gynecologic procedures for the general surgeon

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Volume 9, Number 2 June 2007

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Editorial: Gynecologic Procedures for the
General Surgeon
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he general surgeon prides him or herself on having fa-miliarity and reasonable competence in performing sur-

ery on almost any part of the human body. I still remembery training in burr-hole placement, shoulder relocation and

ortic root cannulation for cardiac bypass. Although increas-ng subspecialization has decreased the need for general sur-eons to do many such procedures today, the abdomen is stillhe most common stomping ground for the general surgeon,nd familiarity and reasonable competence in surgically man-ging all organs within its confines is a necessary part of beinggeneral surgeon. Thus, the general surgeon will unavoidably

ncounter gynecologic problems when treating intraabdomi-al organ disease elsewhere and the ability to take care of at

east relatively straightforward disease of the uterus and ad-exa will be to his or her advantage. Obviously more complexisease will require the assistance of a gynecologist, but tonow when to call and what the fundamentals are in man-gement will still serve the general surgeon well.

This issue of Operative Techniques in General Surgery is thusedicated to providing this perspective on gynecologic man-gement for the general surgeon. The gynecologist is reallyhe only other nongeneral surgeon who regularly operates in
he abdomen (the urologist really manages retroperitoneal
524-153X/07/$-see front matter © 2007 Elsevier Inc. All rights reserved.oi:10.1053/j.optechgensurg.2007.06.005

rgans) and so the gynecologist needs a similar familiarityith the abdomen. Dr. George Olt, this month’s Guest Edi-

or, is a gynecologic oncologist whose technical expertisetems not just from extensive experience and training, butlso from frequently being one of a team of many surgeonsddressing multivisceral abdominal disease. Since such dis-ase can originate in the gut, the female organs, the bladder orlsewhere, he has assisted and helped train many generalurgeons, urologists and other subspecialists shoulder tohoulder in the operating room. Herein he draws on thisxtensive experience and his knowledgeable collaborators toresent the fundamentals of gynecologic surgery for the gen-ral surgeon.

Walter A. Koltun, MDProfessor of Surgery,

Peter and Marshia CarlinoProfessor of Inflammatory Bowel Disease,

Chief, Section of Colon and Rectal Surgery,Penn State College of Medicine,

Milton S. Hershey Medical Center

Editor-in-Chief

51

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Volume 9, Number 2 June 2007

5

Introduction

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n the past, general surgeons were extensively trained ingynecologic surgical techniques. As the breadth of surgical

rocedures has greatly expanded, little time is left for formalxposure to gynecologic surgery during residency, thus mostecently trained general surgeons have had minimal exposureo even common procedures such as hysterectomy. However,here are times when such operations may need to be per-ormed if a gynecologist is not available (perhaps performingdelivery). The article on total abdominal hysterectomy withnd without salpingooophorectomy should be helpful inroviding techniques and tips for avoiding complicationsnd poor results.

Another common occurrence surgeons may encounter, es-ecially in smaller communities where a gynecologic oncol-gist is not available, is an intraoperative request for assis-ance with a patient who has an undiagnosed ovarian cancer.t is of utmost importance to precisely stage such a patient torovide correct therapy and to avoid a re-operation to guidereatment. Studies have demonstrated that roughly one thirdf incompletely staged ovarian cancer patients felt to be stageat the time of initial surgery are found to have stage IIIisease when re-staged. These patients would not have re-eived cytotoxic chemotherapy, resulting in poorer survival.

A second important principle of ovarian cancer surgery is
hat survival is greatly improved by optimal cytoreduction of
2 1524-153X/07/$-see front matter © 2007 Elsevier Inc. All rights reserved.doi:10.1053/j.optechgensurg.2007.06.004

umor masses to less than one centimeter. While generalurgeons are well equipped to perform necessary bowel re-ections, the article on debulking provides techniques for lessell-known procedures.In a similar fashion, patients with endometrial cancer areost commonly operated on by general gynecologists. Pa-

ients with disease invasive into the myometrium have beenhown to benefit from pelvic and para-aortic lymphadenec-omy and omentectomy. Most general gynecologists are notrained to perform these procedures and frequently requestonsultation.

As minimally invasive surgery has become more common,n opportunity exists to evaluate the pelvis during abdominalaparoscopy such as cholecystectomy and appendectomy. Ifn adnexal mass is inadvertently discovered it may be re-oved safely if certain principles outlined in the article on

aparoscopic oophorectomy are followed.It was the goal of this issue on gynecologic techniques to

rovide the general surgeon with advice on dealing with gy-ecologic situations which occur not infrequently and areelevant to their practice. Hopefully we have been successful.

George Olt, MD

Guest Editor

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varian Cancer Stagingiz Y. Han, MD, and Robert L. Coleman, MD

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rimary malignancy of the ovary is fortunately a relativelyuncommon condition. In 2007, an estimated 22,430 new

ases and 15,280 deaths are expected.1 However, the numberf women who succumb to this disease eclipses the totalontribution of all other distinct gynecologic cancers com-ined, distinguishing it as the most lethal. Histologically, theost common form of the disease is epithelial, accounting forore than 80% of primary malignant diagnoses. However,

varian cancer may also arise from the germ cells, ovariantroma, and other supporting tissues. In addition, a sizeableroportion of younger women with ovarian cancer will haveproliferative, but noninvasive element designated as “lowalignant potential” or “borderline” epithelial ovarian tu-or. Individual risk factors and therapeutic options for these

ubtypes are important to clearly distinguish given their oc-urrence in women of reproductive potential and uniqueatural history.The focus of this contribution will center on the manage-ent and care of patients with epithelial ovarian cancer;owever, surgical approaches to staging of these rarer ovarianancers are similar in the absence of desired fertility preser-ation. A brief outline of these considerations appears at thend of this discussion.

Although the incidence of ovarian carcinoma ranks secondn all malignancies of the female reproductive tract, it remainshe most deadly. Risk factors for epithelial ovarian carcinomare well established. Although pregnancies and oral contra-eptive use are protective, age is the strongest patient-relatedisk factor. Overall, it is estimated that 1 in 70 women willevelop ovarian cancer in their lifetime with age-specific in-idence peaking at 75 to 80 years of age.2 This is especiallytartling considering the aging population of the Unitedtates. Furthermore, a family history of ovarian cancer, breastancer, or both, is the second strongest risk factor. Womenho are heterozygous for mutations of either BRCA 1 orRCA 2 have an estimated lifetime risk of 16% to 60%.3 Otherisk factors may also include nulliparity, involuntary infertil-ty, early menarche, and late menopause.2

Failure of early detection is the principle reason behindvarian carcinoma’s high mortality. More than 90% of

rom the Department of Gynecologic Oncology, The University of Texas-M.D. Anderson Cancer Center, Houston, TX.

ddress reprint requests to Robert L. Coleman, MD, Professor, Director ofClinical Research, The University of Texas-M.D. Anderson Cancer Cen-ter, Department of Gynecologic Oncology, 1155 Herman Pressler,CPB6.3244, Unit 1362, Houston, TX 77030. E-mail: RColeman@

tmdanderson.org.


omen diagnosed with ovarian cancer have symptoms ante-ating the diagnosis by several months, however, these areften vague (abdominal bloating, pelvic pressure, urinaryysfunction, etc.) contributing to a delayed diagnosis.4 CA-25 has proven to be an excellent marker of surveillance forreatment response; however, its diagnostic value is yet to beroven. Seventy-five percent of this malignancy is diagnosed

n advanced stages when the disease has spread beyond theelvis.1,5 The 5-year survival for these patients is only 30% to0%.6 These factors underlie the importance of not only earlyetection, but also proper surgical staging and optimal dis-ase debulking with subsequent adjuvant chemotherapy toaximize survival potential.In general, the surgical principium of ovarian cancer is

ccurate staging for limited disease and cytoreduction fordvanced or metastatic disease. Surgical staging in the ab-ence of visible metastatic spread requires broad and directedampling of “at-risk” tissues sufficient to assign an appropri-te stage in accordance with FIGO guidelines (Table 1). Inhe presence of more advanced disease, surgical extirpation isndertaken to remove the primary site of disease and levy thereatest impact on tumor burden. Frequently this is referredo as performing an “optimal cytoreduction” procedure.

The definition of optimal cytoreduction in ovarian carci-oma remains controversial, although the most widely ac-epted is residual disease less than 1 cm.7 The survival ad-antage gained from debulking was first described by Meigsn 1934,8 and explored in a systematic fashion by Griffiths in975 where longer survival is associated with lesser residualisease.9 Since then, the survival advantage of optimal de-ulking is further proven retrospectively by various authors;

n fact, Bristow and co-workers demonstrated that for each0% decrease in residual tumor volume, there is a 5.5%

ncrease in median survival.10,11

Currently, there is a trend to establish optimal cytoreduc-ion as no visible residual disease. Published studies haveemonstrated that prognosis is directly related to number ofesidual implants as well as volume of residual disease.12,13

arious series reflect optimal cytoreduction is obtainable inpproximately 20% to 25% of patients presenting with ad-anced ovarian cancer.14,15 Furthermore, in GOG trials ex-mining primary cytoreduction and adjuvant chemotherapy,atients with no visible residual disease had the best progno-is for survival.6,16,17 Therefore, some authors have con-luded that all efforts including resection, ablation, aspira-
ion of all visible disease as allowed by medical status and
53

