staging laparotomy in epithelial ovarian cancer

Staging laprotomy for epithelial ovarian cancer

1. STAGING LAPAROTOMY

2. PROCEDURE OF SURGICAL STAGING Patient Positioning: Supine position or dorsal modified lithotomy position . Hips slightly abducted, thighs parallel to the floor. Knees flexed in obstetric stirrups. Incision Approach: Incision extends from the  symphysis pubis to the xiphoid process. .

3. Cytological Evaluation If free fluid is present, it should be submitted for cytological analysis. TUMOR REMOVAL Any ovarian tumor should be removed intact. If possible, a  frozen section  should be obtained for pathological evaluation. Peritoneal Washings (If No Free Fluid is Present) 50-200 ml of normal saline is installed and recovered from: Cul-de-sac Each paracolic gutter Beneath each hemidiaphragm Systematic Exploration A thorough examination of all intra-abdominal surfaces and viscera is performed to assess the extent of disease.

4. Systematic Exploration of Abdominal Cavity Begin at the Cecum (Cephalad Direction) Follow the Paracolic Gutter Inspect the Ascending Colon up to the Right Kidney Evaluate the Liver and Gallbladder Examine the Right Hemidiaphragm Check the Entrance to the Lesser Sac at the Para-aortic Area Move Across the Transverse Colon Inspect the Left Hemidiaphragm Follow Down the Left Paracolic Gutter Assess the Descending Colon and Rectosigmoid Colon Inspect the Small Intestine and its Mesentery from Treitz Ligament

5. Hysterectomy with Salpingo -Oophorectomy (BSO) is Standard of care for definitive staging. Removal of the uterus, ovaries, and fallopian tubes to prevent disease recurrence

6. Biopsy Biopsy of Suspicious Areas: Any suspicious areas or adhesions  on the peritoneal surfaces should be biopsied. Biopsies in Absence of Disease: If there is no visible evidence of disease, multiple intraperitoneal biopsies should be performed. Tissue should be obtained from the following sites: Peritoneum of cul-de-sac Both paracolic gutters Peritoneal bladder Intestinal mesenteries Omentectomy ( Infracolic Omentectomy): The  omentum  should be resected from the transverse colon . This procedure is termed  infracolic omentectomy. TOTAL omentectomy is diffuse omentum is involved Retroperitoneal Exploration: The retroperitoneal spaces should be explored. Evaluation of  pelvic and para-aortic lymph nodes  should be performed.

7. Lymph Node Evaluation in Ovarian Cancer Surgery Advanced Disease (Stage III-IV): Selective lymphadenectomy  (removal of only enlarged/suspicious nodes) is performed if optimal cytoreductionis achievable. Systematic lymphadenectomy has not shown a significant survival advantage in patients with advanced disease. Early-Stage Disease (Stage I-II): Routine pelvic and paraaortic lymph node sampling is crucial as: Up to one-third of patients with apparent early-stage disease may have occult metastases. It provides  accurate staging  and influences prognosis and treatment decisions

8. Mucinous Histology:   Appendectomy is commonly performed in patients with mucinous ovarian tumors due to the risk of appendiceal involvement.

9. OPEN VS MIS Open Laparotomy:  The preferred approach for most patients with suspected ovarian cancer. Advantages: Provides better exposure for staging and cytoreduction . Lower risk of tumor spillage. More effective inspection of abdominal structures. Incision: Vertical midline incision is recommended for better access and exposure. Minimally Invasive Surgery (MIS):  Laparoscopic or robotic-assisted approaches are controversial and should only be considered in carefully selected early-stage patients. Concerns with MIS: Higher risk of intraoperative tumor rupture (RR 1.17, 95% CI 1.06-1.29). Challenges in thorough peritoneal assessment. Potential risk of port site metastasis. Advantages of MIS:  Reduced blood loss, shorter hospital stays, and fewer postoperative complications. Carbon Dioxide Pneumoperitoneum: Does not seem to negatively impact survival outcomes in advanced disease.

10. Robotic-Assisted vs. Traditional Laparoscopy Robotic-Assisted Laparoscopy: Lower conversion-to-open surgery rates (7.2% vs. 17.9% with traditional laparoscopy). Similar survival outcomes compared to traditional laparoscopy. Potential advantages include improved dexterity and visualization. Traditional Laparoscopy: Less costly and widely available. Requires highly skilled surgeons for optimal outcomes.