**7. Common complications**

#### **7.1. Vascular injury**

**5. What is the role of lymphadenectomy in apparent early stage** 

tion/sampling (Pommel type B1) with a gynaecological oncologist [8].

or above cancers, high-grade lesions and all clear cell cancers of the ovary [9].

A number of women will undergo surgery for an apparently benign ovarian cyst. Postoperatively, those women with confirmed malignancy can be offered staging including lymphadenectomy. Approximately, 30% of women with ovarian cancers apparently confined to the ovaries will be upstaged following further surgery including a pelvic/para aortic node dissec-

It is important to understand that lymph node status is not the only factor that determines the need for adjuvant chemotherapy. Many centres offer chemotherapy to women with stage Ic

However, node status is important for a number of reasons: it may influence whether or not chemotherapy is given, the number of cycles or types of chemotherapy and it may result in complete cytoreduction of the cancer. Node status also partially determines the true FIGO

The ACTION trial was a randomised controlled trial (RCT) of 448 women with stage IA, IB grades 2–3, all IC, IIA and all clear cell cancer stage I–IIA and compared the administration of adjuvant chemotherapy with a control arm. The main finding showed overall survival was significantly better with the administration of chemotherapy. A subset analysis revealed that stage I patients with complete surgical staging did not benefit from chemotherapy contrast to patients that underwent incomplete staging [10]. Long-term follow-up of this study has confirmed these results [11]. It has been surmised that patients that have not being staged harbour more advanced disease, and therefore have a poorer prognosis and chemotherapy

In older women with complex masses or those felt to have a high risk of cancer, an intraoperative frozen section histopathological analysis may be performed. A study from the Gateshead Gynaecological Oncology Centre reported a with a sensitivity of 92%, specificity of 88%, positive predictive value of 82% and negative predictive value of 95% for frozen section analysis [12]. This is equally important in determining which women should not be exposed to unnec-

Laparoscopic staging is possible, though requires a high degree of specialist training. Several centres have reported on full laparoscopic staging and have found it feasible [13, 14]. Chi et al. performed a case control study comparing staging via laparoscopy or laparotomy in 80 women [13]. They found no difference in specimen sizes and lymph nodal counts. The laparoscopic group had levels of reduced blood loss and a reduced hospital stay. A laparoscopic nodal dissection/sampling should include both the pelvic and para aortic basins to the level of the renal vessels. A case series by Nezhat et al. [15] concluded that laparoscopic staging when

Robotically assisted laparoscopic surgery is an evolution of minimal access surgery rather than a revolution. Perceived benefits include three-dimensional vision, control of the laparoscope by the operating surgeon, more precise instrument movement and a shortened learning

performed by a gynaecological oncologist did not compromise survival.

**ovarian cancer?**

264 Ovarian Cancer - From Pathogenesis to Treatment

stage and prognosis.

does not compensate for incomplete staging.

essary surgery such as a para aortic node dissection.

Working in close proximity to the large blood vessels poses a risk of major haemorrhage. Reducing this risk involves an appropriate surgical incision with a good operative exposure involving dissection/identification of anatomical structures. This allows easier identification of vascular anomalies and reduces the risk of collateral damage to structures such as the kidney and ureter. Initial management includes pressure to the area and appropriate communication with the rest of the team including the anaesthetist. Small vascular injuries may be oversewn using a vascular needle and small monofilament suture, ideally avoiding constricting the vessel's diameter. Larger defects require the vascular clamp and the expertise of a vascular surgeon.

macroscopic resection of all disease. Around 640 women were randomised to either a full systematic lymph node (SLN) or no lymph node dissection and the study results are due in late 2017. The primary end point is overall survival (OS) and secondary endpoints include

The Role of Lymphadenectomy in Ovarian Epithelial Cancer

http://dx.doi.org/10.5772/intechopen.72702

267

The French CURACO trial is a randomised controlled trial including women with stage III–IV epithelial ovarian cancer with complete macroscopic resection. The women are being randomised to SLN versus no node dissection. The primary end point is progression free

Spread to the lymphatic system is common in epithelial ovarian cancer is common and is an early event. Para aortic and bilateral pelvic node dissection sampling (Pommel type B1) should be included in surgical staging to determine chemotherapy use and to improve prognosis in ovarian cancer apparently confined to the ovary based on the results of the ACTION

In women with advanced ovarian, the retroperitoneal lymph nodes should be assessed and bulky lymph nodes removed in an attempt to achieve complete cytoreduction. Systematic lymph node (SLN) of the para aortic nodes should not be routinely performed pending the

[1] Elattar A, Bryant A, Winter-Roach BA, et al. Optimal primary surgical treatment for advanced epithelial ovarian cancer. The Cochrane Database of Systematic Reviews. 2011;

[2] Burghardt E, Girardi F, Lahousen M, et al. Patterns of pelvic and paraaortic lymph node

[3] Cass I, Li AJ, Runowicz CD, et al. Pattern of lymph node metastases in clinically unilateral stage I invasive epithelial ovarian carcinomas. Gynecologic Oncology. 2001;**80**(1):56-61.

involvement in ovarian cancer. Gynecologic Oncology. 1991;**40**(2):103-106

progression free survival (PFS) and quality of life (QOL).

results of the LION and CURACO studies.

Address all correspondence to: hans.nagar@mac.com

**8**:CD007565. DOI: 10.1002/14651858.CD007565.pub2

Northern Ireland Cancer Centre, Belfast Trust, UK

DOI: 10.1006/gyno.2000.6027

survival.

trial.

**9. Conclusion**

**Author details**

Hans Nagar

**References**

#### **7.2. Lymphocyst formation**

The incidence of lymphocyst after the para aortic/pelvic dissection maybe as high as 43% [22]. The vast majority of these will resolve spontaneously and do not require any intervention. Occasionally, a larger lymphocyst may require aspiration typically by interventional radiological drainage. Occasionally, chylous ascites develop in association with an aortic node dissection especially at the level of the renal vessels. This illustrates the importance clipping large lymphatic channels especially in this region. Management of how chylous ascites includes the low-fat diet, the administration of somatosatin and occasionally total parenteral nutrition.

#### **7.3. Other complications**

Other complications associated with lymph node dissection include postoperative ileus, damage to the duodenum, damage to relevant nerves and long-term lymphoedema.
