**4.2 Intraoperatively**

A midline laparotomy is always required in order to allow a good access to all the pelvic and intraabdominal areas mentioned above. An understanding about the radicality of the procedure is further required, and this is highlighted in **Table 2** [35].

The majority of ovarian cancers present in advanced stages and are treated by debulking surgery and platinum-based chemotherapy. The disease starts in the pelvis, involving the ovaries, tubes, the uterus, and the bowel and then spreads to the upper abdomen. Once established that an R0 is feasible the procedure starts in the pelvis.

In the case all pelvic organs are matted, a technique is needed to remove the tumour with cancer free margins. To achieve the least residual disease, multivisceral pelvic and upper abdominal surgery is often necessary [36–39].

Ten steps of the en-bloc resection of the pelvis (**Figure 2**) are described below [24]:

**97**

**Figure 1.** *Total omentectomy.*

**Table 2.**

*Description of surgical radicality.*

the meso-sigmoid

4.Access to the pre-sacral space.

6.Colpotomy of the anterior vaginal wall.

7.Retrograde resection of the parametria.

*The Role of Ultra-Radical Surgery in the Management of Advanced Ovarian Cancer: State or Art*

*NICE* Standard Total abdominal hysterectomy, bilateral salpingo-oophorectomy,

resection, non-multiple bowel resection) Ultraradical Diaphragmatic stripping, extensive peritoneal stripping, multiple

Supra-radical Diaphragmatic stripping, liver resection, cholecystectomy,

*Pomel* Standard Hysterectomy, bilateral salpingo-oophorectomy, pelvic peritonectomy,

lymphadenectomy

Radical Recto-sigmoid resection

omentectomy (**Figure 1**), pelvic and/or para-aortic lymphadenectomy, bowel surgery outside the definition of 'ultra-radical' (localised colonic

resections of the bowel (excluding localised colonic resection), liver resection, partial gastrectomy, cholecystectomy, splenectomy

splenectomy, any digestive resection excluding recto-sigmoid resection

total omentectomy, appendicectomy, pelvic and/or para-aortic

3.Mobilisation of the sigmoid from the sacrum by coagulation and resection of

5.Mobilisation of the bladder peritoneum with access to the vesico-vaginal space.

*DOI: http://dx.doi.org/10.5772/intechopen.97638*

**Classification Groups Criteria**


*The Role of Ultra-Radical Surgery in the Management of Advanced Ovarian Cancer: State or Art DOI: http://dx.doi.org/10.5772/intechopen.97638*


### **Table 2.**

*Ovarian Cancer - Updates in Tumour Biology and Therapeutics*

and the bladder peritoneum.

oncologist.

**4. Surgical procedure**

the right and left upper quadrants.

infundibulo-pelvic ligament.

2.Resection of sigmoid.

**4.1 Preoperatively**

**4.2 Intraoperatively**

**Table 2** [35].

the pelvis.

laparotomy only, and this represents a limiting factor.

trunk needs to be assessed. The latter two can be examined by palpation at

b.In the *mid abdomen* the omentum is fully assessed, the ileocaecal junction is identified and small bowel is run u to the point of DJ junction (duodenojeoujenal junction), as well as the root of the small bowel mesentery and the small bowel serosa. If the small bowel serosa is extensively affected requiring removal of a large part of the small bowel in order to achieve R0 (leaving a small bowel of less than 150 cm), a debulking procedure should be abandoned.

c.The *lower abdomen (pelvis)* - a thorough assessment looks at the extent of the disease in the pelvis starting with spread to the uterine body, fallopian tubes, round ligaments and sigmoid, with further assessment of the pouch of Douglas

After all these assessments the conclusion can be withdrawn as whether the surgery will be beneficial and results in no residual disease. This often requires an intra-operative multi-disciplinary consultation between two senior gynaecological

A close collaboration and clear communication with the anaesthetist and the other members of the team are hugely important, as the preparation of the patient is paramount. The patient is positioned in Lloyd Davis with attention to avoiding common peroneal nerve injury/femoral nerve neuropraxia or lower limb compartment syndrome. The use of the correct retractor (i.e. Greys, Bookwalter) will also help in gaining an optimal access to the pelvis, but also to

