ABSTRACT
This chapter is dedicated to a pioneer of laparoscopic surgery in gynecologic oncology who tragically died in a motorcycle accident on Valentine’s Day, Joel Childers (1955-2002).
DEMAND FOR LAPAROSCOPIC SURGERY
The public demand for minimally invasive surgical approaches exists in the community, as evidenced by the acceptance of the laparoscopic approach for cholecystectomy, adnexal surgery, and hysterectomy. Many surgeons are finding themselves in a competitive environment where they are perceived as inferior if they are not “keeping up” with these
advances (36). Hopkins (37) wrote a thorough critique of laparoscopic surgery that he documents some of the controversies and myths, which he believes are communicated by advocates of the procedures. His major objections are the potential dissemination of cancer cells and the inability to utilize all of the surgeon’s senses during the operation, especially the sense of touch. Academic caution has been exemplified by authors like David Grimes, in his review “Frontiers of operative laparoscopy: A review and critique of the evidence” (30). He concludes with the statement “Mechanisms are urgently needed to evaluate surgical innovations in gynecology with the same degree of rigor currently afforded medical innovations.” The Gynecologic Oncology Group met this challenge and opened the randomized trial comparing laparotomy to laparoscopy for the surgical treatment and staging of endometrial cancer (EC). The goal is to validate the efficacy and safety of this innovative technique to surgically treat this disease. The study has enrolled over 1000 women, with twothirds initially approached laparoscopically. The authors endorse the plea of Drs. Grimes and Hopkins-that gynecologic oncologists should enroll all women interested in the laparoscopic approach for the treatment of EC in this prospective trial until data are available to generalize this approach to standard community practice. Clinical Outcomes of Surgical Therapy (COST) Study Group (78) has published the short-term, quality-of-life outcomes for their randomized trial comparing laparoscopic approach to open colectomy for colon cancer. They reveal disappointing results; laparoscopy was only able to affect the hospitalized pain medication requirements and the 2-week post-surgery global rating scale. There was no difference at the 2-month time point. The length of stay was 6.4 days for the open technique, 5.6 days for those assigned to laparoscopy, and 5.1 days for those who successfully completed the laparoscopic approach. They document that 74% of the attempted laparoscopic procedures were completed without conversion to laparotomy. The associated editorials (51) ask why are we considering this an advance in surgical technique if there is no quantifiable quality of life or cost benefit? This may be the wrong operation to utilize the
laparoscopic technique since the prolonged ileus of colon resection cannot be easily overcome by laparoscopic techniques. The survival and sites for recurrence of colon cancer treated in this clinical trial will be reported at a later date.