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54 L.Y. Han and R.L. Coleman

ntraoperative patient stability should be performed tochieve complete cytoreduction.18

varian Carcinoma Stagingreoperative Evaluation and Considerationsreoperative imaging with computed tomography (CT) scan

s most helpful in initial evaluation of disease spread. In ad-ition, CT findings such as diffuse disease sites and perito-eal thickenings may be predictors of suboptimal debulk-

ng.19-22 Other predictors for suboptimal debulking includereoperative CA-125 level greater than 500.23 In patientsith extensive disease and elevated CA-125 with multiple

omorbidities, neoadjuvant chemotherapy may be anotherption.Published retrospective data revealed that up-front che-otherapy can reduce morbidity and mortality while offer-

ng higher rates of optimal interval cytoreduction withouturvival compromise.24,25

varian Carcinoma Stagingfter appropriate preoperative medical and anesthesia assess-ent, patients requiring formal staging or cytoreduction

hould undergo exploration with laparotomy. Incidentalarly stage ovarian cancers discovered during laparoscopicvaluation of an adnexal or pelvic mass may be staged viaaparoscopy as long as the same procedure and staging biop-

able 1 Ovarian Cancer Staging by FIGO Criteria (1986)

I. Growth limited to the ovariesIA. Tumor limited to one ovary; capsule intact, no tumor

on ovarian surface; no malignant cells in ascites orperitoneal washings

IB. Tumor limited to both ovaries; capsules intact, notumor on ovarian surface; no malignant cells inascites or peritoneal washings

IC. Tumor limited to one or both ovaries with any of thefollowing: capsule ruptured, tumor on ovarian sur-face; malignant cells in ascites or peritoneal wash-ings

II. Tumor involves one or both ovaries with pelvicextensionsIIA. Extension and/or implants on uterus and/or tube(s);

no malignant cells in ascites or peritoneal washingsIIB. Extension to other pelvic tissues; no malignant cells

in ascites or peritoneal washingsIIC. Pelvic extension with malignant cells in ascites or

peritoneal washingsIII. Tumor involves one or both ovaries with peritoneal

metastasis outside the pelvis and/or retroperitoneal oringuinal node metastasisIIIA. Microscopic peritoneal metastasis beyond pelvisIIIB. Macroscopic peritoneal metastasis beyond pelvis 2

cm or less in greatest dimensionIIIC. Peritoneal metastasis beyond pelvis more than 2

cm in greatest dimension and/or regional lymphnode metastasis

V. Distant metastasis (excludes peritoneal metastasis) toliver parenchyma or malignant pleural effusion

ies can be obtained including retroperitoneal lymph nodes. t

The debulking procedure begins generally with a midlineertical skin incision from the level of the pubic symphysisxtending cephalad around the umbilicus to a point felt suf-cient to evaluate the upper abdomen and diaphragmaticeritoneum. We generally prefer extension around the rightide umbilicus or directly through the umbilicus, in case aiverting colostomy is necessary as part of the cytoreductionrocedure. The abdomen is then opened to the peritoneumith care exercised inferiorly to avoid injury to the bladder. Ifpatient has massive ascites, drainage at the most ventral

spect of the abdomen before opening is prudent. In thebsence of ascites, 100 to 150 mL of sterile saline is used tobtain washings from the pelvis, paracolic gutters, and dia-hragm bilaterally. This fluid should be sent for permanentytological evaluation.

At this point, a survey of the abdomen and pelvis is per-ormed to evaluate the disease extent. A methodical and thor-ugh system should be adopted in this evaluation to encom-ass the following: upper abdomen including the liverurface, gall bladder, dome of the diaphragm bilaterally, thetomach, pancreas, and retroperitoneally, the kidneys. Themall bowel is examined from the cecum to the ligament ofreitz, paying attention to both serosal disease as well asesenteric involvement, and same technique is applied to

he large bowel survey. The entirety of the peritoneal surface,ncluding the paracolic gutters should be palpated for diseaseresence. The omentum is fanned out for visual inspection.ext, the pelvic organs such as ovaries, fallopian tubes andterus, including the anterior and posterior cul-de-sacs,ectosigmoid, are evaluated.

What appears to be early stage ovarian carcinoma (ie,tages I and II) by initial abdominal and pelvic survey meritdditional peritoneal and lymph node biopsies as informa-ion gained may upstage the diagnosis in 25% of cases.26

andom peritoneal biopsies should be performed in the pel-is and abdomen, including the paracolic gutters. The mostanageable approach is completed using pickups and Met-

enbaum scissors to excise the peritoneum in the locationsisted and applying electrocautery for hemostasis (Fig 1).

Lymph node biopsies are obtained from the pelvis as well ashe para-aortic regions. Pelvic lymphectomy begins with ade-uate exposure of the external iliac vessels (Fig 2). The nodalundle straddling the vessels can be peeled away using a com-ination of sharp dissection with the Metzenbaum scissors andemo-clips to occlude the arterioles and venules to achieve he-ostasis. The external iliac vein is then retracted laterally with

xposure of the obturator space that allow for collection of ad-itional nodal tissue whereas carefully dissecting the obturatorerve. The retroperitoneum dissection is then extended supe-ior and medially with electrocautery, carefully avoiding the ure-er as it courses over the common iliac vessels, and retractedaterally to allow for adequate visualization (Fig 3 A, B). Thenferior mesenteric artery is then isolated approximately 3 cmuperior to the aortic bifurcation and the nodal bundle aroundhe aorta is retrieved in a similar fashion. The superior border ofhis dissection is the renal vein.

Routine appendectomy is not indicated in ovarian staging.owever, if frozen section returns with a diagnosis of muci-ous tumor of the ovaries, 8% of the appendices are involved;herefore, appendectomy should be performed.27 Liver resec-
ion and splenectomy are not part of ovarian cancer staging;

Ovarian cancer staging 55

Figure 1 (A, B) Suggested location of tissue biopsies required for systematic evaluation for metastatic disease, based on
theorized flow of metastatic cells in abdominal cavity.

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herefore, should only be performed as part of a radical de-ulking with a feasible aim for optimal cytoreduction.

otal Abdominalysterectomy With Bilateralalphino-Ophorectomy and Omentectomyhe core of ovarian carcinoma staging involves total abdom-

nal hysterectomy and bilateral salphino-ophorectomy, fol-owed by omentectomy (see “Hysterectomy” elsewhere inhis issue). As tumors often distort the anatomy and generateense adhesions, restoration of normal anatomy is para-ount before starting any procedure. Furthermore, careful

solation of the ureter from the beginning provides tremen-ous advantage.Once adequate exposure of the pelvis is obtained, Kelly

lamps are then placed on the uterine cornua bilaterally topply traction during the procedure. The round ligamentsre identified and suture ligated with absorbable sutures andransected. This step allows the division of the anterior andosterior leaflets of the broad ligament that provides an entry

nto the retroperitoneal space where on clearance of the are-lar tissues, the ureter is found along the medial surface of theroad ligament. A small window is made in an avascularpace of the broad ligament to isolate the infundibular pelvicIP) ligaments encompassing the ovarian vessels. The IPigaments then are double clamped, suture ligated andransected.

The anterior leaflet of the broad ligament is then incisednferiorly along the uterine contour then the bladder reflec-ion to construct a bladder flap. The bladder is then gentlyissected off the lower uterine segment as well as the cervix.ephalad traction on the uterus facilitates this process. The

Figure 2 Adequate sampling of lymphatic tissues in thjunctional, and common iliac nodes.

terine vessels are skeletonized, clamped, transected, and i

igated. The cardinal and uterosacral ligaments are sequen-ially clamped, transected, and stitched followed by the com-lete amputation of the uterus with intact cervix using Jor-ensen scissors. The vaginal cuff is then reapproximatedsing a series of figure-of-eights. Vaginal cuff hemostasis isital as it is one of the most common site of postoperativeemorrhage.28 Occasionally, the pelvis structures present as aiffuse amalgamation incorporating bladder peritoneum,terus, fallopian tubes, and ovaries as well as the sigmoidolon. This may be effectively accomplished through modi-ed posterior exenteration procedure described below.29

The omentum is then fanned out and its attachments to theransverse colon are identified (Fig 4 A-C). The posterioreaflet of the omentum is then incised with electrocautery,nd an avascular space between the omentum and the trans-erse mesocolon is developed superiorly to the level of theesser sac by finger dissection. Along the greater curvature ofhe stomach, the omental side of the gastroepiploic and itsnastomotic short gastric vessels are isolated and transectedith linear dissecting stapler to free the entire omentum.

pecial Surgical Considerationshe abdominal and pelvic survey renders a diagnosis of stage.n advanced ovarian carcinoma (ie, stages III and IV), whatnsues this evaluation is the decision making process to de-ermine whether an optimal cytoreduction can be achieved.ptimal cytoreduction rates are varied and dependent on

umor volume and location.30 The possible morbidity in-urred from a radical debulking procedure should be bal-nced against the survival benefits gained from an optimalebulking; however, if optimal disease resection cannot bechieved, then radical surgery fails to be justified as prognosis

s should include four areas: obturator, external iliac,
e pelvi
s uninfluenced by residual disease greater than 2 cm.11


Figure 3 (A, B) Paraortic node sampling should include tissue from below and above the level of the inferior mesenteric
artery bilaterally.

