En bloc Pelvic Resection

Locally advanced ovarian cancer frequently distorts the pelvic anatomy encasing the adnexae, pelvic peritoneum, cul-de-sac, and rectosigmoid (Fig. 7-5). A retroperitoneal approach to the hysterectomy and bilateral salpingo-oophorectomy allows en bloc removal of the ovarian tumor and surrounding structures affected by confluent disease, including portions of the rectosigmoid and bladder.17 The procedure involves extending the peritoneal incisions along the paracolic gutters caudally

Pelvic Anatomy Ovary
20 -

Years after diagnosis

Figure 7-5. Locally advanced ovarian cancer with confluent extension to and encasement of the reproductive organs, pelvic peritoneum (including vesicouterine peritoneal reflection), cul-de-sac of Douglas, and rectosigmoid colon. OvT, ovarian tumor; Ut, uterus. (From Bristow RE, del Carmen MG, Kaufman HS, et al: Radical oophorectomy with primary stapled colorectal anastomosis for resection of locally advanced epithelial ovarian cancer. J Am Coll Surg 197:565-574, 2003, Figure 1.)

Figure 7-5. Locally advanced ovarian cancer with confluent extension to and encasement of the reproductive organs, pelvic peritoneum (including vesicouterine peritoneal reflection), cul-de-sac of Douglas, and rectosigmoid colon. OvT, ovarian tumor; Ut, uterus. (From Bristow RE, del Carmen MG, Kaufman HS, et al: Radical oophorectomy with primary stapled colorectal anastomosis for resection of locally advanced epithelial ovarian cancer. J Am Coll Surg 197:565-574, 2003, Figure 1.)

Bladder,//

Bladder,//

Bladder Tumour Resection

Sigmoid colon

Figure 7-6. Radical oophorectomy. A

circumscribing peritoneal incision encompasses all pan-pelvic disease, the round ligaments and ovarian vessels are divided, the ureters are mobilized, and the anterior pelvic peritoneal tumor is dissected from the bladder muscularis. (From Bristow RE, del Carmen MG, Kaufman HS, et al: Radical oophorectomy with primary stapled colorectal anastomosis for resection of locally advanced epithelial ovarian cancer. J Am Coll Surg 197:565-574, 2003, Figure 2.)

Round ligament

Uterine vessels

Ext. iliac

Ureter preserved

Sigmoid colon

Round ligament

Uterine vessels

Ext. iliac

Figure 7-6. Radical oophorectomy. A

circumscribing peritoneal incision encompasses all pan-pelvic disease, the round ligaments and ovarian vessels are divided, the ureters are mobilized, and the anterior pelvic peritoneal tumor is dissected from the bladder muscularis. (From Bristow RE, del Carmen MG, Kaufman HS, et al: Radical oophorectomy with primary stapled colorectal anastomosis for resection of locally advanced epithelial ovarian cancer. J Am Coll Surg 197:565-574, 2003, Figure 2.)

Ureter preserved along the psoas muscles and then medially along the symphysis pubis. The infundibu-lopelvic and round ligaments are then secured retroperitoneally and the ureters detached from the medial leaf of the peritoneum and traced down to the ureteral canal. The uterine vessels are then skeletonized and ligated at the level of the ureters, allowing them to be mobilized off the specimen. The peritoneum overlying the bladder is detached sharply admitting access to the vesicouterine space, which is further developed (Fig. 7-6). The hysterectomy is completed in a retrograde fashion by first entering the vagina anteriorly and circumscribing the remaining anterior and lateral vagina along with the cardinal ligaments. The posterior vaginal wall is finally incised, exposing the rectovaginal space. The overlying cul-de-sac and attached tumor can then be mobilized off the rectosigmoid (Fig. 7-7).

Alternatively, the rectosigmoid can be resected en bloc with the specimen in the event of deep or extensive infiltrating disease. The proximal rectosigmoid is resected 2 to 3 cm above the uppermost extent of disease using a linear gastrointestinal stapler, and its mesentery is secured caudally. The distal rectosigmoid is then divided using thoracoabdominal stapler (Fig. 7-8). Once the specimen is removed, the continuity

Drawing Sexy Surprise

Figure 7-7. Radical oophorectomy. A, The anterior pelvic peritoneal tumor has been dissected from the bladder dome, the proximal vagina is exposed, and a transverse anterior colpotomy is created using electrocautery to enter the vagina. B, The remaining cardinal ligament attachments are divided between Heaney clamps working in a ventral-to-dorsal direction toward the cul-de-sac tumor mass. (From Bristow RE, del Carmen MG, Kaufman HS, et al: Radical oophorectomy with primary stapled colorectal anastomosis for resection of locally advanced epithelial ovarian cancer. J Am Coll Surg 197:565-574, 2003, Figure 3.)

Figure 7-7. Radical oophorectomy. A, The anterior pelvic peritoneal tumor has been dissected from the bladder dome, the proximal vagina is exposed, and a transverse anterior colpotomy is created using electrocautery to enter the vagina. B, The remaining cardinal ligament attachments are divided between Heaney clamps working in a ventral-to-dorsal direction toward the cul-de-sac tumor mass. (From Bristow RE, del Carmen MG, Kaufman HS, et al: Radical oophorectomy with primary stapled colorectal anastomosis for resection of locally advanced epithelial ovarian cancer. J Am Coll Surg 197:565-574, 2003, Figure 3.)

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