Elsevier

Journal of Minimally Invasive Gynecology

Volume 20, Issue 6, November–December 2013, Pages 754-765
Journal of Minimally Invasive Gynecology

Review Article
Role of Minimally Invasive Surgery in Ovarian Cancer

https://doi.org/10.1016/j.jmig.2013.04.027Get rights and content

Abstract

The standard treatment of ovarian cancer includes upfront surgery with intent to accurately diagnose and stage the disease and to perform maximal cytoreduction, followed by chemotherapy in most cases. Surgical staging of ovarian cancer traditionally has included exploratory laparotomy with peritoneal washings, hysterectomy, salpingo-oophorectomy, omentectomy, multiple peritoneal biopsies, and possible pelvic and para-aortic lymphadenectomy. In the early 1990s, pioneers in laparoscopic surgery used minimally invasive techniques to treat gynecologic cancers, including laparoscopic staging of early ovarian cancer and primary and secondary cytoreduction in advanced and recurrent disease in selected cases. Since then, the role of minimally invasive surgery in gynecologic oncology has been continually expanding, and today advanced laparoscopic and robotic-assisted laparoscopic techniques are used to evaluate and treat cervical and endometrial cancer. However, the important question about the place of the minimally invasive approach in surgical treatment of ovarian cancer remains to be evaluated and answered. Overall, the potential role of minimally invasive surgery in treatment of ovarian cancer is as follows: i) laparoscopic evaluation, diagnosis, and staging of apparent early ovarian cancer; ii) laparoscopic assessment of feasibility of upfront surgical cytoreduction to no visible disease; iii) laparoscopic debulking of advanced ovarian cancer; iv) laparoscopic reassessment in patients with complete remission after primary treatment; and v) laparoscopic assessment and cytoreduction of recurrent disease. The accurate diagnosis of suspect adnexal masses, the safety and feasibility of this surgical approach in early ovarian cancer, the promise of laparoscopy as the most accurate tool for triaging patients with advanced disease for surgery vs upfront chemotherapy or neoadjuvant chemotherapy, and its potential in treatment of advanced cancer have been documented and therefore should be incorporated in the surgical methods of every gynecologic oncology unit and in the training programs in gynecologic oncology.

Section snippets

Laparoscopic Evaluation, Diagnosis, and Staging of Apparent Early Ovarian Cancer

Early ovarian cancer is defined as cancer limited to 1 or both ovaries corresponding to FIGO stage I. Traditionally, staging surgery has been performed via a vertical midline incision, which provides excellent exposure of the upper abdomen, diaphragmatic surfaces, and pelvis. Meticulous surgical staging leads to upstaging in 16% to 35% of presumed early-stage ovarian carcinoma [10].

Several retrospective and case series reports have demonstrated the feasibility and safety of a laparoscopic

Minimally Invasive Surgery for Cytoreduction of Advanced Ovarian Cancer

There is a paucity of data on laparoscopic cytoreductive surgery for advanced ovarian cancer. The first report of successful videolaparoscopic cytoreduction of advanced ovarian cancer was a case series that included 3 patients, all of whom underwent successful total laparoscopic primary or secondary cytoreduction [8].

In 2010, Nezhat et al [17] reported a series of 32 patients with advanced ovarian, fallopian tube, or primary peritoneal cancer who underwent laparoscopic evaluation for debulking.

Hand-Assisted Laparoscopy

Krivak et al [19] reported 25 patients with ovarian carcinoma who underwent surgical staging and cytoreduction via hand-assisted laparoscopy. Six patients had apparent advanced ovarian cancer at referral, and of the 19 patients with presumed early-stage cancer, the disease was upgraded in 5 patients on the basis of retroperitoneal lymph node involvement. In 3 the disease had metastasized to other pelvic structures, and 2 had microscopic disease in the omentum. Twenty-two surgical procedures

Robotic-Assisted Laparoscopy

Recently, there have been reports of use of robotic-assisted surgery in patients with advanced ovarian cancer. In a retrospective case-control study, Magrina et al [20] compared 25 patients with ovarian cancer undergoing a robotic-assisted approach with 27 similar patients undergoing conventional laparoscopy and 119 undergoing laparotomy. In the respective groups, 60%, 75%, and 87% of patients were found to have FIGO stage III/IV disease, and the remaining patients had FIGO stage I/II disease.

Laparoscopic Assessment of Feasibility of Upfront Optimal Surgical Cytoreduction

The mainstay of treatment for advanced invasive epithelial ovarian cancer is ideally cytoreduction to no visible disease (microscopic) followed by platinum-based combination chemotherapy [6], which is associated with the best survival 21, 22, 23, 24. However, cytoreduction to microscopic disease is not possible in all patients at the initial surgery. To increase the rate of complete or optimal debulking and to limit perioperative morbidity, neoadjuvant chemotherapy with interval cytoreduction

Laparoscopic Reassessment or Second-Look Surgery

In the past, second-look surgery was suggested as part of the therapeutic triage in patients with advanced ovarian cancer. Today this procedure is performed primarily in clinical trials or in selected cases with uncertain clinical response of patients. The minimally invasive approach had been used in second-look assessment in patients with a complete clinical response to platinum-based combination chemotherapy. Disease recurrence after negative second-look surgery was reported to be similar for

Laparoscopic Assessment and Cytoreduction of Recurrent Disease

The role of secondary cytoreduction surgery to treat recurrent ovarian carcinoma is debatable. Recently, several authors have suggested some criteria including isolated recurrence, lack of ascites, and optimal debulking at the primary surgery as indications for secondary debulking 33, 34. In these selected cases, laparoscopic secondary cytoreduction has been reported in case reports and series, with acceptable results insofar as efficacy and outcomes 8, 35, 36, 37, 38 (Fig. 2).

Trinh et al [36]

Conventional Laparoscopy

Closed or open transumbilical or left upper quadrant (Palmer point) entry using a Veress needle is used most often. A 0-degree laparoscope, and at times a 30-degree laparoscope, is used via a port placed 4 to 5 cm supraumbilically. We use three 5- to 12-mm ancillary ports in the mid–lower abdomen when the primary lesion is below the pelvic brim. Additional upper abdominal ports can be placed for extensive upper abdominal debulking. Pelvic washings are collected for cytologic analysis, and

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