Metastatic spread of ovarian cancer to local pelvic structures is a common occurrence, with International Federation of Gynecology and Obstetrics Stage IIB-IV disease representing a majority (70%) of all patients newly diagnosed with epithelial ovarian cancer. Survival determinants are multi-factorial; however, the strongest clinician-driven predictors of clinical outcome are the administration of platinum-based chemotherapy and the amount of residual tumor following primary surgery, with complete tumor resection being associated with the most favorable survival outcome. Resection of the primary tumor mass is a key component of the initial cytoreductive surgical effort to achieve optimal (≤ 1 cm) or no gross residual disease.

In 1968 and 1973, Hudson and Chir described the technique of “radical oophorectomy” designed for the intact removal of a fixed ovarian tumor en bloc with attached peritoneum and surrounding structures. The cardinal feature of the radical oophorectomy procedure is the retroperitoneal approach to ovarian cancer encasing the pelvic viscera, using the “false capsule” within the pouch of Douglas to effect en bloc excision. The most commonly performed variant of radical oophorectomy is the Type II procedure, which includes en bloc modified radical hysterectomy, bilateral salpingo-oophorectomy, rectosigmoid colectomy, and pan-pelvic peritonectomy. The indications for radical oophorectomy have been summarized by Eisenkop et al. as follows: 1) gross evidence of ovarian cancer supported by frozen section biopsy; 2) extensive confluent tumor involvement of one or both adnexae and their adjacent peritoneum, cul-de-sac, posterior uterine serosa (if present), and the sigmoid colon; 3) the surgeon subjectively judges that complete removal of disease could not be effected simple hysterectomy and salpingo-oophorectomy and piecemeal dissection, resection, or ablation of serosal and peritoneal metastases; 4) an overall optimal resection would be otherwise achievable; and 5) the procedure is not medically contraindicated.

In preparation for surgery for a suspected ovarian cancer, all patients should undergo a comprehensive history and physical examination focusing on those areas that may indicate a reduced capacity to tolerate major surgery or place the patient at elevated risk for postoperative complications. Routine laboratory testing should include a complete blood count, serum electrolytes, age-appropriate health screening studies, a chest radiograph, and electrocardiogram for women aged 50 years and older. Serum tumor markers are not a prerequisite; however, a preoperative serum CA-125 level is recommended, not so much for its diagnostic value, but rather to serve as a baseline level in the event that an ovarian cancer diagnosis is confirmed pathologically. Preoperative computed tomography of the abdomen, pelvis, and chest is recommended to evaluate the extent of disease and for surgical planning purposes.

Because ovarian cancer surgery carries the possibility of bowel resection or injury, preoperative mechanical
bowel preparation (oral polyethylene glycol solution or sodium phosphate solution with or without bisacodyl) is recommended according to the surgeon’s preference. Prophylactic antibiotics (Cephazolin 1 g, Cefotetan 1 to 2 g, or Clindamycin 800 mg) should be administered 30 minutes prior to incision, and thromboembolic prophylaxis (e.g., pneumatic compression devices and/or subcutaneous heparin) should be initiated prior to surgery. Reservation of an intensive care unit bed postoperatively is advisable if extensive or prolonged surgery is anticipated, and type and cross-matched blood should be available.

Surgery for ovarian cancer requires access to both pelvic and abdominal structures, often simultaneously. A self-retaining retractor (e.g., Bookwalter, Codman Division, Johnson & Johnson, Piscataway, NJ) with a fixed arm attaching the retractor ring to the operating table is essential to optimizing exposure, maximizing patient safety, and reducing surgeon fatigue. At the surgeon’s discretion, additional standard equipment may include: an electrosurgical unit (ESU or “Bovie”), vessel-sealing device, argon beam coagulator, cavitron ultrasonic surgical aspirator, and automated stapling devices. Following is a brief description of the surgical procedure used (see also video: Cytoreductive Surgery for Ovarian Cancer: Radical Oophorectomy).