A midline laparotomy is always required in order to allow a good access to all the pelvic and intraabdominal areas mentioned above. An understanding about the radicality of the procedure is further required, and this is highlighted in

The majority of ovarian cancers present in advanced stages and are treated by debulking surgery and platinum-based chemotherapy. The disease starts in the pelvis, involving the ovaries, tubes, the uterus, and the bowel and then spreads to the upper abdomen. Once established that an R0 is feasible the procedure starts in

In the case all pelvic organs are matted, a technique is needed to remove the tumour with cancer free margins. To achieve the least residual disease, multivisceral

1.Access to the retroperitoneal space: isolation of the ureter, ligation of the

Ten steps of the en-bloc resection of the pelvis (**Figure 2**) are described below [24]:

pelvic and upper abdominal surgery is often necessary [36–39].

**96**

*Description of surgical radicality.*


### **Figure 2.**

*En-bloc modified posterior pelvic exenteration-including bladder, pelvic, peri-ureteric peritoneum, uterus, cervix, tubes, ovaries and rectosigmoid.*


A particular attention needs to be given to bowel resection. Recto-sigmoid resection (RSR) is the most commonly non-gynaecologic procedure performed. It can be associated with early postoperative complications, most severe being the breakdown of the anastomosis or anastomotic leak [36, 40, 41].

The literature reports 0.8% - 6.8% risk of anastomotic leak in patients who underwent bowel resection during debulking surgery for ovarian cancer [36]. Therefore, sigmoid rectum resection is sometimes accompanied by a diverting loop ileostomy (DLI) with the aim to reduce the anastomotic leak. This is not without complications, and although it is typically intended to be reversible, the non-reversal rate of ileostomy is 9.5–35% in the colorectal literature [36, 42–46].

RSR is the resection of any large bowel segment from the pelvic brim to the anal canal. The decision to undertake RSR is made at the time of surgery and was usually part of an en-bloc resection of the pelvis [36, 47].

DLI is a loop of small bowel, 10–15 cm proximal to the ileocaecal junction, used to divert the faecal stream and protect the colorectal anastomosis. The indications for DLI are [29, 33]:


DLI reversal was planned at the end of the chemotherapy and if the patient has three months disease-free interval verified on CT scan. The morbidity of DLI is

**99**

**Figure 3.**

*The Role of Ultra-Radical Surgery in the Management of Advanced Ovarian Cancer: State or Art*

very challenging, and more for patients who are metabolically deranged, older age, low albumin level, fluid imbalance. DLI morbidity can delay chemotherapy due to dehydration. The optimal timing for reversal remains unclear, usually 6–8 weeks postoperatively [36]. End-colostomy is easier to manage than an end-ileostomy [36, 48], hence for the patients presenting with risk factors for non-reversal, a careful consideration should be given to the type of bowel diversion performed

According to a study performed by Tozzi et al. [47] patients in IDS had a slightly higher rate of bowel diversion compared to patients in PDS group (46% vs. 26.5%). Also, patients in IDS were more likely to receive bowel diversion due to impaired tissue quality (44.8% vs. none) while patients in PDS were more likely to receive a bowel diversion when receiving multiple bowel resections (92.3% vs. 34.5%) [47]. Bowel resection has to be limited to what is required, as multiple bowel resections will increase the morbidity [29], as already mentioned above. The tumour must be excised whilst the blood supply is avoided. In order to safely do this, a technique is to dim the theatre light, assess the blood supply and identify the right colic, middle colic, left colic. Once the bowel resection is performed, further assess-

It is possible to perform small bowel mesenteric peritonectomy or excision of the

