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We read with interest the article port-site metastases in patients with gynecological cancer after robot-assisted operations by Iavazzo et al. [1] published online in Archives of Gynecology and Obstetrics. The authors analyzed robotic port-site metastasis in the field of gynecological oncology at existing literature data. They have found port-site metastasis is a rare complication of robotic surgery as it is a rather new technique with a limited time of usage Also, they have recommended additional studies to clarify port-site metastasis rates in gynecological oncology patients and to elucidate the possible mechanisms of this type of local recurrence. We notice that additional data for of the patient's management would be beneficial if it is possible.The laparoscopic procedures for malignancies have been widely used in the last 30 years. Whether it is laparoscopic or robotic, similar complications could be seen. One of the complications of this procedure is port-site metastasis. Surgeons are trying to find an appropriate method for the prevention of port-site metastatic disease. In one of the review which was published by Freitas et al. [2] in 2013, they have analyzed the conditions related to port-site metastasis after laparoscopy in gynecologic malignancies. They have divided the measures into two for avoiding the development of port-site metastasis. One of them is preoperative, the other is technical. In the preoperative measures there are proper patient selection, avoidance of laparoscopic surgery in the presence of ascites, compliance guidance and adequate equipment for advanced laparoscopic surgery, knowledge of the principles of prevention in the event of intraoperative discovery of malignant disease, adequate duration of the procedure and the proper training of the surgeon [2][3][4]. In the technical measures, there are protected puncture of ovarian cyst, resection without rupture of an ovarian cyst, minimal tumor manipulation, resection of the tumor with adequate margin, peritoneal lavage with heparin to avoid the adhesion of free cells or lavage with cytocidal solutions, use of protective bags for tissue retrieval, avoiding CO 2 leaks and sudden desufflations, use of heated and humidified CO 2 , exsufflation of the peritoneum before removal of the ports, drainage placement (if needed) before abdomen deflation, irrigation of the ports with heparin or povidone-iodine solution before removal, administration systematic or intraperitoneal of methotrexate, closure of all abdominal layers including the peritoneum and early chemotherapy [2,[4][5][6][7][8][9]. The authors mention some of them. But we are curious about whether in the study, application of these measures would be beneficial or not. The authors emphasized critical points about port-site metastasis. We consider that knowledge of these parameters in the study patients would be interesting to the readers.
We read with interest the article port-site metastases in patients with gynecological cancer after robot-assisted operations by Iavazzo et al. [1] published online in Archives of Gynecology and Obstetrics. The authors analyzed robotic port-site metastasis in the field of gynecological oncology at existing literature data. They have found port-site metastasis is a rare complication of robotic surgery as it is a rather new technique with a limited time of usage Also, they have recommended additional studies to clarify port-site metastasis rates in gynecological oncology patients and to elucidate the possible mechanisms of this type of local recurrence. We notice that additional data for of the patient's management would be beneficial if it is possible.The laparoscopic procedures for malignancies have been widely used in the last 30 years. Whether it is laparoscopic or robotic, similar complications could be seen. One of the complications of this procedure is port-site metastasis. Surgeons are trying to find an appropriate method for the prevention of port-site metastatic disease. In one of the review which was published by Freitas et al. [2] in 2013, they have analyzed the conditions related to port-site metastasis after laparoscopy in gynecologic malignancies. They have divided the measures into two for avoiding the development of port-site metastasis. One of them is preoperative, the other is technical. In the preoperative measures there are proper patient selection, avoidance of laparoscopic surgery in the presence of ascites, compliance guidance and adequate equipment for advanced laparoscopic surgery, knowledge of the principles of prevention in the event of intraoperative discovery of malignant disease, adequate duration of the procedure and the proper training of the surgeon [2][3][4]. In the technical measures, there are protected puncture of ovarian cyst, resection without rupture of an ovarian cyst, minimal tumor manipulation, resection of the tumor with adequate margin, peritoneal lavage with heparin to avoid the adhesion of free cells or lavage with cytocidal solutions, use of protective bags for tissue retrieval, avoiding CO 2 leaks and sudden desufflations, use of heated and humidified CO 2 , exsufflation of the peritoneum before removal of the ports, drainage placement (if needed) before abdomen deflation, irrigation of the ports with heparin or povidone-iodine solution before removal, administration systematic or intraperitoneal of methotrexate, closure of all abdominal layers including the peritoneum and early chemotherapy [2,[4][5][6][7][8][9]. The authors mention some of them. But we are curious about whether in the study, application of these measures would be beneficial or not. The authors emphasized critical points about port-site metastasis. We consider that knowledge of these parameters in the study patients would be interesting to the readers.
We would like to thank Dr. Ali Kagan Coskun and Dr. Zuhal Yapici Coskun for their interest in our paper [1] and their useful comments [2].Our paper is the first systematic review analysing portsite metastases in patients with gynaecological cancers undergoing robotic operations. As noted by our colleagues, there is already enough and valuable knowledge in the field based on laparoscopic operations. Till now, the recurrence rates seem to be similar to laparoscopy [3]; however, as robotic is a rather new technique, we do not know yet if such recurrences are underreported or if such recurrences would be increased with the increased volume of robotic operations. On the other hand, better surgical training and raised awareness of such a complication might lead to minimizing such a rare finding. The main mechanisms which explain such a recurrence are similar to laparoscopy; however, according to Lönnerfors et al. [4] there are some extra mechanisms related to the robotic technique itself, including sliding of the patient and strong lateral movements of the robotic arms which lead to larger abdominal wall trauma and easier tumour cell implantation. Moreover, tumour manipulation seems to be one of the principal factors acting in cell spillage and so the force applied due to the lack of tactile sensation on the lymph nodes during dissection or retrieval may also lead to port metastases [4].The main aim of our paper is to raise the clinical suspicion in order to optimize the measures taken to prevent such a rare complication. Based on Freitas et al. paper [5], we agree that such measures should be divided into preoperative and technical, and as suggested by our group in a recent paper [6] these measures should take into account all the patient-related, tumour-related, wound-related and surgical technique-related parameters.Once again, we agree with our colleagues and we thank them for their valuable comments.Conflict of interest None.
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