LAPAROSCOPIC MANAGEMENT OF OVARIAN MALIGN OMAS

A controversial discussion has arisen between endoscopists and oncolog ists about laparoscopic management of ovarian cancer and borderline tu mours. A questionnaire was mailed to 273 German Departments of Gyn./Ob st. A response rate of 46% (127 hospitals) was obtained concerning the endoscopical technique used, the kind and delay of post-endoscopical cancer operation and the early findings (follow-up) in cases of ovaria n cancer, dysgerminoma, malignant teratoma, tubal cancer and borderlin e tumours of the ovary. In this German survey it could be shown that l aparoscopic management of malignant ovarian tumours was not uncommon b etween 1991-1994. Totally, 61% of ovarian cancer stage Ia and 84% of o varian borderline tumours stage Ia have been reported without any path ological finding in laparotomy subsequent to laparoscopic management o f the lesions. The 192 cases cited here are undoubtedly an underestima te of the real present frequency of endoscopically managed ovarian mal ignancies. Patients with this early ''negative'' report should be foll owed up carefully and may not permit conclusions that laparoscopic man agement of ovarian malignancies may be harmless for them. In 16% of th e stage Ia borderline tumours and in 39% of the stage Ia ovarian cance r early spread has been found totally, demonstrating that implantation s and metastases subsequent to the endoscopical procedure can be found even in an early follow-up phase. In 92.4% laparoscopic capsule ruptu re, tumour morcellement with intraabdominal spilling, subsequent cyste ctomy or adnectomy had been the technique of choice with additional ri nsing of the intraabdominal cavity. This was harmful for the majority of patients if the subsequent cancer surgery by laparotomy was delayed for more than 8 days. Early progression of these cases to stage Ic ha s been reported in 20% (7/36 cases) and to stage II-III in 53% (19/36 cases). Only in 7.4% the endobag procedure was used in laparoscopic ma nagement of ovarian cancer stage Ia. In ovarian cancer stage Ic-III (n = 50) an early seeding in the laparoscopic tract was reported in 52% (13/25) if subsequent cancer surgery by laparotomy was delayed more th an 8 days. The endoscopical techniques and the early findings after an endoscopical management are reported in detail. In conclusion, in res pect of common oncological standards the actual practice in laparoscop ic management of ovarian malignancy is considered poor surgery. Capsul e rupture, tumour morcellement and unprotected ''biopsy'' in the intra abdominal cavity and an additional delay of adequate cancer surgery ar e the main pitfalls of that procedure. For the overwhelming majority o f patients undergoing such endoscopical procedures very early implants and metastases in the pelvis, the abdominal cavity or the laparoscopi c tract have been found. It seems necessary that laparoscopic manageme nt of ovarian malignancies and borderline tumours under the present te chnical conditions are given up and that we should return to reliable standards of oncological surgery comparable to laparotomy. This should be discussed urgently.