1、卵巢癌手术治疗腹腔镜与开腹谁更合适1990s2000s2010s Second-look operation for evaluations with laparoscopyHand-assisted laparoscopy Staging LaparoscopyLaparoscopic Cytoreduction CONTENTS010302腹腔镜在早期卵巢癌分期手术中的价值腹腔镜在晚期卵巢癌细胞减灭手术中的应用腹腔镜下复发性卵巢癌减瘤术的应用及价值0101全面手术分期+减瘤术0202低级别浆液性癌/G1子宫内膜样癌观察随访以铂为基础的静脉化疗36疗程内分泌治疗0303A或B期/G2子宫内膜
2、样癌观察以铂为基础的静脉化疗36疗程0404A或B期高级别浆液性癌或G3子宫内膜样癌和C期以铂为基础的静脉化疗36疗程0505证据支持期患者的初次化疗需要6疗程以上的化疗2018 NCCN卵巢癌包括输卵管癌及原发性腹膜癌临床实践指南冰冻切片提示为恶性生殖细胞肿瘤、恶性线索-间质肿瘤，可行保留生育功能的手术无生育要求者或间质肿瘤患者或癌肉瘤患者，进行全面手术分期。根据病理术后可选择观察或相应化疗2018 NCCN卵巢癌包括输卵管癌及原发性腹膜癌临床实践指南l腹腔镜可被用于评估是否能达到满意的减瘤术l腹腔镜可被用于有经验的妇瘤医生完成手术分期及满意的减瘤术l若腹腔镜减瘤术不理想，必须中转开腹手术基
3、本原则2018 NCCN卵巢癌包括输卵管癌及原发性腹膜癌临床实践指南手术步骤Step Four全子宫+双侧附件切除；需要保留生育功能的患者，在符合适应证的前提下可考虑行单侧附件切除术或双侧附件切除术手术过程必须尽力完整切除肿瘤并避免肿瘤破裂可根据需要切除肠管、阑尾、脾脏、胆囊、部分肝脏、部分胃、部分膀胱、胰尾、输尿管及剥除膈肌和其他腹膜；力求使残余肿瘤病灶直径1cm，最好切除所有肉眼可见病灶腹腔冲洗液行细胞学检查；对腹膜表面进行全面诊视，腹膜活检切除能够切除的肿大或者可疑淋巴结；盆腔外肿瘤病灶2cm者（即B期）必须行双侧盆腔和主动脉旁淋巴结切除术Step ThreeStep TwoStep O
4、ne2018 NCCN卵巢癌包括输卵管癌及原发性腹膜癌临床实践指南腹腔镜手术争议术中肿瘤破裂气腹致肿瘤扩散手术分期不全面穿刺孔肿瘤种植ABC腹腔镜术中出血更少(466.8 95%CI,340.1-593.4 vs 233.8;95%CI,195.7-272.0 mL;P .001)组间术后分期提高无明显差异(I2=43.8%)腹腔镜术中肿瘤破裂率为可接受范围内(I2=35.6%,总体 25.4%)Staging laparoscopy for the management of early-stage ovarian cancer:a meta-analysisHyun Jong Park e
5、t al./American Journal of Obstetrics&Gynecology/JULY 2013开腹手术出血更多PFS无显著差异OS无显著差异PPT模板下载： et al./European Journal of Obstetrics&Gynecology and Reproductive Biology 201(2016）腹腔镜与开腹手术分期范围相似Laparoscopic surgical staging in women with early stage epithelial ovarian cancer81 of 665(12.2%)laparoscopy group
6、VS 126 of 656(19.2%)laparotomy groupUpstaged on the final pathological evaluation(P 0.001)腹腔镜手术的肿瘤负荷较开腹手术小组间PFS及OS无显著性差异Laparoscopic staging for apparent stage I epithelial ovarian cancerAlexander Melamed et al./American Journal of Obstetrics&Gynecology/JANUARY 2017LAC 手术在早期EOCLonger operative time-
7、not statistically significantLower estimated blood loss (WMD=156.5 mL;95%CI,216.4 to 96.5),Shorter length of hospital stay (WMD=3.7 days;95%CI,5.2 to 2.1)Lower postoperative complication rate (odds ratio OR=0.48;95%CI,0.290.81)Upstaging (OR=0.81;95%CI,0.551.20)Cyst rupture (OR=1.32;95%CI,0.523.38)Ra
8、tes were similar between groups.A shorter time to chemotherapy (WMD=5.16 days;95%CI,8.68 to 1.64).Survival outcomes were not influenced by the route of surgery.Minimally Invasive Surgical Staging in Early-stage OvarianCarcinoma:A Systematic Review and Meta-analysisGiorgioBogani,et al./Journal of Min
9、imally Invasive Gynecology,Vol 24,No 4,May/June 2017小结 术中出血少 术后住院日短有经验的手术医生可将腹腔镜更广泛地应用于早期卵巢癌的全面分期手术 未提高手术分期 无更高的肿瘤破裂率，且术中破裂并不明确影响预后 PFS及OS相比开腹手术无显著性差异CONTENTS010302腹腔镜在早期卵巢癌分期手术中的价值腹腔镜在晚期卵巢癌细胞减灭手术中的应用腹腔镜下复发性卵巢癌减瘤术的应用及价值PDSNACT+IDS晚期卵巢癌的初始手术策略Phase III randomised clinical trial comparing primary surg
10、ery versus neoadjuvant chemotherapy in advanced epithelial ovarian cancer with high tumour load(SCORPION trial):Final analysis of peri-operative outcome A.Fagotti et al./European Journal of Cancer 59(2016)22e33Fagotti laparoscopy-based scoreN.R.Gmez-Hidalgo et al./Gynecologic Oncology 137(2015)55355
11、8“The Fagotti laparoscopy-based score is a useful predictor of optimal cytoreduction.”Predictive Index Value(PIV)2 Low Tumor LoadG.Vizzielli et al./Gynecologic Oncology 142(2016)1924“Early identification of high-risk patients could help the surgeon to adopt tailored strategies on individual basis.”A
12、 laparoscopic risk-adjusted model to predict major complications afterprimary debulking surgery in ovarian cancer:Asingle-institution assessmentn More favorable estimated blood loss and median length of stay and TTC.n No difference in PFS or OS.n Minimally invasive approach could representation adva