After the disease in the pelvis has been tackled the procedure continues in the upper abdomen. To achieve complete resection, extensive upper abdominal procedures are warranted. Strong evidence suggests that upper abdominal procedures improve the survival rates regardless of the time of the debulking [33, 49–55]. The upper abdomen is divided in right and left quadrant and a systematic approach is required. The assessment starts with the mobilisation of the liver (**Figures 3**–**5**), dividing the falciform ligament, the coronary ligaments in order to

Diaphragmatic peritonectomy (**Figures 6** and **7**) with or without pleurectomy, partial liver resection, cholecystectomy, splenectomy with or without distal pancreatectomy and resection of the tumour at the porta hepatis (PH) may be required in

Diaphragmatic assessment for cancer invasion is paramount. One of the key dilemmas is to decide which patient would benefit from full diaphragmatic resection, as opposed to peritonectomy only [56, 57]. Tozzi et al. performed a study on

*DOI: http://dx.doi.org/10.5772/intechopen.97638*

during debulking surgery [36, 47].

ment for potential ischaemic changes is required.

assess the posterior aspect of the liver.

order to achieve complete resection [33].

*Mobilisation of the liver. Large xiphopubic incision required.*

mesocolon without the need to perform full bowel resection.

### *The Role of Ultra-Radical Surgery in the Management of Advanced Ovarian Cancer: State or Art DOI: http://dx.doi.org/10.5772/intechopen.97638*

very challenging, and more for patients who are metabolically deranged, older age, low albumin level, fluid imbalance. DLI morbidity can delay chemotherapy due to dehydration. The optimal timing for reversal remains unclear, usually 6–8 weeks postoperatively [36]. End-colostomy is easier to manage than an end-ileostomy [36, 48], hence for the patients presenting with risk factors for non-reversal, a careful consideration should be given to the type of bowel diversion performed during debulking surgery [36, 47].

According to a study performed by Tozzi et al. [47] patients in IDS had a slightly higher rate of bowel diversion compared to patients in PDS group (46% vs. 26.5%). Also, patients in IDS were more likely to receive bowel diversion due to impaired tissue quality (44.8% vs. none) while patients in PDS were more likely to receive a bowel diversion when receiving multiple bowel resections (92.3% vs. 34.5%) [47].

Bowel resection has to be limited to what is required, as multiple bowel resections will increase the morbidity [29], as already mentioned above. The tumour must be excised whilst the blood supply is avoided. In order to safely do this, a technique is to dim the theatre light, assess the blood supply and identify the right colic, middle colic, left colic. Once the bowel resection is performed, further assessment for potential ischaemic changes is required.

It is possible to perform small bowel mesenteric peritonectomy or excision of the mesocolon without the need to perform full bowel resection.

After the disease in the pelvis has been tackled the procedure continues in the upper abdomen. To achieve complete resection, extensive upper abdominal procedures are warranted. Strong evidence suggests that upper abdominal procedures improve the survival rates regardless of the time of the debulking [33, 49–55].

The upper abdomen is divided in right and left quadrant and a systematic approach is required. The assessment starts with the mobilisation of the liver (**Figures 3**–**5**), dividing the falciform ligament, the coronary ligaments in order to assess the posterior aspect of the liver.

Diaphragmatic peritonectomy (**Figures 6** and **7**) with or without pleurectomy, partial liver resection, cholecystectomy, splenectomy with or without distal pancreatectomy and resection of the tumour at the porta hepatis (PH) may be required in order to achieve complete resection [33].

Diaphragmatic assessment for cancer invasion is paramount. One of the key dilemmas is to decide which patient would benefit from full diaphragmatic resection, as opposed to peritonectomy only [56, 57]. Tozzi et al. performed a study on

**Figure 3.** *Mobilisation of the liver. Large xiphopubic incision required.*

*Ovarian Cancer - Updates in Tumour Biology and Therapeutics*

8.Colpotomy of the posterior vaginal wall, access to the recto-vaginal septum.

