Surgical techniques

Oxford American handbook of oncology. Second Edition. Oxford University Press (2015)

For surgical procedures designed to achieve diagnosis and staging, the most minimally invasive technique possibly should be used. For surgical procedures performed for curative intent, the entire tumor must be resected with negative surgical margins.

The en bloc technique—removal of the primary tumor and an appropriate amount of adjacent soft tissue—is most often used in cancers with a predominantly lymphatic spread and to optimize the achievement of negative surgical margins. This technique is best developed in surgery of head and neck cancer, esophageal cancer, and soft tissue sarcomas.

Minimally invasive surgery

There has been an exponential growth in minimally invasive surgery (MIS) for cancer during the past decade. For some MIS procedures, proved advantages include decreased hospital stay, less postoperative pain and analgesia requirement, less inflammatory response, faster return to full activity, fewer overall complications, and more effective compliance with adjuvant therapy.

Conservative and radical surgery

There are increasing data to support conservative (less radical) resections for selected tumors. For example, thyroid lobectomy is the recommend surgical approach to treat minimally invasive follicular carcinoma of the thyroid gland, as opposed to total thyroidectomy; wide local excision (when followed by radiotherapy) is adequate treatment for selected breast cancer patients provided the resection margin is at least 0.5 cm.

Limb-conserving surgery, often with endoprosthetic bone and joint replacement, is suitable for young patients with bone tumors around the knee in highly specialized centers to avoid amputation.

Radical surgery still has its place in the patient with large hepatomas and mesothelioma, and total mastectomy is still required for some patients with breast cancer.

Occasionally, liver transplantation is performed for primary liver cancer or secondary endocrine tumors of the liver, but the benefits of such a transplant are debatable.

Reconstructive surgery

To return patients to an adequate and reasonable quality of life after cancer surgery, reconstruction should be offered, where possible (if the patient wishes). For example, after mastectomy the breast can be reconstructed using implant, tissue expander, transverse rectus abdominis muscle (TRA M), or latissimus dorsi flaps.

After major head and neck resections, oncological plastic surgeons use free vascularized flaps to replace skin, muscle, and bone. Examples include radial and fibular free flaps.

Although hand transplant is technically feasible, fewer than 10 have been performed worldwide because of poor functional results and considerable psychological morbidity.

Prophylactic cancer surgery

Surgical resection is used in the prevention of cancer in selected patients.

There are several conditions, either acquired or inherited, in which preventative surgery has a major role after careful counseling of the patient. These include the following:

  • Orchidopexy or occasionally orchidectomy in the patient with a maldescended testis
  • Total colectomy in patients with polyposis coli
  • Total colectomy in patients with ulcerative colitis involving the entire colon (over 10 years) and who have changes of dysplasia
  • Total thyroidectomy for patients at risk of medullary cell carcinoma of the thyroid gland, who have the MEN syndrome (type 2)
  • Bilateral mastectomy in selected patients carrying the BRCA1 gene

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