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CLEVELAND CLINIC: P EDRO ESCOBAR, M.D., received a referral from a gynecologic oncologist who had recently performed a bilateral oopho- rectomy. The patient's postsurgical pathology had revealed an early-stage cancer developing in her fallopian tubes. The new cancer, coupled with the patient being identified as having muta- tions in her BRCA1 and BRCA2 genes, increased the complexity of her care. The genetic mutations exponentially increased the possibility of developing future gynecologic cancers. Dr. Escobar made the decision to prophylactically remove her uterus and lymph nodes. Several days after the oophorectomy. Through the same incision. Through her umbilicus. Dr. Escobar's patient is among an increasing number of gynecologic oncology patients at Cleveland Clinic who benefit from laparoendoscopic single-site (LESS) surgery. Pioneered at Cleveland Clinic, the technique enables surgeons to use several robotic devices through a single incision made in the patient's umbilicus. Cleveland Clinic's team approach of involving multiple specialists can be the most important factor in long-term survival. Physicians from Cleveland Clinic's Taussig Cancer Institute and Ob/Gyn & Women's Health Institute make up a multidisciplinary team of gynecologic surgeons, gynecologic pathologists, radiologists, medical oncologists and other specialists who collaborate on each case. "Laparoscopic surgery used to involve up to seven 5-millimeter incisions to accommodate the robotics. The ergonomics of the technology could be cumbersome for the surgeon because of wrist movements and discomfort," says Dr. Escobar, Director of Minimally Invasive Surgery and Robotics at Cleveland Clinic's Ob/Gyn & Women's Health Institute. Dr. Escobar uses the latest in miniatur- ized robotics. A 15-millimter incision is made and a multichannel port is inserted to allow several robotic devices to be used simultaneously. Organs and tissues are removed through the patient's vagina. "LESS surgery is fairly new, but we already see several potential advantages of single-port over conventional mul- tiport laparoscopy," says Dr. Escobar. "We anticipate a possible decrease in morbidity related to visceral and vascular injury during trocar placement, as well as risk reduction of postoperative wound infection, hernia formation and elimina- tion of multiple trocar site closures." Studies also suggest improved postop- erative pain profiles when compared to conventional laparoscopic surgery. This may be due to the use of the umbilicus as the single site of the incision, as it is one of the thinnest regions on the abdominal wall, containing few blood vessels, muscles and nerves. Finally, LESS contributes to patients' postsurgical self-image because of superior cosmesis from a relatively hidden umbilical scar. "The Holy Grail of surgery is to leave little or no scars. Technology is finally catching up with the goal," says Dr. Escobar. Meet ViKY the Robot The use of several robotic devices through such a small incision create a crowded condition that can hinder 38 | Cleveland-Akron-Canton MD NEWS MDNEWS.COM NOVEMBER-DECEMBER 2011 WITH INNOVATIVE GYNECOLOGIC ONCOLOGY SURGERY Is MORE delicate surgery. A prime contributor has been the fiber-optic camera that sur- geons need to see their work. Surgeons stop using the surgical instruments in order to work the camera controls, and merely redirecting the camera tip can bump the instruments. Dr. Escobar was the first to use a voice-activated robotic camera. He wears a wireless earpiece and microphone to communicate with the camera, nicknamed ViKY. "She" even responds if unable to complete the command. "Innovations like LESS and ViKY make our program one of the leaders in the country in gynecologic oncology surgery. The opportunity to collaborate with world-class cancer care clinicians and geneticists in the Taussig Cancer Institute sets us apart," says Dr. Escobar. Cleveland Clinic gynecologic oncolo- gists understand the fear and uncertainty a diagnosis of cancer brings. Their special- ized services and supportive care, such as access to support groups and home care, arranged by clinical nurse specialists who also provide counseling, are available to help patients through this difficult time. At Cleveland Clinic, cancer special- ists, surgeons, researchers, nurses and technicians are dedicated to developing and applying the latest and most effec- tive medical techniques to achieve long-term survival and improve the quality of life. U.S. News & World Report has consistently ranked Cleveland Clinic one of the top cancer and gynecology centers in the nation. To contact Pedro Escobar, M.D., please call (216) 445-8486 or e-mail escobap@ ccf.org. To make a referral, please call 1-800-553-5057. n