The management of patients with cervical cancer is either surgery or a combination of chemo and radiotherapy. Surgery maintains an important role especially in patients with early-stage and recurrent disease. In patients with locally advanced disease or with spread to the lymph nodes, it is largely accepted that chemoradiation is the first treatment modality, with surgery confined to patients with persistent or recurrent disease. Endoscopy has a clear role in the primary surgical treatment, with the intrinsic benefits provided over a laparotomy. In addition, it may be used to facilitate and tailor the efficacy of the chemoradiation by removing large lymph nodes or detecting microscopic metastasis.

FIGO staging of patients with cervical cancer is based on a clinical examination, but this has a low sensitivity and specificity. Radiology can enhance staging information. Surgical staging can provide further information to detect spread to the lymph nodes status and adjacent organs. Querleu published the first series on surgical staging in 1991 on 39 patients with early-stage cervical cancer who had laparoscopic pelvic lymphadenectomy for staging purposes [1]. Since this report numerous retrospective studies were published confirming feasibility and safety of a laparoscopic approach. In 2006, Benedetti Panici et al. [2] compared the outcomes of 168 patients who had undergone an open transperitoneal, open extraperitoneal and laparoscopic pelvic lymphadenectomy in a prospective randomized trial. They did not find statistical differences in intraoperative or postoperative complications. Postoperative recovery was faster in the laparoscopic and extraperitoneal groups. Despite a lower lymph node harvest at laparoscopy, the number of nodes was considered adequate. In 2008 Lim et al. [3] published a prospective study of 83 patients with cervical cancer stage IB2-IVA who had a pre-treatment laparoscopic staging. All patients had pelvic and para-aortic lymphadenectomy. Despite a 15.2 % rate of surgery related complications, all patients completed the planned radiotherapy. In 2013 Benedetti Panici et al. [4] reported a series of 167 consecutive patients with local advanced cervical cancer who had laparoscopic staging. Minor laparoscopy complication rate was 1 %. The median overall survival was 65 months. They concluded that laparoscopic staging is a feasible and safe procedure. Marnitz et al. [5] published in 2012 the results of a prospective study. They demonstrated that in patients with early cervical cancer, laparoscopic staging with the use of frozen section of the lymph nodes successfully tailored the treatment. In this study 90 % of the patients had no need for adjuvant treatment. They concluded that surgical staging should be used as routine procedure. In 2011 Ghezzi et al. [6] analyzed the radiation-induced bowel complications following an open or laparoscopic staging for gynecological cancers. Using multiple regression analysis they found an independent protective role of minimal-access surgery. Several cases series [7, 8] have confirmed the utility of a laparoscopic re-staging in patients with incidental finding of early stage cervical cancer following a simple hysterectomy or a sub-total hysterectomy. By means of laparoscopy, lymphadenectomy and radical parametrectomy could be performed for patients with microscopic or macroscopic tumor left behind and for those at risk of parametrial invasion. In 2012 Li et al. [9] reported 28 cases of laparoscopic nerve-sparing parametrectomy, recording two intra-operative complications. After a median follow-up of 38 months, no recurrences were recorded.

Fertility sparing surgery can be performed for patients with cervical cancer FIGO stage Ib1 and a tumor size less than 2 cm. Laparoscopy is used to perform the lymphadenectomy prior to a radical vaginal trachelectomy, or to perform a fully laparoscopic radical trachelectomy. Radical trachelectomy removes the cervix, the inner aspect of the parametrium and the upper third of the vagina, but retains the body of the uterus. In 2010 Kim et al. [10] reported 27 cases of laparoscopic radical trachelectomy. Six patients required transfusions, but no further complications were reported. After a median follow-up of 31 months there was one recurrence with death from disease. In 2013, Ebisawa et al. [11] evaluated obstetrical outcomes of a series of 56 patients treated with laparoscopic radical trachelectomy. They reported a pregnancy rate of 52 %, with 13 live births. Preterm premature rupture of membranes was the most common complication.

Radical hysterectomy remains the standard of treatment for patients with stage 1bi cervical cancer. Feasibility and safety of a laparoscopic approach to radical hysterectomy is now well accepted.

