Figure 37.13 The resection of the pelvic tumor may include removal of the uterus, tubes, and ovaries, as well as portions of the lower intestinal tract. The arrows represent the plane of resection. (From Berek JS, Hacker NF. Berek & Hacker’s Gynecologic Oncology. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2010:465, with permission.) and the remainder of the tissues within the cardinal ligaments completes the hysterectomy and resection of the contiguous tumor.
Because epithelial ovarian cancers tend not to invade the lumina of the colon or bladder, it is usually feasible to resect pelvic tumors without having to resect portions of the lower colon or the urinary tract (154,155). Resection of a small portion of the bladder may be required and, if so, a cystotomy should be performed to assist in resection of the disease (155).
Intestinal Resection Resection of focal areas of disease involving the small or large intestine should be performed if that would permit the removal of all or most of the abdominal metastases and leave the patient with optimal disease at the end of the cytoreduction. Apart from the rectosigmoid colon, the most frequent sites of intestinal metastasis are the terminal ileum, the cecum, and the transverse colon. Resection of one or more of these segments of bowel may be necessary (154,156).
If the disease surrounds the rectosigmoid colon and its mesentery, that portion of the colon may have to be removed in order to clear the pelvic disease (Fig. 37.13) (154). When the pararectal space is identified in such patients, the proximal site of colonic involvement is identified, the colon and its mesentery are divided, and the rectosigmoid is removed along with the uterus en bloc. A reanastomosis of the colon is performed.
Omentectomy Advanced epithelial ovarian cancer often completely replaces the omen-tum, forming an “omental cake.” This disease may be adherent to the parietal peritoneum of the anterior abdominal wall, making entry into the abdominal cavity difficult. After freeing the omentum from any adhesions to parietal peritoneum, adherent loops of small intestine are freed by sharp dissection. The omentum is lifted and pulled gently in the cranial direction, exposing the attachment of the infracolic omentum to the transverse colon. The peritoneum is incised to open the appropriate plane, which is developed by sharp dissection along the serosa of the transverse colon. Small vessels are ligated with hemoclips. The omentum is separated from the greater curvature of the stomach by ligation of the right and left gastroepiploic arteries and ligation of the short gastric arteries (Fig. 37.14).
Figure 37.14 Separation of the omentum from stomach and transverse colon. Arrow, the direction of the initial surgical approach. (From Heintz APM, Berek JS. Cytoreductive surgery for ovarian carcinoma. In: Piver MS, ed. Ovarian malignancies. Edinburgh, UK: Churchill Livingstone, 1987:134, with permission.)
The disease in the gastrocolic ligament can extend to the hilus of the spleen and splenic ﬂexure of the colon on the left and to the capsule of the liver and the hepatic ﬂexure of the colon on the right. Usually, the disease does not invade the parenchyma of the liver or spleen, and a plane can be found between the tumor and these organs. It will occasionally be necessary to perform splenectomy to remove all the omental disease (157).