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The pre-surgical multidisciplinary discussion

Except in emergency situations, surgery should be planned within the therapeutic protocol. The discussion with the other members of the multidisciplinary team should provide the definition of the best surgical intervention for each patient.

The prior common drafting of therapeutic protocols allows the diffusion of good practice recommendations and speeds up patient treatment. Prior to surgery, the surgeon should ensure that all of the necessary resources are available to him to determine whether or not he will be able to respect the protocol. Otherwise, he should discuss the case with his colleagues, (surgeons and physicians) in order to define the best treatment before taking the lancet.

Poor initial surgical treatment can never be corrected, even by the best radiotherapy or the most audacious chemotherapy. Sometimes it is wiser to immediately carry out a new surgical procedure, in the best conditions (well prepared patient, enough operating time, more competent surgeon in the specialised field).

Previous knowledge of tumour histology

This is one of the most important concepts in surgical oncology: the surgeon should already know what kind of histological tumour he is going to remove.

In breast carcinoma, pre-operative stereotaxic biopsies should prove the malignant characteristics of any suspicious mammography image; for head and neck cancers, pre-operative biopsies will be performed during laryngeal endoscopies. The same should always apply for tumours of the stomach, the lungs, the colon.

Similarly, endoscopic resection of a bladder carcinoma through loop excision is required before cystectomy.

Only in exceptional cases should surgery be exploratory without previous knowledge of cancer diagnosis.

In these situations, the surgeon should be surrounded by suitably competent histology specialists in order to obtain the extemporaneous examination of surgical biopsies. This is most important for confirming a breast or thyroid cancer before any surgical amputation. The pathological certainty is mandatory (be it, in some cases, only for medico-legal reasons).

In the majority of so-called emergency situations, the pre-operative diagnosis has not been sufficiently backed up by paraclinical adapted examinations and the surgeon should know, in advance, what surgical situation he will discover and what kind of excisions he will have to perform, thus anticipating enough operating time, intensive care necessity as well as blood supply to enable him to work in comfortable and secure circumstances.

A surgical procedure that is well planned and as complete as possible

In spite of important recent progress in other treatments, the surgical procedure remains the best therapy in the majority of cancers. It must, therefore, be carried out by a surgeon belonging to a multidisciplinary team, but who perfectly appreciates the power and the limits of his acts and who anticipates the adjuvant therapies (such as radiotherapy or chemotherapy).

Many studies have shown that patients have a better prognosis if surgery is carried out by an oncology surgeon (for head and neck, ovarian and breast cancers).

All the necessary procedures should be followed to prepare patients for the surgical operation (for instance digestive preparation for ovarian carcinoma due to the possibility of intestine surgery) with pre-operative reanimation or alimentation.

The ease of the post-operative recovery is of utmost importance: simple effects will allow the rapid setting up of adjuvant therapies which are mandatory to increase the patient’s chances of survival; on the contrary, difficult effects with complications like infections, fistulae, haemorrhage, surgery resumption, will slow down the commencement of other therapies, thus reducing the patient’s chances of survival.