Gynaecological cancers are malignant tumours that affect the female reproductive system. According to the Singapore Cancer Registry, they are among the top 10 most common cancers affecting Singaporean women.
In most cases, patients are treated with surgery, which in the past comprised only one option – open surgery, a procedure that involves one long cut on the belly. "This is because navigating surgical instruments in a confined space with limited movement range and vision was difficult without a large incision in the abdomen," explains Dr Lisa Wong, a gynaecological oncologist at Mount Elizabeth Hospital.
Minimally invasive surgery for women's cancers
Thanks to clinical advancements, minimally invasive surgery (MIS), also known as laparoscopy or keyhole surgery, is overshadowing traditional procedures. MIS permits surgeons to access the pelvic area through several incisions of about ½ – 1cm and to operate with the use of smaller specialised tools. Compared to the traditional cut that is almost 10 times longer, smaller incisions mean less pain and shorter recovery time, hence patients are able to resume their day-to-day activities sooner.
Dr Wong also emphasises that MIS reduces the risk of developing complications that are associated with pelvic surgeries. For example, those who undergo open surgery spend more time in bed after the operation than MIS patients. This predisposes them to deep vein thrombosis, which is the formation of blood clots in the patient's leg due to the lack of movement.
Dr Wong explains that this is because "after undergoing open surgeries, patients tend to experience a lot of pain so they are often unwilling to move. But with keyhole surgery, patients can get out of their bed faster and move around, reducing the chances of developing such complications."
In addition to these benefits, MIS is cosmetically more effective since it produces smaller scars as compared to the large ones associated with open surgery.
Dr Wong concludes that in comparison with open techniques, MIS offers similar – if not better – surgical outcomes, without compromising on the cancer outcome for patients with gynaecological cancers, making the process of recovery smoother.
The option of robotic surgery
MIS is often likened to operating with long chopsticks and there are circumstances where there are limitations working within the confined space of the pelvis. For instance, patients who have a history of multiple operations are at risk of adhesions, which may make MIS difficult. This is when robotic surgery comes in.
Robotic surgery is recommended when precise and fine work is required because the use of a robotic arm offers improved dexterity with a wider range of movement, as well as a 3D high-definition camera. "During robotic surgery, the arm acts like a wrist with more flexibility, finer movements and less tremor, while the enhanced camera provides better vision for surgery. This allows surgeons to do accurate work and provide patients with better outcomes," Dr Wong explains.
Nevertheless, Dr Wong qualifies that robotic surgery may not always be better than MIS or keyhole surgery. She qualifies that "if keyhole can get the job done then it should be considered first. But if keyhole is not an appropriate option, I will consider robotic surgery."
When minimally invasive surgery is unsuitable
Certain cancers may also present surgeons with challenges that MIS has yet to overcome. According to Dr Wong, one example is ovarian cancer, which is rarely treated with MIS. This is because most patients with advanced stage cancer have malignant tumours that are either too big or scattered around the surrounding areas.
"For such complicated surgeries, MIS may not clear out all the cancerous tissues," Dr Wong explains. "So treatment may be reverted to traditional open surgeries." Open surgery allows the surgeon to inspect the abdomen thoroughly to remove the ovaries and other affected areas, such as the large intestine or the abdominal lining, where ovarian cancer may spread.