1532463

Laparoscopic surgery began in the early 19th century. Prior to this, the ability to use a camera to look inside the body of a living patient was a long-held dream in medicine.

The eventual development of these minimally invasive operations transformed surgery and they are now the gold standard in many surgical specialties.

Laparoscopic surgery uses much smaller cuts than the traditional “open” method. A special camera is inserted via these tiny incisions, the tummy is inflated with gas to provide working and viewing space for the surgeon, and the images are transmitted to video monitors in the operating theatre.

This system essentially allows the surgeon to perform the same operations as a laparotomy—the usual open method—but with much smaller incisions.

This means quicker recovery for the patient, less pain, shorter stay in hospital and even less scarring.

Although the role of laparoscopic surgery, (sometimes known as keyhole surgery), has expanded to include intestinal surgery, gallbladder surgery and liver surgery among many others, this technique historically was first developed in my own field of gynaecology.

I was always immensely proud of this fact – the pioneering work of several gynaecologists from the 1940s onwards revolutionised surgery as we knew it. And as a young doctor in the gynae specialty in the UK in the early 2000s, laparoscopic surgery was an essential part of my training.

From ovarian cysts to ectopic pregnancies, sterilisations, fertility evaluations and even hysterectomies, there seemed to be no end to the wonder of this “new” surgical technique.

The women who had this procedure left hospital sometimes on the same day and were happy and pain-free.

As this technique gained traction over the years with widespread acceptance, it was only a matter of time before its use was expanded to include the treatment of cancers.

The rapid adoption of laparoscopic surgery for gynaecological cancers occurred worldwide. As a gynae-oncologist myself, I was witness to this chain of events, and the impact it had on everyday practice.

For uterine (or endometrial cancers), this surgical approach has proved enduring and remains the method of choice for these malignancies.

However, for other gynae cancers, particularly early cervical cancers, there is now new data that is genuinely concerning.

For more than a century, women with early-stage cancer of the cervix have been treated with a procedure called a radical hysterectomy, traditionally performed via the abdominal or open surgical method – the one with a fairly large cut on the abdomen.

Nevertheless, after the introduction of laparoscopic surgery years ago, this was also subsequently adopted for radical hysterectomies.

The first alarm bells started ringing in 2018 after the eminent New England Journal of Medicine (NEJM) published a trial that compared open versus laparoscopic radical hysterectomies for cervical cancer.

Quite unexpectedly, the keyhole route was found to be associated with a higher rate of cancer recurrence and death when compared with the open group.

In other words, the researchers found that if you had cancer of the cervix and your radical hysterectomy was performed via the laparoscopic route, you were four times more likely to have your cancer come back, and six times more likely to die, when compared to those who had the traditional open route.

Even more worrying is that another recent study published several weeks ago by the oncology edition of the Journal of the American Medical Association (JAMA) seems to confirm these findings. And for cancers of the ovary, the use of laparoscopic surgery similarly showed inferior outcomes.

This prompted the journal to immediately issue a stark editorial titled, “Minimally Invasive Surgery for Gynaecologic Cancers — A Cautionary Tale”.

I was more than dismayed with these findings as they are directly in my area of specialty and may well be a prime example of too hurried adoption of new techniques before thorough long-term research.

Having said this, I cannot stress enough that laparoscopic or keyhole surgery remains the recommended choice for many disorders in a multitude of specialties, and rightly so, especially in benign (non-cancer) gynaecological conditions, where it is safe and effective.

But for some gynaecological cancers, there is now a clear concern and many centres worldwide have reverted to the traditional open technique for cancer of the cervix following publication of these worrying findings.

This particular disease is very common in our country where several gynaecology doctors are still performing this now controversial procedure.

In the end, I can only hope that the potential risks and benefits are thoroughly discussed with these women so that they are able to make an informed decision.

September is Gynae Cancer Awareness Month––please

see your doctor for a

check-up and screening.