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Many have commented on the radicality of ovarian cancerebulking to achieve optimal cytoreduction, especially inulky stage IIIC and IV diseases. Patients may require exten-ive upper abdominal organ resections such as diaphragmeritonectomy or full-thickness resection, splenectomy withr without distal pancreatectomy, cholecystectomy for gall-ladder surface tumor or resection of parenchymal liver ororta hepatic disease in addition to possible ablative upperbdominal procedures using electrocautery, Cavitron ultra-onic aspirator (CUSA) or argon-beam coagulator (ABC).31

oreover, patients may also exhibit extensive tumor spreadn the pelvis, often involving the rectosigmoid and theul-de-sac where a modified posterior exenteration and lowectal anastomosis must be performed.29

Isolated diaphragmatic tumors can often to be ablated.owever, extensive diaphragmatic disease can be removedy stripping the peritoneum away from the muscle, and more

Figure 4 (A-C) The omentum can contain a substantialrepresents a large surface area for early implantationresection is often necessary for bulky omental disease.

nvasive implants often require full thickness resection with l

epair. Postoperative complications often include pneumotho-ax and symptomatic pleural effusion that necessitate medicalnterventions (see “Surgical Management of Diaphragm Diseasen Ovarian Cancer” elsewhere in this issue).32

Superficial splenic metastasis can be ablated, and splenec-omy is performed for the following indications: (1) involve-ent of the splenic surface, hilum, and/or vasculature with

ulky disease contiguous with omental metastases; (2) iso-ated or confluent hilar and/or capsular metastases that couldot be resected, ablated, or aspirated; and (3) parenchymaletastases.33 The gastrosplenic and splenorenal ligaments

re divided and separated from the spleen at the level of theplenic flexure of the colon, and its vessels are clamped, cutnd ligated with absorbable sutures. If disease is involved inhe hilum and the pancreatic tail, the distal pancreas is mo-ilized with electrocautery as well. The splenic artery and veinre then dissected away from the pancreas and clamped, cut and

t of metastatic disease. In cases of no visible disease, itscoring its importance in surgical staging. Supracolic

amoununder

igated. The pancreas is then divided with a linear stapler.33

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For contiguous tumor involvement of the cul-de-sac andhe rectosigmoid, a modified posterior exenteration and lowectal anastomosis may be necessary (Fig 5 A, B).33 The pro-edure begins with bilateral opening the peritoneum cover-ng the rectosigmoid colon to mobilize the colon. Care isaken to preserve the ureters. A linear stapler is then applied tohe rectosigmoid colon slightly below the sacral promontory.he rectum is then dissected away from the sacrum to the coc-yx, and the rectal stalk is sequentially ligated and transectedrom its lateral attachments. The hysterectomy is performed asreviously described with the exception that the ureters areleared from the cardinal web bilaterally, and the combina-

igure 5 Pelvic disease may be extensive, including the cul-de-sacnd recto-sigmoid. A modified posterior exenteration and recto-igmoidectomy may be necessary.

ion of the uterine and rectal dissections allows for opening of c

he paravesical and pararectal spaces. The lateral ligamentsan then be serially ligated close to the pelvic sidewall withhe specimen on cephalad traction. The vagina and rectumre transected at the level of the levator muscle and above theevator sling, respectively. The rectum can then be processedor anastomosis with a mobilized descending colon using anutomatic surgical stapler.34 A diverting ileostomy may bendicated if the anastomotic suture line is felt to be tenuous.

onepithelial and Lowalignant Potential Tumors

pproximately 15% of ovarian malignancies occur in womenf reproductive age, therefore, special consideration must beiven to fertility sparing surgical approaches such as unilat-ral cystectomy and oophorectomy in the setting of propertaging with cytology and multiple pelvic and abdominaliopsies.35 Ovarian germ cell tumors (with the exception ofysgerminomas) are almost always unilateral, therefore,reservation of the contra-lateral ovary and uterus is ofteneasible.36 Approximately 80% of juvenile granulose cell tu-

ors, a subset of sex cord stromal ovarian carcinoma, isiagnosed in women under 20 years of age.35 Consideringhat 95% of this type of tumor is unilateral, and confined tohe ovaries at time of diagnosis, this tumor type can be ap-ropriately treated with conservative measures as well.Low malignant potential (LMP) tumors of the ovary typi-

ally is found in younger women when compared with theirpithelial ovarian carcinoma counterparts, and account for5% of all epithelial ovarian carcinoma, and has a 10-yearurvival of 90%.37 For both serous and mucinous LMP tu-ors, 60% and 90% of cases are confined to one ovary,

herefore, affording the opportunity for fertility sparing sur-eries.35 However, because LMP tumors are often diagnosedn permanent sections for pathological evaluation, a manage-ent dilemma arises as to the clinical relevance of restaging.etrospective data have shown that patients with provisionaltage IA disease are upstaged 7% to 15% when re-operatedor complete diagnosis, and current recommendations re-ains conflicting.38,39 However, serous histology and initial

ystectomy are two risk factors that contribute to upstagingnd patients with these risk factors should be considered fore-exploration.

onclusionroper ovarian staging provides vital information in terms ofatient diagnosis and prognosis. Published studies haveemonstrated that survival of women with advanced ovarianarcinoma is improved when the primary surgery is per-ormed by gynecologic oncologists versus general gynecolo-ists or surgeons.40-42 A recently published study examinedroper staging techniques for early stage ovarian carcinoma,nd found that significantly more gynecologic oncologists areikely to perform lymph node dissection than general gyne-ologists and surgeons. Furthermore, patients treated by gy-ecologic oncologists had better outcomes compared withheir counterparts treated by generalists.43 Nonetheless, hos-ital and surgeon specific procedure volumes are not strongredictors of survival outcomes after surgery for ovarian can-
er among older women.44 As cytoreduction is intimately

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ntertwined in this surgical staging process, appropriate re-erral to a gynecologic oncologist is often indicated.

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5. Partridge EE, Barnes MN: Epithelial ovarian cancer: Prevention, diag-nosis, and treatment. CA Cancer J Clin 49:297-320, 1999

6. Ozols RF, Bundy BN, Greer BE, et al: Phase III trial of carboplatin andpaclitaxel compared with cisplatin and paclitaxel in patients with opti-mally resected stage III ovarian cancer: A Gynecologic Oncology Groupstudy. J Clin Oncol 21:3194-3200, 2003

7. Eisenkop SM, Spirtos NM: What are the current surgical objectives,strategies, and technical capabilities of gynecologic oncologists treatingadvanced epithelial ovarian cancer? Gynecol Oncol 82:489-497, 2001

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9. Griffiths CT: Surgical resection of tumor bulk in the primary treatmentof ovarian carcinoma. Natl Cancer Inst Monogr 42:101-104, 1975

0. Bristow RE, Tomacruz RS, Armstrong DK, et al: Survival effect of max-imal cytoreductive surgery for advanced ovarian carcinoma during theplatinum era: A meta-analysis. J Clin Oncol 20:1248-1259, 2002

1. Hoskins WJ, McGuire WP, Brady MF, et al: The effect of diameter oflargest residual disease on survival after primary cytoreductive surgeryin patients with suboptimal residual epithelial ovarian carcinoma. Am JObstet Gynecol 170:974-979, 1994; discussion 979-980

2. Farias-Eisner R, Teng F, Oliveira M, et al: The influence of tumor grade,distribution, and extent of carcinomatosis in minimal residual stage IIIepithelial ovarian cancer after optimal primary cytoreductive surgery.Gynecol Oncol 55:108-110, 1994

3. von Georgi R, Franke FE, Munstedt K: Influence of surgery and post-operative therapy and tumor characteristics on patient prognosis inadvanced ovarian carcinomas. Eur J Obstet Gynecol Reprod Biol 111:189-196, 2003

4. Aletti GD, Dowdy SC, Gostout BS, et al: Aggressive surgical effort andimproved survival in advanced-stage ovarian cancer. Obstet Gynecol107:77-85, 2006

5. Del Campo JM, Felip E, Rubio D, et al: Long-term survival in advancedovarian cancer after cytoreduction and chemotherapy treatment. Gy-necol Oncol 53:27-32, 1994

6. Armstrong DK, Bundy B, Wenzel L, et al: Intraperitoneal cisplatin andpaclitaxel in ovarian cancer. N Engl J Med 354:34-43, 2006

7. Omura GA, Bundy BN, Berek JS, et al: Randomized trial of cyclophos-phamide plus cisplatin with or without doxorubicin in ovarian carci-noma: A Gynecologic Oncology Group Study. J Clin Oncol 7:457-465,1989

8. Eisenkop SM, Spirtos NM, Lin WC: “Optimal” cytoreduction for ad-vanced epithelial ovarian cancer: A commentary. Gynecol Oncol 103:329-335, 2006

9. Nelson BE, Rosenfield AT, Schwartz PE: Preoperative abdominopelviccomputed tomographic prediction of optimal cytoreduction in epithe-lial ovarian carcinoma. J Clin Oncol 11:166-172, 1993

0. Bristow RE, Duska LR, Lambrou NC, et al: A model for predictingsurgical outcome in patients with advanced ovarian carcinoma usingcomputed tomography. Cancer 89:1532-1540, 2000

1. Dowdy SC, Mullany SA, Brandt KR, et al: The utility of computed
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in women with advanced ovarian carcinoma. Cancer 101:346-352,2004

2. Meyer JI, Kennedy AW, Friedman R, et al: Ovarian carcinoma: Value ofCT in predicting success of debulking surgery. AJR Am J Roentgenol165:875-878, 1995

3. Chi DS, Venkatraman ES, Masson V, et al: The ability of preoperativeserum CA-125 to predict optimal primary tumor cytoreduction in stageIII epithelial ovarian carcinoma. Gynecol Oncol 77:227-231, 2000

4. Kayikcioglu F, Kose MF, Boran N, et al: Neoadjuvant chemotherapy orprimary surgery in advanced epithelial ovarian carcinoma. Int J Gy-necol Cancer 11:466-470, 2001

5. Vergote I, De Wever I, Tjalma W, et al: Neoadjuvant chemotherapy orprimary debulking surgery in advanced ovarian carcinoma: A retro-spective analysis of 285 patients. Gynecol Oncol 71:431-436, 1998

6. Buchsbaum HJ, Brady MF, Delgado G, et al: Surgical staging of carci-noma of the ovaries. Surg Gynecol Obstet 169:226-232, 1989