*En-bloc modified posterior pelvic exenteration-including bladder, pelvic, peri-ureteric peritoneum, uterus,* 

A particular attention needs to be given to bowel resection. Recto-sigmoid resection (RSR) is the most commonly non-gynaecologic procedure performed. It can be associated with early postoperative complications, most severe being the break-

RSR is the resection of any large bowel segment from the pelvic brim to the anal canal. The decision to undertake RSR is made at the time of surgery and was usually

DLI is a loop of small bowel, 10–15 cm proximal to the ileocaecal junction, used to divert the faecal stream and protect the colorectal anastomosis. The indications

DLI reversal was planned at the end of the chemotherapy and if the patient has three months disease-free interval verified on CT scan. The morbidity of DLI is

The literature reports 0.8% - 6.8% risk of anastomotic leak in patients who underwent bowel resection during debulking surgery for ovarian cancer [36]. Therefore, sigmoid rectum resection is sometimes accompanied by a diverting loop ileostomy (DLI) with the aim to reduce the anastomotic leak. This is not without complications, and although it is typically intended to be reversible, the non-rever-

sal rate of ileostomy is 9.5–35% in the colorectal literature [36, 42–46].

• air spillage through the anastomosis at trans-anal air test.

9.Dissection, coagulation and division of the meso-rectum.

down of the anastomosis or anastomotic leak [36, 40, 41].

part of an en-bloc resection of the pelvis [36, 47].

for DLI are [29, 33]:

**Figure 2.**

• multiple bowel resections.

• RSR < 6 cm from anal verge.

• non-tension free anastomosis.

• poor tissue quality.

10. Resection of rectum ± anastomosis.

*cervix, tubes, ovaries and rectosigmoid.*

**98**

**Figure 4.** *Type III liver mobilisation exposing retrohepatic space.*

**Figure 5.** *Liver mobilisation.*

170 patients who underwent diaphragmatic surgery and described a meticulous classification to reduce the morbidity but also achieve maximum cytoreductive effort in the upper abdomen. Soleymani majd et al. reported that in patients with diaphragmatic metastasis, 28% had disease spread to the muscle, and 20% of patients had full thickness disease involving the pleura [57–59]. Hence diaphragmatic peritonectomy alone would have left disease in the muscle and the pleura, and complete cytoreduction would not have been possible. The decision about full

**101**

**Figure 7.**

**Figure 6.**

*Diaphragmatic peritonectomy.*

*The Role of Ultra-Radical Surgery in the Management of Advanced Ovarian Cancer: State or Art*

thickness diaphragmatic resection versus diaphragmatic peritonectomy requires

The porta hepatis (PH) shall always be assessed prior to laparotomy, as encasement of the vessels is an absolute contraindication to proceed with radical debulking surgery. Inspection and palpation of the portal vein, hepatic artery, and bile duct are required, along with assessment of the hepato-coeliac lymph nodes. The pringle manoeuvre should be performed prior to liver mobilisation to maximise surgical safety.

Resection of ovarian disease at the PH was feasible in 90.3% of patients in the Tozzi et al. study [33]. No intra- or postoperative complications were associated with

prospective studies balancing morbidity against survival benefits [56].

*Peritoneum after diaphragmatic peritonectomy (removal in one piece).*

*DOI: http://dx.doi.org/10.5772/intechopen.97638*

*The Role of Ultra-Radical Surgery in the Management of Advanced Ovarian Cancer: State or Art DOI: http://dx.doi.org/10.5772/intechopen.97638*

**Figure 6.** *Diaphragmatic peritonectomy.*

*Ovarian Cancer - Updates in Tumour Biology and Therapeutics*

*Type III liver mobilisation exposing retrohepatic space.*

170 patients who underwent diaphragmatic surgery and described a meticulous classification to reduce the morbidity but also achieve maximum cytoreductive effort in the upper abdomen. Soleymani majd et al. reported that in patients with diaphragmatic metastasis, 28% had disease spread to the muscle, and 20% of patients had full thickness disease involving the pleura [57–59]. Hence diaphragmatic peritonectomy alone would have left disease in the muscle and the pleura, and complete cytoreduction would not have been possible. The decision about full

**100**

**Figure 5.** *Liver mobilisation.*

**Figure 4.**

**Figure 7.** *Peritoneum after diaphragmatic peritonectomy (removal in one piece).*

thickness diaphragmatic resection versus diaphragmatic peritonectomy requires prospective studies balancing morbidity against survival benefits [56].

