Risk of spread of ovarian cancer after laparoscopic surgery Michel Canis, Benoit Rabischong, Revaz Botchorishvili, Stephano Tamburro, Arnaud Wattiez, Ge  rard Mage, Jean Luc Pouly and Maurice Antoine Bruhat The incidence of the spread of ovarian cancer after laparoscopic surgery is difficult to establish from the current literature. The prognosis incidence of a trocar site metastasis without peritoneal dissemination is not known. Data from general surgeons in prospective studies from a single institution suggested that in colon cancer the risk is low, whereas it seems to be much higher in multicentric studies of undiagnosed gallbladder cancer. Experimental studies suggested that laparoscopy has advantages and disadvantages. However, the risk of dissemination is high when a large number of malignant cells and a carbon dioxide pneumoperitoneum are present, a situation encountered when managing adnexal tumours with large vegetations. Animal studies will allow the development of a peritoneal environment adapted to the treatment of cancer. The ovary is an intraperitoneal organ and ovarian cancer a peritoneal disease, so the risk of peritoneal spread may be higher in ovarian cancer than in other gynecological cancers. A careful preoperative evaluation appears to be the best way to prevent these risks. It should also be used to choose which patient should be operated by which surgical team. The second step is a careful and cautious laparoscopic diagnosis, so that more than 98% of ovarian cancers encountered can be treated immediately and effectively. The laparoscopic management of ovarian cancer remains controversial; it should be performed only in prospective clinical trials. Until the results of such studies become available, an immediate vertical midline laparotomy remains the gold standard if a cancer is encountered. Curr Opin Obstet Gynecol 13:9±14. # 2001 Lippincott Williams & Wilkins. Department of Obstetrics, Gynecology and Reproductive Medicine, Clermont Ferrand, France Correspondence to Michel Canis, Department of Obstetrics, Gynecology and Reproductive Medicine; CHU 13 Boulevard Charles de Gaule, 63033 Clermont Ferrand, France Tel: +33 73 31 60 53; fax: +33 73 93 17 06; e-mail: mcanis@chu-clermontferrand.fr Current Opinion in Obstetrics and Gynecology 2001, 13:9±14 # 2001 Lippincott Williams & Wilkins 1040-872X Introduction Laparoscopic surgery has become the gold standard in the management of benign adnexal masses [1 . ,2]. As preoperative selection cannot be perfect, some cases of ovarian cancer, encountered in masses expected to be benign, are managed by laparoscopy. Case reports about dissemination and national surveys have raised concerns about the safety of laparoscopic surgery in ovarian cancer [3±5]. To prepare this review we performed a medline search encompassing the years 1999 and 2000 using the keywords `cancer' and `laparoscopy', `ovary' and `laparo- scopy', `ovarian cancer' and `laparoscopy'. Clinical data from gynecology Twenty-one cases of the spread of ovarian cancer after laparoscopic surgery were reported during the period of this survey [6 .. ,7±9]; 36 cases had been reported previously [1 . ,10]. In the study by van Dam et al. [6 .. ], all patients who developed a trocar site metastasis had an advanced ovarian cancer diagnosed before the proce- dure. The occurrence of trocar site metastasis was related to the volume of ascites, and to the delay before chemotherapy or debulking. The incidence of port site metastasis was signi®cantly lower in patients who underwent an open laparoscopy and a careful closure of the abdominal wall (2%) when compared with patients who had blind trocar insertion and a skin closure (58%). In other cases of tumour spread reported recently, the number of patients managed by these groups was not reported so that the incidence cannot be calculated. Moreover, the management was often inadequate, the tumour was diagnosed as benign, sometimes morcellated and extracted without a bag [7±9]. In the study by Leminen and Lehtovirta [8], four patients with stage I disease at initial laparoscopy were upstaged because of peritoneal spread, which appeared to be the conse- quence of the laparoscopic approach. However, the quality of the initial laparoscopic inspection may be questioned, given that four out of eight cancers were diagnosed as benign. Previously, when a re-staging laparotomy was positive, the surgeon who performed the ®rst laparotomy was blamed because he did not achieve an adequate evaluation of the peritoneal cavity [11,12], whereas the laparoscopic approach is now blamed and the initial laparoscopic evaluation of the peritoneum is assumed to have been adequate, even though a complete staging procedure had not been performed and the cancer was often misdiagnosed. 9