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Hysterectomy with bilateral salpingo-oophorectomy for early stage ovarian cancer


Medical editor Claes Tropè MD
Gynecological Oncologist
Oslo University Hospital

General

When ovarian cancer is confirmed, radical surgery is usually performed by removal of both ovaries (bilateral salpingo-oophorectomy – BSO) and the uterus (hysterectomy), as well as extirpation of pelvic and paraaortal lymph nodes. It is very important to thoroughly inspect the peritoneum in the upper abdomen including the diaphragm.  Random biopsies are taken of the peritoneum lateral to the ascending and descending colon. This type of surgery can also be performed by conventional laparascopy or robot-assisted surgery.

For ovarian cancer in younger women wishing to preserve their fertility, it may be possible to leave the healthy ovary and uterus. This is possible if the tumor is localized to one ovary and the patient is at low risk for recurrence. 

The risk assessment is based on the histological type, grade of differentiation, and ploidy. The result of these examinations will not be available until some time after the operation. If the examinations indicate a high risk for recurrence, it may be necessary to remove the remaining ovary in a subsequent laparoscopic procedure. 

Borderline ovarian cancer usually occurs in younger women still wishing to become pregnant. Since these tumors are rarely bilateral, it may be adequate to perform a unilateral adnexal extirpation. It is recommended to do an omentectomy for a full stage evaluation. If the contralateral ovary is normal in appearance, it is recommended to avoid taking a biopsy from this ovary. There are no reasons for lymph node staging.

With spreading of borderline tumors, it is recommended to resect as much as possible. For aneuploid tumors, there is a significant risk for recurrence. This is the cause for immediate surgery with a bilateral salpingo-oophorectomy and omentectomy. A hysterectomy is not necessary unless there are implantations on the uterus.

The appendix is removed in the case of mucinous tumors.

Because of the danger of spreading of ovarian cancer to the peritoneum, the omentum is also often removed (omentectomy).

The ovary can also be removed if there is suspicion of cancer to establish a histological diagnosis. During the operation, the ovary is examined using frozen sections to obtain a histological diagnosis. The diagnosis is normally available after 30 minutes. Based on the histological diagnosis, further course of action for the operation is planned.  

Indication

  • Suspect or confirmed ovarian cancer

Goal

  • Curative treatment and stage determination

Equipment

Gynecological surgery tray


Preparation

  • Large bowel emptying
  • Thrombosis prophylaxis
  • Antibiotic prophylaxis

Implementation

 

  • The patient lies in the supine position.
  • For cancer of the adnexa, a mid-line incision is made.
  • Make an incision from the top of the symphysis to the navel extending into the epigastrium as needed. Make the incision long enough allowing for sufficient space to prevent rupturing of  the ovaries during mobilization.
  • If present, aspirate ascites into a syringe with a catheter.  
  • If there are no ascites, rinse the abdomen with 50 ml NaCl 9 mg/ml and aspirate in the same syringe. Deliver the aspirate for a cytological examination. 
  • Arrange the Bookwalters retractor to obtain optimal working space and overview.
  • Inspect and palpate the entire abdomen for possible metastasis.  Inspect the adnexa and abdominal cavity. Check the liver, spleen, lymph nodes, diaphragm, stomach, intestines, and omentum.
  • Pack away the intestines with compresses saturated with NaCl 9 mg/ml. Keep them in out of the operation field with disharp and the retractors.  
  • Check that the individual retractors are not pressing on the psoas muscles and femoral nerve to avoid compression injuries, neuropathy, and paralysis in the femoral area.
  • Lower the cranial end of the opration table (Trendelenburg’s position).
  • Clamp with Kochers forceps on each corner of the uterus. The assisting surgeon should hold the uterus.
  • Clamp the round ligament on both sides.
  • Split the peritoneum over the bladder. 
  • If the tumor is localized to the adnexa without adherances to the peritoneum, a simple removal of the adnexa is carried out. The specimen is sent for frozen sectioning. If there is infiltration of the peritoneum, the infiltrated part is removed along with the adnexa. 
  • Split the peritoneum along the pelvic wall.
  • Open the extraperitoneal space along the pelvic wall.
  • Identify the ureter and avoid it.
  • Divide the suspensory ligament containing the blood supply to the adnex.
  • Dissect the peritoneum off the ureter and its accompanying structures, and push the ureter down before the peritoneum is divided.
  • Dissect along the peritoneal to the uterus.
  • Separate the adnex from the uterus.
  • Send the adnexa for examination by frozen microscopy.
  • Push the bladder peritoneum down to below the cervix.
  • Clamp the parametrium close to the uterus using Leibingers forceps.
  • Place the Leibinger forceps closely and obliquely towards the vagina and cut with scissors.
  • Place Kocher forceps on the vagina immediately under the cervix to lift the vagina.
  • Use diathermy to remove the uterus and cervix immediately distal to the cervix.
  • Close the top of the vagina with surures.
  • Carry out  lymph node staging.  
  • Perform an omentectomy.  
  • Close the abdominal wall. 

Follow-up

Observe for normal postoperative complications.


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