7. Trope C, Kaern J: Primary surgery for ovarian cancer. Eur J Surg Oncol32:844-852, 2006

8. Harris WJ: Complications of hysterectomy. Clin Obstet Gynecol 40:928-938, 1997

9. Eisenkop SM, Spirtos NM: Procedures required to accomplish com-plete cytoreduction of ovarian cancer: Is there a correlation with “bio-logical aggressiveness” and survival? Gynecol Oncol 82:435-441, 2001

0. Eisenkop SM, Friedman RL, Wang HJ: Complete cytoreductive surgeryis feasible and maximizes survival in patients with advanced epithelialovarian cancer: A prospective study. Gynecol Oncol 69:103-108, 1998

1. Eisenhauer EL, Abu-Rustum NR, Sonoda Y, et al. The addition of ex-tensive upper abdominal surgery to achieve optimal cytoreduction im-proves survival in patients with stages IIIC-IV epithelial ovarian cancer.Gynecol Oncol 103:1083-1090, 2006; Epub 2006 Aug 4

2. Cliby W, Dowdy S, Feitoza SS, et al: Diaphragm resection for ovariancancer: Technique and short-term complications. Gynecol Oncol 94:655-660, 2004

3. Eisenkop SM, Spirtos NM, Lin WC: Splenectomy in the context ofprimary cytoreductive operations for advanced epithelial ovarian can-cer. Gynecol Oncol 100:344-348, 2006

4. Wheeless C: Atlas of pelvic surgery. Baltimore, MD: Williams &Wilkins, 1997

5. Gershenson DM: Fertility-sparing surgery for malignancies in women.J Natl Cancer Inst Monogr (34):43-47, 2005

6. Gershenson DM: Management of early ovarian cancer: Germ cell andsex cord-stromal tumors. Gynecol Oncol 55(Pt 2):S62-S72, 1994

7. Sherman ME, Mink PJ, Curtis R, et al: Survival among women withborderline ovarian tumors and ovarian carcinoma: A population-basedanalysis. Cancer 100:1045-1052, 2004

8. Fauvet R, Boccara J, Dufournet C, et al: Restaging surgery for womenwith borderline ovarian tumors: Results of a French multicenter study.Cancer 100:1145-1151, 2004

9. Land R, Perrin L, Nicklin J: Evaluation of restaging in clinical stage 1Alow malignant potential ovarian tumours. Aust N Z J Obstet Gynaecol42:379-382, 2002

0. Junor EJ, Hole DJ, Gillis CR: Management of ovarian cancer: Referral toa multidisciplinary team matters. Br J Cancer 70:363-370, 1994

1. Junor EJ, Hole DJ, McNulty L, et al: Specialist gynaecologists and sur-vival outcome in ovarian cancer: A Scottish national study of 1866patients. Br J Obstet Gynaecol 106:1130-1136, 1999

2. Kehoe S, Powell J, Wilson S, et al: The influence of the operatingsurgeon’s specialisation on patient survival in ovarian carcinoma. Br JCancer 70:1014-1017, 1994

3. Earle CC, Schrag D, Neville BA, et al: Effect of surgeon specialty onprocesses of care and outcomes for ovarian cancer patients. J NatlCancer Inst 98:172-180, 2006

4. Schrag D, Earle C, Xu F, et al: Associations between hospital and sur-geon procedure volumes and patient outcomes after ovarian cancer
resection. J Natl Cancer Inst 98:163-171, 2006

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urgical Managementf Diaphragm Disease in Ovarian Cancerilliam Cliby, MD, and Giovanni Aletti, MD

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n a recent report from a questionnaire to the membershipof the Society of Gynecologic Oncologists (SGO),1 bulky

iaphragm disease was one of the three most commonly re-orted sites of disease that resulted in suboptimal cytoreduc-ion. Nearly half of respondents that most frequentlychieved low rates of optimal cytoreduction cited lack ofvidence that performing radical procedures improved sur-ival.

This philosophy conflicts with the longstanding belief thatolume of residual disease is one of the most important in-ependent predictors of survival. Additionally, there is ampleata demonstrating a benefit for patients treated with radicalpper abdominal procedures to achieve a low residual dis-ase.2,3 Widespread intra-abdominal tumor (carcinomato-is), large amounts of ascites, nodal metastasis, and high his-ologic grade are all considered signs of tumor aggressivenessnd associated with poor survival. However, there is also atrong association with most of these factors and low optimalebulking rates in most series.4-7 Thus, the question of theelative roles of tumor biology and residual disease is unclear.nfortunately, no independent factors have been identified

hat adequately predict either tumor resectability or biologi-al aggressiveness in typically advanced stage disease. Impor-antly, there is no method yet to “a priori” predict in vivoensitivity and thus select those patients most likely to benefitrom complete surgery. Considering these observations, and

rom the Department of Obstetrics and Gynecology, Mayo Clinic, Roches-ter, MN.

ddress reprint requests to William Cliby, MD, Department of Obstetricsand Gynecology, Mayo Clinic, Rochester, MN 55902. E-mail: cliby.

[email protected].


ecognizing the importance of intrinsic biological behavior invarian cancer, surgical cytoreduction remains the corner-tone of management of advanced stage ovarian cancer pa-ients.8-10 Recognizing this, it behooves us to maximize ourbility to safely resect difficult tumors.

Several procedures have been described as feasible in thepproach to upper abdominal disease.11-14 However, there isuch evidence suggesting limited use of these procedures.ata from the National Survey of Ovarian Carcinoma in 1993

evealed that only 42% to 45% of patients primarily treatedy a gynecologic oncologist received optimal debulking.15

he corrected rate would be lower recognizing the definitionf optimal debulking used in that study exceeded the com-only accepted definition today of less than 1 cm. The sur-

ey of SGO membership also suggests relative lack of treat-ent of diaphragm disease.1 Memorial Sloan Ketteringancer Center has published results demonstrating that ef-

orts to improve upper abdominal surgical experience canignificantly impact the percentage of patients optimally andompletely cytoreduced.16 We have progressively been mod-fying our own approach to diaphragm disease and attempt toreat it as we would disease in other locations in the abdom-nal cavity. Initially, our attempt utilized a combination ofechniques including ablative techniques. This approach hasvolved to one focused primarily on resection. Close workingelationship with hepatobiliary surgeons has been extremelyaluable in gaining familiarity and experience in mobilizationf the liver during the learning curve. We feel that this ap-roach is safe in patients deemed able to undergo radicalurgical procedures necessary for debulking surgery. We willescribe the technique used and the impact on survival we
ave observed after such procedures.
61

62 W. Cliby and G. Aletti

Operative Technique

the xyphoid process, dividing the cartilage if necessary.

Figure 1 Before mobilizing the liver, little room or exposuthe outer muscular region of the diaphragm is only slighstrong retraction of costal margin and liver. Attemptingof uncontrollable hemorrhage if vascular injury occurs anincision used for abdominal procedures is extended to

re is available to safely approach the diaphragm. As seen heretly visible and none of the central portion can be seen despitetreatment of disease utilizing only retraction is subject to riskd generally results in under-treatment of disease. The midline

Surgical management of diaphragm disease 63

Figure 2 Liver mobilization begins by division of the hepatic ligamentum teres near the abdominal wall, and then the
falciform ligament. The ligamentum teres generally requires ligation for hemostasis.


Figure 3 With downward traction on the liver, the falciform ligament is divided further in the posterior direction until
the hepatic veins are just visible.


Figure 4 The right coronary and triangular ligaments are then divided exposing the bare area of the liver and completely
freeing the liver from the peritoneal attachments to the diaphragm, posterior abdominal wall, and right kidney.


Figure 5 The liver can now be rotated medially and retracted inferiorly, allowing complete exposure to the righthemidiaphragm. The diaphragm can be seen grossly to consist of a central tendinous portion and a peripheral portionthat is more muscular (central tendinous portion labeled D). The peritoneum overlying the kidney (K) and adrenal (Ad)
can be seen.

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here are limited descriptions in the literature of technique ofiaphragm stripping or resection. We have previously de-cribed our technique but without the benefit of graphicisplay.14 The few reports in the literature do a cursory job ofetailing steps of liver mobilization that we emphatically be-

ieve is the key to safely performing these procedures. Theight diaphragm is more commonly involved than the leftiaphragm, and presents the greatest difficulty with exposureecause of the close proximity of the liver. To obtain properxposure requires three steps: (1) adequate incision; (2) mo-ilization of the liver; (3) strong retraction of the costal mar-in, generally through the use of a fixed external retractionevice (ie, third arm retractor) as shown fully in Fig 2 andsed for all figures (Figs 1-6).

onclusionshe question of survival benefit of is always raised duringiscussions of extended procedures used for cytoreduction ofvarian cancer. We have previously shown that such proce-ures are well tolerated with acceptable morbidity.14 In pa-ients with significant lung disease and limited pulmonaryeserve this operation may carry significant respiratory com-romise but it is unlikely they would be candidates for radicalebulking operations. Regarding survival, intuitively if oneelieves the dogma and evidence regarding a survival benefitor lower residual disease, it is difficult to argue against dia-hragm resection. Is it more justified to resect disease in theight colic gutter compared with disease on the diaphragm?n the other hand, is lack of familiarity with the procedure

