Place of Laparoscopy in Gynecologic Cancer Who Should Do It?

 Courtesy of FIGO

Dr. John Sheperd: "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.  

Thank you.”