John Shepherd, MD

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       "Thank you very much indeed, I’m very grateful.        It’s actually not Paul McCartney; it was Tony McCartney, Paul       McCartney’s still singing.  I       received this invitation to stand in for Tony McCartney on my way over       here in the airplane when I was going through my e-mails less than       twenty-four hours ago.  I’m       very grateful to the Program Committee for this opportunity at an       extremely short notice to stand in and give a talk.        The talk that Tony McCartney from Australia was asked to give, and       I’m sure had prepared in an extremely erudite way, was on who should       carry out laparoscopic surgery.  I’m       going to ask you and suggest to you who should not carry out laparoscopic       surgery.         

There is no doubt as we’ve heard from       our speakers just now from their excellent presentations that we know what       can be carried out but we have to think very carefully about who should be       carrying these procedures out and on what patients.        Thinking is something that surgeons in the past have not been       renowned for doing very well on occasions, we are told and, therefore, we       do have to think very carefully.  I       would suggest to you that our forefathers such as John Hunter would have       been horrified to allow certain procedures to be performed by the       laparoscope.  John Hunter was       the first person to be able to carry out a radical hysterectomy because as       you can see here these specimens from 1720, which are in the museum in       Royal College of Surgeons, are some of the original radical hysterectomy       specimens carried out in cadavers.  Now       all that proves is that anything can be done by certain surgeons at some       time, and what we’re learning is that the laparoscope does allow us the       facility to carry out almost any procedure that can be done by open       laparotomy.  As has been so       elegantly shown, it is now possible to extend this technique into       oncological surgery.  But as       oncological surgeons, we have to be able to select very carefully what       procedures should and what procedures shouldn’t be carried out.        We have to minimize the morbidity of our treatment, be it combined       treatment with radiotherapy with chemotherapy or surgery, in order to       allow the best possible chance of cure for the patients that we are       treating.  We can clear the       pelvis thoroughly like this by open laparotomy but it would be quite       inappropriate to attempt to do so by laparoscopy.        Now sometimes we get surprises as to what we see in the abdomen and       laparoscopy has been likened on occasions to peeping and squeaking into       the abdomen and sometimes on the inside we get a surprise.  

The answer is who should be carrying out       laparoscopic surgery - the surgery should be performed in cancer by cancer       surgeons who are familiar with the anatomy, with the natural history of       the disease, and who understand the pathophysiology of what they are       dealing with.  It is quite       inappropriate for non-oncologically trained surgeons to carry this out       because the decision has to be made as to what procedure for that       individual patient is the most appropriate and that can never, never be       forgotten.  Laparoscopy is       part of a surgical armamentarium that all surgeons - gynecologists,       general surgeons, and now even thoracic surgeons should be carrying out       minimal access surgery for their own procedures in the thorax.        We as gynecologists have to train all our junior staff when       carrying out surgery to be able to perform laparoscopy and operative       laparoscopy as well as diagnostic laparoscopy.        That doesn’t mean that all operative laparoscopists and       gynecologists should be doing periaortic node dissections in the manner       that we have heard, otherwise the roll operation will be carried out on       the wrong patient.  There is       no doubt that the laparoscope allows the diagnosis, staging, and treatment       to be performed without the need of a large abdominal wound but       appropriate management should not be compromised to suite the limitations       of either the technique or indeed, dare I say it, the surgeon.  

We have a wonderful view of the pelvis as       we’ve seen, and we can carry out procedures retroperitoneally or       transperitoneally as has been very elegantly shown.        There is no doubt that this must be added to the armamentarium of       gynecological oncologists but we have to learn that in cancer we have to       have site specialized individuals and we have to have properly trained       surgical oncologists dealing with the appropriate part of their particular       specialty.  It’s a question       of clinical governance and common sense; the right people have to be       treating appropriate patients.  So       we return to the days of our forefathers, in those days many people would       come and watch operations.  Now       however, laparoscopy is going to mean that we will have to video all of       these procedures so that they can be watched at a later date, and I would       remind you that medical/legal complications will, therefore, be seen far       more readily but we will now be able to review all our cases in an       appropriate way by video recording.  

Finally, I would, just as a salutary       thought, remind you that what we are seeing today is a reemergence of       surgery that has been carried out for many decades.        We are seeing the reemergence of vaginal surgery and a radical       vaginal surgery but in a much more appropriate way, in a way that is       controlled by being able to assess the abdomen from inside using the       laparoscope and using this as a facilitator for carrying out more       extensive surgical procedures vaginally and more radical procedures but       under direct vision and control and allowing us to assess the abdomen       before that radical vaginal surgery is carried out.        What we have to do is to prevent an increase of morbidity at the       expense of decreasing a successful cure.        Thank you very much for this opportunity of being provocative, I       hope, after two excellent presentations before.         

Articles

OBGYN.net Conference CoverageINTERNATIONAL FEDERATION of GYNECOLOGY & OBSTETRICS: Washington DC, USA

Place of Laparoscopy in Gynecologic Cancer Who Should Do It?

