Robotic-assisted surgery for gynecological cancers
In addition to its well-documented advantages in surgery and recovery, robotic-assisted surgery offers gynecological cancer patients the benefit of hastening the next phase of cancer care—chemotherapy or systemic therapy.
Surgeons with Penn Gynecologic Oncology are performing robotic-assisted surgery (RAS) to stage early-stage endometrial cancers and to treat ovarian, cervical, and uterine cancers.
RAS has gained significant momentum in gynecologic oncology in the last two decades, with the accumulation of evidence that the technology’s high-definition 3D optics, wristed instrumentation, and improved ergonomics provide substantial advantages in surgery and beneficial outcomes for patients. The latter includes lower rates of complications, improved postoperative recovery, and faster return to normal activity. For patients with gynecological cancers, these benefits have the further advantage of hastening the next phase of cancer care—chemotherapy or systemic therapy.
RAS at Penn Medicine
Typically, the care journey for patients considering robotic surgery at Penn begins with a comprehensive evaluation. This process may also include prehabilitation to enhance the patient's overall health, strength, and readiness for surgery. Additionally, a multidisciplinary review with the care team is conducted to ensure the safety and successful outcome of surgery.
Applications for RAS in gynecologic cancer
At Penn Gyn-Onc, RAS is performed for a wide range of gynecologic malignancies, including ovarian, cervical, endometrial, and uterine cancers, as well as a host of benign conditions.
In advanced or recurrent ovarian cancers, RAS has a role in the prediction of optimal cytoreduction, as well as interval debulking surgery and dissection of metastases in close proximity to critical structures in the pelvis and abdomen, including the diaphragm, spleen, and liver, to achieve complete cancer resection.
Minimally invasive RAS hysterectomy is available for select patients with early-stage, uncomplicated cervical and endometrial cancers, as well as for uterine malignancies. RAS is also used for early-stage endometrial cancer staging.
Penn Gyn-Onc surgeons also perform robotic surgery for complex benign gynecological conditions, including severe endometriosis, large fibroids, and the presence of significant scarring or adhesions from previous surgeries.
Post-recovery considerations
Recovery after RAS is monitored by the in-hospital nursing team and APPs, who also participate in outpatient care and clinic visits. Patient follow-up occurs two to three days post-procedure. Additionally, Penn Medicine offers monitoring by a texting algorithm to assess patients’ conditions.
Case report
Mrs. M, a 70-year-old female, was referred to Nawar Latif, MD, for consultation following evidence of an ovarian cancer recurrence. After a discussion of the risks and benefits of further intervention, including the risks and advantages of RAS, she consented to have surgery.
Procedure description: Following standard preoperative procedures (e.g., general anesthesia, DVT prophylaxis, IV antibiotics, and draping), attention was turned to Mrs M’s abdomen. Insufflation of the peritoneal cavity was then achieved, and a small (8 mm) incision was made left of midline above the navel for placement of the robotic camera port and a blunt obturator.
A laparoscope was then inserted, and the peritoneal cavity explored. An additional robotic port was placed in the right lower quadrant, and the LigaSure (a device that uses radiofrequency energy to cut and seal blood vessels and tissue bundles) was then used to perform lysis of adhesions between the bowel and left of midline of the anterior abdominal wall.
After the placement of an additional 8mm robotic port under direct visualization, the falciform ligament of the liver was dissected to the level of the diaphragm using the LigaSure. Following a shift in Mrs. M’s position, the robot was docked to the robotic ports, and the robotic instruments were inserted, again under direct visualization.
A careful survey of the abdomen was performed, resulting in the finding of a 3 cm metastatic nodule on the diaphragm with superficial attachment to the right posterior dome of the liver. Mrs. M’s bowel, omentum, and liver were otherwise normal, and no other gross disease was evident in her pelvis or upper abdomen. There was, moreover, no evidence of visceral injury.
The liver was then gently retracted away from the diaphragm to expose the nodule, and careful dissection was performed in a circumferential manner. The nodule attachment to the liver was noted to be superficial, and it was removed from the posterior liver surface with minimal electrocautery. The diaphragm was noted to have slightly more invasion; however, the overall nodule was removed in its entirety using gentle blunt dissection and electrocautery, and without extensive injury to the underlying diaphragm. The site was then irrigated and found to be hemostatic.
The robotic instruments were removed, the robot undocked, and the various port incisions closed and stitched. Mrs. M was taken to the PACU in stable condition. She left the hospital on the same day of surgery, recovered well over the next days and weeks, and has been in remission for 3 years and counting since her surgery.
About Penn Gynecologic Oncology
An integral part of the Abramson Cancer Center, the Division of Gynecologic Oncology serves as a major referral center for the diagnosis and treatment of patients with premalignant or invasive cancers of the female genital tract. The gynecologic oncologists participating in the Program are board-certified or eligible in gynecologic oncology and perform all aspects of gynecologic cancer surgery and complex benign gynecologic surgery, including minimally invasive and robotic surgery.
Clinical consult and patient referral
To refer a patient or receive a consultation from Penn Gynecologic Oncology, please call 877-937-7366, or submit a referral through our secure online referral form.