The ovarian tumor should be removed intact, if possible, and a frozen histologic section should be obtained. If ovarian malignancy is present and the tumor is apparently confined to the ovaries or the pelvis, thorough surgical staging should be performed. Staging involves the following steps (3,132): 1. Any free ﬂuid, especially in the pelvic cul-de-sac, should be submitted for cytologic evaluation.
Table 37.2 FIGO Staging for Primary Carcinoma of the Ovary
These categories are based on findings at clinical examination or surgical exploration or both. The histologic characteristics are to be considered in the staging, as are results of cytologic testing as far as effusions are concerned. It is desirable that a biopsy be performed on suspicious areas outside the pelvis. FIGO, International Federation of Obstetrics and Gynecology. aTo evaluate the impact on prognosis of the different criteria for allotting cases to stage IC or IIC, it would be of value to know if rupture of the capsule was (i) spontaneous or (ii) caused by the surgeon and if the source of malignant cells detected was (i) peritoneal washings or (ii) ascites. Reproduced from Berek JS, Hacker NF, Berek & Hacker’s Gynecologic Oncology. 5th ed. Lippincott Williams & Wilkins. 2010:455, adapted from FIGO Annual Report, Vol 26, Int J Gynecol Obstet 2006;105:3–4.
2.
If no free ﬂuid is present, peritoneal washings should be performed by instilling and recovering 50 to 100 mL of saline from the pelvic cul-de-sac, each paracolic gutter, and beneath each hemidiaphragm. Obtaining the specimens from under the diaphragms can be facilitated with the use of a rubber catheter attached to the end of a bulb syringe.
3.
A systematic exploration of all the intra-abdominal surfaces and viscera is performed, proceeding in a clockwise fashion from the cecum cephalad along the paracolic gutter and the ascending colon to the right kidney, the liver and gallbladder, the right hemidiaphragm, the entrance to the lesser sac at the para-aortic area, across the transverse colon to the left hemidiaphragm, down the left gutter and the descending colon to the rectosigmoid colon. The small intestine and its mesentery from the Treitz ligament to the cecum should be inspected.
4.
Any suspicious areas or adhesions on the peritoneal surfaces should be biopsied. If there is no evidence of disease, multiple intraperitoneal biopsies should be performed. Tissue from the peritoneum of the pelvic cul-de-sac, both paracolic gutters, the peritoneum over the bladder, and the intestinal mesenteries should be taken for biopsy.
5.
The diaphragm should be sampled, either by biopsy or by scraping with a tongue depressor, and a sample obtained for cytologic assessment. Biopsies of any irregularities on the surface of the diaphragm can be facilitated by use of the laparoscope and the associated biopsy instrument.
6. The omentum should be resected from the transverse colon, a procedure called an infracolic omentectomy. The procedure is initiated on the underside of the greater omen-tum, where the peritoneum is incised just a few millimeters away from the transverse colon. The branches of the gastroepiploic vessels are clamped, ligated, and divided, along with all the small branching vessels that feed the infracolic omentum. If the gastrocolic ligament is palpably normal, it does not need to be resected.