The patient may be positioned in the dorsal low-lithotomy (perineolithotomy) position using Allen Universal Stirrups (Allen Medical Systems, Cleveland, OH) or supine on the operating table. The low-lithotomy position is preferable, as it permits intraoperative bimanual examination to accurately ascertain the extent of cul-de-sac tumor involvement and allows access to the perineum for resection and re-anastomosis of the rectosigmoid colon. Abdominal entry and exposure are best achieved through a midline xiphopubic incision with placement of a self-retaining retractor. A preliminary assessment is taken of the extent of disease, with particular attention to the feasibility of resecting upper abdominal disease. Directing initial cytoreductive efforts toward bulky upper abdominal disease and exploring the abdominal retroperitoneum will facilitate exposure to the pelvis and ensure a reasonable likelihood of achieving an optimal (<1 cm) or complete (no macroscopic residual) overall resection prior to undertaking the radical pelvic dissection.

The Type II radical oophorectomy procedure is initiated by incising the paracolic gutters bilaterally and mobilizing the cecum, terminal ileum, and sigmoid colon. The paracolic gutter incisions are extended into the pelvis, along the psoas muscles, moving ventromedially along the posterior margin of the symphysis pubis. All pan-pelvic disease is circumscribed and included within this peritoneal incision (Figure 19.1). The pelvic dissection proceeds in a centripetal fashion. The round ligaments should be located retroperitoneally, ligated, and divided as laterally as possible.

An early step of the pelvic operation is development of the retroperitoneal potential spaces. The pelvic viscera are separated from one another and the pelvic walls by eight potential spaces (Figure 19.2). These potential spaces are filled with fatty or areolar connective tissue and are two-dimensional until surgically developed, thereby serving as natural cleavage planes and allowing relatively bloodless isolation of diseased tissue or viscera. The pararectal and paravesical spaces are developed using a combination of sharp and blunt dissection, exposing the cardinal ligament. The ureters are identified within the pararectal space and mobilized from their attachments to the medial leaf of the broad ligament, moving from the pelvic brim to the tunnel of Wertheim, and held for traction with vessel loops. The central pelvic tumor mass should be devascularized early in the course of the operation by dividing the infundibulopelvic ligaments at or above the pelvic brim.

The anterior pelvic peritoneum is grasped and placed on traction with Allis clamps, and the retropubic space of Retzuis is developed. A plane of dissection is established between the anterior pelvic peritoneum and the bladder dome muscularis using the ESU or argon beam coagulator. The anterior pelvis is then deperitonealized moving ventral to dorsal and lateral to medial toward the uterus until the pubo-vesico-cervical fascia is reached (Figure 19.3).

The uterine vascular pedicles are skeletonized, doubly ligated, and divided at the level of the ureters in the fashion of a modified radical hysterectomy, allowing lateral displacement of the ureters from the central specimen (Figure 19.4). The ureters are extricated from within the bladder pillars by developing the ureteral tunnels using a right angle clamp and dividing them with the ESU or securing them with suture ligatures.

Division of the proximal sigmoid colon can be performed whenever it is most convenient during the operation, once it has been determined that bowel resection is necessary to achieve an optimal surgical result. The sigmoid colon is divided 2 to 3 cm above the most proximal extent of gross tumor in an area that is free of diverticuli. A variety of methods can be used to divide the bowel; however, the Gastrointestinal anastomosis (GIA)
stapling device (4.8 mm) is the most expedient and has the advantage of placing two rows of staples on either side of the divided bowel, thus controlling both proximal and distal fecal contamination (Figure 19-5). To ensure an adequate resection of mesocolon and associated mesenteric lymph nodes, the peritoneal incision is extended along the sigmoid mesentery from the point of proximal bowel division medially toward the right sacroiliac joint to join the right-sided circumscribing pelvic peritoneal incision, thus incorporating a “wedge” of colonic mesentery with the central pelvic tumor.