Laparoscopic Bilateral Salpingo-oophorectomy in Breast Cancer Patients after Transverse Rectus Abdominis Myocutaneous Flap Reconstructive Surgery
Laparoscopic Bilateral Salpingo-oophorectomy in Breast Cancer Patients after Transverse Rectus Abdominis Myocutaneous Flap Reconstructive Surgery
Abstract & Commentary
By Robert L. Coleman, MD, Associate Professor, University of Texas; M.D. Anderson Cancer Center, Houston, is Associate Editor for OB/GYN Clinical Alert.
Synopsis: Laparoscopic RRSO is safe and feasible in patients who have undergone a prior TRAM flap reconstruction.
Source: Awtrey CS, et al. Laparoscopic bilateral salpingo-oophorectomy in breast cancer patients after transverse rectus abdominis myocutaneous flap reconstructive surgery. Gynecol Oncol. 2005;99:720-725.
It has become increasingly documented that removal of the ovaries in high-risk women can not only reduce the risk of gynecologic malignancy but also improve the outcome of women with breast cancer. Resection may be accomplished via laparoscopy or laparotomy; the former is preferred given the reduction in potential complications, shorter recovery, and improved cosmesis. However, laparoscopic removal of the adnexa in breast cancer patients who have had a reconstruction procedure involving a rectus flap can present a challenge both mechanically and anatomically. Awtrey and colleagues reviewed their experience of risk-reducing salpingo-oophorectomy (RRSO) over a 7-year period, dichotomizing the cohort on the basis of whether the procedure was performed in those with rectus muscle reconstruction (TRAM, n = 10) or without reconstruction (n = 92). No differences were noted with respect to patient demographics, body mass index, previous abdominal surgery, menopausal status, or preoperative ultrasound adnexal characteristics. Both cohorts appeared to be similar in operative outcome, post-operative stay, and complications. The only distinguishing variable was the duration of time to completion for those with a history of TRAM reconstruction. Satisfactory operative outcome in relationship to ovarian resection was similar. These data support the feasibility and safety of laparoscopic salpingo-oophorectomy in patients with a history of breast cancer, including those in whom TRAM reconstruction has been performed.
Commentary
The performance of RRSO via laparoscopy has been popular given the accessibility of the adnexa and the benefits of this surgical approach. The procedure is largely performed in the outpatient setting with patients returning to normal activity within a few weeks postoperatively. However, when performing this procedure among patients with a history of breast cancer, special challenges may be encountered, particularly in those undergoing rectus reconstruction. This latter procedure involves migrating the rectus muscle and fascia to the desired location over the chest wall. The resultant defect on the lower abdomen is closed either primarily or with mesh, particularly if a bilateral procedure is undertaken. While the abdominal cavity is rarely violated in this procedure, large non-expandable mesh grafts can preclude abdominal distention—a obvious, desired result for laparoscopic visualization. In addition, the umbilicus, a standard reference point for not only the pelvic brim but also the bifurcation of the aorta, may be misaligned from its natural location.
Both cephalad/caudal and left/right deviations may occur alone or in combination following the procedure. Finally, the transverse incision frequently used for the abdominoplasty may or may not be in an advantageous line for lateral port placement—although that is the desired placement site if possible. For safe and successful laparoscopy, knowledge of these potential situations is critical. Awtrey et al documented in more than 100 patients that the procedure could be safely accomplished in both those with and without TRAM reconstruction. Of the 10 patients with a prior history of TRAM reconstruction, 4 also had synthetic mesh grafts. None of these 10 patients required conversion to laparotomy. This was similar to the rate of conversion observed in patients without reconstruction and similar to the limited experiences of other authors.1-3 They did record 1 patient in this cohort who had an infection of the mesh prosthesis. A similar rate of wound infection was recorded in the 92 other patients undergoing laparoscopy in non-TRAM cases.
Overall, these data are encouraging and should provide some support for the procedure to those who wish to attempt laparoscopy RRSO. Knowledge of the vascular supply to the umbilicus, location of the umbilicus to the underlying anatomy, reference level of the transverse scar and knowledge of the type of reconstruction performed are critical elements to review prior to attempting the procedure.
References
- Jacobsen WM, et al. Autologous breast reconstruction with use of transverse rectus abdominis musculocutaneous flap: Mayo Clinic experience with 147 cases. Mayo Clin Proc. 1994;69:635-640.
- Kauff ND, et al. Risk-reducing salpingo-oophorectomy in women with a BRCA1 or BRCA2 mutation. N Engl J Med. 2002;346:1609-1615.
- Muller CY, et al. Laparoscopy in patients following transverse rectus abdominis myocutaneous flap reconstruction. Obstet Gynecol. 2000;96:132-135.
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