Park retrospectively compared the survival and surgical outcomes of 115 laparoscopic radical hysterectomy (LRH) vs 118 open radical hysterectomy (ORH) in patients with stage IB2 to IIA2 [12]. Conversion to laparotomy occurred in two patients. There were no differences in 5-years disease-free survival (78 % vs. 77 %) and 5-years overall survival (83 % in both groups). However the estimated blood loss, length of hospital stay, time to recover bowel movement and postoperative complications favored the patients in the LRH group.

In 2004 Steed et al. [13] compared peri-operative morbidity and recurrence-free survival between 71 patients treated with laparoscopic-assisted radical vaginal hysterectomy and 205 patients with radical abdominal hysterectomy. They demonstrated similar clinical outcomes but less intra-operative blood loss and shorter hospital stay in the laparoscopic group. They reported more intraoperative complications however (13 % vs. 4 %).

Hertel et al. [14] reported their experience of 200 patients operated by a laparoscopic assisted radical vaginal hysterectomy. Major intra and post-operative complications rates were 6 and 8 %, respectively. Overall 5-years survival was 83 %, but in patients with stage Ib1 and no risk factors (L0V0N0), it was as high as 98 %.

In 2012 Nam et al. [15] compared in a retrospective study, 263 ORH with 263 LRH for patients with early-stage cervical cancer. No differences in overall survival or disease free survival were found. LRH group had a shorter postoperative hospital stay and a lower estimated blood loss. Although intraoperative complication rates were similar, postoperative complication rates were less in LRH group.

Pellegrino et al. [16] published in 2009 the results of a prospective study on the surgical and clinical outcomes of 107 patients who underwent a total laparoscopic hysterectomy for stage Ib1. Conversion to laparotomy occurred in six patients. Two patients had minor intraoperative complications, while five patients needed a second surgical procedure for a postoperative complication. After a median period of follow up of 30 months, they reported 11 recurrences and a survival rate of 95 %.

In 2010 Naik et al. [17] published the first randomized phase II trial comparing laparoscopic vs abdominal radical hysterectomy. Although they reported outcomes of only 13 patients, the study confirms benefits of laparoscopic approach in terms of blood loss, hospital stay and analgesic requirement.

Traditionally radical hysterectomy is associated with a 5–10 % neurogenic bladder dysfunction, namely reduced perception of fullness, impaired urge and weakened voiding capacity. These side effects are caused by injury of the pelvic splanchnic nerves and the inferior hypogastric plexus during the dissection and resection of parametrium. Since 2000, when Possover et al. [18] described the first series of nerve-sparing radical hysterectomy, papers have confirmed the efficacy of the laparoscopic technique (LNSRH) in identifying and sparing these sympathetic and parasympathetic pelvic nerves. In 2010 Liang et al. [19] compared 82 LNSRH with 81 LRH. They reported less urinary complications in LNSRH group. After a median follow up of 22.3 months no recurrences were recorded. In 2011 Park et al. [20] in a retrospective study evaluated 125 consecutive LNSRH. They reported 13 urological complications, but they concluded that LNSRH is a feasible technique.

Anterior, posterior or total exenteration is performed in selected patients with recurrent cervical cancer following radical radiotherapy. Surgery is aborted due to the presence of unresectable disease in up to 45 % of patients. An explorative laparoscopy has proved useful in the assessment of these patients, minimizing the number of patients whose exenterative surgery is abandoned [21].

Other authors have reported on a laparoscopic technique to perform pelvic exenteration for patients with cervical cancer [22, 23], demonstrating feasibility and safety of the technique. However due to the small numbers of the patients included in the studies, the oncological outcome remains to be proven.

In the last few years, the use of robotic surgery in gynecology oncology has become more common. Several studies were published comparing different techniques of radical hysterectomy, including robotic. In 2008 Magrina et al. [24] in a case control study, compared robotic radical hysterectomy (RRH) to laparoscopy and to laparotomy. They reported 27 cases of robotic surgery. There were no significant differences in intra- or postoperative complications among the three groups, but in patients with minimal invasive surgery the blood loss and hospital stay were reduced compared to laparotomy. Similar results were obtained by Maggioni et al. [25] in a case control study. In 2008 Boggess et al. [26] compared 51 robotically assisted radical hysterectomies with 49 open radical hysterectomies. There were significant differences in blood loss, operative time and number of nodes removed in favor of the robotic group. They also reported 7.8 % vs. 16.3 % postoperative complications respectively. In an interesting review [27] Kruijdemberg et al. compared 342 robotic radical hysterectomies vs. 943 laparoscopic radical hysterectomies. They reported fewer blood transfusions in the robotic group, but a higher rate of major postoperative complications (9.6 % vs. 5.5 %). In 2013 Chong et al. [28] compared 50 consecutive robotic NSRH with a cohort of 50 LNSRH. They found that blood loss and intraoperative complication rate were significantly lower in robotic surgery. Similar results are reported from other case series [29, 30].

