**2. Applications for gynecologic oncology**

The majority of studies done to date in gynecology oncologic are case series or longitudinal studies done at major facilities in the United States, United Kingdom, and China. The first reports of use and feasibility highlighted the expected benefits of standard laparoscopy with the improvement of single incision cosmesis, decreased blood loss, and decreased pain. Decreased pain was the most consistent finding among early publications, which was noted in a Cochrane review of LESS in benign and oncologic gynecology [14]. Here we will outline specific advantages of the singlesite technique and other considerations for specific gynecologic malignant processes.

#### **2.1 Uterine cancers**

The majority of LESS procedures have been performed for hysterectomy in uterine cancers, (mirroring the LAP2 trial [2]) and for risk-reducing salpingectomies. These have included, in some studies, lymphadenectomy for cancer staging purposes [15]. Given the literature available, there are many potential benefits

**71**

**Figure 2.**

*vNOTES procedure.*

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

preservation for pathologic analysis, and facilitation of extraction.

ease at transition to a multiport procedure when needed [17].

offered by LESS techniques, including: preventing peritoneal tumor spillage, tissue

LESS requires more time to master for advanced retroperitoneal dissection and lymphadenectomies, but a surgeon adept at traditional laparoscopic surgery can overcome these challenges and master these techniques relatively quickly. Patient selection is also of the utmost importance, as obesity is a well known major risk factor for endometrial cancer, and this excess adiposity can increase the difficulty

In 2012 a publication from Memorial Sloan Kettering Cancer Center on sentinel node biopsy in endometrial cancer, it was suggested to change the standard practice in the United States to a sentinel node algorithm rather than comprehensive lymphadenectomy in most patients with endometrial adenocarcinoma [16]. Their algorithm suggested: (1) peritoneal evaluation thorough inspection and washing, (2) retroperitoneal evaluation with excision of all mapped or suspicious nodes, (3) side specific lymph node dissection in case of no mapping into a hemi-pelvis, (4) paraaortic node dissection performed at the discretion of the attending surgeon [12]. Sentinel node biopsy and mapping was gained acceptance as the standard of care for endometrial cancer. This comes after multiple publications such as the FIRES trial which paved the way for the NCCN guidelines suggesting LESS techniques may be adopted more easily, given the need for less extensive dissection and

A new subfield of LESS, vaginal natural orifice transluminal endoscopic surgery (vNOTES) is emerging in the field of gynecologic surgery. While the vast majority of investigation of vNOTES has been in benign gynecology, there are recent documented applications for oncologic purposes, specifically for early stage endometrial

*Single site wound retractor applied to the vagina status post vaginal hysterectomy, accessing the peritoneum for* 

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

of the already complex LESS procedure.

cancer (**Figure 2**).

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

offered by LESS techniques, including: preventing peritoneal tumor spillage, tissue preservation for pathologic analysis, and facilitation of extraction.

LESS requires more time to master for advanced retroperitoneal dissection and lymphadenectomies, but a surgeon adept at traditional laparoscopic surgery can overcome these challenges and master these techniques relatively quickly. Patient selection is also of the utmost importance, as obesity is a well known major risk factor for endometrial cancer, and this excess adiposity can increase the difficulty of the already complex LESS procedure.

In 2012 a publication from Memorial Sloan Kettering Cancer Center on sentinel node biopsy in endometrial cancer, it was suggested to change the standard practice in the United States to a sentinel node algorithm rather than comprehensive lymphadenectomy in most patients with endometrial adenocarcinoma [16]. Their algorithm suggested: (1) peritoneal evaluation thorough inspection and washing, (2) retroperitoneal evaluation with excision of all mapped or suspicious nodes, (3) side specific lymph node dissection in case of no mapping into a hemi-pelvis, (4) paraaortic node dissection performed at the discretion of the attending surgeon [12].

Sentinel node biopsy and mapping was gained acceptance as the standard of care for endometrial cancer. This comes after multiple publications such as the FIRES trial which paved the way for the NCCN guidelines suggesting LESS techniques may be adopted more easily, given the need for less extensive dissection and ease at transition to a multiport procedure when needed [17].

A new subfield of LESS, vaginal natural orifice transluminal endoscopic surgery (vNOTES) is emerging in the field of gynecologic surgery. While the vast majority of investigation of vNOTES has been in benign gynecology, there are recent documented applications for oncologic purposes, specifically for early stage endometrial cancer (**Figure 2**).

#### **Figure 2.**

*Single site wound retractor applied to the vagina status post vaginal hysterectomy, accessing the peritoneum for vNOTES procedure.*

*Single Port Gynecologic Laparoscopic and Robotic-Assisted Surgery*

what many authors refer to as the so-called "Goldilocks" concept of specimen removal [10], allowing the surgical oncologist to laparoscopically remove larger organ systems, a feat which which would have required laparotomy previously. Multiple methods of large specimen extraction in standard laparoscopy have been described, ranging from mini-laparotomy [11, 12] and nonstandard incisions [13], to incisional extension. While useful techniques, these are less studied in malignant processes and their long term sequelae are less elucidated. Therein, many would consider that Laparoendoscopic Single-site Surgery (LESS) techniques have great

*(A) Completion of Salpingectomy vNTOES single site (B) Single site vNOTES visualization of the ureter. (C) Large adnexal mass liberated during laparoscopic single site surgery. (D) Uterine artery ligation and* 

The majority of studies done to date in gynecology oncologic are case series or longitudinal studies done at major facilities in the United States, United Kingdom, and China. The first reports of use and feasibility highlighted the expected benefits of standard laparoscopy with the improvement of single incision cosmesis, decreased blood loss, and decreased pain. Decreased pain was the most consistent finding among early publications, which was noted in a Cochrane review of LESS in benign and oncologic gynecology [14]. Here we will outline specific advantages of the singlesite technique and other considerations for specific gynecologic malignant processes.

The majority of LESS procedures have been performed for hysterectomy in uterine cancers, (mirroring the LAP2 trial [2]) and for risk-reducing salpingectomies. These have included, in some studies, lymphadenectomy for cancer staging purposes [15]. Given the literature available, there are many potential benefits

merit and promise in Gynecologic Oncology (**Figure 1**).

**2. Applications for gynecologic oncology**

**70**

**2.1 Uterine cancers**

**Figure 1.**

*cauterization during vNOTES.*
