Patients’ selection, teqnique and limits in laparoscopic visceral peritoneal debulking surgery in advanced stage ovarian cancer: Paduan experience.

Background: Ovarian cancer is the ninth most common type of cancer and the fifth most common cause of death due to cancer in women. Patients with ovarian cancer often present few or no symptoms, making clinical diagnosis of early-stage ovarian cancer difficult: over 75% of them in advanced stages, meaning FIGO stage III-IV, of disease. The aim in the surgical treatment for advanced stage disease is the complete cytoreduction of all macroscopic visible disease: debulking surgery is traditionally performed through a xifo-pubic laparotomy. There is a direction in seeking to reduce surgical morbidity, time to recovery, and time to start adjuvant chemotherapy because patients with ovarian cancer are thought to start chemotherapy quickly. Objective: A non-randomized phase I-II clinical trial (ULTRA-LAP) was registered to test safety, side effects and efficacy of laparoscopic Visceral-Peritoneal Debulking (L-VPD) in patients with stage III-IV ovarian cancer (OC). A miniature, feasibility part of the trial aimed at identifying which ovarian cancer patients are suitable to undergo laparoscopic visceral peritoneal debulking, is conducted in Padua hospital in order to demonstrate its applicability in a different context. Materials and methods: All consecutive Paduan patients with advanced stage ovarian cancer, fitting for surgery, underwent to exploratory laparoscopy (EXL), between April 2021 and April 2023: in patients where the disease could be submitted to a complete resection (CR), was practiced a visceral peritoneal debulking (VPD), making a consistent attempt at completing laparoscopic visceral peritoneal debulking (L-VPD). Primary endpoint of the initial feasibility part of the trial was to identify which ovarian cancer patients could safely and effectively undergo L-VPD. Results: 64 ovarian cancer patients had EXL in the study period. Thirty (46,9%) underwent interval visceral peritoneal debulking and 34 (53,1%) up-front visceral peritoneal debulking. Overall, 55 patients had VPD by laparotomy (85,9%) and 9 (14,1%) had L-VPD, of which 4 (44,4%) patients as interval debulking surgery and 4 (44,4%) as up-front (uL-VPD). CR was accomplished in 7 (77,8%) patients in L-VPD group and in 44 (83%) in the VPD one. Intra and postoperative complications have been presented in 2 (22,2%) patients of the L-VPD group and in 31 (56,4%) patients of the VPD one. Small bowel resections, multiple bowel resections, ostomies, lymphadenectomies, pleurectomies, liver resections, porta hepatis peritonectomies, mesenteric resections were accomplished just in the VPD group. Conclusions: Having demonstrated that L-VPD is feasible, efficacious and safe, it has been identified a group of patients who had the highest chance of a complete cytoreduction with this surgical approach. Initial analysis supports the feasibility of L-VPD in two groups of patients: those with no gross disease at interval surgery and those with gross visible disease at upfront or interval surgery, but limited to pelvis (including recto-sigmoid), gastro colic omentum, peritoneum and diaphragmatic peritoneum, the latter not requiring dorsal liver mobilization.