The evolving role of open abdominal surgery in gynecological malignancies in the era of minimally invasive and precision oncology.

BACKGROUND: Oncological surgery is undergoing profound transformation driven by advances in systemic therapy, immunotherapy, and minimally invasive techniques. This narrative review examines whether open abdominal surgery retains clinical relevance in gynecological malignancies or has been superseded by modern alternatives. METHODS: A literature search was conducted in PubMed combining terms related to gynecological malignancies, abdominal surgical procedures (open, laparoscopic, robotic, cytoreduction, pelvic exenteration), and personalized systemic therapies. Original articles, reviews, and guidelines in German and English were included. Two independent reviewers screened titles, abstracts, and full texts, extracting data on study design, interventions, and clinical endpoints (R0 resection, morbidity, progression-free and overall survival). RESULTS: For cervical cancer, open radical abdominal hysterectomy as the standard of care was internationally confirmed. In endometrial cancer, minimally invasive approaches are established for early-stage disease, while laparotomy remains the gold standard in advanced stages requiring cytoreductive surgery. For ovarian, tubal, and primary peritoneal carcinoma, open cytoreductive surgery with the goal of macroscopically complete resection remains guideline recommended. Emerging biomarkers such as circulating tumor DNA may further refine patient selection and surgical decision-making. CONCLUSION: Open abdominal surgery remains indispensable in gynecological oncology. Rather than being replaced, it is evolving into a specialized, biology-adapted component of multimodal treatment strategies. Surgical indications are becoming less frequent but more complex and individualized. Patient selection in experienced centers remains the decisive factor.