Robotic surgery has been used in trachelectomy also. Nick et al. [31] compared 25 open vs 12 robotic radical trachelectomy, showing similar morbidities but less blood loss and hospitalization in the robotic group. Personn et al. [32] demonstrated similar results comparing robotic trachelectomy vs. vaginal trachelectomy. Initial case reports or small series have also reported the use of robotic surgery in patients with advanced and recurrent cervical cancer.

In 2010 Lambaudie et al. [33] compared robotic vs. laparoscopy vs. laparotomy in staging of locally advanced cervical cancer. Complication rate was similar, as was the recurrence rate.

Lim et al. [34] in 2009 reported the first case of robotic pelvic exenteration for a recurrent cervical cancer with an ileal loop urinary diversion. Davis et al. [35] and Lambaudie et al. [36] published in 2010 two other small series of robotic anterior pelvic exenteration. The numbers are very small but the expansion of robotic surgery will enable more surgeons to use endoscopic surgery and abandon the traditional laparotomy.

Single port surgery (SPS) has been reported very little in the treatment of patients with cervical cancer. In 2010 Hahn and Kim [37] reported two cases of single port laparoscopic pelvic lymph nodes dissection with a modified vaginal hysterectomy in patients with stage IA2.

The use of endoscopic surgery in the treatment of patients with cervical cancer has been supported by a large number of studies. Although no phase III clinical trial has been published so far, the safety and efficacy of the technique is beyond doubt and the oncologic outcomes appear equivalent to open surgery. Endoscopy delivers significant benefits for patients with cervical cancer.

Ovarian cancer remains the most common cause of death from a gynecological malignancy [38]. The high lethality is due to the common presentation of advanced stage disease (75 % present with FIGO stage 3–4). Patients with early stage display a median 90 % 5 year survival rate.

Ovarian cancer can be assessed and treated by laparotomy, laparoscopy and robotic surgery. Again, laparoscopy and robotic surgery offer multiple advantages due to the smaller incisions—less need for postoperative analgesics, quicker recovery, shorter hospital stay and a lower risk of complications such as infections, blood loss, wound infection, ileus and incisional hernias. Laparoscopy has been found to reduce the risk of post-operative incisional hernia. The reported incidence of incisional hernia through the 10/12 mm laparoscopic trocar site is 3 % [39] compared to 16.9 % following a midline laparotomy for a gynecological oncology procedure [40].

Port site recurrence has been a concern. In a study by Zivanovic, the port site recurrence rate was 1.96 % following laparoscopy for ovarian, fallopian tube or primary peritoneal cancer [41].

As much as 30 % of women with apparent early stage disease have microscopic metastasis [42, 43]. Full staging of presumed early stage disease provides important prognostic information. In case of patients whose disease is upstaged, there is a recommendation for adjuvant chemotherapy. When stage I disease is confirmed, no chemotherapy is required, and in young women a fertility sparing treatment can be offered. Early stage disease can be upstaged due to microscopic tumor deposits in the omentum, pelvic and/or para-aortic lymph nodes and contra-lateral ovarian involvement.

Upstaging can occur due to intra-operative mass rupture leading to contamination of the peritoneal cavity with tumor cells. Whilst only retrospective data are provided on the prognostic effect [44], mass rupture changes the stage from potential IA to IC, with the immediate implication that chemotherapy will be prescribed in patients otherwise requiring no adjuvant treatment [45, 46]. The risk of intraoperative mass rupture is also present at laparotomy but seems to be increased by a laparoscopic approach. In view of this, laparoscopy may be more suitable for re-staging procedures following a primary removal of the ovary at a previous operation. There is no risk of intraoperative mass rupture since the tumor has already been removed.

