**2.2 Cervical cancers**

Interestingly, there were successful publications on using single-site for radical hysterectomy for early stage cervical cancers. The theoretical benefits of LESS were similar to the general benefits mentioned previously. Unfortunately, a landmark 2018 study performed by Ramirez et al., (the LACC trial,) [18] demonstrated a decrease in overall and disease-free survival with laparoscopic radical hysterectomies for early cervical cancers. As a result, laparoscopic radical hysterectomies have become rare in practice [19]. Therefore, until confounding literature published, many gynecologic oncologists feel the utility of LESS for radical hysterectomy is limited and maybe more of an interesting historical footnote than a viable procedure.

## **2.3 Ovarian cancer**

While it is widely considered that advanced ovarian cancers may still be best managed via laparotomy, laparoscopy and robot assisted laparoscopy is still routinely utilized in early stage ovarian cancers. Complete staging is imperative for all ovarian malignancies. The protocol for assessing these early ovarian cancers includes: lymph node dissection, peritoneal biopsies, and omentectomy. These measures allow for peritoneal sampling which allows for improved detection of micrometastatic disease, which, in turn, optimizes adjuvant chemotherapeutic selection and prognosis for patients.

Perhaps the greatest area of potential use in Gynecologic Oncology for LESS techniques would be adnexal masses. When the uterus is left in situ in traditional laparoscopic surgery retrieval of a large adnexal mass can be very frustrating. A 10 or 12 mm incision is often not large enough for removal of a large specimen. As a result, this scenario requires an incision to be extended, (including fascial extension) and creates a risk of injury to the bowel or other structures, as well as a risk of spillage from the isolating bag. LESS techniques in general will require a 2-3 cm umbilical incision but this can be made larger for certain clinical scenarios. Making the incision in a natural defect such as the umbilicus can yield excellent cosmetic results when a larger incision for extraction is required [20].

For a suspicious mass large extraction bags are available in sizes up to 17 cm. These vary in size and shape and are available from various manufacturers. They can be deployed intraperitoneally and the mass can be brought out through the umbilical incision, or if necessary, drained while contained. If a frozen section

**73**

*Utility of Robotic Assisted and Single Site Laparoscopy to Gynecologic Oncology*

slightly large incision in the umbilicus usually allows for easy removal.

It is important to note that the above techniques for adnexal mass removal are not appropriate for all patients. For any patients in which a malignancy is suspected, great care must be taken to avoid any technique that introduces the risk of spilling malignant cells in the abdominal cavity, effectively working to spread the lesion. For patients with a low suspicion of malignancy, however, we feel that the technique is a welcome addition to the armamentarium of the gynecologic surgeon. We welcome further research, including case studies and described techniques. This will serve to further develop the minimally invasive literature as well as to stimulate ideas for

A number of studies have been performed in the realm of benign gynecology with robotic LESS with varied success. Few, however, have been published specifically on oncologic robotic surgery. The most notable of these demonstrated the feasibility of robotic single-site [21]. The benefits and pitfalls of robotic single-site surgery are similar to benign gynecology as previously discussed in this text [22].

Despite the various sources listed in this chapter and the multitude of studies on LESS for gynecologic oncology, there is an overall lack of data on the topic given its relatively new emergence. With only a decade passing since first recorded data in this topic, more research will need done before long-term conclusions can be drawn. To date, the longest single study follow up our authors could find was

Perhaps more than any other adverse outcome, there is evidence that LESS techniques may hold a higher hernia rate than previously expected [1, 13–16]. One study by Multon *et* al. demonstrated that hernia rates within 1 year are similar to standard laparoscopy (5.5%), 3 year follow up seemed to indicate a significant increase in hernia rates as high as 23% [1]. As a result, several authors have stated that it would appear the increased incision size for LESS may have a greater effect on incisional

The technical difficulties of LESS techniques are identical to the benign gynecologic applications of the surgical method, including loss of triangulation, arm clashing, and surgeon comfort [27]. With training, time, and improving surgical

is obtained and this reveals a borderline or ovarian malignancy, the surgeon may feel an infracolic omentectomy is indicated. Generally, the LESS port provides an incision large enough to deliver omentum intact and large enough to perform a relatively easy and quick infracolic omentectomy using whatever laparoscopic energy device has already been used. This technique is similar to previous described techniques of omentectomy performed through a miniature laparotomy (**Figure 3**). For the very large benign appearing mass with normal tumor markers in a young patient, a LESS approach through the umbilicus can facilitate contained drainage. After placing the LESS port of choice the mass can be visualized before insufflation. One technique is to place two purse string sutures of 3-0 monofilament suture into the mass concentric to each other. A small hole is then made and the suction aspirator inserted with the inner stitch tied to contain leakage. Once the mass is decompressed the suction aspirator is removed, and the outer stitch can be tied to prevent any further spillage. The decompressed mass is then removed laparoscopically. The

*DOI: http://dx.doi.org/10.5772/intechopen.96547*

new clinical trial protocols.

**2.4 Robotic applications**

3 years [23, 24].

**3. Limitations and considerations**

hernia than previously thought [25, 26].

instruments, these limitations may be overcome.