The porta hepatis (PH) shall always be assessed prior to laparotomy, as encasement of the vessels is an absolute contraindication to proceed with radical debulking surgery. Inspection and palpation of the portal vein, hepatic artery, and bile duct are required, along with assessment of the hepato-coeliac lymph nodes. The pringle manoeuvre should be performed prior to liver mobilisation to maximise surgical safety.

Resection of ovarian disease at the PH was feasible in 90.3% of patients in the Tozzi et al. study [33]. No intra- or postoperative complications were associated with tumour resection at the PH, moreover the resection of PH disease was effective, significantly contributing to a 90% rate of achieving R0. Raspagliese et al. [33, 60], along with this study [33] highlight the importance of routinely exploring the PH area, if aiming for complete cytoreduction.

The excision of lymph nodes beyond abdomen and pelvis is controversial, however leaving an enlarged/bulky lymph node despite all other maximal cytoreductive efforts, may mean that no residual disease status was not achieved. Removal of the cardio-phrenic lymph nodes has to be assessed on individual circumstances and localization of the lymph nodes. In the circumstance, that an enlarged pericardiac lymph node is noted, and the gynaecological oncologist is not trained or confident in removing it, then cardiothoracic expertise would be required in order to achieve complete cytoreduction. The Lion study intraoperatively randomly assigned 647 patients with newly diagnosed advanced ovarian cancer (Stage IIB to IV) who had undergone macroscopically complete resection and had normal lymph nodes (both before and during surgery) to either undergo or not undergo lymphadenectomy. In total, 323 had lymphadenectomy whilst 324 did not. The median overall survival was 69.2 months in the non-lymphadenectomy group and 65.5 months in the lymphadenectomy group. The median progression-free survival was 25.5 months in both groups. Postoperative complications were more prevalent in the lymphadenectomy group. Therefore, the Lion study concluded that systematic pelvic and para-aortic lymphadenectomy in patients with advanced ovarian cancer, was not associated with longer overall or progression-free survival but was associated with a higher incidence of postoperative complications, when compared with those who had no lymphadenectomy [61].

**Figure 8** illustrates the opening of the right pelvic side wall.

Surgical debulking in ovarian cancer (especially for advanced disease) has traditionally been performed via an open abdominal route. Laparoscopy in advanced ovarian cancer has mostly been used to explore the feasibility of a complete surgical resection [30]. However, there are a few recent studies in the literature, which report complete response to chemotherapy and no gross residual disease after a laparoscopic approach. In the past, concern about the use of laparoscopy included inadequate radicality, the risk of vaginal and/or port site metastasis secondary to

**103**

*The Role of Ultra-Radical Surgery in the Management of Advanced Ovarian Cancer: State or Art*

tumour contamination and the use of CO2. In the recent reports, complete resection was achieved at laparoscopy, making it a potentially feasible alternative, warranting consideration [30]. Safe laparoscopy in advanced ovarian cancer consists of thorough preoperative preparation and study of the CT scan images, matching it with the laparoscopic findings, and exploring all peritoneal surfaces. Particular care needs to be taken in avoiding tumour contamination, seeking for cleavage planes in healthy tissue and minimising tumour manipulation. Endobags should be used to extract all specimens, which should be removed intact. Tumour extraction through

