Discover how minimally invasive surgery transforms gynecologic cancer treatment
By Siti Salihah
Not only does minimally invasive surgery for gynecologic cancer offer patients faster recovery and reduced scarring—which many of them appreciate for both practical and cosmetic reasons—but it also brings fewer complications than traditional open surgeries.
Leading the way in this field is Dr. Khoo Boom Ping, a Consultant Obstetrician and Gynecologist, Gyne-oncologist, and Laparoscopic Surgeon at Columbia Asia Hospital, Bukit Jalil. In this interview with 1Twenty80, Dr. Khoo sheds light on why minimally invasive surgery is an option in cancer care and what patients can look forward to when opting for these techniques.
1Twenty80: Can you explain what minimally invasive surgery is and how it differs from traditional open surgery?
Dr. Khoo: As the name suggests, open surgery typically requires a large incision, which can be between 15 to 30 centimetres, depending on the procedure. This incision, whether transverse or longitudinal, often leaves a noticeable scar.
In contrast, minimally invasive surgery uses much smaller incisions to achieve the same results. For example, when treating fibroids, which can grow quite large, traditional methods involve a laparotomy, where we would open the abdomen to remove the fibroid and then close the uterus. Today, we can achieve the same outcome with minimally invasive techniques like laparoscopy. For this procedure, we make a small 1.5 centimetre incision to insert a camera and two smaller incisions (each about 0.5 to 1 centimetre) for other instruments. With these three to four small incisions, we can remove the fibroid and perform the necessary repairs, all while minimising scarring and recovery time.
Minimally invasive surgery can be further divided into several types:
- Laparoscopy
- Multiport laparoscopy
- Single-port laparoscopy
- Robotic surgery
- vNOTES (vaginal natural orifice transluminal endoscopic surgery)
vNOTES stands out as a completely scarless option, with all incisions made inside the vagina, leaving no visible scars on the outside. In comparison, laparoscopic and robotic surgeries may result in small abdominal scars, but these are usually faint and not noticeable unless closely examined.
1Twenty80: What are the primary benefits of minimally invasive surgery for patients compared to traditional methods?
Dr. Khoo:
- Cosmetic Outcome
Traditional open surgery leaves large scars, which may not be aesthetically pleasing, and can sometimes lead to hypertrophic or keloid scars.
Minimally invasive surgery involves much smaller incisions (around 1 cm each), reducing visible scarring and offering a more cosmetically appealing result.
- Pain Reduction
Large incisions from open surgery cause significant nerve disruption, leading to intense post-operative pain that can last up to two weeks.
With laparoscopic surgery, pain is minimal—patients are often able to sit up and move around within six hours after anaesthesia wears off.
- Lower Risk of Complications
Open surgery (with a 20–30 cm incision) carries a higher risk of complications like wound infections or scar dehiscence (where the incision reopens).
Minimally invasive surgery uses smaller incisions (1 to 1.5 cm), reducing the risk of infections and making any complications easier to manage.
- Reduced Bleeding & Faster Recovery
Laparoscopy typically leads to less bleeding during surgery, and in skilled hands, the operating time can be shorter.
Faster recovery means patients can move sooner, improving circulation and promoting bowel movement.
- Earlier Mobilisation
Early movement after surgery helps prevent serious risks like fluid accumulation in the lungs (which can lead to pneumonia) and deep vein thrombosis (DVT), a potentially life-threatening condition.
Early ambulation promotes faster recovery, reduces hospital stays, and leads to an earlier return to normal activities.
- Smoother Cancer Treatment Recovery
Minimally invasive surgery reduces complications, allowing cancer patients to begin chemotherapy or radiation sooner.
In contrast, traditional open surgery can delay these treatments due to slower recovery and complications, affecting the overall treatment timeline.
1Twenty80: Are there specific conditions or patient demographics where minimally invasive surgery may not be the best option?
Dr. Khoo: Yes, there are some cases where minimally invasive surgery may not be ideal, though advancements have greatly expanded its suitability.
- Obesity
Traditionally, obese patients were often considered unsuitable for laparoscopy due to their larger body size. However, today, larger patients can actually benefit more from laparoscopic surgery. With open surgery, accessing the abdominal cavity through a thick layer of tissue is much more challenging. Laparoscopy, on the other hand, involves small incisions and uses gas to create space in the abdomen, making it easier to operate on larger patients.