™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™Figure 6 A typical lesion is shown here. This particular loften encountered: the management is the same. Initibe completely resected by simply stripping the peritoneurequired (B). Thick or invasive lesions generally requiretendinous portion require resection as well as it is nUnfortunately, it is usually not reliably predictable whetbegun by incising the peritoneum over the muscular porsome noninvolved areas of the muscular diaphragm.dissection. The peritoneum is loosely adherent to the mover the tendinous portion as noted above. We feel thacarry a high risk of either perforation of the diaphragmcannot be stripped further, we grasp the lesion with lonperformed. Orienting the incision transversely carries lnerve owing to the pattern of innervation. The resultingteam is informed of the defect and resultant pneumothorof the inner surface of the diaphragm and inspectionMeticulous hemostasis secured to avoid a hemothoraxclosed with monofilament delayed absorbable sutures irupted sutures can be used. Sutures are started at eitherpoint. A 16 French rubber catheter is temporarily placepatient is placed in steep Trendelenburg position and lotaneously having the anesthesia team apply and hold pslowly withdrawn and removed while tying down there-expansion. The diaphragm is inspected for leaks and fis generally obvious in the steep Trendelenburg positionWe do not place a chest tube at surgery in most patientscases and any significant pneumothorax managed with asymptoms, subsequent chest radiographs are not routin
will require a chest-tube postoperatively.
he critical obstacle? We have analyzed our own cohort ofatients consecutively treated to determine the impact onurvival and this was recently published.17 Briefly summariz-ng, 244 patients were analyzed with a mean age of 64 yearsrange, 24-87) and 5-year overall survival (OS) was 31.5%.or the entire cohort, residual disease (RD) was the only

ndependent prognostic factor in multivariate analysis (P �.0001) when considering other factors including demo-raphic, intraoperative findings and procedures performed.or the subgroup of patients with tumor involving the dia-hragm (N � 181), patients who underwent diaphragm sur-ery (stripping of the diaphragmatic peritoneum, full or par-ial thickness diaphragm resection, excision of nodules orUSA) had improved 5-year OS relative to those that did not

53% vs. 15%; P � 0.0001). Furthermore, in multivariatenalysis of patients with diaphragm disease, both RD anderformance of diaphragm surgery were independent predic-ors of outcome (P � 0.001). Considering the subgroup ofatients with RD �1 cm, we noted a strong survival advan-age for those patients who underwent diaphragm surgicalrocedures (5 years survival: 55% vs. 28%; P � 0.0005).16

e believe that these data are reliable and justify these pro-edures given the relative safety with which they can bechieved.

cknowledgmente wish to thank David A. Factor, section of illustration and

esign, Mayo Clinic for his wonderful artistic help in creatinghe figures for this manuscript.

™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™™relatively isolated, though more confluent plaques are

e inspect to try to determine whether the lesion canhe diaphragm (A) or if a diaphragmatic resection will beickness resection of the diaphragm: those overlying thempossible to strip the peritoneum over this section.ipping will suffice or if resection is needed. Stripping isthe diaphragm or over the posterior abdominal wall oreritoneum is then stripped using sharp and cauteryr portion of the diaphragm and more intimately fusedpts at destruction with either electrocautery or CUSA

ing residual disease. When a lesion is encountered thatclamps to evert the diaphragm, and sharp resection isoretical risk of transaction of branches of the phrenict with lung visible is shown in (B). The anesthesiologypleura and lung are carefully inspected using palpation

urther disease that will preclude complete resection.ostoperative period. The diaphragmatic defect is then-lock horizontal mattress fashion—alternatively inter-f the defect, meeting in the middle, but not tied at thise pleural space before tying the final sutures (C). Thetinuous suction is applied to the catheter while simul-end-expiratory pressure to the lungs. The catheter is

utures to evacuate the pneumothorax and allow lungous evidence of significant residual pneumothorax; thispears as a bellowing of the diaphragm with ventilation.- or intraoperative chest radiograph is performed on alltube. In the absence of pneumothorax, physical sign, orrformed. Using this approach, roughly 10% of patients

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eferences1. Eisenkop SM, Spirtos NM: What are the current surgical objectives,

strategies, and technical capabilities of gynecologic oncologists treatingadvanced epithelial ovarian cancer? Gynecol Oncol 82:489-497, 2001

2. Montz FJ, Schlaerth JB, Berek JS: Resection of diaphragmatic perito-neum and muscle: Role in cytoreductive surgery for ovarian cancer.Gynecol Oncol 35:338-340, 1989

3. Eisenkop SM, Spirtos NM: Procedures required to accomplish com-plete cytoreduction of ovarian cancer: Is there a correlation with “bio-logical aggressiveness” and survival? Gynecol Oncol 82:435-441, 2001

4. Potter ME, Partridge EE, Hatch KD, et al: Primary surgical therapy forovarian cancer: How much and when. Gynecol Oncol 40:195-200,1992

5. Farias-Eisner R, Teng R, Olivera M, et al: The influence of tumor grade,distribution, and extent of carcinomatosis in minimal residual stage IIIepithelial ovarian cancer after optimal primary cytoreductive surgery.Gynecol Oncol 55:108-110, 1994

6. Le T, Krepart GV, Lotocki RJ, et al: Does debulking surgery improvessurvival in biologically aggressive ovarian cancer. Gynecol Oncol 67:208-214, 1997

7. Silvestrini R, Daidone MG, Veneroni S, et al: The clinical predictivity ofbiomarkers of Stage III–IV epithelial ovarian cancer in a prospectiverandomized treatment protocol. Cancer 82:159-167, 1998

8. Griffiths CT: Surgical resection of tumor bulk in the primary treatment
of ovarian carcinoma. NCI Monogr 42:101, 1975
9. Randall TC, Rubin SC: Cytoreductive surgery for ovarian cancer. SurgClin North Am 81:871-883, 2001

0. Hoskins WJ: Epithelial ovarian cancer: Principles of primary surgery.Gynecol Oncol 55:S91-S96, 1994

1. Deppe G, Malviya VK, Boike G, et al: Surgical approach to diaphrag-matic metastases from ovarian cancer. Gynecol Oncol 24:258-260,1986

2. Brand E, Pearlman N: Electrosurgical debulking for ovarian cancer: Anew technique using the argon beam coagulator. Gynecol Oncol 39:115-118, 1990

3. Kapnick SJ, Griffiths CT, Finkler NJ: Occult pleural involvement instage III ovarian carcinoma: Role of diaphragm resection. Gynecol On-col 39:135-138, 1990

4. Cliby W, Dowdy S, Feitoza SS, et al: Diaphragm resection for ovariancancer: Technique and short-term complications. Gynecol Oncol 94:655-660, 2004

5. Nguyen HN, Averette HE, Hoskins W, et al: National survey of ovariancarcinoma. Part V. The impact of physician’s specialty on patients’survival. Cancer 15:72:3663-36701993

6. Eisenhauer EL, Abu-Rustum NR, Sonoda Y, et al: The addition of ex-tensive upper abdominal surgery to achieve optimal cytoreduction im-proves survival in patients with stages IIIC-IV epithelial cancer. Gy-necol Oncol 103:1083-1090, 2006

7. Aletti GD, Dowdy SC, Podratz KC, et al: Surgical treatment of dia-phragm disease correlates with improved survival in optimally de-bulked advanced stage ovarian cancer. Gynecol Oncol 100:283-287,
2006

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elvic and Para-Aortic Lymphadenectomyndrew P. Soisson, MD

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he primary indication for pelvic and para-aortic lymphnode sampling or lymphadenectomy is to evaluate or

reat gynecologic or other malignancies that have a propen-ity for metastases to the retroperitoneal nodes in the pelvisnd lower abdomen. Accurate histologic documentation ofodal metastases is essential so that appropriate surgical stag-

ng can be assigned so that rationale decisions regarding post-perative therapy can be made. For instance, in women withndometrial cancer, metastases to the retroperitoneal nodesesignate the patient as having surgical stage IIIC disease anduch women would be candidates for adjuvant pelvicr extended field radiation.1-3 In addition, retroperitonealymphadenectomy may be indicated for the treatment ofulky tumor metastases that might offer significant palliationrom pain and may prevent thrombotic complications in theuture. Women with uterine cervical cancer or sarcomas fromhe corpus of the uterus often have large retroperitonealodal metastases and surgical resection will provide signifi-ant palliation and may greatly improve response to radiationr chemotherapy.4 Finally, the presence or absence of retro-eritoneal nodal metastases may change the type of postop-rative therapy. In women with epithelial ovarian cancer whondergo optimal cytoreductive surgery (residual diseaseithin the abdominal cavity �1 cm), postoperative chemo-

herapy is clearly indicated and administration through anntraperitoneal (IP) catheter is associated with improved sur-ival compared with intravenous administration. However,he presence of retroperitoneal nodal metastases is a relativeontraindication to IP treatment and if present might neces-itate changing the therapy to intravenous administration ofytotoxic drugs.5

In this manuscript, the surgical process for retroperitonealxploration and resection of lymphatic tissues will be dis-ussed. It should be emphasized that the surgical techniquesllustrated have the potential for significant immediate andate surgical complications, thus, appropriate surgical train-ng is required before initiating these procedures. Clearly, thencidence of surgical complications, especially immediatenes such as hemorrhage and vessel injury, are directlyelated to the skill and experience level of the surgeon.6 The

rom the Division of Gynecologic Oncology, Department of Obstetrics andGynecology, University of Utah, Salt Lake City, UT.

ddress reprint requests to Andrew P. Soisson, MD, Director, Division ofGynecologic Oncology, Department of Obstetrics and Gynecology, Uni-versity of Utah, 30N, 1900E, Suite 2B200, Salt Lake City, UT 84132.

fE-mail: [email protected].


ncidence of short-term and long-term complications associ-ted with lymphadenectomy is listed in Table 1.

