CHAPTER 28

Ovarian Tumor Debulking

Ovarian cancer is a surgically staged disease, and most cases are advanced stage III or IV at the time of initial diagnosis. The cornerstone of therapy for ovarian cancer is maximal surgical cytoreduction, or tumor debulking, surgery. Ovarian cancer is thought to spread by contiguous growth and by dissemination through the lymphatics. Once the cancer has reached the external surface of the ovary, the cells exfoliate and implant inside the abdominal-pelvic cavity, causing peritoneal disease. Once ovarian cancer has disseminated, it tends to grow on the lining of the peritoneum and on the outside of the viscera in the abdomen and pelvis. Once outside the ovary, this malignancy has a predilection to metastasize to the deep portions of the anterior and posterior cul-de-sacs, the surface of the diaphragm (especially the right side), and the omentum, including both infracolic and gastrocolic portions. Additionally, ovarian cancer is found to involve the surfaces of the large and small bowel and its mesentery, the spleen, the liver, and the stomach. Approximately one fourth of cases of ovarian cancer are confined to the ovary. It is of paramount importance to completely surgically stage these cases at the time of diagnosis so that the appropriate treatment can be given. Surgery for an undiagnosed pelvic mass or a presumed ovarian cancer customarily begins with a vertical midline skin incision (Fig. 28–1A–D). This approach allows for removal of the mass or ovary (especially if it is large) and, more important, for maximal exposure of the abdominal-pelvic cavity, so that a thorough exploration can be performed. The incision usually is started at the level of the pubic symphysis and is extended cephalad. It can be extended all the way to the xyphoid process if necessary.

In a minority of cases, ovarian cancer can be confined to the ovary, and a “conservative staging procedure” can be performed (Fig. 28–2A, B). A conservative staging procedure consists of unilateral adnexectomy, pelvic washings, peritoneal biopsies, omentectomy, and lymph node dissection (usually to include pelvic and para-aortic areas; Fig. 28–3A, B). This conservative staging technique should be limited to children, adolescents, and women of childbearing years whose malignancy is grossly confined to one ovary.

To date, no accurate screening test has been developed for ovarian cancer; therefore most ovarian cancers have spread into the abdominal-pelvic cavity by the time of diagnosis (Fig. 28–4A–D). The goal of surgical treatment in these cases is maximal tumor debulking, also termed surgical cytoreduction

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