Hacker and Berek demonstrated that patients whose largest residual lesions were less than 5 mm had a superior survival rate, which was substantiated by Van Lindert et al. (145–148). The median survival of patients in this category was 40 months, compared with 18 months for patients whose lesions were less than 1.5 cm and 6 months for patients with nodules greater than 1.5 cm. Patients whose disease is completely resected to no macroscopic (microscopic only) residual disease have the best overall survival (149) (Fig. 37.12). Approximately 30% to 40% of patients in this category will be free of disease at 5 years.
The resectability of the metastatic tumor is usually determined by the location of the disease. Optimal cytoreduction is difficult to achieve in the presence of extensive disease on the diaphragm, in the parenchyma of the liver, along the base of the small bowel mesentery, in the lesser omentum, or in the porta hepatis.
The ability of cytoreductive surgery to inﬂuence survival is limited by the extent of metastases before cytoreduction, presumably because of the presence of phenotypically resistant clones of cells in large metastatic masses. A patient whose metastatic tumor is very large (i.e., >10 cm before cytoreductive surgery) has a shorter survival than those with smaller areas of disease (147,149). Extensive carcinomatosis, the presence of ascites, and poor tumor grade, even with lesions that measure less than 5 mm, may shorten the survival (150–153).
Exploration The supine position on the operating table may be sufficient for surgical exploration of most patients. For patients with extensive pelvic disease and for whom a low resection of the colon may be necessary, the low lithotomy position should be used. Debulking operations should be performed through a vertical incision to gain adequate access to the upper abdomen and to the pelvis.
After the peritoneal cavity is opened, ascites ﬂuid, if present, should be evacuated. In some centers, ﬂuid is submitted for in vitro research studies, such as molecular analyses. In cases of massive ascites, careful attention must be given to hemodynamic monitoring, especially for patients with borderline cardiovascular function.
The peritoneal cavity and retroperitoneum are thoroughly inspected and palpated to assess the extent of the primary tumor and the metastatic disease. All abdominal viscera must be palpated to exclude the possibility that the ovarian disease is metastatic, particularly from the stomach, colon, or pancreas. If optimal status is not considered achievable, extensive bowel and urologic resections are not indicated, except to overcome a bowel obstruction. Removal of the primary tumor and omental cake is usually both feasible and desirable.
Pelvic Tumor Resection The essential principle of pelvic tumor removal is the retroperitoneal approach. To accomplish this, the retroperitoneum is entered laterally, along the surface of the psoas muscles, which avoids the iliac vessels and the ureters. If the uterus is present, the procedure is initiated by bilateral division of the round ligaments. The peritoneal incision is extended cephalad, lateral to the ovarian vessels within the infundibulopelvic ligament, and caudally toward the bladder. With careful dissection, the retroperitoneal space is explored, and the ureter and pelvic vessels are identified. The pararectal and paravesicular spaces are identified and developed, as described in Chapter 36.
The peritoneum overlying the bladder is dissected to connect the peritoneal incisions anteriorly. The vesicouterine plane is identified, and with careful sharp dissection the bladder is mobilized from the anterior surface of the cervix. The ovarian vessels are isolated, doubly ligated, and divided.
Hysterectomy is then performed. The ureters must be carefully displayed to avoid injury. During this procedure, the uterine vessels can be identified. Ligation of the uterine vessels