Innovation in Gynecological Surgery
Pelvic surgeon and Specialized in Laparoscopic surgery in Gynecology and Gynecology Oncology
PD Dr. Andreas N. Kavallaris, Pelvic surgeon, Gynecologist oncologist surgeon, Head of the Department of Gynecology oncology and minimal invasive surgery in gynecology of St. Loukas Hospital, Thessaloniki, Greece
Treatment of benign gynecological disease:
- Treatment of benign diseases of the uterus or ovaries, require removal of the uterus (hysterectomy):
Total Laparoscopic hysterectomy with or without BSO (ovaries). (Myomas/Fibroids, Adenomyosis of the uterus, benign tumor of the ovaries). - Treatment of the fibroids/Myomas in order to preserve the uterus and Fertility:
Laparoscopic myomectomy/fibrectomy with Hysteroscopy and Hystero-Salpinography, Hysteroscopic surgery for Submucosal fibroids
- Treatment of Endometriosis:
Laparoscopic resection of endometriomas of the ovaries, resection of endometriotic tissue from the peritoneum, Laparoscopic resection of deep infiltrating endometriosis, with preserve of the hypogastric nerves, preserve the fertility. - Treatment of hydrosalpinx, adheasion of the fallopian tubes, prereserve and re-fertilisation of the Fallopian tubes:
Laparoscopic treatment of the hydrosalpinx with salpingoplasty and re-fertilization of the fallopian tubes. - Treatment of pelvic organ prolapse, uterus prolapse with cystocele and rectocele, vaginal vault prolapse after hysterectomy and stress urinary incontinent:
Laparoscopic sacrocolpopexy with mesh for pelvic organ prolapse,
Laparoscopic BURCH for stress urinary incontinent,
TVT-O (tension-free obturator tape, minimally invasive surgical correction of stress urinary incontinence). - Treatment of chronic pelvic pain:
Laparoscopic diagnosis with biopsy, adhesiolysis, nerve-sparing resection of endometriotic tissue. - Treatment of HPV associate disease, Warts, dysplasia of cervix and vulva:
Laser treatment, Cryotherapy, LEEP (Loop electrosurgical excision), Cone biopsy. - Treatment of uterus pathology:
Hysteroscopic surgery for Ashermann syndrome, uterus septum, polyps etc. - Treatment of congenital anomalies:
Abnormalities of the uterus, ovaries, vagina and vulva (birth defects) are abnormalities that occur during the development of the fetus. Recognition of congenital anomalies of the genital system at a young age is of particular importance because early diagnosis and treatment, helps prevent complications associated with fertility and the psychosomatic condition and development of women.
The treatment depends entirely on the patient’s wishes, her reproductive history and her plans for her future fertility. There are various hysteroscopic and laparoscopic procedures to correct structural abnormalities of the uterus such as arched uterus, biceps uterus, cervical uterus, septal uterus and unicorn uterus (each case is examined separately and not all uterine abnormalities need to be corrected). Mayer-Rokitansky-Küster-Hauser (MRKH) Plastic surgery may be necessary to create an artificial vagina (vaginoplasty). There are a variety of different surgical techniques that may be used and there is no consensus as to which technique is best. Females who undergo surgery to create an artificial vagina will most likely need to use vaginal dilators after the surgery to enhance the chance of success.
Treatment Oncological diseases
Crucial for the treatment of oncological diseases is, the surgery that the patient will undergo, to be performed by specialized Gynecologists – Oncologists.
- Cervical cancer:
- Radical Hysterectomy type III-IV according to Piver, with nerve-sparing technique (preserve the hypogastrich nerves), depend from the tumor diameter, the surgery can performed Laparoscopicaly.
- Total laparoscopic radical Trachelectomy, for the treatment of early stage cervical cancer (1Β1, 2cm, squamous cell carcinoma) and preserve the Fertility.
- Laparoscopic radical pelvic and para-aortic lymphadenectomy, use of the innovation technique for Sentinel Lymph Node mapping with IMAGE1 S™ RUBINA K.Storz.
- Endometrial cancer:
- Total Laparoscopic Hysterectomy with BSO.
- Laparoscopic radical pelvic and para-aortic lymphadenectomy, according to the tumor stadium, use of the innovation technique for Sentinel Lymph Node mapping with IMAGE1 S™ RUBINA K.Storz.
The Sentinel Lymph Node is the first lymph node to receive lymph from the tumor. When the SLN found and examined by rapid biopsy(frozen section) and it is negative, no extensive lymphadenectomy is required, removal of all pelvic lymph nodes is not necessary. This ensures an excellent oncological result, reducing the surgical time and minimizing the possibility of complications for the patient.
- Treatment of Ovarian cancer, Fallopian tube cancer and Peritoneal cancer:
Crucial to the progression of the disease and overall survival, is the first surgery that the patient will undergo do be performed by specialized Gynecologists – Oncologists
- Diagnostic Laparoscopy with biopsies, Staging of the Disease (always taking the necessary measures to prevent the spread of cancer cells).