        “Thank you very much indeed, and good morning once again, ladies       and gentlemen.  You       heard from the two previous speakers about the role of surgery in       recurrent disease, and I certainly agree with Dr. Ungar’s       comments about the need for the referral of appropriate patients and for       trying to pick up recurrent disease early.        I’m going to look at this problem with a slightly broader look at       reconstructive surgery across the board for recurrent pelvic cancer and       try and show you that now in this day and age we have to think very       carefully about further surgical techniques and try and rehabilitate some       of these ladies who’ve suffered quite considerably in the past.        This is arguably one of the most beautiful ladies in the world,       sitting in the Louvre for now, and I guess it would be a tragedy to try       and reconstruct her.  Maybe       she should be returned to her original home.         

Cancer is a       destructive process and the treatment for cancer be it by radiotherapy or       by extirpative surgery is destructive.        The process of recurrence of cancer is even more destructive if       it’s for cervical cancer, which may occur centrally and then spread out       laterally and locoregionally involve the pelvic sidewalls, bony       involvement, etc. That is a destructive process so the pathophysiology       leads to destruction and the treatment to try and cure the disease also is       destructive.  Surgery has two       aims, and you’ve heard both of those this morning.        Dr. Ungar has alluded to trying to cure patients surgically for       recurrent cancer, and Dr. Hoskins has indicated that we have to consider       very carefully the role of palliative surgery in order to try and help       patient’s symptoms in appropriate cases.  

Radiotherapy,       whichever way you look at it, destroys the cancer but does have an effect       on surrounding tissue, just as much as extirpative surgery by exenteration       will have an effect on surrounding tissue.        If we look at pelvic exenteration, this has been well described and       historically put into perspective by Dr. Ungar.        There are three parts to this particular procedure - one is the       resection of the tumor, which can be by anterior, posterior, or total       pelvic exenteration.  The       second part involves diverting the urinary and the fecal streams, and       traditionally, this has been to stomas.        The third part in this day and age is reconstruction; trying to       reconstruct a continent bladder, a functioning vagina, restore rectal       continuity, and try and restore some form of cosmetic appearance and       function to the vulva.  You       can see here the first of the reconstructions - the diversions that were       developed which is the formation of a urinary bladder as initially       described, of course, by Bricker and this is the method that Leadbetter       described when implanting ureters with inevitably a diverting urostomy.        So that was a low-volume, high-pressure conduit if you will to a       urostomy, and if one has to divert the fecal stream, one has to have a       colostomy.  

Now if you       look at reconstruction the aim of reconstruction is to re-establish a       functioning organ and at the same time remember, Kasmesus,       as part of reconstruction, tried to recreate and restore body image.        We’ve heard from Dr. Ungar about the possibilities for       continent bladder reconstruction, and we really are now in the day and age       of continent bladder reconstruction, re-anastomosing the rectum.        The good Lord in all his wisdom gave us 10 meters of bowel, the       first 2 feet of bowel from top end to the other, it’s true to say some       people appear to have more but traditionally the conduit utilizes the       terminal ileum.  But we do       have a considerable amount more of ileum proximal to that terminal area       and indeed, the ascending curve of the cecum.        These can be utilized for reconstructing continent bladders.        The technique that Dr. Ungar referred to that we described from       Bart’s which we call the APER procedure or the anterior pelvic       exenteration and reconstruction, it seems to be renamed the Budapest       procedure now, it involves using 48 cm of terminal ileum and taking the       ureters and re-implanting these into a large volume, low pressure conduit.        This does offer the opportunity for retaining the urethra if indeed       it is possible.  Remember that       the radiotherapy effects on that lower part of the bladder and the trigone       and especially the urethra may not be as extensive in cervical cancer as       when radiotherapy is administered for either bladder cancers or for rectal       cancers and utilizing that portion of the small bowel and re-implanting       the ureters with this method that we’ve       shown, and tunneling them into the wall of this large volume bladder.  

We’ve       modified the technique from the original technique described whereby we       used a portion of proximal ileum to re-implant these ureters and have       modified that so that we actually are tunneling them directly into the new       bladder.  There is less reflux       with this technique.  There       are other procedures that have been described; we’ve heard about the       Budapest method, there is of course, the Miami method, which       utilizes more of the ascending colon and cecum.        There’s the mica pouch from Germany       which utilizes more of the terminal ileum and there are various other       methods including the Indiana pouch.        Just about any large city in the developed world has developed its       own particular technique, which indicates that there’s a lot of interest       but perhaps not one actual gold standard method.        Therefore, it behooves us if we’re going to utilize these       methods, to use the one that suits us and our particular techniques in       each accordingly.  So we now       have the possibility for bladder reconstruction, what about the vagina?