A further concern with endoscopy in ovarian cancer is that spread and implantation of ovarian cancer cells may be facilitated during laparoscopy by the CO₂ under pressure. This may be the reason for port site metastases [47, 48]. A large retrospective series has identified port-site metastasis in 20 of 1,694 patients (1.18 %) with malignant intraperitoneal disease undergoing laparoscopy. Fifteen of the 20 patients with port-site metastases had a diagnosis of fallopian tube or ovarian cancer, but only 2 patients had early stage ovarian cancer [41]. In order to reduce the risks when employing laparoscopy for the management of patients with early stage ovarian cancer there should be adequate surgical expertise, meticulous technique with limited tissue manipulation and the use of an endobag for tissue extraction.

Despite these concerns, the use of laparoscopy in early stage ovarian cancer is increasing, and data supports this development. Brookbank demonstrated 94 % 5 years disease free survival and a 100 % overall survival at a median 18 months (range 3–59) follow-up [49]. The rate of conversion to laparotomy in the literature is averagely below 5 %, with a range 3.2–10 % [50].

Robotic surgery has been used in early stage ovarian cancer. A recent study matched 25 robotic cases of epithelial ovarian cancer staging with 27 laparoscopic and 119 open cases. All patients were operated on during the same period and the groups were matched by age, BMI, type, and number of procedures done. Compared with open surgery, the robotic and laparoscopic groups had a decreased hospital stay. No difference in outcomes was reported between robotic and laparoscopic surgery. Survival was also unaffected by surgical approach [51].

Laparoscopy in patients with advanced disease has limited application. It can be used to confirm a suspected diagnosis, but this is increasing performed by radiologically guided biopsy. A second application is to predict whether cytoreductive surgery is possible. However, small volume abdominal disease may be missed at laparoscopy, particularly in areas like the small bowel and the mesentery.

The use of laparoscopy in cytoreduction in patients with presumed stage 3 primary ovarian cancer has been reported [52]. Patients had CT evidence of omental metastasis and ascites. Twenty-three cases (92 %) were successfully cytoreduced without conversion to laparotomy. Median operative time was 2.3 h and median blood loss was 340 ml. All tumors were debulked to less than 2 cm and 36 % had no residual disease.

A retrospective analysis by Magrina on 52 selected patients with recurrent ovarian cancer undergoing secondary cytoreduction by laparoscopy, laparotomy or robotics was performed between January 2006 and December 2010 [51]. Robotics and laparoscopy provided similar perioperative outcomes, such as reduced blood loss and shorter hospital stay as compared to laparotomy. The comment of the author was that use of robotics is preferable when all recurrent disease can be excised without redocking and need of additional trocars. In addition it was most suitable for isolated recurrences particularly in the diaphragms, liver, peri-rectal area, and in the pelvis. Laparoscopy was preferable in the presence of limited disease and when redocking would be necessary. Laparotomy seemed preferable for patients with widespread peritoneal implants, multiple sites of recurrence, and/or extensive adhesions.

There is evidence to support the use of endoscopic surgery in early stage ovarian cancer management without compromising survival. Its use in advanced disease is less established with far fewer reported studies. Most studies have supported the equivalence of robotic surgery and laparoscopy in many perioperative outcomes. Some studies suggest that robotic surgery may have advantages over laparoscopy in the learning curve required to perform complex gynecological oncology procedures. However, this is entirely dependent on the surgeon and the final outcomes seem to be unchanged between laparoscopy and robotic.

Endometrial cancer is the third most common cancer in women accounting for 6–9 % of all cancers in female patients [53–55]. The standard treatment for patients with early-stage endometrial cancer is surgery with a total hysterectomy (TH) and bilateral salpingo-oophorectomy with or without pelvic and para-aortic lymph node resection based on risk factors [56, 57]. A midline laparotomy has been the traditional route of choice for extended surgery with lymph node removal. However, patients with endometrial cancer frequently present with co-morbidities such as obesity, diabetes and cardio-vascular disease. The morbidity associated with a laparotomy can be substantial in this group of patients, especially with regards to infection, wound dehiscence, thrombosis and embolism [58]. The most validated alternative approach for patients with early endometrial cancer is laparoscopy. Several prospective controlled studies showed that total laparoscopic (TLH) was an effective, minimally invasive, safe alternative to total abdominal hysterectomy (TAH) for benign indications [59, 60].