The first step in understanding any surgery is achieving a clear overall picture of the patient. If the patient is healthy enough medically, nutritionally, and mentally to undergo debulking surgery, then the surgeon must have a concrete understanding of the anatomy involved.¹ Without a thorough understanding of the anatomy, many pitfalls and complications may occur. The anatomy of the entire abdomen needs to be under the purview of the gynecologic oncologist. Because gynecologic cancers do not remain confined to the pelvis, our anatomic knowledge cannot remain confined to the pelvis.

Morrow and Curtin² have previously elegantly illustrated that certain conditions must be met prior to creating any bowel anastomosis. First, healthy tissue with good blood supply needs to be used in both the afferent and efferent bowel limbs. If blood supply is questionable, then fluorescein dye with a wood’s lamp can be used to visualize the blood supply.³ Second, an adequate, nonstrictured, water-tight, hemostatic lumen must be created. Third, the anastomosis should be free of tension. Fourth, an anastomosis should not be created in the presence of established peritonitis. Applying these guidelinesto any bowel anastomosis is crucial.

The stomach at the proximal end of the small bowel is a site frequently involved with disease extending over from the lesser or greater omentum. Infrequently, disease is large enough to require wedge resection for complete cytoreduction or gastrojejunostomy for palliation secondary to a large node or mass obstructing the pylorus or proximal duodenum.^4,5 Hoffman et al⁶ described cases in which en bloc resection of the left upper quadrant intra-abdominal contents (including 2 cases of partial gastrectomy), was able to leave the patient with minimal residual disease. In a larger series, Walter et al⁴ have shown that partial gastrectomy (or wedge resection) can be safely performed in radical debulking of ovarian cancer.

The most common surgery performed on the small bowel (jejunum and ileum) in gynecologic oncology is small bowel resection with primary reanastomosis. This can be performed for a variety of reasons by gynecologic oncologists. The resection may be for obstruction by cancer, debulking of cancer, radiation damage causing fistula or stricture, or for dead or damaged bowel as a complication of therapy.

Bristow et al⁷ demonstrated the safety and utility of colorectal resection and reanastomosis in women with ovarian cancer. Three years later, Hoffman⁸ built upon their study and echoed the safety of similar procedures. Both of these papers showed that large resections of the colon could be safely performed to aid in cytoreduction. Silver and Walter separately have shown that subtotal colectomies can be safely performed in achieving complete cytoreduction.^9,10 These extensive resections with pouches (Figure 14-1) are associated with complications but are tolerated well by patients.¹¹ Once the protective ostomy is reversed, patients will have continence but increased fecal frequency.⁹ This topic will be covered more extensively in Chapter 15.

Pertinent anatomic figures are provided in Chapter 2. The stomach is the most proximal abdominal organ of the digestive tract. It lies asymmetrically in the abdomen to the left of midline and is comprised of 4 parts: cardia, fundus, body, and pyloric antrum. The cardia surrounds the cardiac orifice where the stomach attaches to the esophagus just inferior to the lower esophageal sphincter. The cardiac notch or angle of His lies between the esophagus and fundus, and approximates the location of the gastroesophageal (GE) junction. The horizontal plane of the GE junction marks the inferior border of the ­distensible fundus, which is bounded superiorly by the left dome of the diaphragm and laterally by the spleen. The fundus is the most superior aspect of the stomach. The largest ­portion of the stomach is the body, which is located between the ­fundus and the pyloric antrum. It is bound on the right by the lesser curvature and on the left by the greater curvature. The sharp angle of the lesser curvature, the angular incisure, identifies the junction of the body and the pyloric antrum. Distally, the pylorus connects the antrum to the proximal duodenum.

The stomach is anteriorly related to diaphragm, left lobe of the liver, and anterior abdominal wall. The posterior surface of the stomach forms the anterior wall of the omental bursa. The gastrosplenic ligament attaches the proximal greater curvature to the spleen. Inferiorly, the stomach is attached to the transverse colon by the gastrocolic omentum as it courses along the greater curvature to the left colic flexure (splenic flexure). The lesser curvature is attached to the liver by the hepatogastric ligament (part of the lesser omentum).

