Surgery is an important phase of treatment for all types of ovarian cancer and should be undertaken as soon as the diagnostic survey has been completed, assuming the patient’s condition allows it. A low transverse incision is inappropriate with a presumptive diagnosis of ovarian carcinoma. The surgeon selecting this incision should forewarn the patient that an upper abdominal incision may be required if carcinoma is encountered. Upon entering the abdomen, the surgeon performs a thorough exploration to evaluate the extent of disease. Ovarian carcinoma spreads predominantly by intraperitoneal implantation and retroperitoneal lymphatic metastasis. The undersurface of the diaphragm, surface of the liver, omentum, retroperitoneal nodes, paracolic gutters, parietes, pelvic peritoneum, pelvic cul-de-sacs, and small and large bowel surfaces are inspected and palpated for signs of spread. Findings suggestive of malignancy include: bilateral ovarian tumors, ascites (especially bloody ascites), surface papillations, and a cystic/solid tumor. None of these is, however, diagnostic of malignancy.

After exploration of the abdomen and in the absence of ascites or obvious extraovarian spread, cytologic specimens (washings) should be obtained from over the liver, the posterior cul-de-sac, and both paracolic gutters. The surgeon must guard against rupturing a malignant cyst if intraperitoneal spread is not already apparent, as spillage of fluid from a malignant mass increases the stage, and may worsen prognosis.

The surgical procedure most appropriate for epithelial ovarian carcinoma depends largely on the patient’s age, the tumor histology, and the extent of disease. Premenopausal women with borderline tumors in whom there is no evidence of metastatic disease can be managed with cystectomy in the case of a unilocular cyst that shells out easily, or unilateral salpingo-oophorectomy otherwise. Generally, hysterectomy and bilateral salpingo-oophorectomy are only indicated if the patient is postmenopausal or if there is widespread involvement of the pelvic organs.

In the case of a frankly invasive ovarian carcinoma, if the patient is desirous of future fertility and the carcinoma is limited to one adnexa, unilateral salpingo-oophorectomy is appropriate. In all other cases, total abdominal hysterectomy and bilateral salpingo-oophorectomy is considered the standard of care. An exception is the young woman with a germ cell tumor, in whom a unilateral salpingo-oophorectomy cn be considered even in the face of metastatic disease, given the marked chemosensitivity of these tumors. If there is no evidence of extrapelvic disease, multiple peritoneal biopsies (including pelvic, right and left paracolic gutters, and right diaphragmatic), greater omentectomy, and bilateral pelvic and aortic nodal sampling should be performed. If the disease is widespread the goal is to remove as much of the tumor as possible. Ideally, the patient should be left with no residual disease. If this is not possible, leaving less than 1 cm of tumor (optimal debulking) results in an improved disease-free survival. If it is clear at surgery that the patient cannot be adequately debulked, then biopsy for diagnosis followed by closure of the abdomen is in order.

At times, the malignancy is so extensive, or the patient’s condition is so poor, that initial surgical management is not feasible. In such instances, diagnosis is established via aspiration of pleural or peritoneal effusions, or fine needle aspirate of metastatic tumor.