Fixed omentum-Infiltration of posterior aspect of the diaphragm-Suprahepatic vessels -POsterior aspect of the porta-Lesser sac-Coeliac trunck

PCI index (Sugarbaker)/

Photos-videos

Behind my extreme attitude CONCLUSION

Contract of good practice:

Appropiate Human ressources and hospital :

-Hospital (ITU / 24H imaging availability …)

-Doctors :

Radiologist, Pathologist, Surgeons with vascular, urologic, colorectal expertises., medical / Gyn-onc

« Surgery for advanced gynaecological cancer

is not a limites to gynaecological surgery »

Appropriate management and MDT (including medical alternatives)

Balance the decision

« quality of life / quantity of life »

48

CULTURAL AND LINGUISTIC COMPETENCY Governor Arnold Schwarzenegger signed into law AB 1195 (eff. 7/1/06) requiring local CME providers, such as

the AAGL, to assist in enhancing the cultural and linguistic competency of California’s physicians

(researchers and doctors without patient contact are exempt). This mandate follows the federal Civil Rights Act of 1964, Executive Order 13166 (2000) and the Dymally-Alatorre Bilingual Services Act (1973), all of which

recognize, as confirmed by the US Census Bureau, that substantial numbers of patients possess limited English proficiency (LEP).

California Business & Professions Code §2190.1(c)(3) requires a review and explanation of the laws

identified above so as to fulfill AAGL’s obligations pursuant to California law. Additional guidance is provided by the Institute for Medical Quality at http://www.imq.org

Title VI of the Civil Rights Act of 1964 prohibits recipients of federal financial assistance from

discriminating against or otherwise excluding individuals on the basis of race, color, or national origin in any of their activities. In 1974, the US Supreme Court recognized LEP individuals as potential victims of national

origin discrimination. In all situations, federal agencies are required to assess the number or proportion of LEP individuals in the eligible service population, the frequency with which they come into contact with the

program, the importance of the services, and the resources available to the recipient, including the mix of oral

and written language services. Additional details may be found in the Department of Justice Policy Guidance Document: Enforcement of Title VI of the Civil Rights Act of 1964 http://www.usdoj.gov/crt/cor/pubs.htm.

Executive Order 13166,”Improving Access to Services for Persons with Limited English

Proficiency”, signed by the President on August 11, 2000 http://www.usdoj.gov/crt/cor/13166.htm was the genesis of the Guidance Document mentioned above. The Executive Order requires all federal agencies,

including those which provide federal financial assistance, to examine the services they provide, identify any

need for services to LEP individuals, and develop and implement a system to provide those services so LEP persons can have meaningful access.

Dymally-Alatorre Bilingual Services Act (California Government Code §7290 et seq.) requires every

California state agency which either provides information to, or has contact with, the public to provide bilingual

interpreters as well as translated materials explaining those services whenever the local agency serves LEP members of a group whose numbers exceed 5% of the general population.

~

If you add staff to assist with LEP patients, confirm their translation skills, not just their language skills.

A 2007 Northern California study from Sutter Health confirmed that being bilingual does not guarantee competence as a medical interpreter. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2078538.

US Population

Language Spoken at Home

English

Spanish

AsianOther

Indo-Euro

California

Language Spoken at Home

Spanish

English

OtherAsianIndo-Euro

19.7% of the US Population speaks a language other than English at home In California, this number is 42.5%

49

http://www.imq.org/

http://www.usdoj.gov/crt/cor/pubs.htm

http://www.usdoj.gov/crt/cor/13166.htm

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2078538

Documents

Extreme Laparoscopy: Expanding the Surgical Horizon ...GALAXY CARE LAPAROSCOPY INSTITUTE ,PUNE , INDIA Disclosures No financial relationships to disclose OBJECTIVES… To evaluate