Gynecologic Malignancies The role of laparoscopy in the management of gynecologic malignancy is not clearly established (69–71). A study performed by the Gynecology Oncologic Group showed that laparoscopic management of presumed stage I endometrial cancer was feasible (72). Larger-scale studies suggest that women treated with a laparoscopic approach do not fare worse than those treated via laparotomy (73,74). The potential for laparoscopic lymphadenectomy fostered a resurgence of interest in vaginal radical hysterectomy for stage I carcinoma of the cervix. Laparoscopy is being investigated for the staging of early ovarian malignancy and for second-look surgery (75,76).
The rationale, alternatives, risks, and potential benefits of the selected approach should be explained to the prospective patient. She should be advised concerning the likely outcome of expectant management if the procedure was not performed.
The expectations and risks of diagnostic laparoscopy, and those of any other procedures that may be needed, must be explained. It may be helpful to compare risks and recovery with the same procedure performed via abdominal surgery. The risks of laparoscopy include those associated with anesthesia, infection, bleeding, and injury to the abdominal and pelvic viscera. The possibility of conversion to laparotomy if a complication should occur or if the procedure cannot be completed via laparoscopic surgery should also be discussed. Infection is uncommon with laparoscopic surgery. For procedures involving extensive dissection, there is a higher risk for visceral injury. These risks should be clearly presented in a fashion that includes both the possibilities of immediate and delayed recognition. The patient should be given realistic expectations regarding postoperative disability. Because pain and visceral dysfunction normally continue to improve after uncomplicated laparoscopy, the patient should be instructed to communicate immediately any regression in her recovery. After diagnostic or brief operative procedures, patients can be discharged on the day of surgery and usually require 24 to 72 hours off work or school. If extensive dissection—a major surgical procedure performed laparoscopically—is necessary or if the surgery lasts longer than 4 hours, hospital admission may be necessary, and the period of disability may then be as long as 10 to 14 days.
Preoperative mechanical bowel preparation was perceived as reducing the morbidity of colonic surgery should an injury occur and improving visualization and exposure of the operative field at laparoscopy. There is an abundance of high-quality evidence demonstrating that preoperative mechanical bowel preparation does not reduce the morbidity of colonic surgery (77). There is one high-quality trial that shows that mechanical bowel preparation may not improve visualization at gynecologic laparoscopy (78). It is premature to abandon preoperative bowel preparation to improve visualization, because, in a small subset of patients, it may facilitate surgery. Mechanical bowel preparation should be considered to help improve visualization in selected instances where stool in the colon might compromise visualization of the operative field.
Communication with the family or other designated individuals should be arranged prior to the procedure. The patient should arrange for a friend or family member to be present to discuss the results of the procedure with the physician and to drive her home if she is discharged the same day.
To facilitate the discussion of laparoscopic equipment, supplies, and techniques, it is useful to divide procedures into “core competencies,” which are as follows: 1.
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Manipulation of tissue and ﬂuid 6.
Cutting, hemostasis, and tissue fastening 7.
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