urgical Techniquereoperative Evaluationcareful history should be taken on all patients undergoing

elvic and para-aortic lymphadenectomy to determine ifhere is any exposure to anticoagulants including aspirinherapy. In addition, all patients requiring retroperitonealxploration will require some form of deep vein thrombosisDVT) or pulmonary embolism prophylaxis. In patients withynecologic malignancies undergoing surgery the incidencef DVT ranges from 17% to 40%.7 At our institution, full-ength pneumatic compression stockings are employed. Itemains controversial whether combined therapy using com-ression stockings and unfractionated heparin or low molec-lar weight heparin is beneficial. It is also controversial as tohether the use of these agents for extended periods after

hey leave the hospital provides clinically significant prophy-axis against DVT. The use of prophylactic oral or intravenousntibiotics is also controversial but should be considered.inally, the surgeon should consider mechanical, antibioticowel prep, or both, in the preoperative period. In mostases, exposure of the retroperitoneum requires mobilizationf either the ascending colon, descending colon, or the duo-enum and injury to these structures can occur. Finally, priorxposure to pelvic or extended field radiation to the para-ortic region or the presence of retroperitoneal fibrosis canake exposure of these areas extremely difficult.

urgical Approachwo surgical approaches (retroperitoneal or transperitonealissection) can be utilized for exposure to the pelvic andbdominal retroperitoneal spaces both of which will be dis-ussed below.

etroperitoneal Approachcompletely retroperitoneal approach has the advantage of

voiding the peritoneal cavity and minimizing large andmall bowel adhesions. This approach should be consideredhen postoperative radiation will be employed because it haseen demonstrated in multiple studies that this surgical ap-roach will reduce gastrointestinal complications of obstruc-ion and fistula formation after retroperitoneal exploration
ollowed by radiation compared with a transperitoneal sur-

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Pelvic and para-aortic lymphadenectomy 71

ical approach.8,9 Retroperitoneal dissection should be per-ormed through a transverse incision made from a point 2 cm

edial to the anterior-superior iliac crest and then 2 cmnferior to this to a second point 2 to 4 cm superior to theymphysis pubis in the midline and then to the correspond-ng point laterally (Fig 1). A natural cleavage plane can beeveloped in both directions from the midline between thendersurface of the rectus-abdominus muscle and the supe-ior surface of the peritoneum until the retroperitoneal spacesre exposed. Exposure to the retroperitoneal structures wille greatly facilitated by the use of a self-retaining retractoruch as a Bookwalter retractor or other similar devices. Afterhe dissection has been completed, it would be advisable to

able 1 Incidence of Operative Complications Associatedith Retroperitoneal Lymph Node Dissection

Complication Incidence (%)

Hemorrhage 1 to 2Incidence of transfusion 1 to 2Vessel injury 1 to 2Deep vein thrombosis 2 to 5Lymphedema 30Lymphocyst 15

Figure 1 Anatomic landmarks for M

eave an action drain to prevent formation of a lymphocyst inhis essentially closed space. A retroperitoneal approachould be relatively contraindicated in the patient who hasreviously undergone retroperitoneal exploration. In this sit-ation, the natural tissue planes have been obliterated andhe dissection will be compromised. Finally, this technique isptimal for a retroperitoneal approach limited to the pelvisnd the retroperitoneal structures below the aortic bifurca-ion. Exposure of the abdominal spaces above the aortic bi-urcation will be limited, especially if the dissection isrimarily on the left side of the aorta; in this situation aransperitoneal dissection is preferred and should be con-idered.

ransperitoneal Approachor Para-Aortic Explorationxploration of the retroperitoneal structures both in the pel-is and the abdomen can be achieved through this approachnd for most situations is preferable to a completely retroper-toneal dissection as exposure is better. Usually, a midlineertical incision below and above the umbilicus is employed.fter visual examination and palpation of the abdominal cav-

ty and organs is performed, retroperitoneal dissection can be

allard or Cherney incision.

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72 A.P. Soisson

ccomplished utilizing a variety of techniques to facilitatexposure depending on the location of the pathology. Whenxposure of the vena-cava is desired, transsection of the peri-oneal attachments to the ascending colon followed by mo-ilization of it superiorly and medially and dissection of theonadal vein to its insertion into the IVC, will greatly facilitatexposure to this area (Fig 2). The ureter should be mobilizedway from these structures and should be dissected awayrom the medial leaf of the peritoneum to avoid injury. Theonadal vein can be ligated at its insertion into the vena cavand the duodenum can be mobilized superiorly to gain ex-osure of the IVC to the renal vessels. The retroperitonealortion of the duodenum, ascending colon, and ureter canhen be protected by placement of the blades of the self-etaining retractor. If exposure to the left side of the aorta ishe primary objective, two techniques can be utilized forxposure to this area. If exposure to the left common iliacrtery and lower aorta is desired, reflection of the descending

Figure 2 Exposure of the right para-aortic reg

olon and its mesentery medially will allow sufficient expo- l

ure to these structures. The ureter should be mobilized withhe colon and dissection from its peritoneal attachments isot necessary (Fig 3). If exposure of the aorta from its bifur-ation to the renal vessels is required, it may be necessary toigate the inferior mesenteric artery and ressect a portion ofhe mesentery of the descending colon. In this instance, itould be advisable to completely mobilize the ureter and

etract it laterally to avoid injury to it (Fig 4).

ransperitoneal Approach forelvic Retroperitoneal Explorationxposure of the retroperitoneal structures of the pelvis below

he pelvic brim is a common procedure in the surgical treat-ent of gynecologic and other pelvic malignancies. Exposure

f these structures is relatively easy and associated with loworbidity when done properly. If the surgical procedure is

imited to a pelvic retroperitoneal exploration, a vertical mid-

ilizing mobilization of the ascending colon.

ine or transverse incision can be used. The use of a transverse


Figure 3 Exposure of the left (low) para-aortic region utilizing mobilization of the left colon and ureter.

74 A.P. Soisson

Figure 4 Exposure of the left (high) para-aortic region utilizing mobilization of the ureter laterally.


Figure 5 Development of the pelvic para-rectal and para-vessicle spaces.

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allard or Cherney incision may be advisable and is easy toerform. These incisions utilize the same landmarks for aransverse incision described above. After the skin incision isade, the lateral border of the rectus-abdominus muscle is

xposed from the umbilicus to the insertion of the musclento the symphysis pubis. The inferior epigastric artery andein should be ligated and transected to prevent bleeding.fter this is accomplished, the rectus muscle can be transectedbove its tendinous insertion (Mallard), or through its tendi-ous insertion (Cherney) and then reflected superiorly.hese incisions provide good exposure to the pelvic retroper-

toneal areas. After exploration of the abdomen, the smallowel is packed into the upper abdomen with a self-retainingetractor. We advise that the procedure be performed in atepwise fashion utilizing the following maneuvers: (1) Theeritoneum over the ileo-psoas muscle is transected fromhe pelvic brim to the inguinal ligament in the direction of theleo-psoas. If the uterus has not been removed at a priorurgery, the round ligament should be ligated and divided.2) The para-rectal and para-vessicle spaces are developed bylunt dissection to expose the ureter, common iliac, external

liac, and internal iliac artery and veins (Fig 5). (3) Using aein retractor the external iliac artery and vein can be re-racted laterally and superiorly to expose the obturator nervend lymph nodes in this region. (4) The lymph nodes can be
emoved over these vessels with sharp dissection and can be
acilitated with the use of hema-clips to prevent bleeding andhe formation of lymph edema and lymphocyst.

eferences. Keys HM, Roberts JA, Brunetto VL, et al: A phase III trial of surgery with

or without adjuvant external pelvic radiation therapy in intermediaterisk endometrial adenocarcinoma: A gynecologic oncology group study.Gynecol Oncol 92:744-751, 2004

. Creutzberg CL, van Putten WL, Koper PC, et al: Survival after relapse inpatients with endometrial cancer fro a randomized trial. Gynecol Oncol89:201-209, 2003

. Lee CM, Szabo A, Shrieve DC, et al: Frequency and effect of adjuvantradiation therapy among women with stage I endometrial adenocarci-noma. JAMA 295:389-397, 2006

. Moutardier V, Houvenaeghel G, Martino M, et al: Surgical resection oflocally advanced cervical cancer: A single institutional 70 series. Int JGynecol Cancer 14:846-851, 2004

. Armstrong DK, Bundy B, Wenzel L, et al: Intraperitoneal cisplatin andpaclitaxel in ovarian cancer. N Engl J Med 354:34-43, 2006

. Cliby WA, Clarke-Pearson DL, Dodge R, et al: Acute morbidity and mortal-ity associated with pelvic and para-aortic lymphadenectomy in the surgicalstaging of endometrial adenocarcinoma. J Gynecol Tech 1:19, 1995

. Maxwell GL, Clarke-Pearson D: Pulmonary embolism after major abdomi-nal surgery in gynecologic oncology. Obstet Gynecol 108:209-211, 2006

. Schellhas HF: Extraperitoneal approach to the pelvis after radiation ther-apy or radical surgery. Am J Obstet Gynecol 137:367-376, 1980

. Sonoda Y, Leblanc E, Querieu D, et al: Prospective evaluation of surgicalstaging of advanced cervical cancer via a laparoscopic extraperitoneal
approach. Gynecol Oncol 91:326-331, 2003

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ysterectomy is the second most common operation per-formed on women in the United States. It is anticipated

hat the general surgeon will at some time encounter a gyne-ologic condition necessitating an abdominal hysterectomy.ossible indications for hysterectomy include malignancy,enign growths, functional problems, structural abnormali-ies, or involvement of the uterus with adjacent structureseing excised (Figs 1-7).If the abdomen is not already open when hysterectomy is

ontemplated, the most important consideration for the pel-ic surgeon is the choice of incision. Adequate exposure forhe intended procedure is certainly the most important fac-or. Transverse incisions are used more by the pelvic surgeonecause the entire incision is located over the area of interest.ransverse incisions are less painful postoperatively and healith a lower risk of dehiscence or hernia formation. Exposure

o the lateral aspects of the pelvis is limited by the typicalfannenstiel incision where the rectus muscles are simplyetracted laterally from the midline. Although exposurehrough a transverse incision can be increased by transectinghe rectus muscles through the muscle belly (Maylard inci-ion) or through the muscle tendon (Cherney incision), spaceo work around a large mass or uterus is still limited andccess to the upper abdomen is essentially impossible. Aertical incision may be more uncomfortable and is associ-ted with greater healing difficulties, but will obviously pro-ide the greatest exposure and free access throughout thebdominal cavity.