- Gynecologic Conditions
Most gynecologic conditions, such as abnormal bleeding or fibroids, are suitable for laparoscopic surgery, regardless of the fibroid size. However, larger fibroids can make the procedure more challenging and may extend the surgery time. Despite this, laparoscopic surgery is still an option for these cases.
- Ovarian tumour/cancer
When we encounter an ovarian tumour that looks suspicious for cancer, we typically avoid minimally invasive surgery, even if it seems to be an early-stage tumour. The reason is that laparoscopy involves small incisions—usually around 1.5 cm. Removing a larger tumour (such as, 5 to 6 cm) through such a small incision isn’t feasible without breaking it into pieces. If the tumour is cancerous, breaking it could lead to spillage, which can cause the cancer to spread. This could upgrade the cancer stage from Stage 1 to Stage 1C or even Stage 2, worsening the prognosis.
However, laparoscopy still has a role in advanced ovarian cancer cases. While we may not be able to perform a full surgical procedure, laparoscopy can be useful for:
- Confirming the diagnosis
- Reducing the disease burden temporarily before further treatment
After diagnosis, patients typically proceed with chemotherapy and may undergo more extensive surgery at a later stage.
- Endometrial cancer
Minimally invasive surgery is particularly effective for early-stage endometrial cancer and is considered the gold standard treatment. It offers all the benefits previously mentioned—reduced pain, quicker ambulation, earlier discharge, faster return to normal activities, and an earlier transition to any necessary follow-up treatments. This approach works best when the uterus isn’t too large. In cases where the uterus is of a manageable size, studies show that minimally invasive surgery provides significant advantages, making it the preferred choice for treating early endometrial cancer.
- Cervical cancer
Not all types of cervical cancer are suitable for laparoscopic surgery, but some early-stage cases can be treated this way. Cervical cancer surgery is more complex than a standard hysterectomy because it involves removing not just the uterus but also surrounding tissues to prevent cancer from spreading. This procedure, called a radical hysterectomy, includes the removal of the cervix, parts of the vagina, and surrounding ligaments, along with any nearby lymph nodes that may be at risk of containing cancer cells. Since this surgery is technically challenging and requires precise skill, laparoscopic radical hysterectomy is typically reserved for early-stage cervical cancer, where the cancer has not spread extensively.
1Twenty80: What recent advancements in technology have contributed to the growth of minimally invasive surgical techniques?
Dr. Khoo: There have been many recent advancements that have significantly enhanced minimally invasive surgical techniques. Here are some of the key advancements:
- Camera System
The clarity of camera systems has advanced greatly over the years. Initially, we had only standard definition (like our old TV), but today we have high-definition options, 4K resolution, and even 3D imaging. In laparoscopy, we can wear 3D glasses to view the operating field in three dimensions. That’s a huge advancement.
- Energy Devices
Traditionally, in surgery, we would clamp the tissue to control bleeding, then cut it, and finally suture it to seal off the area. This process required separate steps: clamping to stop the blood flow, dividing the tissue by cutting, and then suturing to close it up. Now we have these energy devices:
- Cutter
The cutter works by clamping onto the tissue, then using controlled electrical energy to cut through it automatically, allowing for a clean division without manual suturing.
- Vessel Sealer
A vessel sealer is used to clamp structures that might bleed. When we activate it, the device seals the tissue by applying heat, essentially cauterising (burning) it to stop the bleeding. - Advanced Bipolar (Combination of cutter and vessel sealer)
With this, we clamp, activate, and can divide the tissue all in one step. It combines both the cutter and vessel sealer functions. In the past, we had three separate steps (clamp, divide, and tie), but with this, we can do all of that in a single, continuous movement, saving time and improving efficiency.
- Morcellator
For fibroids that are typically large, we used to only remove them with laparotomy. But with laparoscopy, which requires a small incision, we now use a morcellator. This device spins at a high speed, slicing larger tissue into smaller strips that can pass through the small incision for removal.
- Adhesion Barriers
To reduce the risk of tissues sticking together post-surgery, we use biodegradable adhesion barriers. This layer is applied between the operating area and surrounding structures, preventing adhesion and reducing the risk of post-operative complications.
- Specimen Retrieval Bags
These bags allow us to safely remove specimens through the small incisions without the risk of tissue spillage during extraction.
