Laparoscopic management of gynecological malignancies

The primary surgical management of endometrial and cervical carcinoma requires four operations: simple and radical hysterectomy, and pelvic and aortic lymphadenectomy. All these four operations can now be carried out laparoscopically with significant reduction in morbidity and among the patient population that develops these malignancies, namely, the elderly and the obese. Moreover, as judged by the number of nodes harvested and the proportion of positive nodes, the radicality of laparoscopic lymphadenectomy is equivalent to its 'open' counterpart. Thus, laparoscopic management is feasible in almost every patient who has carcinoma of the endometrium or cervix. Experience with the laparoscopic management of ovarian cancer is more limited. There has been concern that the increased frequency of cyst rupture makes laparoscopic management inappropriate, but cyst rupture per se does not impair survival provided patients are managed appropriately with adjuvant chemotherapy, and all but stage I, grade I ovarian cancer is treated with neoadjuvant chemotherapy. Many patients who have stage II-IV disease can be satisfactorily 'debulked' laparoscopically, and a significant proportion of those who cannot be debulked primarily can be debulked laparoscopically after neoadjuvant chemotherapy. The laparoscopic management of ovarian cancer promises to be the most active area of advance over the next few years.