The duodenum is the most proximal segment of the small intestine, lying partially in the retroperitoneum. It is also the shortest segment of small intestine, only 25 cm in length. It has a C-shaped course around the head of the pancreas, beginning just distal to the pylorus and ending at the ligament of Treitz (duodenojejunal junction). It is divided into 4 parts: superior, descending, inferior, and ascending. Proximally, the superior part is attached to the hepatoduodenal ligament (lesser omentum) containing the portal triad. The descending portion curves around the head of the pancreas and is entirely retroperitoneal. The inferior part courses horizontally and is crossed by the superior mesenteric artery and the root of the mesentery of the jejunum and ileum. Posteriorly, the inferior part is related to the inferior vena cava, aorta, and right ovarian vessels. The ascending part of the duodenum curves anteriorly to join the jejunum at the duodenojejunal flexure.

The main blood supply to the stomach comes from the celiac axis and its branches. The lesser curvature is supplied by anastomoses formed between the right and left gastric arteries, arising from the hepatic artery and celiac trunk, respectively. An anomalous hepatic artery can arise from the left gastric artery 15% to 20% of the time, which occasionally is the only arterial flow to the left hepatic lobe. The gastroduodenal artery arises from the hepatic artery and supplies the right portion of the greater curvature along with part of the omentum (through the right gastroepiploic). The splenic comes either off a named branch or directly off the celiac trunk giving blood supply to the proximal greater curvature and fundus via short gastrics, and blood to the omentum and greater curvature through the left gastroepiploic before supplying the named organ. The duodenum is supplied by the superior and inferior pancreaticoduodenal arteries, via the celiac trunk (branch of gastroduodenal artery) and superior mesenteric artery, respectively. The veins of the stomach and duodenum parallel the arteries and drain into the hepatic portal vein either directly or indirectly via the superior mesenteric vein and splenic vein.

Because of its length (15–30 feet, with the female average of 21 feet), the small bowel is a frequently involved area with tumor or complications from therapy. The jejunum and ileum comprise the intraperitoneal portion of the small intestine, beginning at the duodenojejunal junction and extending to the ileocecal junction. It can be difficult to grossly distinguish between the ileum and jejunum as there is no distinct anatomic marking identifying them. Most of the jejunum lies in the left upper quadrant of the infracolic compartment of the abdomen, comprising about two-fifths of the small bowel. The ileum primarily resides in the right lower quadrant and makes up the remaining three-fifths of the small bowel. The jejunal mucosa is thicker with more prominent plicae circulares. The mesenteric vessels form one or two arcades with long, straight vasa recta. The ileum has a thinner wall with slightly smaller caliber, more prevalent mesenteric arcades and short vasa recta. There is also increased mesenteric fat in the ileum.

The superior mesenteric artery with its numerous branches is the main blood supply to the small bowel (embryologic midgut). It can be found arising from the aorta just posterior to the pancreas. The pancreaticoduodenal is the first branch followed by a variable number of jejunal and ileal branches (12–15). Next come the ileocolic, right colic, and middle colic vessels. The ileocolic and right colic may branch of together from the aorta before dividing, and so this is an anatomic variation.

The colon has 4 parts: ascending, transverse, descending, and sigmoid. The ascending colon is approximately 15 cm in length and is a secondarily retroperitoneal continuation of the cecum, extending between the level of the ileocecal valve and the right colic flexure. The transverse colon, the longest (45 cm) and most mobile part of the large intestine, is ­suspended between the hepatic and splenic flexures and attached to the greater omentum along its superior aspect. Like the ascending colon, the descending colon is also ­secondarily retroperitoneal, beginning at the splenic flexure and extending approximately 25 cm to the left iliac fossa. It is fixed against the retroperitoneum posteriorly with the lateral and anterior surfaces as true intraperitoneal structures. The white line of Toldt is the lateral peritoneal reflection that can be used as a guide to mobilize the colon. It should be noted that this lies in close proximity to the left ureter and ovarian vessels. At the level of the pelvic brim, the descending colon transitions to the S-shaped sigmoid colon with a mesentery (pelvic mesocolon) that is fixed to the posterior pelvic wall. It is highly variable in length (15–50 cm) and smaller in caliber than the descending colon. The sigmoid colon terminates at the rectosigmoid junction at the level of the sacral promontory, as do the characteristic markings of the colon—teniae, haustra, and omental appendices.

