Ovarian Cancer Resection and Debulking in the Lower Abdomen
Kenneth D. Hatch
GENERAL PRINCIPLES
Optimal cytoreductive surgery (CRS) can be performed in 70% to 90% of the cases of ovarian epithelial carcinoma. Radical resection of the pelvic tumor in the lower abdomen and pelvis is necessary to achieve this goal. Resection and anastomosis of the sigmoid colon is required in up to 57% of the cases. Resection of other large or small bowel segments is performed in 5% to 12% of the cases.
Definition
Complete CRS is nearly always possible in the pelvis. Removal of the uterus (if present), tubes, ovaries, and the peritoneum of the ovarian fossa from the ovarian vessels to the cul-de-sac can always be performed. Radical resection of pelvic tumor requires opening the pelvic retroperitoneum, dissecting the ureters away from the tumor, and resecting the entire pelvic peritoneum with resection of the rectosigmoid, if necessary. The ureters and bladder usually do not need resection. The bladder peritoneum often has a coating of tumor and will need to be peeled away. This sometimes requires cystotomy and resection of a portion of the bladder.
Differential Diagnosis
The diagnosis of ovarian cancer is usually obvious from the presentation of ascites, omental and peritoneal metastases, and elevated CA-125. However, primary colon cancer and metastatic cancer to the ovary may present in this manner. A frozen section should be performed to confirm the diagnosis.
Anatomic Considerations
A thorough knowledge of the pelvic anatomy is mandatory. This includes the sigmoid, rectum, ureters, bladder, uterus, tubes, ovaries, and vagina. All the blood vessels, nerves, and lymph nodes associated with these organs are important to know.
Nonoperative Management
Neoadjuvant chemotherapy (NACT) may be considered for patients deemed to be poor candidates for primary CRS.
Medical conditions that may be indications for NACT include severe malnutrition with albumin of 2.6 or lower, prealbumin less than 10 mg/dL, and weight loss of 15% of usual body weight.
Serious comorbidities such as COPD, uncorrected coronary artery disease, and morbid obesity may be contraindications.
Age over 75 has been reported as a relative contraindication to primary radical debulking surgery.
IMAGING AND OTHER DIAGNOSTICS
Many investigators have published results of imaging with CT, MRI, or PET-CT to determine which patients may benefit from NACT and interval debulking.
A review of these reports shows that CT and MRI are of equal value, and the PET-CT should only be used if there are no findings on CT or MRI; and yet, ovarian or peritoneal carcinoma is suspected from symptoms and perhaps elevated biomarkers.
PREOPERATIVE PLANNING
We recommend mechanical bowel preparation for patients undergoing debulking procedures, assuming there is no evidence of gastrointestinal obstruction. Clear liquids for 24 hours and oral cathartic have been the standard for many years. Recent literature supports elimination of the oral cathartic even in patients who may have a bowel resection; however, many gynecologic oncologists and colorectal surgeons still consider there are significant surgical benefits with the elimination of solid waste in the colon for planned large bowel surgery.
Type and crossmatch at least 2 units of packed red blood cells depending on the preoperative hemoglobin and surgeon estimates of anticipated blood loss. Surgical literature reports blood loss with ovarian debulking procedures that range from 700 to 4,000 cc. Radical debulking surgery should be performed in a hospital that has the capability of rapidly providing additional blood, ICU expertise, and appropriate consultants (e.g., hepatobiliary, vascular, and thoracic).
SURGICAL MANAGEMENT
Positioning
The lithotomy position in the Yellofins or Allen stirrups is necessary so that the surgeon has access to the vagina, anus, and rectum to aid in resection and to perform the stapled anastomosis.
PROCEDURES AND TECHNIQUES
Ovarian Cancer Resection and Debulking in the Lower Abdomen
The operative procedures described in this section and illustrated in the video are examples of radical resection of ovarian carcinoma in the pelvis. A retrograde hysterectomy is performed in both cases. In the first case, the rectosigmoid is not removed and in the second, a sigmoid resection and anastomosis is performed (Video 27.1 
).
).Determine resectability
The abdomen is explored to determine the full extent of the disease. Radical resection of the pelvic tumor including resection of the rectosigmoid may not be indicated if the patient has upper abdominal disease that cannot be reduced to optimal status. This is particularly important if the patient has comorbidities that may lead to significant surgical morbidity and mortality.
The omental cake is usually removed first to facilitate packing of the bowel out of the pelvis.
The round ligament should be identified and opened, leading to the lateral retroperitoneal space.
The peritoneum lateral to the ovarian vessels is opened to the pelvic brim or higher if tumor implants extend above the pelvis.
If the paravesical and pararectal spaces can be opened without endangering the external iliac artery, then the tumor is resectable.
Ligate major blood supply
Dissect the ureter off the peritoneum and place a vessel loop or Penrose drain.
Divide the ovarian vessels at the pelvic brim or higher.
Dissect the ureter off the peritoneum into the pelvis.
Identify the umbilical ligament and develop the lateral paravesical space.
Dissect medial to the umbilical ligament or develop the medial paravesical space.
Follow the umbilical ligament cephalad until the uterine artery is encountered and divided.
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