13、ntage alternative surgical way.Minimally invasive versus standard laparotomic interval debulking surgery in ovarian neoplasmS.Gueli Alletti et al./Gynecologic Oncology 143(2016)516520The high rate of complete cytoreductionis perhaps because of the accurate selection of patientsLaparoscopy potentiall
14、y improves the detection of microscopic peritonealimplantsLaparoscopy significantly reduces procedure-related morbidity and expedites recovery.Fanning et al Feuer et al suggested laparoscopy in advanced ovarian cancerFanning J,Yacoub E,Hojat R.Laparoscopic-assisted cytoreduction for primary advanced
15、 ovarian cancer:success,morbidity and survival.Gynecol Oncol.2011;123:472011.Laparoscopic Management of Ovarian Cancer Patients Journal of Minimally Invasive Gynecology,Vol 23,No 4,May/June 2016CONTENTS010302腹腔镜在早期卵巢癌分期手术中的价值腹腔镜在晚期卵巢癌细胞减灭手术中的应用腹腔镜下复发性卵巢癌减瘤术的应用及价值影像学或临床复发考虑再次减瘤术后参加临床试验或以铂为基础的联合化疗或按复发
16、治疗或支持治疗化疗后继续参加临床试验或部分或完全缓解者既往用过贝伐珠单抗者继续贝伐珠单抗维持治疗，或考虑尼拉帕尼、或奥拉帕尼或雷卡帕尼维持治疗铂耐药复发参加临床试验或支持治疗或按复发治疗首选非铂类单药化疗生化复发可以参加临床试验、或推迟至出现临床复发再治疗、或立即开始以铂为基础的联合化疗或支持治疗。复发性上皮性卵巢癌治疗原则铂敏感复发2018 NCCN卵巢癌包括输卵管癌及原发性腹膜癌临床实践指南 减瘤术 化疗或临床试验或支持治疗复发性少见病理组织学类型的卵巢肿瘤2018 NCCN卵巢癌包括输卵管癌及原发性腹膜癌临床实践指南l初次化疗结束后612个月后复发l病灶孤立可以完整切除或病灶局限l无腹水
17、手术指征2018 NCCN卵巢癌包括输卵管癌及原发性腹膜癌临床实践指南Minimal access surgery can be a possible treatment option for recurrent ovarian cancer.Laparoscopy is a feasible and safe approach to optimal cytoreductionValerio Gallotta et al/Surgical EndoscopyJune 2014,Volume 28,Issue 6,pp 18081815Robotic-assisted surgery is sa
18、fe and feasible approachA.Lucidi et al./Best Practice&Research Clinical Obstetrics and Gynaecology 45(2017)74e82Laparoscopic approach for spleen removal is feasible.Journal of Minimally Invasive Gynecology,Vol 23,No 3,March/April 2016Complete removal of the recurrent disease was achieved in all pati
19、ents.All postoperative complications were managed without long-term sequeale.Secondary Laparoscopic Cytoreduction in Recurrent Ovarian Cancer:A Large,Single-Institution ExperienceValerio Gallotta,et al./Journal of Minimally Invasive Gynecology,Vol 25,No 4,May/June 2018难以达到满意的减瘤前次手术可能致盆腹腔粘连影响手术操作腹腔镜S
20、CS手术难点您的内容打在这里，或者通过复制您的文本，在此框中选择粘贴，并选择只保留文字。您的内容打在这里，或者通过复制您的文本后，在此框中选择粘贴，并选择只保留文字。您的内容打在这里，或者通过复制您的文本后，在此框中选择粘贴，并选择只保留文字。Analysis of secondary cytoreduction for recurrent ovarian cancer by robotics,laparoscopy and laparotomyJ.F.Magrina et al./Gynecologic Oncology 129(2013)336340For selected patient
21、s“Extensive recurrent disease and/or ascites were not considered candidates for minimally invasive cytoreduction”接受微创手术患者肿瘤负荷小、病灶少(P0.01）微创手术术中出血少、术后住院时间短(P0.01）组间完全减瘤率无差异组间PFS、OS无差异For selected patients“Selection was based on surgeon preference rather than tumor and/or patient characteristics,and s
22、election was highly dependent on the individual surgeons experience with MAS.”Feasible and Safe！Minimal access surgery(MAS)compared to laparotomy for secondary surgical cytoreductionA.G.Z.Eriksson et al./Gynecologic Oncology 146(2017)263267Minimally invasive surgery(MIS)is practiced by more than 90%
23、of gynecologic oncologists.Knowledge of anatomy,the disease process,and surgical technique is key during these complicated surgical procedures.Several studies have shown that 10 to 20 cases are needed to gain proficiency with a certain procedure.MIS reduces blood loss,transfusions,length of hospital stay,and wound complications without compromising adequacy of the procedure or staging even in(extremely)morbidly obese patients.1234Role of Minimally Invasive Surgery in Gynecologic Malignancies掌握解剖HIGH VOLUME量变 质变仍待相关结果更多NCT探索最佳选择
