Ovarian cancer is one of the most treatable solid tumours. The majority are sensitive to anti-cancer therapies. However, the disease has the highest fatality to case ratio because ovarian tumours are difficult to diagnose. At initial diagnosis, about 60-70% have reached stage 3 or 4 with only 15 to 25% of these patients surviving 5 years.

At stage 3 and 4, cure is unlikely. Current practice in gynaecological oncology is to offer "debulking" or cytoreductive surgery. The rationale of this approach is to reduce the tumour burden, and then to consolidate this treatment with chemotherapy. The literature reveals that debulking surgery provides:

1. improvement in quality of life

2. higher respond rates to chemotherapy

3. longer progression-free intervals for patients who are optimally debulked

4. enhanced immunological competence of the patient

In the hands of subspecialist trained gynaecological oncologists these debulking operations are feasible in 70-90% of women. If such patients are operated by less experienced surgeons, it is common for a biopsy to be taken and the abdomen closed.

Debulking surgery usually includes removal of the pelvic primary tumour together with total abdominal hysterectomy and bilateral salphingo-oophorectomy.

Sometimes en bloc resection incorporating the involved bowel and peritoneum ios necessary. Bowel continuity is then restored by primary colonic anastomosis.

Further surgery can involve:

1.mtectomy

2. drainage of ascites

3. removal of tumour masses in the paracolic gutters

4. excision of involved small gut particularly if obstruction is imminent, or if such excision would result in optimal debulking.

Satisfactory debulking is not possible in th epresence of:

1.massive upper abdominal disease (particularly subdiaphragmatic)

2. parenchymal liver disease.

3. porta hepatis masses

4. tumour masses involving the root of the small bowel mesentery.

However, even in the presence of such diseases, it may be appropriate to remove an incarcerated pelvic tumour in order to palliate the inevitable pressure symptoms with a consequent improvement in quality of life.

Finally, there are some situations where debulking surgery would be inappropriate:

1. the very elderly women with other medical problems

2. those 'in extremis' from the disease, ie poor performance status

3. women who state they will not consider post operative chemotherapy

4. those who refuse blood transfusion are usually not considered for such surgery.