ALWAYS get a referral for a gynecological oncology surgeon if you are suspected to have ovarian cancer. My surgery took over 4 hours hours.
(Editors note: I used PDF converter to apply this to my blog)
INDICATIONS / FINDINGS:
On opening the abdomen, the patient was found to have bilateral malignant ovarian masses with the right ovary that was stuck in the pelvic cul-de-sac. These were removed and frozen section pathology revealed malignancy. She had extra-ovarian disease with tumor masses primarily involving the pelvic peritoneum with smaller masses involving the peritoneum over the small bowel mesentery and the pericolic gutter as well as the right hemidiaphragms although minimally. The patient had a tumor mass adjacent to the rectosigmoid colon which was excised. She had tumor involving the appendix and she had significant periaortic lymphadenopathy. She had no evidence of a bowel obstruction. At the end of the procedure the patient was optimally debulked with no tumor masses greater than a few millimeters in size. Therefore, an intraperitoneal Port-A-Cath was placed for subsequent intraperitoneal chemotherapy.
DESCRIPTION OF PROCEDURE: The patient was brought into the operating room and placed supine on the operating room table. She had a general anesthetic induced. She was placed in lithotomy position on the operating rating room table using Allen stirrups. SCDs were placed on the legs to prevent DVT. She received preoperative antibiotics and heparin. She was prepped and draped in normal fashion for an abdominal procedure. A surgical pause was performed. The patient's identity and surgical procedure were confirmed by all the surgical personnel.
After the patient was prepped and draped, we proceeded with a laparotomy incision. This was started at the pubis, taken to the right of the umbilicus and carried cephalad. This was taken through all layers into the peritoneal cavity. On opening the abdomen, the patient was found to have turbid ascites of approximately 500 to 1000 mL. This was aspirated. A general exploration then ensued with the above noted findings. A BookWalter retractor was used for retraction. The small and large bowel were packed into the upper abdomen and held in place with retractors. We proceeded first with a BSO. The uterus was placed on traction. The round ligaments were transected with cautery and the retroperitoneum was opened. The infundibulopelvic ligaments were then isolated separate of the ureters, divided between clamps and ligated. The utero-ovarian ligaments were then divided between clamps. The right tube and ovary were then mobilized by incising the broad ligament. It was then delivered out of the pelvis and sent for frozen section pathology. On the other side a similar procedure was performed. The left tube and ovary were similarly sent fresh.
We then proceeded to complete the hysterectomy. The patient had tumor masses over the bladder peritoneum. The incisions were made to include the tumor masses on the bladder peritoneum adjacent to the uterus. The bladder was sharply and bluntly dissected off of the lower uterine segment and upper vagina. The uterine vessels were skeletonized. They were then cross-clamped, divided and suture transfixed. Similarly the cardinal ligaments and uterosacral ligaments were cross-clamped, divided and suture transfixed.
The upper vagina was cross-clamped. The uterus and cervix were then excised from the upper vagina and taken off the field. The vaginal angles were sutured, transfixed and the remaining vagina was closed with interrupted figure-of-eight sutures. Hemeostasis was secure.
The patient had multiple tumor masses involving the pelvic peritoneum. We systematically either excised these or fulgurated them. Tumor masses over the bladder peritoneum were excised by excising the peritoneal implants. The patient had a. tumor plaque involving the left pelvic sidewall. The left ureter was mobilized off the medial leaf of the broad ligament extensively. We then made a peritoneal incision to excise the entire left pelvic sidewall tumor plaque. The patient had tumor in the back of the vagina which was excised. She had a large tumor plaque in the right pericolic region and this was removed by making a peritoneal incision and excising the tumor intact. The remaining tumor masses were fulgurated or excised. The patient was noted to have a tumor mass adjacent to the rectosigmoid colon on the mesenteric side. This was similarly excised intact. Homeostasis was obtained with figure-of-eight sutures and cautery.
We then carefully inspected the small bowel. The patient was noted to have tumor on the appendix and therefore an appendectomy was performed. The appendiceal mesentery was coapted with the Ligasure device and then divided. The base of the appendix was crushed, doubly ligated and then the appendix was excised from the stump and taken off the field. The base was fulgurated. Hemeostasis was secure. We continued to look for tumor implants over the small bowel mesentery and as these were encountered, they were systematically fulgurated. Similarly the patient had tumor implants over the right pericolic gutter which were fulgurated including a tumor mass adjacent to the posterior inferior aspect of the right lobe of the liver next to the superior pole of the right kidney. This was fulgurated. The patient had miliary implants over the hemidiaphragm and there was no need to remove these since they were so small.
An omentectomy was performed. The omentum was mobilized off the transverse colon and then the lesser sac was widely developed. The gastroepiploic vessels were then serially sealed and divided using the Ligasure device. The omentum was taken off the field.
The remaining tumor involved the right and left periaortic lymph nodes. The peritoneum overlying the right common iliac artery was incised and the incision was taken cephalad to the third part of the duodenum which was mobilized and retracted cephalad. There was extensive malignant lymphadenopathy in the right precaval area and these tumor masses including the right common iliac region all the way up to the left renal vein going over the aorta. The right ovarian artery was encountered, clipped and divided as part of the resection of the malignant lymphadenopathy. The patient also had lymphadenopathy in the left periaortic region. These were excised off of the aorta. The patient also had malignant lymph nodes just in the left periaortic region just below the left renal vein. We similarly dissected these areas and sent them for permanent pathology. During the process we encountered the left ovarian artery which was similarly clipped and divided as part of the resection of the malignant nodes. The abdomen and pelvis were copiously irrigated. The patient had scant bleeding around the left renal vein and this was controlled with placement of Fibrillar Surgicel.
Because the patient was optimally debulked, we decided to place an intraperitoneal Port-A-Cath. The patient had the skin overlying the right subcostal region infiltrated with 1% lidocaine with epinephrine. An oblique incision was made in the skin. The dermis and subcutaneous tissue were divided. A subcutaneous pocket was developed over the fascia overlying the ribs. Using a tunneler, the intraperitoneal catheter was brought from the subcutaneous pocket into the abdomen. It was attached to the hub. Stay sutures of 2-0 Vicryl were then placed to secure the hub to the underlying fascia. The catheter was flushed with heparinized saline. The subcutaneous fascia was closed with a running 2-0 Vicryl and the skin was closed w1th running 4-0Monocryl. The catheter in the abdomen was cut to about 8 cm in length.
Again, the abdomen and pelvis were copiously irrigated and hemeostasis was secure. All instruments and lap tapes were then removed from the abdomen. The abdominal wall was then closed in the routine fashion using a mass closure technique of #l PDS from the superior and inferior aspects and median mid portion. Subcutaneous tissue was irrigated, hemeostasis secured and skin closed with staples. A pressure dressing was placed.Sponge, needle and instrument count were correct times 2. Estimated blood loss was approximately 300 to 400 mL. The patient received no blood intraoperatively. She was allowed to wake up in the operating room and taken to the recovery room in good condition.
Preliminary Report - if not signed by author