JGH leads Canada in performing advanced robotic surgery for gynecologic cancer

The JGH has become the first hospital in Canada—and one of the very few in the world—to perform an advanced type of robotic surgery for gynecologic cancer, in which all of the medical instruments are inserted into the abdomen via a single, tiny incision in the navel.

Dr. Walter Gotlieb

Previously, when operations for gynecologic cancers were performed robotically at the JGH, several small incisions were made in the abdomen and one robotic instrument was inserted into each of the openings.

The new operation, known as single-site incision surgery, enables patients to recover more quickly and with less pain. As an added psychological advantage, patients are left with a one-inch scar that is so hard to see that there is virtually no visible reminder for the patient—or anyone who looks at her—that cancer surgery has taken place.

Between December 2017 (when the surgery was introduced) and March 2018, four such operations for gynecologic cancers took place at the JGH. According to Dr. Walter Gotlieb, Director of the JGH Division of Gynecologic Oncology, all of the patients recovered well and were able to return home within 24 hours.

Among them was Suzanne Paillé, who is now in good health, having undergone single-site incision surgery in mid-December in an operation performed by Dr. Gotlieb’s departmental colleague, Dr. Susie Lau. Ms. Paillé says the surgery took place in the morning and, after just one night in the hospital, she was able to return home.

“Everything was very well explained before the operation,” Ms. Paillé recalls, “and that’s exactly how it turned out. Getting this information made me feel confident when I went into the surgery, and Dr. Lau did a great job.”

Close-up view of the instruments of a surgical robot, which have been inserted through a special device that sits atop a 1 inch incision in the navel.

She adds that she experienced a little pain afterwards, “but nothing serious. I just felt that I needed to sleep when I got home.” Three weeks later, a resident gave her a clean bill of health and told her to return in July for a follow-up examination.

“There’s a small scar in my navel,” says Ms. Paillé, “but it’s not something you can see very easily.”

“When I was a medical student, the paradigm was, ‘The bigger the scar, the bigger the surgeon,’” recalls Dr. Gotlieb. “That paradigm has now basically evolved into, ‘The smaller the scar, the bigger the surgeon.’ Ultimately, it will become, ‘The absence of a scar is best for the patient.’ That’s what we’re aiming for.”

Dr. Gotlieb and Dr. Lau have performed single-site incision surgery at the JGH, after being specially trained in the procedure. However, he says, they also relied on strong collaboration among members of the team, including Dr. Shannon Salvador (of the Department of Obstetrics and Gynecology), Nancy Drummond (Nurse Navigator in Gyne-Oncology), Jeremie Abitbol (of the Lady Davis Institute) and the fellows, residents and support staff, as well as the vision of the administration and the JGH Foundation.

Dr. Gotlieb notes that he and Dr. Lau were able to take this major step as a direct result of their own extensive experience with robot-assisted surgery, having performed close to 1,400 robotic operations at the JGH since the hospital acquired the technology in 2007. This has led to 28 peer-reviewed manuscripts, six book chapters, 110 invited lectures, and proctoring 22 robotic programs nationally and internationally.

In single-site incision surgery, this scene is typical of what a surgeon sees when looking into the abdomen of a patient through the viewer of a surgical robot. Using the robotic controls, the surgeon can manipulate the instruments at left and right.

To Dr. Gotlieb’s knowledge, the only other places in the world that have reported performing single-site incision surgery for gynecologic cancers are Johns Hopkins Hospital in Baltimore (information published about 20 cases), the Catholic University in Rome (23 cases) and a medical centre in Seoul (one case).

During each two- to three-hour operation, surgeons remove the patient’s uterus, ovaries and fallopian tubes. In addition, they take out the sentinel lymph nodes, which are examined to help determine whether or how far the cancer has spread.

Single-site surgery is “more complex,” says Dr. Gotlieb, because it does not provide surgeons with the easy access or flexibility of inserting the robotic instruments through several incisions. However, for the patients’ benefit, “we’ve been willing to compromise on flexibility, so we’ve been putting a little more strain on ourselves.”

Another major reason for this effort, he explains, is that single-site surgery is a key stepping-stone on the path to the ultimate form of scarless surgery: the ability to insert a robotic tool through one of the body’s natural orifices—the mouth, vagina or rectum—and perform the operation without breaking the skin at all.

Here are the steps toward that goal:

• Multi-port surgery is what most of the world practices and what the JGH is moving away from—several incisions in the abdomen, with one robotic instrument inserted into each opening.

• Single-site surgery has just been introduced at the JGH—a one-inch incision in the navel, through which several robotic instruments are inserted.

• Single-port surgery is being performed only experimentally (and not yet at the JGH). Once again, the navel is the point of entry. However, the only item that is inserted is a single, narrow, metallic tool whose interior is packed with several miniaturized robotic instruments. These are deployed once the tool has reached its destination in the body. Afterward, they pulled back into the shaft and out through the navel. This form of surgery will be performed mainly to enable surgeons to get comfortable with the all-in-one bundle of instruments, which will be needed for the next step.

• NOTES (natural orifice transluminal endoscopic surgery) is the ultimate objective, whose technology is still being developed. This totally scarless surgery uses a single tool of self-contained instruments, which enters through the mouth, vagina or rectum. For example, if the tool is inserted through the mouth, it snakes down into the stomach, makes a small incision to pass through the stomach wall, and then continues deeper into the body. At the surgical site, multiple robotic instruments are deployed from the single tool. Once surgery ends, the instruments are drawn back into the shaft, and the tool is pulled back into the stomach (where the incision is sutured) and out through the mouth.

By becoming one of today’s leaders in single-site surgery, Dr. Gotlieb says, the JGH is positioning itself to eventually perform single-port and NOTES surgery, once the new robotic technology and surgical techniques have been refined, tested and approved.

“That may still be years away,” he adds, “but we want to be at the forefront of our evolving field to be able to do as much as we can, as soon as we can, for our patients.”