Box 30-1 Master Surgeon's Corner
The liver needs to be mobilized for the appropriate evaluation and treatment of right diaphragm disease.
If omental disease extends to the splenic and hepatic fl exures, these need to be mobilized completely during omentectomy.
The retroperitoneal approach to resection of pelvic tumor often allows for easier access and removal of pelvic structures "en bloc" compared to a transperitoneal approach.
Ovarian cancer is one of the few solid tumors in which surgical cytoreduction is indicated for advanced metastatic disease. The most common indication for cytoreductive surgery is suspected or confirmed advanced-stage ovarian cancer. In selected cases, cytoreductive surgery is indicated for other advanced or recurrent gynecologic cancers. The goal of the cytoreductive surgery, defined in terms of the diameter of the largest residual implant, has evolved over the last 3 decades. Although leaving no residual tumor larger than 1 cm is currently defined as "optimal," maximal survival benefit is associated with removal of all gross tumor. Therefore, the goal should be to attempt removal of all visible disease (complete cytoreduction). The available surgical techniques have similarly evolved during the same period to achieve this goal and now include upper abdominal procedures, tumor ablation techniques, and radical pelvic surgery.
Whether performed for primary or recurrent tumors or following neoadjuvant therapy, the same surgical principles and techniques of cytoreductive surgery discussed in this chapter are applicable.
Cytoreduction procedures are often lengthy and complex and carry the potential for significant intra- and postoperative morbidities. The patient needs to be evaluated thoroughly to assess whether she is able to tolerate such procedures, to optimize any underlying medical condition, and to plan postoperative care.
As in any patient assessment, the initial step is to take a detailed history, not only of the complaint that led to the suspicion or diagnosis of advanced ovarian cancer, but also of any associated symptoms that can indicate the existence or severity of associated comorbidities. Specifically, any respiratory symptoms should be investigated, because multiple etiologies can coexist. These can be related to the diagnosis of ovarian cancer (eg, pleural effusion, ascites) or simply denote the presence of a medical comorbidity (eg, chronic lung disease, cardiac disease) that either needs to be optimized prior to surgery or may contraindicate an extensive surgery. The presence of nausea and vomiting, abdominal distention, and difficulty with bowel movements may indicate bowel obstruction. A history of recent significant weight loss can point to potential malnutrition. If severe malnutrition is confirmed on laboratory evaluation, preoperative parenteral nutrition should be considered.
A detailed physical examination should specifically look for findings that denote the extent of disease or the underlying condition of the patient, or even suggest a different or coexistent primary malignancy (eg, breast exami-nation, rectal examination). The abdomen is examined closely for ascites, which can cause significant abdominal distention, ...