Once hysterectomy is decided on and the abdominal cav-ty is entered, the bowel should be packed out of the pelvisnd held with a self-retaining retractor. The uterus is graspedt both cornua with Péan or Kocher clamps for manipulationnd traction of the uterus out of the pelvis and into thencision. The uterus is pulled to one side placing the oppositeound ligament under tension. Once on tension, the roundigament can be suture ligated with a No. 0 absorbable suturend cut with scissors or, alternatively, can be transected withlectrocautery. Once the round ligament is transected, airill dissect beyond the peritoneum of the broad ligament

nto the underlying areolar tissue. The peritoneal incisionan then safely be extended from the transected round

rom the Department of Obstetrics and Gynecology, Penn State College ofMedicine/Milton S. Hershey Medical Center, Hershey, PA.

ddress reprint requests to Paul R. Kramer, MD, Department of Obstetricsand Gynecology, Penn State College of Medicine/Milton S. Hershey Med

pCenter, Hershey, PA 17033. E-mail: [email protected].


igament cephalad along the infundibulopelvic ligamentontaining the ovarian vessels. Blunt dissection of the are-lar tissue in the retroperitoneal space will permit identi-cation of the ureter along the medial leaf of the broad

igament as it courses into the pelvis over the bifurcation ofhe common iliac artery. A similar procedure is performedn the opposite side.At this point in the operation, the decision to remove or

reserve the ovaries must be made. Ovaries may be removedecause of suspicious morphology, known benign or malig-ant conditions, the presence of breast cancer, an increasedisk of ovarian cancer, including BRCA mutations, or simplyecause the patient is postmenopausal. If the ovaries are to beemoved, after identification of the ureter, an incision is cre-ted in the medial leaf of the broad ligament between thenfundibulopelvic ligament and the ureter below. The infun-ibulopelvic ligament is doubly clamped with Kelly oreaney clamps, transected, and doubly ligated with a No. 0

bsorbable tie and suture. This is repeated on the oppositeide. In the event the ovaries are to be preserved, a similarefect is created in the medial leaf of the broad ligamentbove the ureter. The utero-ovarian ligament is doublylamped with Kelly or Heaney clamps between the ovary andhe uterine cornu, transected with scissors, and doubly tiedith a No. 0 absorbable suture. This is likewise performedilaterally. For visualization and safety, the preserved ovariesan be packed out of the pelvis until completion of the hys-erectomy.

Once the ovaries have been managed, upward traction islaced on the uterus to place the anterior vesicouterine peri-oneum on stretch. This peritoneum is incised from oneransected round ligament to the other with areolar tissuegain encountered. This areolar tissue is dissected down tohe anterior surface of the cervix. The peritoneal edge overhe bladder can be grasped with forceps or an Allis clampnd the bladder is sharply dissected away from the anteriorurface of the cervix with Metzenbaum scissors or electrocau-ery. Blunt dissection can also be used to develop this vesi-ocervical and vesicovaginal space, although it may result inore bleeding and a higher incidence of bladder injury. The

ladder must be mobilized from the cervix and vagina belowhe point where the cervix and vagina meet. The length of theervix and extent of required bladder mobilization can beasily determined by palpation. The surgeon’s hand is placedn the pelvis with the fingers behind the uterus and cervix andith the thumb anterior to the cervix. The cervix is easily
alpated as it protrudes into the vagina.
77

78 P.R. Kramer

Figure 1 Division of the ovarian artery and vein (infundibulopelvic ligament) when performing a salpingo-oophorectomy.

Hysterectomy 79

Figure 2 Division of the utero-ovarian ligament when preserving the ovary.

80 P.R. Kramer

Figure 3 Advancement of the bladder.

Hysterectomy 81

Figure 4 Division of the uterine artery and vein at the junction of the fundus and cervix.

82 P.R. Kramer

Figure 5 Division of the cardinal ligament.

Hysterectomy 83

Figure 6 Removal of the uterus and cervix.

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84 P.R. Kramer

After the bladder is safely reflected away from the uterusnd cervix, the uterine vessels are identified at the uterinesthmus or cervicouterine junction. The vessels are clampedilaterally, placing curved Heaney or Zeppelin clamps at a0-degree angle to the vessels (parallel to the floor) and slid-

ng the tip of the clamps off the side of the cervix. Clampingilaterally generally obviates the need to deal with backleeding, other than the blood in the uterus itself. The vesselsre then cut with Metzenbaum scissors and ligated with aeaney transfixion stitch of a No. 0 absorbable suture.The bladder is again examined to assure it is mobilized

ufficiently from the underlying vagina just beyond the junc-ion of the cervix and vagina. The cardinal ligament can thene clamped, cut, and sutured. This may require a successionr repetitive steps, depending on the length of the cervix.

Figure 7 V

sing a straight clamp, the cardinal ligament is clamped by t

liding the tips off the cervix and by staying inside of (medialo) the ligated uterine vessel pedicle. If successive bites areequired to reach the cervicovaginal junction, all clamps arelaced in a like manner, sliding off the cervix and staying

nside the previous pedicle. Once clamped, the cardinal lig-ment pedicle is transected with Mayo scissors or a scalpelnd is ligated with a Heaney transfixion stitch of a No. 0bsorbable suture.

When the cervicovaginal junction is reached, curvedeaney or Zeppelin clamps are placed just below the palpa-le cervix. These clamps incorporate the vaginal angles andhe uterosacral ligaments posteriorly. The tips of the clampsan meet in the midline, although this is not necessary. Theladder should be reflected away from the underlying vaginanough to prevent grasping bladder edge in the clamps. Al-

closure.

ernatively, the anterior vagina can be opened with a scalpel

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Hysterectomy 85

r electrocautery. There should be about a 5 mm margin be-ween this incision and the edge of the reflected bladder toermit safe closure of the vagina at the completion of the hys-erectomy. Curved Heaney or Zeppelin clamps are then placedilaterally across the vaginal angles and uterosacral ligaments,

ust below the cervix, with the anterior tips of the clamps insidehe opened vagina. Regardless of the approach to the upperagina, the uterus and cervix are amputated from the vaginalong these clamps using heavy scissors. The vaginal angles areigated with a Heaney transfixion stitch of a No. 0 absorbableuture. The anterior and posterior vaginal edges are graspedith Kocher or Allis clamps with care taken to incorporate theaginal mucosa. The vagina is closed anterior to posterior withnterrupted figure-of-eight No. 0 absorbable sutures.

The pelvis is irrigated and hemostasis is assured. Pelvic
eperitonealization is unnecessary. The bowel packs are re-
oved allowing the bowel, and preserved ovaries, to returno the pelvis.

uggested Reading.S. Department of Health and Human Services, Office of Women’s Health.

Hysterectomy. Available at: http://www.4woman.gov/faq/hysterectomy.htm. Accessed December 22, 2006

ones HW 3rd: Hysterectomy, in Rock JA, Jones HW 3rd (eds): TeLinde’s Op-erative Gynecology. Philadelphia, PA: Lippincott Williams & Wilkins,2003, pp 810-816

orrow CP, Curtin JP: Gynecologic Cancer Surgery. New York: ChurchillLivingstone, 1996, pp 491-495

rantcharov TP, Rosenberg J: Vertical compared with transverse incisions inabdominal surgery. Eur J Surg 167:260-267, 2001

isen A, Rebbeck TR, Wood WC, et al: Prophylactic surgery in women withhereditary predisposition to breast and ovarian cancer. J Clin Oncol
18:3454-3455, 2000
http://www.4woman.gov/faq/hysterectomy.htm










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aparoscopic Oophorectomyerald Harkins, MD

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dvances in laparoscopy have had a tremendous impacton the role of surgery for the female patient. Some of the

arliest applications of laparoscopy in day-to-day surgery in-olved laparoscopic tubal sterilization beginning in the940s.1 Gynecologists now routinely employ laparoscopy asart of their protocol for the evaluation and treatment ofelvic pain. This is also true in the diagnosis and manage-ent of adnexal and ovarian masses. Most ovarian masses are

enign and laparoscopy can be safely utilized in the majorityf patients. The indications for removal of an ovary, oopho-ectomy, include persistent pelvic pain, recurrent ovarianysts, endometriomas, chronic pelvic inflammatory disease,elvic ovarian adhesions, or a persistent adnexal or ovarianass in a postmenopausal patient.2 Many of these can be

pproached via laparoscopy.Prophylactic oophorectomy remains a controversial issue.varian cancer is the fifth leading cause death in the United

tates3 and prophylactic oophorectomy remains the mostffective means for the prevention of ovarian cancer.4 Therecise role of prophylactic oophorectomy in patients with atrong family history of ovarian cancer or in patient withositive genetic findings of the BRCA1 and BRCA2 mutationsemains unclear. Recent studies, though, confirm that pro-hylactic bilateral oophorectomy reduces the risk of ovarianancer in women with a BRCA mutation by 95%.5 Addition-lly, prophylactic bilateral oophorectomy in premenopausalRCA carriers can reduce the risk of breast cancer by 50%.6

The benefits of laparoscopic management of adnexal andvarian masses as opposed to laparotomy have been wellstablished. They include decreased operative morbidity andlood loss, as well as reduced postoperative pain, decrease inospital length of stay and quicker return to activities of daily

iving and work.7,8

rom the Department of Obstetrics and Gynecology, Penn State College ofMedicine/Milton S. Hershey Medical Center, Hershey, PA.

ddress reprint requests to Gerald Harkins, MD, Department of Obstetricsand Gynecology, Penn State College of Medicine/Milton S. Hershey Med-

mical Center, Hershey, PA 17033. E-mail: [email protected]


Laparoscopic management is safe and effective in theands of experienced laparoscopic surgeons. However, thereave been concerns regarding laparoscopic management ofvarian masses because of the possibility of misdiagnosingvarian malignancy, concern for possible tumor spillage, andncomplete surgical staging with laparoscopy. Because manyeneral surgical procedures are undertaken via laparoscopicechniques, it is important for the general surgeon to be ableo safely perform laparoscopic removal of diseased adnexa.

