Ovarian Cancer Resection and Debulking in the Upper Abdomen
Robert W. Holloway
Walter Gotlieb
David Cibula
Kenneth D. Hatch
GENERAL PRINCIPLES
Outcome survival analyses of patients with stage III and IV epithelial ovarian cancer (EOC) have consistently shown that the most important predictor of progression-free and overall survival is the size of residual disease following primary surgery. Optimal resection of ovarian cancer either as primary cytoreductive surgery (CRS) or after neoadjuvant chemotherapy (NACT) may require radical upper abdominal surgery that includes stripping or resection of the diaphragm, splenectomy, or partial pancreatectomy with splenic flexure mobilization for complete omentectomy.
Definition
CRS means surgically removing the maximum amount of cancer possible in order to optimize the patient’s chances of cure or control with chemotherapy.
The best survival outcomes following CRS is for patients with no visible residual disease.
In order to achieve maximum CRS in the upper abdomen, resection of the omentum is required in 100%; splenectomy in 1% to 43%; distal pancreatectomy in 1% to 9%; and diaphragm stripping or resection in 6.5% to 44% of cases.
Differential Diagnosis
The diagnosis of ovarian cancer is usually suggested from the presence of ascites, pelvic mass, omental cake, and peritoneal and diaphragmatic implants detected by physical examination and CAT scans.
Other diseases to consider are metastases from colon cancer, gastric cancer, pancreatic cancer, breast cancer, or other solid organs.
Anatomic Considerations
A thorough knowledge of the upper abdominal anatomy is essential to avoid serious complications. The anatomy will be discussed in each of the sections of this chapter and illustrated with the videos.
Nonoperative Management
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, pre-albumin 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.
Indications for NACT include advanced age with poor performance status, severe malnutrition, stage IV disease (e.g., lung metastases, pleural nodules, liver parenchymal metastases, malignant pleural effusions, mediastinal and supraclavicular node metastases), porta hepatis involvement, and suprarenal node metastasis).
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 colorectal surgeons still consider there are significant surgical benefits with the elimination of solid waste in the colon for planned large bowel surgery.
Typing and cross-match at least 2 units of packed red blood cells depending on the preoperative hemoglobin and surgeon estimates of radicality or 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, thoracic).
SURGICAL MANAGEMENT
The surgical management section will be in four parts:
Laparotomy With Splenectomy
Laparotomy With Diaphragm Stripping and Resection
Robotic Splenectomy for Recurrent Ovarian Cancer
Robotic Diaphragm Stripping and Resection
The video (Video 26.1 
) by Dr. David Cibula shows laparotomy for splenectomy and diaphragm stripping. The video (Video 26.2 
) shows the robotic operations of splenectomy (by Dr. Robert W. Holloway) and the robotic diaphragm (by Dr. Walter Gotlieb).
) by Dr. David Cibula shows laparotomy for splenectomy and diaphragm stripping. The video (Video 26.2 ) shows the robotic operations of splenectomy (by Dr. Robert W. Holloway) and the robotic diaphragm (by Dr. Walter Gotlieb).PART 1: LAPAROTOMY WITH OMENTECTOMY AND SPLENECTOMY
Surgical Management of Splenectomy
Positioning
Supine position
Approach
Midline incision to the xiphoid process.
Self-retaining upper abdominal retractor.
PROCEDURES AND TECHNIQUES
Part I: Laparotomy with Omentectomy and Splenectomy (Video 26.1, Part 1)
Omentectomy
A complete omentectomy is performed.
The infracolic omentum is dissected from the transverse colon to the splenic flexure.
The gastrocolic omentum is dissected, being careful to preserve the transverse colon mesentery.
Divide the vessels that attach the omentum to the greater curvature of the stomach.
Phrenicocolic ligament
The omentum is separated from the splenic flexure of the transverse colon.
The phrenicocolic ligament is then divided and the colon is now mobilized away from the spleen (Tech Fig. 26.1).
 Tech Figure 26.1. Surgical anatomy of the spleen. |
Gastrolienal ligament
The omentum is further separated from the greater curvature of the stomach until the gastrolienal ligament is reached. The gastrocolic ligament has two layers: the ventral one is the short gastric vessels which go to the spleen, and the dorsal one may contain gastrolienal vessels.
The superior pole of the spleen is reached. There may be adhesions from the stomach to the spleen that will be taken down.
Phrenicolienal ligament
The attachments from the spleen to the diaphragm are taken down. There may be cancer adherent to the diaphragm that requires peeling the diaphragm peritoneum.
Dissection of the splenic hilus
The hilum can be exposed by the ventral approach to ligate the splenic artery (Tech Fig. 26.2). The splenic artery is a branch of the celiac artery and runs along the superior margin of the pancreas to the tail of the pancreas. It usually branches into two or three vessels. The tail of the pancreas is within 1 cm of the splenic hilum.
The peritoneum in the lesser sac is incised to expose the splenic arteries and they are divided. This will allow the spleen to shrink in size and some blood can return to the systemic circulation.
The posterior approach is then used to identify the tail of the pancreas. The pancreas is dissected to expose the renal veins and they are divided. The posterior approach is less likely to injure the pancreas.
If the tail of the pancreas is resected, a linear stapler with vascular load should be used.
The splenic bed does not need to be drained unless hemostasis is not satisfactory.
 Tech Figure 26.2. Anatomy of the blood vessels of the spleen. |
POSTOPERATIVE CARE FOR SPLENECTOMY
Nasogastric suction is used to prevent dilation of the stomach, which could disrupt the sutures on the gastric vessels. There may be a prolonged ileus that is typical for patients with a major debulking operation. Anemia with hematocrit (Hct) below 25 should be treated with transfusion. Fluid shifts are normal since most patients will have several liters of ascites removed. This leads to a low albumin and low urinary output. Conservative use of crystalloid and more reliance on blood products has been our policy. This will avoid fluid overload and pulmonary edema. Enoxaparin should be withheld until the Hct is stable.
COMPLICATIONS FOR SPLENECTOMY
Pleural effusion, atelectasis of the left lung, pneumonia, hemorrhage, and splenic vein thrombosis have been reported. A subphrenic abscess is most likely the result of injury to the stomach or the colonic at the splenic flexure. Pancreatic fistula or pseudocyst has been reported in 27% of patients. The rate was decreased to 4% when a polyethylene glycolic felt with fibrin sealant was placed. Postsplenectomy syndrome leads to a hypercoagulable state with a rise in platelets above 750,000 and increase in clotting risk. Monitoring platelets daily will identify the problem. Sepsis due to pneumococcus may occur. For this reason, patients should be given pneumococcal vaccine. Meningococcal and Haemophilus influenza vaccines are also recommended.
PROCEDURES AND TECHNIQUES
PART 2: Laparotomy with Diaphragm Stripping and Resection (Video 26.1, Part 2)
Liver mobilization
Liver mobilization is performed by dividing the round ligament (umbilical vein remnant) and the falciform ligament (Tech Fig. 26.3A). The leaves of the falciform ligament diverge as they approach the diaphragm, forming the superior margin of the coronary ligament (Tech Fig. 26.3B).
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