There       are many methods of reconstructing the vagina either as a delayed       procedure or concurrent reconstruction with exenteration surgery.        Perhaps the most well known straightforward simple procedure is the       Williams vulvo-vaginoplasty, which utilizes either the labia or if       they’ve been removed, can utilize the inner aspects of the thigh if       there’s enough flexible tissue and, of course, the split thickness       graph, a well-known procedure.  But       at the same time as exenteration, it is quite feasible to utilize       myo-cutaneous grafts, either the gracilis, rectus abdominus, or the       gluteal muscles all tentatively to utilize other bits of bowel, part of       that 32 feet; again, 10 meters can be used to reconstruct a functional       vagina either using the ileum and the sigmoid, or the cecocolon which are       certainly our preferred preference.  The       McIndoe-Reed

procedure would be straightforward; you remember it       requires an obturator or mold, which is placed into the vaginal space       between the bladder and the rectum.  This       is a good procedure for primo genesis but less straightforward because of       scarring and constriction and radiotherapy effects, I have to say, for       after exenteration.  So the       procedure that we have favored as having utilized part of the terminal       island to reconstruct a continent bladder is to take the next part of the       bowel, the cecum, and the colon and to mobilize this and to use this to       bring down as a functioning ceco-colon vaginoplasty first described by       Turner Warick who brought down the hepatic flexor end of the colon.        We’ve slightly modified this and instead of turning it, we bring       it down and bring the cecum down.  We       have to take the appendix off otherwise you may have a second vaginal       orifice and pouch which can be a little bit confusing and bring this down       and then re-anastomosing it.

This       particular technique as we’ve described here avoids the need for a       urostomy and at the same time does give a functioning vagina.        This particular lady has had a slightly different form of continent       bladder reconstruction, utilizing a  technique that utilizes a       catheter as a spout out unto the anterior abdominal wall but has also had       a vaginoplasty.  Now       some exenterative surgeries, you can see here, involves intra levator       resection of the vulva and the vagina and the perineum leaving large       deficiencies which require a thinning with musculocutaneous flaps which       can be mobilized as is shown here in order to try and close that       particular defect.  We must       remember that the majority of flaps in reconstruction that need to be       used, of course, are for vulva cancers.        On occasions we can be presented with huge tumors replacing the       vulva, the inner thigh, a fierce change of paramedial tissue is affected       by cancer in some circumstances, and trying to resect this is certainly       possible and feasible but provides an enormous challenge for the pelvic       surgeon to try and get primary closure.        He’ll turn to leave this to granulate which, of course, in this       day and age especially when bed days at hospital are being counted, is       unacceptable, let alone from the body image point of view.  

Some of those       circumstances we have to use our imagination and learn the message from       the reconstructive surgeons who have taught us with the dreadful problems       they’ve had to deal with over the last few wars that have occurred with       burns and tissue destruction.  We       can actually now utilize musculocutaneous flaps either as rotational flaps       or indeed free flaps or graphs with a microvascular reanastomosis but we       can now virtually fill any defect by imaginative reconstruction and       rotation of tissue as you can see here this large potential defect from       this huge vulva tumor.  The       plan here is having carried out a bilateral DELETE vulvectomy, as shown       here.  Utilize rex abdominus       flaps, as you can see here.  Bring       them down as is being shown here to cover this large defect that has       resulted.  The flaps are then       brought down, and this is a picture three months later, as you can see       here, with some intricate cosmetic reconstruction that is being carried       out here.  This gives a       functioning organ that needs to be utilized and the patient encouraged to       use, and we’ll discuss that shortly.        But there are many other flaps that can be mobilized and used       including the gluteus maximus, the iliotibial tract, and the gracilis       muscle.  Indeed, there are       free flaps utilizing the pectoral muscles and latissimus dorsi much in the       way that breast surgeons do.  This       is a larger flap.  We’re now       in a day and age whereby we have to offer our patients reconstructive       surgery, the day and age of traditional destruction to extirpate cancer       has gone.  We now have to       consider these reconstructive techniques, and we must remember that on       occasions we may have to carry out reconstructional diversion following       the effects of radiotherapy, again, for palliative purpose.        We have to counsel these patients very, very carefully.        We need to prepare these patients for their surgery, their family       for the understanding of the natural history of the disease and,       therefore, why such treatment is necessary.        We have to plan our surgery, we have to include reconstruction in       the armamentarium of the potential treatment management plan, and we have       to remember as Dr. Ungar pointed out that there are potential       complications, and it is certainly true that the reoperation rate for many       of these procedures is not small.  We       have to rehabilitate these patients, teaching them, and encouraging them       to use their reconstructed organs.  This       particular patient has got a reconstructed continent bladder; she’s got       a reconstructed vulva, a reconstructed functioning cecocolon vagina.        I would like to say she’s had a rectal reconstruction as well but       in fact to that date she hadn’t.  This       is a management plan that involves a multidisciplinary team in oncology       units but the most important member of that team is the part that we can       read in the middle and that, of course, is the patient.        In this way, we can overcome these huge       challenges that are in front of this central part of our management team,       the patient and her disease.  

Thank       you very much indeed for your attention.”

Author | John Shepherd, MD

Articles

Place of Laparoscopy in Gynecologic Cancer Who Should Do It?

Role of Reconstructive Surgery