- Hemostatic Agent
Available in powder or mesh form, help control bleeding by being applied to areas prone to haemorrhaging. They assist in achieving immediate hemostasis (as their name suggests) and prevent excessive blood loss.
1Twenty80: How do recovery times compare between minimally invasive surgeries and traditional open surgeries?
Dr. Khoo: In traditional open surgery, pain typically lasts for at least two weeks after the procedure, gradually decreasing over time. In contrast, with minimally invasive surgery (laparoscopy), pain is significantly reduced, and patients often experience relief as early as the first day.
Recovery time is also faster with laparoscopy. Studies have shown that patients who undergo laparoscopy are typically discharged one to two days earlier than those who have open surgery. However, this comparison assumes there are no complications with the open surgery. If there are additional issues, such as bowel problems or other complications, the recovery time and hospital stay may be longer.
When it comes to returning to normal activities, patients who have had laparoscopy can often resume near-normal activities within a week. For those who undergo open surgery, it may take at least two weeks to achieve the same level of recovery.
1Twenty80: What criteria do you use to determine if a patient is a good candidate for minimally invasive surgery?
Dr. Khoo: Any patient could be a candidate for minimally invasive surgery—unless there are specific factors that would prevent it. That said, several key criteria are taken into consideration:
- Overall Health: The patient’s general health and any pre-existing conditions are assessed. This includes evaluating the ability to tolerate surgery and heal properly after the procedure.
- Condition Type: The nature of the condition being treated is a crucial factor. For example, conditions like fibroids, endometriosis, and early-stage cancers may be suitable for minimally invasive surgery, while more advanced cancers or complicated conditions may require an open approach.
- Anatomical Considerations: The location, size, and accessibility of the target area can affect the decision. Some conditions, such as large fibroids or certain cancers, may make it harder to perform minimally invasive surgery effectively.
- Obesity: While obesity was once considered a barrier to minimally invasive surgery, we now know that even obese patients can benefit from this approach. In fact, laparoscopy can sometimes offer better access compared to open surgery in these cases.
- Previous Surgeries and Scar Tissue: Patients with a history of abdominal surgery may have scar tissue (adhesions) that complicates the process. However, laparoscopy is still often possible, though it may be more technically demanding.
- Patient Preference and Cosmetic Concerns: Cosmetic outcomes, like smaller scars and quicker recovery, are often an important consideration, especially for patients with conditions like fibroids or endometriosis.
Ultimately, the decision to proceed with minimally invasive surgery is based on an individualised assessment of these factors.
1Twenty80: How has the training for surgeons evolved with the rise of minimally invasive surgery techniques?
Dr. Khoo: Gone are the days when surgical training only focused on open surgeries. Today, newer surgeons begin their training with minimally invasive surgery techniques. This shift has been driven by the growing popularity of minimally invasive surgery. As a result, medical colleges and universities now incorporate minimally invasive surgery training into their curricula.
Additionally, there are numerous courses available for both postgraduate students and practising surgeons who want to learn new skills or improve existing ones. With so many opportunities to learn and refine techniques, it’s become much easier for surgeons to gain expertise in minimally invasive surgery..
1Twenty80: Starting to learn minimally invasive surgery is one thing for new surgeons, but what about veteran surgeons—how do they approach it?
Dr. Khoo: Many veteran surgeons are embracing minimally invasive surgery now, despite not being exposed to it earlier in their careers. They often attend courses to transition from traditional surgery to minimally invasive techniques.
However, some are still resistant. But when it comes down to it, we must prioritize what’s best for the patient. If a procedure can be done with minimally invasive surgery, why choose a large incision?
For example, with benign ovarian cysts or fibroids, we’ve moved beyond the smaller cases. We’re now able to remove even large fibroids—up to 20 to 30 cm—using minimally invasive techniques, which is quite remarkable.
1Twenty80: Are there any studies or data that show the long-term outcomes of patients who undergo minimally invasive surgery compared to those who have traditional surgery?
Dr. Khoo: When it comes to early-stage endometrial cancer, the outcomes of laparoscopic surgery are just as good as traditional open surgery. However, if there’s a risk of tissue spillage or complications, we still choose open surgery.
Studies comparing both methods show that laparoscopic surgery is just as effective as open surgery. We call this “non-inferior,” meaning laparoscopic surgery provides the same or even better results. If laparoscopy didn’t meet the standard of open surgery, we wouldn’t use it. But since it delivers the same results, and offers smaller incisions, less pain, and quicker recovery, we definitely consider it.