The rectum extends approximately 12 to 15 cm into the true pelvis and is mostly extraperitoneal. The posterior rectal wall is covered in a thin fascia propria (visceral layer) opposed by a thicker, presacral fascia (parietal layer) that covers presacral veins. A fine areolar fascia is present between the anterior surface of the parietal layer and the posterior surface of the visceral layer of the rectum. The Waldeyer’s fascia is formed by fusion of these 2 layers just superior to the coccyx. Anteriorly, Denonvilliers fascia, a bilaminar fascial layer, separates the anterior rectum from the vagina. It is also known as the rectovaginal septum and is continuous with the uterosacral folds.

The ascending and transverse colon is supplied by branches of the superior mesenteric artery, including ileocolic, right colic, and middle colic arteries. Beginning at the splenic flexure, the remainder of the colon and rectum is supplied by branches of the inferior mesenteric artery, including the superior and inferior left colic arteries, multiple sigmoid arteries, and the middle rectal artery. The posterior wall of the rectum is also supplied by branches of the median sacral artery. One area of confusion that continues until today regarding the blood supply of the colon is caused by the different names used for vessels. The central anastomotic artery of the mesocolon is sometimes referred to as the arc of Riolan and sometimes as the marginal artery of Drummond. The key point to understand is that this vessel extends from the ileocolic artery to the lowest sigmoid vessel (Figure 14-2).

At our institution, before performing any surgical procedure on a woman with a pelvic mass albumin and prealbumin are checked.¹² If the prealbumin level is below 10 mg/dL, then patients are started on parenteral nutrition even if tolerating supplemental enteral feeds. If the prealbumin does not increase to at least 10 mg/dL after 7 to 10 days, the patient will undergo paracentesis or percutaneous biopsy to attempt to get a cancer diagnosis. Once the diagnosis is made, they will be offered neoadjuvant chemotherapy because of the increased risk of morbidity and mortality when operating on women with a low prealbumin level.¹ All patients with a starting prealbumin from at least 10 to 18 mg/dL are placed on postoperative supplementation with oral supplements being preferred.

Although the redundant blood supply of the stomach makes the stomach a forgiving organ on which to operate, several points exist about which to be aware when operating on the stomach. Surgical adventures to the patient’s right of the angular notch can turn into misadventures if the biliary tree is damaged. If performing gastrostomy, then it is best to sew the stomach to the anterior wall to decrease the chances of spilling gastric contents into the abdomen.

Preservation of the blood supply of the small bowel is paramount. Careful surgical manipulation of the mesentery and bowel wall is of utmost importance. Although the small bowel can be stripped of its mesentery in creating an ileostomy for up to 6 cm, this is often not necessary and potentially harmful if done incorrectly.^13,14

While operating on the colon, several key points must be considered. First, while the small intestine’s arcades allow up to 6 cm of bowel to be devascularized, the colon’s vascular redundancy is more proximal; therefore, only 2 cm can be devascularized without necrosis. Next, operating on the left colon near the splenic flexure and sigmoid near Sudeck point, can be precarious if the surgeon is not aware of the vascular watershed areas. It is best to create anastomoses proximal or very distal to these points.

A further point of caution has recently been illustrated.¹⁵ It is critical for good outcomes when performing ovarian cancer cytoreduction, especially bowel resections and anastomoses, to not allow hypothermia to occur. Patients in whom core temperatures dropped below 96.8°F (36°C) had increased complications compared to those in whom hypothermia did not occur.¹⁵

Bowel resections are performed in gynecologic oncology most commonly for either debulking or obstruction. Each of these is fraught with potential pitfalls for the unwary. Also, each is more quickly performed if the surgeon is knowledgeable of the surgical anatomy, surgical techniques, and surgical tools. Over the past few decades, the paradigm has shifted away from preoperative oral antibiotic bowel preparation and mechanical bowel preparation to using just parenteral antibiotics one hour before incision. The paradigm may be shifting again. Recent data demonstrate that the best combination to achieve the lowest surgical site infection rate in patients undergoing elective colon surgery is the combination of preoperative oral antibiotic bowel preparation, mechanical bowel preparation, and parenteral antibiotics within 1 hour of incision.¹⁶

If an ostomy is being considered preoperatively, then enterostomal therapy is consulted to talk with the patient and mark optimal sites. In any patient that receives an ostomy, enterostomal therapy is consulted immediately postoperatively to begin patient education.

Currently, most intestinal anastomoses are performed using mechanical surgical devices and endomechanical surgical devices.¹⁷ These are supplied by a variety of companies. The specific devices associated with each procedure are discussed in the related section along with device sizes and staple diameters.