There are a number of well-known benefits of a laparoscopic approach, including: reduced blood loss, decreased pain, earlier discontinuation of analgesia, shorter hospital stay, lower rate of complication and infection. Some researchers report that a short postoperative period is very important in the prognosis of cancer patients and affects survival [30, 62–66]. Surgery has been associated with an increased risk of metastasis and tumour recurrence. The main responsible mechanisms are tumour cell dissemination, shedding, enhanced adhesion, increased tumour growth secondary to reduced apoptosis, increased release of growth factors and angiogenesis, transient but profound suppression of cell-mediated immunity (CMI). The latter controls the minimal residual disease which is present at a cytological level in patients with ovarian cancer. The degree of surgical trauma is noted to correlate with immune depression and with tumour growth [30, 62–66]. Laparoscopy, however, causes reduced trauma and as a consequence a lower inflammatory response, an increased TH1 cytokine production, faster return to normal lymphocyte count and an absence of tumour growth factors in the serum [30, 65]. These effects contribute to a reduced recurrence rate [30, 66], as well as a faster recovery of the immune system in patients with ovarian cancer during their chemotherapy, as they

The data reported so far is for the use of laparoscopy in interval debulking

The Quality of Life (QoL) needs to be assessed after such a major and long surgery, which sometimes lasts up to ten hours. QoL questionnaires were sent out to the patients in the Lion study [61]. At the time of discharge, most patients had a poor quality of life, but this improved at follow up (at the end of chemotherapy). An ultra-radical surgery with the aim of leaving no residual disease (R0) is not successful if the approach to the patient is not holistic; an assessment of whether the patient's quality of life could be improved has to be performed. This surgery should be offered to suitable patients only. Du Bois et al. demonstrated in their study that the benefit was exclusively seen in patients with complete resection (R0) indicating the importance of both the optimal selection of the patients, and of centres with

In ovarian cancer surgery, a multidisciplinary approach is required for successful

surgery, there is no data on its use in primary debulking surgery [30].

*DOI: http://dx.doi.org/10.5772/intechopen.97638*

the vagina is ill advised, if compliance is not adequate [30].

are more prone to anaemia and infections [30, 66].

expertise and a high chance of achieving R0 [26, 67, 68].

The authors declare no conflict of interest.

cytoreductive surgery, keeping the patient at the centre of care.

**5. Quality of Life**

**Conflict of interest**

**Figure 8.** *Right pelvic side wall- exposure of lumbosacral and obturator fossae.*

### *The Role of Ultra-Radical Surgery in the Management of Advanced Ovarian Cancer: State or Art DOI: http://dx.doi.org/10.5772/intechopen.97638*

tumour contamination and the use of CO2. In the recent reports, complete resection was achieved at laparoscopy, making it a potentially feasible alternative, warranting consideration [30]. Safe laparoscopy in advanced ovarian cancer consists of thorough preoperative preparation and study of the CT scan images, matching it with the laparoscopic findings, and exploring all peritoneal surfaces. Particular care needs to be taken in avoiding tumour contamination, seeking for cleavage planes in healthy tissue and minimising tumour manipulation. Endobags should be used to extract all specimens, which should be removed intact. Tumour extraction through the vagina is ill advised, if compliance is not adequate [30].

There are a number of well-known benefits of a laparoscopic approach, including: reduced blood loss, decreased pain, earlier discontinuation of analgesia, shorter hospital stay, lower rate of complication and infection. Some researchers report that a short postoperative period is very important in the prognosis of cancer patients and affects survival [30, 62–66]. Surgery has been associated with an increased risk of metastasis and tumour recurrence. The main responsible mechanisms are tumour cell dissemination, shedding, enhanced adhesion, increased tumour growth secondary to reduced apoptosis, increased release of growth factors and angiogenesis, transient but profound suppression of cell-mediated immunity (CMI). The latter controls the minimal residual disease which is present at a cytological level in patients with ovarian cancer. The degree of surgical trauma is noted to correlate with immune depression and with tumour growth [30, 62–66]. Laparoscopy, however, causes reduced trauma and as a consequence a lower inflammatory response, an increased TH1 cytokine production, faster return to normal lymphocyte count and an absence of tumour growth factors in the serum [30, 65]. These effects contribute to a reduced recurrence rate [30, 66], as well as a faster recovery of the immune system in patients with ovarian cancer during their chemotherapy, as they are more prone to anaemia and infections [30, 66].

The data reported so far is for the use of laparoscopy in interval debulking surgery, there is no data on its use in primary debulking surgery [30].