**Figure 3.** *Omentectomy at the time of minimally invasive removal of suspicious ovarian cyst.*

#### *Utility of Robotic Assisted and Single Site Laparoscopy to Gynecologic Oncology DOI: http://dx.doi.org/10.5772/intechopen.96547*

is obtained and this reveals a borderline or ovarian malignancy, the surgeon may feel an infracolic omentectomy is indicated. Generally, the LESS port provides an incision large enough to deliver omentum intact and large enough to perform a relatively easy and quick infracolic omentectomy using whatever laparoscopic energy device has already been used. This technique is similar to previous described techniques of omentectomy performed through a miniature laparotomy (**Figure 3**).

For the very large benign appearing mass with normal tumor markers in a young patient, a LESS approach through the umbilicus can facilitate contained drainage. After placing the LESS port of choice the mass can be visualized before insufflation. One technique is to place two purse string sutures of 3-0 monofilament suture into the mass concentric to each other. A small hole is then made and the suction aspirator inserted with the inner stitch tied to contain leakage. Once the mass is decompressed the suction aspirator is removed, and the outer stitch can be tied to prevent any further spillage. The decompressed mass is then removed laparoscopically. The slightly large incision in the umbilicus usually allows for easy removal.

It is important to note that the above techniques for adnexal mass removal are not appropriate for all patients. For any patients in which a malignancy is suspected, great care must be taken to avoid any technique that introduces the risk of spilling malignant cells in the abdominal cavity, effectively working to spread the lesion. For patients with a low suspicion of malignancy, however, we feel that the technique is a welcome addition to the armamentarium of the gynecologic surgeon. We welcome further research, including case studies and described techniques. This will serve to further develop the minimally invasive literature as well as to stimulate ideas for new clinical trial protocols.

### **2.4 Robotic applications**

*Single Port Gynecologic Laparoscopic and Robotic-Assisted Surgery*

Interestingly, there were successful publications on using single-site for radical hysterectomy for early stage cervical cancers. The theoretical benefits of LESS were similar to the general benefits mentioned previously. Unfortunately, a landmark 2018 study performed by Ramirez et al., (the LACC trial,) [18] demonstrated a decrease in overall and disease-free survival with laparoscopic radical hysterectomies for early cervical cancers. As a result, laparoscopic radical hysterectomies have become rare in practice [19]. Therefore, until confounding literature published, many gynecologic oncologists feel the utility of LESS for radical hysterectomy is limited and maybe more of an interesting historical footnote than a viable procedure.

While it is widely considered that advanced ovarian cancers may still be best managed via laparotomy, laparoscopy and robot assisted laparoscopy is still routinely utilized in early stage ovarian cancers. Complete staging is imperative for all ovarian malignancies. The protocol for assessing these early ovarian cancers includes: lymph node dissection, peritoneal biopsies, and omentectomy. These measures allow for peritoneal sampling which allows for improved detection of micrometastatic disease, which, in turn, optimizes adjuvant chemotherapeutic selection

Perhaps the greatest area of potential use in Gynecologic Oncology for LESS techniques would be adnexal masses. When the uterus is left in situ in traditional laparoscopic surgery retrieval of a large adnexal mass can be very frustrating. A 10 or 12 mm incision is often not large enough for removal of a large specimen. As a result, this scenario requires an incision to be extended, (including fascial extension) and creates a risk of injury to the bowel or other structures, as well as a risk of spillage from the isolating bag. LESS techniques in general will require a 2-3 cm umbilical incision but this can be made larger for certain clinical scenarios. Making the incision in a natural defect such as the umbilicus can yield excellent cosmetic

For a suspicious mass large extraction bags are available in sizes up to 17 cm. These vary in size and shape and are available from various manufacturers. They can be deployed intraperitoneally and the mass can be brought out through the umbilical incision, or if necessary, drained while contained. If a frozen section

results when a larger incision for extraction is required [20].

*Omentectomy at the time of minimally invasive removal of suspicious ovarian cyst.*

**2.2 Cervical cancers**

**2.3 Ovarian cancer**

and prognosis for patients.

**72**

**Figure 3.**

A number of studies have been performed in the realm of benign gynecology with robotic LESS with varied success. Few, however, have been published specifically on oncologic robotic surgery. The most notable of these demonstrated the feasibility of robotic single-site [21]. The benefits and pitfalls of robotic single-site surgery are similar to benign gynecology as previously discussed in this text [22].

## **3. Limitations and considerations**

Despite the various sources listed in this chapter and the multitude of studies on LESS for gynecologic oncology, there is an overall lack of data on the topic given its relatively new emergence. With only a decade passing since first recorded data in this topic, more research will need done before long-term conclusions can be drawn. To date, the longest single study follow up our authors could find was 3 years [23, 24].

Perhaps more than any other adverse outcome, there is evidence that LESS techniques may hold a higher hernia rate than previously expected [1, 13–16]. One study by Multon *et* al. demonstrated that hernia rates within 1 year are similar to standard laparoscopy (5.5%), 3 year follow up seemed to indicate a significant increase in hernia rates as high as 23% [1]. As a result, several authors have stated that it would appear the increased incision size for LESS may have a greater effect on incisional hernia than previously thought [25, 26].

The technical difficulties of LESS techniques are identical to the benign gynecologic applications of the surgical method, including loss of triangulation, arm clashing, and surgeon comfort [27]. With training, time, and improving surgical instruments, these limitations may be overcome.
