Chapter 193: Surgical Management of Ovarian Carcinoma 2051

the subjacent peritoneum extending to the

Sup. rectal
a. and v.
Middle rectal a. Int. pudendal a.
Inf. rectal a. Ext. sphincter
ani m.
Fig. 12. Vascular anatomy of the colon. (From Edwards EA, Malone PD, MacArthur JD.
Operative Anato-my of the Abdomen and Pelvis. Philadelphia: Lea & Febiger; 1975.)
cannot be overstated. Traditional focus has tates access to the remaining peritoneal
been on the challenges of clearance of pel-vic and nodal disease (Table 5).
disease. In the hands of the experienced Prior to any pelvic dissection, the gastro-
gynecologic oncologist, this has not been as colic omentectomy is first begun. This may
foramen of Winslow. With division of the lat-
eral peritoneal attachments of the liver, one
can retract the organ medially and excise or
fulgurate the posterior peritoneal tumor.
If the transverse colon can be easily mo-
bilized from the underside of the omental
mass, that should be done next. In the event
that the tumor invades the transverse co-lon,
it usually does so in the midportion of the
transverse colon. The most prudent ap-proach
is to leave that dissection for last and begin
working from lateral to medial, freeing up the
omentum from the paracolic gutters and
mobilizing the ascending and descending
colon at the hepatic and splenic flexures,
respectively. This allows mobiliza-tion of
both lateral aspects of the omentum from the
peritoneal surface to which it may be fixed
by tumor.
The omentum is initially mobilized along
the duodenum and then it is divided from the
greater curve of the stomach using the
LigaSure®, entering the lesser sac just to the
left of midline, and dividing the vessels while
working toward the previously opened
paracolic gutters. Then with the omentum
remaining attached only to the transverse
colon one can dissect from lat-eral to medial,
mobilizing the omental mass from the
mesocolon and from the bowel wall. If
necessary, one can remove a seg-ment of
transverse colon at this point and perform a
triangulated everting anastomo-sis with three
firings of a linear stapler. Three full-thickness
stay sutures are ori-ented at 120-degree
intervals, beginning at the mesocolon and
tied down to evert the full-thickness bowel.
Then three firings of the TA 60 ® stapler (3.5
mm) across the everted full-thickness bowel
walls and over-lapping at the sites of the stay
sutures will produce a secure everted
Gambee stapled anastomosis in a very short
time. This cre-ates a wide end-to-end
anastomosis (EEA) that maximizes the
functional capacity of
the anastomosed bowel. Given the extent of
surgical cytoreduction often required, the
time saved with the use of surgical staplers is
extremely valuable, as is the security of the
Nongastrointestinal Transabdominal Surgery

much of a problem as complete removal of
metastatic disease in the upper abdomen. One
also recognizes after complete pelvic
cytoreduction and postoperative chemo-
therapy that there is a trend toward fewer
pelvic recurrences and increasing predomi-
nance of upper abdominal recurrence of
disease, particularly perihepatic recur-rences
of tumor, both in the right sub-phrenic space
and in the subhepatic space.
It is often helpful to plan the upper
abdominal resection and a deliberate se-
quence that removes disease bulk and facili-
be facilitated by mobilization of both the
splenic and the hepatic flexure and resec-tion
of adjacent tumor-bearing paracolic
peritoneum. On the right side, as shown in
Figure 16, the peritoneal surface caudal and
posterior to the liver represents a potential
space that is an early area of spread of tu-mor
cells from the pelvis with implantation of
tumor on the surface that is posterior and
slightly cephalic to the hepatic flexure.
Metastatic disease typically consists of
diffuse peritoneal implants that do not pen-
etrate through and are easily removed with
anastomosis created with this tech-nique.
This technique can also be used on the
sigmoid colon and, less commonly, on the
ascending colon to provide a true EEA.
Rarely, one is faced with bulky tumor af-
fecting virtually the entire left colon to the
midportion of the transverse colon. In this
case, the appropriate maneuver is to dero-tate
the ascending colon, allow the cecum to
move cephalad into the midabdomen and
bring the proximal transverse colon down to
a transanal anastomosis with the residual
rectosigmoid colon.