Robotics in the Modern Era of Ovarian Cancer Management

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1 Robotics in the Modern Era of Ovarian Cancer Management Ginger J. Gardner, MD Gynecology Service, Department of Surgery Memorial Sloan-Kettering Cancer Center

2 Objectives Advantages of Minimally Invasive Surgery (MIS) Benefits/Limitations of the Robotic Platform Role of Robotics in Ovarian Cancer Management Surgical Techniques Results

3 Advantages of Minimally Invasive Surgery Smaller incisions Shorter hospital stay Lower blood loss Less need for analgesics Better Visualization More rapid recovery Earlier ambulation Shorter interval to Chemotherapy (if indicated)

4 Natural Evolution of Technology

5 Evolution of Technology Altair (1974) Scelbi (1974) First personal computer Kit that user had to put together, make it work, and write software 256 Byte RAM $400 IBM 5100 First IBM PC (1975) 50 pounds Programming language (APL or BASIC) 64K storage version $19,975

6 Natural Evolution of MIS

7 da Vinci Si Robotic Platform MSKCC acquired 1 st and only dual console Si in NYC on 10/9/09

8 da Vinci Si Robotic Platform

9 Advantages of Robotic Surgery High-definition three-dimensional view of operative field Improved range of motion of instrument tips Movement is complementary to surgeon hand movements Ergonomic surgeon position Integration of computer platform into the surgical field

10 Limitations of Robotic Surgery Bulky system with potential limited range of motion to the upper abdomen Time for docking and patient positioning Other effective tools for MIS are available Cost

11 Robotics is Simply a New Tool for Minimally Invasive Surgery

12 SGO Robotics Working Group Consensus Statement To date, only a few isolated cases have been reported of the use of robotic surgery in the management of ovarian cancer. Early-stage or small volume disease may be more amenable than more advanced disease to robotic surgery. Robotic surgery is poorly suited for use in patients with advanced ovarian cancer as upper abdominal access is limited with the standard trocar set-up for pelvic surgery. Ramirez PT Gardner GJ, et al. Gynecol Oncol (in press)

13 Robotics in Ovarian Cancer Potential Indications Early Stage Management of a complex adnexal mass Staging for small volume borderline/invasive cancers Advanced Stage Laparoscopic triage for operability Completion surgery following neoadjuvant chemotherapy Primary cytoreductive surgery Debulking of recurrent disease

14 MSKCC Robotics All services

15 Robotic Case Distribution 5/15/07 5/7/11 N=1103

16 Robotic Procedures Trocar Placement 10 cm 8 cm 8 cm 2 cm 12 cm 8 cm cm Minimum distances

17 Robotic Procedures Alternate Trocar Placement Magrina JF, et al. Int J Gynecol Cancer 2010;20:

18 Robotics Patient cart docking Keep as far back from patient as possible Dock 4 th arm first Can reposition cart if not clearing leg

19 Robotics Offset Docking

20 Robotics Instrumentation Switch for the right paraaortic node dissection only 30-degree down scope can help for the PALND and omentectomy

21 Robotics Learning Curve Docking

22

23 Robotics in Ovarian Cancer Staging Procedures 5/1/07 7/31/09 (27 months) Variable LRS (n=22) ROBOT (n=11) P-value Median age (years) 54 (29-78) 46 (30-67) 0.21 Median BMI (kg/m2) 26.2 ( ) 24.8 ( ) 0.37 Converted N(%) 9 (41%) 1 (9%) ns Median room time (min) 300 ( ) 360 ( ) 0.23 Median operative time (min) 244 ( ) ( ) 0.34 Median EBL (cc) 100 (25-190) 62.5 (50-100) Median LOS (days) 2 (1-2) 1 (1-2) 0.14 Median PLN count 13 (6-28) 13.5 (2-34) 0.64 Median PAN count 9 (3-19) 14 (3-21) 0.15 Median Total LN count 27 (15-38) 29 (12-54) 0.34 Leitao MM, Gardner GJ, et al. (SGO 2010)

24 Staging Ovarian Cancer Extent of Lymphadenectomy Chan JK, et al. Obstet Gynecol 2007;109:23-29 (SEER data)

25 Staging Ovarian Cancer Extent of Lymphadenectomy Chan JK, et al. Obstet Gynecol 2007;109:23-29 (SEER data)

26 Ovarian Cancer Staging Conclusions Appropriate surgical staging for ovarian cancer is possible with the robotic platform Options available for patient positioning and trocar placement Likely beneficial for patients who may otherwise have undergone a laparotomy RCT will be difficult

27 Robotics in Ovarian Cancer Potential Indications Early Stage Management of a complex adnexal mass Staging for small volume borderline/invasive cancers Advanced Stage Laparoscopic triage for operability Completion surgery following neoadjuvant chemotherapy Primary cytoreductive surgery Debulking of recurrent disease

28 Laparoscopic Triage for Operability No Malignancy Non-Gynecologic Malignancy: GI, Breast, Lung Ovarian Cancer Resectable Laparoscopy / Robotic / Laparotomy Ovarian Cancer Not Resectable

29 First-line Therapy: Standard Treatment Options

30

31

32 Advanced Ovarian Cancer Laparoscopic Evaluation Fagotti et al (2006) Sixty-four cases of ovarian cases which were evaluated for resectability by laparoscopy and laparotomy in sequence. Laparoscopic parameters measured included ovarian masses, omental cake, peritoneal carcinomatosis, diaphragmatic carcinomatosis, mesenteric retraction, bowel infiltration, stomach infiltration, and liver metastases. A score of 2 was given to each parameter A score of 8 or greater was indicative of suboptimal surgery with a specificity of 100%, positive predictive value of 100%, and negative predictive value of 70% Fagotti A et al, Ann Surg Oncol, 2006, 8:

33 Debulking and MIS Retrospective Case Control Analysis July 2002-December Robot, 27 Laparoscopy, 119 Laparotomy Matched by age, BMI, and type of procedure 3 Types of Debulking Procedures Type I: Primary tumor excision hysterectomy, BSO, LND, omentectomy, appy Type II: Type I + 1 additional major procedure resection of intestines, diaphragm, liver, or spleen) Type III: Type I + 2 major procedures Magrina J, Gynecol Oncol 2011, 121(1):100-5

34 Perioperative Outcomes Based on Type of Surgical Approach Robot (n=25) Laparoscopy (n=27) Laparotomy (n=119) Age (years) BMI Operating Time (min) EBL <0.001 LOS <0.001 Complications, n (%) Intraoperative Postoperative (within 42 d) 3(12) 6(24%) 3(11) 1(4%) 16(13) 40(33%) Pelvic nodes, n Positive, n Aortic nodes, n Positive, n P 1.00 <0.001

35 Secondary Cytorductive Surgery Robotics - MIS Nodal recurrence Isolated bowel wall recurrence Splenic disease Other localized recurrent disease sites Some things to consider: Patients need to be carefully selected No contraindication to laparoscopy / robotics Patient and physician must be willing to proceed with laparotomy Continue to apply stringent surgical principles

36 THANK YOU!

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