These conclusions are supported by large international studies, not just data from one hospital. The long-term outcomes and complication rates are comparable between the two methods.
1Twenty80: What challenges do surgeons face when performing minimally invasive surgeries?
Dr. Khoo: The main challenge with minimally invasive surgery is that it’s physically demanding for the surgeon. In open surgery, the large incision gives us freedom of movement. But with laparoscopy, we’re working through small incisions, which means we have to manoeuvre our instruments at tricky angles. This can be tough on the body.
For surgeons who aren’t used to it, there’s a risk of neck, shoulder, or back pain if posture isn’t kept in check. I’ve said before, it’s like “burning ourselves with the light to create a torch for our patient”—we exhaust ourselves to help them. These physical strains, like shoulder, elbow, and neck injuries, are common, but with practice and better habits, they’re avoidable.
Things like adjusting the height of the operating table, maintaining good posture, and using ergonomic tools can help reduce the risk of injury. While these surgeries can sometimes last as long as open ones, the limited range of motion can make them more tiring. This is even more challenging with single-incision surgeries, where the space is cramped and movement is even more restricted. But on the flip side, for the patient, this approach offers cosmetic benefits like minimal scarring.
1Twenty80: How important is patient education in decision-making with the process regarding minimally invasive surgery?
Dr. Khoo: Patient education is key when it comes to decision-making about minimally invasive surgery. We always ensure that patients give informed consent, which means we fully explain their options, the risks and benefits of each, and why one approach may be better than another. Once they understand, we can make the best recommendation.
Most patients prefer laparoscopic surgery due to its benefits. However, in cases like cancer, we may suggest open surgery instead. If there’s a risk of cancer spreading or worsening during the procedure—such as with tissue spillage—open surgery is the safer choice. While laparoscopic surgery is a great option when it offers the same or better outcomes, it’s not always appropriate, especially when it could lead to complications or a higher cancer stage.
Sometimes patients may push for laparoscopic surgery even when open surgery is a better choice. In these situations, we take the time to explain why the open approach is safer for their specific case. Generally, though, most patients, especially those not dealing with cancer, are happy with the benefits of minimally invasive surgery.
1Twenty80: What is the highest-risk procedure you’ve performed where, despite explaining all the options, the patient still chose minimally invasive surgery?
Dr. Khoo: If a procedure is unsuitable for laparoscopy and requires an open surgery, I wouldn’t compromise just because the patient insists on minimally invasive surgery. While patient autonomy is important, I have to prioritise their safety. If a patient doesn’t agree with my professional recommendation, I’ll advise them to consider their decision carefully or even seek a second opinion.
As a doctor, I can’t proceed with a treatment plan that I believe would cause more harm. Patients come to us for our expertise, and while they have the right to decide, I can’t perform a procedure that isn’t in line with best practices. Ideally, the treatment plan should be a result of discussion between doctor and patient, based on standard, evidence-based practices that offer the safest outcomes.
1Twenty80: How does follow-up care differ from patients who have undergone minimally invasive surgery and open surgery?
Dr. Khoo: The follow-up process is generally the same for both minimally invasive and open surgery patients. We monitor patients post-operation to check for any complications and to ensure the original issue has been resolved without new problems arising. The main difference is that patients who undergo minimally invasive surgery tend to recover much faster.
1Twenty80: Are there any insurance or accessibility challenges associated with minimally invasive surgery?
Dr. Khoo: Yes, most laparoscopic procedures are widely accepted and covered by insurance. However, robotic surgery is relatively new in our country, so insurance currently does not cover the additional charges for using the robot. For example, if we perform a myomectomy to remove a fibroid, the procedure itself is covered, but the cost of using the robot is not. This means patients may need to invest more for robotic assistance, as the bill will show separate charges for the surgery and the robotic equipment, with only the surgery covered by insurance.
1Twenty80: Where do you see the field of minimally invasive surgery heading in the next 5 to 10 years?
Dr. Khoo: The outlook is very positive, and we’re already seeing more people in Malaysia pursuing minimally invasive surgery. Other disciplines have progressed quickly as well. In the gynaecological field, more doctors are now returning to Malaysia after overseas training to practise minimally invasive surgery. In recent years, more hospitals have also invested in laparoscopic and even robotic systems. So, overall, I think the progress is promising, and the outcomes will continue to improve.
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