There have been many studies confirming the safety andfficacy of laparoscopy in the management of ovarian masses.urrent recommendations are that laparoscopy can be the

reatment of choice when managing benign ovarian and ad-exal masses.9 Although there are studies demonstrating theafe management of ovarian malignancies with laparoscopy,t is the current recommendation that suspected ovarian can-er be managed by laparotomy and more specifically by aynecologic oncologist.10

Some guidelines to use when triaging an adnexal ovarianass that would have low potential for malignancy include: a

imple cyst with no septation or vegetative structure within,ysts in premenopausal women, the absence of ascites orelvic fluid, unilateral cysts, and an ovary that is freely mobilen physical examination.11 It has also been recommendedhat pelvic washings be obtained at the initiation of any lapa-oscopy for ovarian cysts if there is any possibility of a malig-ant ovarian tumor. Our recommendation is to collect theashings first and then perform inspection of the ovaries andelvis. The washings do not need to be submitted for cyto-

ogical evaluation if the ovary is clearly benign.12 Likewise,e feel that immediate pathologic evaluation by frozen sec-

ion should be available when necessary.Some authors have recommended preoperative screening

ith pelvic examination, ultrasound, and CA-125 levels tomprove the diagnostic accuracy of malignancy before sur-ery. Elevated CA-125 levels in postmenopausal patientsith an adnexal mass, or sonographic findings that demon-

trate a septum, internal papillary lesions, or increased vas-ularity are all evidence that would make the adnexal mass
ore likely to be malignant.13

Laparoscopic oophorectomy 87

Operative Technique

elvic anatomy.
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88 Gerald Harkins

Figure 2 (A) Grasp the medial pole of the ovary and pull it thru the loop ligature. Secure the ligature at the base of theovary to secure the blood supply (ovarian artery and vein). (B) Grasp the medial pole of the ovary and secure the baseof the ovary with its blood supplies (ovarian vessels, utero-ovarian ligament) with bipolar coagulation or some similar
form of laparoscopic energy source.


Figure 3 Laparoscopic adnexectomy. (A) Identify the ureter as it crosses the pelvic brim and incise the peritoneum overthe infundibulo-pelvic ligament. (B) With laparoscopic graspers, pull the base of the ovary superiorly and lateral awayfrom the ureters and coagulate and cut the IP ligament with its ovarian artery and vein. This will allow you to retract theovary and tube up from the areolar tissue of the broad ligament, always identifying the ureters along the medial leaf ofthe broad ligament. By retracting the adnexal structures superiorly and laterally, this will allow the ureters to fall away
from your operative field.

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90 Gerald Harkins

he technique of laparoscopic oophorectomy or salpingo-ophorectomy begins with the same principles that guideophorectomy via laparotomy. Initial efforts are directed atdentifying important anatomic relationships. The course ofhe ureters must be determined. The ureter is best seen cours-ng over the pelvic brim and moving down into the pelvishrough its course in the medial leaf of the broad ligament.he course of the left ureter can be more difficult to traceince it travels over the pelvic brim near the base of theescending colonic mesentery.Once both ureters have been identified, the next step is to

solate and identify the ovarian vascular supply as it courseshrough the infundibulopelvic (IP) ligament. It is best topen the peritoneum in the mesoovarian space of the broadigament, between the round ligament and fallopian tube andateral to the IP ligament. The peritoneum of this space isomposed of loose areolar tissue and is an avascular planehat allows access to the space between the anterior and pos-erior folds of broad ligament peritoneum. Now, movingephalad, the course of the IP ligament with its ovarian arterynd vein can be isolated and identified. Again, identify theourse of the ureters along the base of anterior medial leaf ofhe broad ligament as it proceeds into the pelvis before divid-ng the IP ligament.

Securing the ovary for removal can be accomplished inany ways. One of the simplest techniques is by way of a

oop ligature or Endoloop. This technique is adequate for aelatively normal size ovary. Once the ovary is dissected free

Figure 3 (C) Continue to retract the adnexal structures, tuuntil you are able to divide the fallopian tube and uteropedicle to allow freeing the adnexa for removal.

f any para-ovarian adhesions and the course of the ureters o

dentified, simply place the loop ligature around the ovarynd secure the knot at the base of the ovary to control thelood supply, or in a similar fashion, place the loop near thevary and reach with a laparoscopic grasper thru the loopnd pull the ovary back into the loop and secure the base.ext the ligature can be cut to leave the base secured and

ndoshears can be used to remove the ovary from its securedascular pedicle.

This technique can be replicated with any of the laparo-copic energy sources. The basic steps of the technique re-ain the same, that is isolate and free the ovary, identify thereters and the IP ligament containing the ovarian artery andein. Transect the IP ligament with cautery or harmonic en-rgy to free the ovary for removal.

For a complete adnexectomy, that is the removal of thevary and its adjacent fallopian tube, it is best to initiatehe dissection in the area of the pelvic brim. Again, be sureo identify the course of the ureter as it crosses the pelvicrim, as well as the iliac vessels as they course laterally tohe pelvis and lower extremities. Incise the peritoneumateral to the IP ligament parallel to its course and pull theP ligament up and away from the ureter. Next secure theP ligament and ovarian blood supply with coagulation.nce coagulation is complete, grasp the tube and ovary

nd gently move them medially and superiorly and dissecthe base of the adnexa from the broad ligament until youre able to completely transect the tube and uteroovarianigament to completely transect the fallopian tube and

d ovary superiorly with careful traction-counter tractionan ligament as a single pedicle. Coagulate and cut this

be, an-ovari

vary as one specimen. The andexa can then be retrieved

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ith a laparoscopic retrieval bag to bring them out of thebdominal cavity. Re-inspect the surgical site to ensureemostasis.

onclusionhe adoption of laparoscopy to evaluate and treat adnexalasses has made a tremendous impact on the care and treat-ent of women. The benefits of laparoscopy over laparotomy

learly make it the treatment of choice for the patient with auspected benign adnexal process. Patients may be treated asn outpatient, have less scaring, less postoperative pain,aster return to full activity and less operative complicationsith equivalent or superior outcomes. However, it is incum-ent on all surgeons who undertake this procedure that theyake themselves aware of the relevant anatomy pertaining to

ophorectomy. Surgeons must always be cognizant of theotential for encountering a malignant ovarian process, andhey should be prepared to correctly handle that contingencyhould it arise.

eferences1. Powers FH, Barnes AC: Sterilization by means of peritoneoscopic tubal

fulgration, a preliminary report. Am J Obstet Gynecol 41:1038-1043, 1941

2. Azziz R, Murphy AA: Operative Laparoscopy and Hysteroscopy (2nded). New York: Springer-Verlag, 1997, p. 147

3. Boring CC, Squires TS, Tong T: Cancer statistics. CA Cancer J Clinic41:19-36, 1991

4. Averette HE, Nguyen HN: The role of phophylactic oophorectomy incancer prevention. Gynecol Oncol 55:S38-S41, 1994

5. Rebbeck TR, Lynch HT, Neuhausen SL: Prophylactic oophorectomy incarriers of BRCA1 or BRCA2 mutations. N Engl J Med 346:1616-1622,2002

6. Kauff ND, Satagopan JM, Robson ME: Risk-reducing salpingoophorec-tomy in women with BRCA1 or BRCA2 mutation. N Engl J Med 346:1609-1615, 2002

7. Gal D, Lind L, Lovecchio JL: Comparative study of laparoscopy vs.laparotomy for adnexal surgery: Efficacy, safety, and cyst rupture.J Gynecol Surg 11:153-158, 1995

8. Hidlebaugh DA, Vulgaropulos S, Orr RK: Treating adnexal masses.Operative laparoscopy vs. laparotomy. J Reprod Med 42:551-558,1997

9. Lee JW, Kim CJ, Lee JE: Selected adnexal cystic masses in postmeno-pausal women can be safely managed by laparoscopy. J Korean Med Sci20:468-472, 2005

0. Vaisbuch E, Dgani R, Ben-Arie A: The role of laparoscopy in ovariantumors of low malignant potential and early-stage ovarain cancer. Ob-Gyn Survey 60:326-330, 2005

1. Marana R, Muzii L, Catalano GF: Laparoscopic excision of adnexalmasses. J Am Assoc Gynecol Laparosc 11:162-166, 2004

2. Pittaway DE, Takacs P, Bauguess P: Laparoscopic adnexectomy: A com-parison with laparotomy. Am J Obstet Gynecol 171:385-389, 1994

3. Ripley D, Golden A, Fahs MC: The impact of laparoscopic surgery in
the management of adnexal masses. Mt Sinai J Med 66:31-34, 1999

gynecologic procedures for the general surgeon

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