- Primary Cytoreduction surgery. It is important to perform the best possible removal of the affected areas throughout the upper and lower abdomen (multiorgan resection), in order to completely remove the disease (primary cytoreduction).
The goal of primary surgery is to completely remove the disease, which often leads the surgeon to extensive surgeries with the exception of various intra-abdominal organs (multiorgan resection). During the operation, the primary tumor in the ovary is excluded and after a rapid biopsy (frozen section), a more radical operation is performed.
- The uterus with its Ovaries and fallopian tubes are removed, the omentum majus, the ovarian ligaments, appendectomy (depending on the cell type) and pelvic as well as para-aortic lymphadenectomy excided. These are the areas where metastases are most common and need to be removed. Also performing enterectomy in case of intestinal infiltration as well as removal of peritoneum with the ultimate goal of complete exclusion of the tumor.
Depending on the stage, the treatment plan is individualized for each patient and is decided by a scientific team of doctors of different specialties (Oncology Council). In specialized oncology centers, young patients with ovarian cancer are able to maintain their reproductive capacity under strict criteria.
- Studies have shown that the complete removal of cancerous lesions in the 1st surgery maximizes the overall survival and effectiveness of chemotherapy. In most cases the treatment is supplemented with adjuvant chemotherapy after the surgery. On the contrary, the stay of foci after the surgery significantly reduces the survival rates and must be treated with additional doses of chemotherapy.
- In some cases where the disease cannot be completely removed the combination of surgery and chemotherapy is the basic therapeutic approach (first chemotherapy after surgery, neoadjuvant chemotherapy).
Complete cytoreductive surgery, the use of adjuvant and neoadjuvant chemotherapy as well as targeted therapies are currently the appropriate weapons for the treatment of ovarian cancer and have managed to greatly improve patient survival in recent years. Even in the event of a recurrence of the disease, the surgical approach and the use of second-line chemotherapy are realistic options that can improve survival.
As ovarian cancer is considered a systemic disease, in recent years great efforts have been made to treat patients individually according to their genetic profile. These studies have already yielded the result of the production of targeted therapies which are increasingly used.
Treatment of Low Malignant Potential Ovarian Tumor (Borderline Tumor)
A borderline tumor, sometimes called low malignant potential (LMP) tumor, is a distinct but yet heterogeneous group of tumors defined by their histopathology as atypical epithelial proliferation without stromal invasion. It generally refers to such tumors in the ovary generally specifically called borderline ovarian tumors (BOT)) but borderline tumors may rarely occur at other locations as well.
Laparoscopic staging of patients Low Malignant Potential Ovarian Tumor (Borderline Tumor)
- Fertility preserves surgery with unilateral Oophorectomy with , peritoneal biopsies (cul-de-sac, pelvic wall and bladder peritoneum), abdominal peritoneum (paracolic grooves and septum) and partial resection of omentum majus. (The excellent prognosis of stage I and the incidence of the disease in women of reproductive age make fertility surgery crucial).
- Tumor malignancy surgery, Laparoscopic hysterectomy with BSO, peritoneal biopsies (cul-de-sac, pelvic wall and bladder peritoneum), abdominal peritoneum (paracolic groove) and diaphragmatic peritoneum, part resection of omentum majus.
- Low Malignant Potential Ovarian Tumor (Borderline Tumor) make up about 15% of all ovarian epithelial tumors and the average age of onset is about 10 years less than the age of onset of ovarian cancer.
- The complete staging of these tumors is a very important prognostic factor and is always exclusively surgical. In contrast to malignant epithelial tumors, marginal malignancies are usually found in the early stages.
Staging is performed according to the FIGO classification for ovarian cancer. Another important element of staging is the description of the implants, which affect the prognosis.
Complete staging of Borderline Tumor has been suggested by many. However, the guidelines recommend biopsies of the pelvic peritoneum (bladder, pelvic wall, and Douglas room), the abdominal peritoneum (paracolic grooves) and the mesentery and lymph nodes.
The two main histological types are serous and mucosal, with the most common being serous. There is evidence to suggest that in many cases these tumors originate from the appendix and therefore appendectomy should be performed during surgery.
In any case, the lack of complete surgical staging makes it very difficult to predict the spread and the prognosis of the disease.
As we mentioned, our oncology team headed by Dr. A. Kavallari, consisting of highly qualified and experienced associates specializing in universities abroad, are key factors in the application of the most innovative and pioneering methods for the treatment of various forms of cancer of the female genital system.
Especially the experience and specialization in Gynecological Oncology and Laparoscopic Surgery in combination with the innovative technology offered by the clinic Agios Loukas Thessaloniki, makes it possible to deal with complex and difficult cases.
