Approximately 70% of patients with epithelial ovarian cancer will have advanced-stage disease at the time of diagnosis. For this group, survival determinants are multifactorial; 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 outcome. As many as 42% of patients with Stage IIIC ovarian cancer will have bulky (>1 cm) disease in the upper abdomen above the greater omentum. These patients often require a more extensive upper abdominal cytoreductive surgical effort to achieve optimal (≤1 cm) or no gross residual disease prior to initiating chemotherapy. For example, while the omentum represents the location of the largest tumor site in many patients with advanced-stage ovarian cancer, direct invasion of the transverse colon and adjacent structures is not infrequent and dictates a broader scope of surgical resection. Splenectomy may also be required, as tumor may extend from the greater omentum to affect the spleen in 5% to 30% of patients with advanced-stage disease. Similarly, metastatic tumor spread to the diaphragm will be encountered in 18% to 41% of patients with Stage III and IV epithelial ovarian cancer. As a result, a maximal surgical effort is dependent on the surgeon’s capacity to successfully manage disease involving the structures of the upper abdomen.

In preparation for surgery for 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 CA125 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 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. If splenectomy is anticipated, a single one-time polyvalent pneumococcal vaccination (Pneumovax) and vaccines against Haemophilus influenza (Hib) and Neisseria meningitidis (Menomune) should be given 10 to 14 days preoperatively. In the circumstance of an unplanned splenectomy, the vaccines should be given 14 days postoperatively.

A self-retaining retractor (e.g., Bookwalter, Codman Division, Johnson and Johnson, Piscataway, NJ) with a fixed arm attaching the retractor ring to the operating table is essential to optimize exposure, maximize patient safety, and reduce surgeon fatigue. At the surgeon’s discretion, additional standard equipment may include an electrosurgical unit (ESU or “Bovie”), vessel-sealing device, argon beam coagulator (ABC), cavitron ultrasonic surgical aspirator (CUSA), and automated stapling devices. Following are brief descriptions of the surgical procedures used (see also videos: Cytoreductive Surgery for Ovarian Cancer— Upper Abdominal Disease: Transverse Colectomy; Splenectomy; Diaphragm).

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. Mechanical ventilation should be confirmed prior to undertaking upper abdominal cytoreductive procedures. Abdominal entry and exposure are achieved through a midline xiphopubic incision, which can be extended alongside the xyphoid process for additional exposure, with placement of a self-retaining retractor positioned to provide firm, upward traction on the costal margins. A preliminary assessment is taken of the extent of disease, with particular attention to the feasibility of resecting upper abdominal disease. Many surgeons prefer to begin the operation with the removal of the omentum, as it is usually extensively involved with tumor and provides a convenient starting point for surgical extirpation of metastatic disease in the upper abdomen. From an anatomic perspective, contiguous extension to the transverse colon, spleen, or diaphragm may require an en bloc resection of one or a combination of these organs with the omental tumor. Even if the omental disease does not directly involve adjacent structures, its removal will improve exposure and facilitate mobilization of the surrounding anatomy so that subsequent resection of isolated metastases can be accomplished with maximum safety.