Stomach

1. Wedge resection

Even after an infragastric omentectomy, the redundancy of the gastric blood supply allows wedge resection to be safely performed. To avoid a key area of complication when working with the lesser omentum or lesser curvature, the surgeon must stay to the patient’s left of the hepatoduodenal ligament in the hepatogastric area of the lesser omentum. The key anatomic point to recognize is the stomach’s angular notch. Damage to the biliary tree can be safely avoided if the surgeon stays to the patient’s left of this anatomic point on the lesser curvature. Using a laparoscopic gastrointestinal linear stapler/cutter (Figure 14-3), a full thickness resection can be safely and easily accomplished using a 45- to 60-mm long stapler with a 3- to 3.5-mm thick staple. A second load is used to create a wedge around the tumor and crossing the original line to seal the stomach (Figure 14-4). This type of resection can be undertaken on either the greater or lesser curvature. The staple line from an endoscopic linear stapler/cutter has 3 rows of staples so oversewing is not usually necessary (see Figure 14-3).

Alternatively, a smaller lesion can be resected with a football or elliptical-shaped resection of the gastric serosa (with or without muscularis and mucosa as indicated). This may result in the stomach mucosa (and the gastric contents momentarily being open. The site should be closed with a delayed absorbable 3-0 monofilament suture (polyglyconate or polydioxanone) on a taper needle. A running or Connell stitch can be used. Recent studies have even demonstrated that a running stitch using a barbed suture is equivalent to a running stitch using a delayed absorbable suture.¹⁸ Whether or not a second imbricating layer is used depends on the patient’s history and status, as well as surgeon preference. A small resection can also be accomplished by pulling the tumor up to be resected, then placing an endoscopic 45- to 60-mm long stapler with a 3- to 3.5-mm staple, and firing it. This results in a closed resection without any exposure of the abdomen to gastric contents.

Small Bowel

1. Gastrojejunostomy

In women with ovarian cancer, the infragastric omentum should already have been surgically resected at the initial debulking, so one difficulty with the gastrojejunostomy in other patients is absent. When performing the procedure, a decision has to be made whether the jejunum is going to be anastomosed to the anterior stomach, the greater curvature, or posterior stomach. If the plan is to perform an anastomosis to the anterior stomach or greater curvature, the jejunum is brought over the transverse colon. If a posterior attachment is planned, then the jejunum is passed through the transverse colon mesentery through a window of Dever.

Either way, the anastomosis is most easily performed using a 60- to 80-mm long linear stapler/cutter (Figure 14-5) with a 2.5- to 3.8-mm staple. For example, the jejunum is placed with its antimesenteric border against the greater ­curvature. Stabilizing sutures can be placed before small incisions are made in the stomach and the jejunum. Alternatively, the two bowel segments can just be carefully aligned or even held with Allis clamps. A small hole is made in the stomach and the jejunum on the antimesenteric side. The linear stapler/cutter is placed with one piece in each lumen and fired (Figure 14-6). The remaining opening can be then closed with a linear stapler (3.5- to 4.8-mm staple) or sewn closed with a 3-0 delayed absorbable suture.

Another surgery performed in women with ovarian cancer is a Stamm gastrostomy procedure.¹⁹ This procedure used to be performed more commonly than it is today because ­percutaneous endoscopic gastrostomy tubes (PEG) can be placed safely in many patients without the need for a laparotomy or laparoscopy.^20,21 In ovarian cancer patients, gastrostomies are used palliatively because of obstruction or tumor ileus rather than for feeding. Because of the specific need, occasionally tumor or ascites prevent percutaneous placement. When still performed, a Stamm gastrostomy can be performed through a 7- to 8-cm upper midline or left subcostal incision. The tube itself can be a standard PEG tube, a Foley catheter or a Mallinckrodt catheter of large gauge. The stomach is grasped on the anterior mid surface near the greater curvature with a Babcock clamp. Two purse string sutures of 3-0 delayed absorbable monofilament are placed around the Babcock clamp with needles left attached. The tube is brought through the anterior wall away from the incision. It is placed through a small puncture wound in the stomach. The purse sutures are closed inner first and then outer, and then the sutures are sewn to the anterior abdominal wall. The tube can be connected to suction or can be left capped only to be opened when needed. Alternatively, a permanent tube can be made from the anterior gastric wall and brought as a gastrostomy through the anterior abdominal wall. The defects are closed with a 3-0 delayed absorbable suture. Complications from this approach include the possibility of gastric contents getting on the skin.