En bloc pelvic resection of ovarian cancer with rectosigmoid colectomy: a literature review

Abstract

Maximal cytoreductive surgery is an important prognostic factor in advanced epithelial ovarian cancer (EOC). To achieve maximal cytoreductive surgery, en bloc pelvic resection with rectosigmoid colectomy can be an effective surgical strategy. This surgical methodology was first described in 1968 as "radical oophorectomy." Since then, it has been adopted by many medical institutions around the world, and its safety has been shown by many studies. However, research on the surgical method is still lacking due to the limited number of prospective comparative studies. We will review the journals on en bloc pelvic resection with rectosigmoid colectomy published to date and discuss its efficacy, complications, and surgical techniques of the procedures.

Keywords: Ovarian cancer; colectomy; cytoreductive surgery; en bloc pelvic resection with rectosigmoid colectomy; optimal debulking; ovarian neoplasms/surgery; ovariectomy/methods; radical oophorectomy.

Figure 1

Radical oophorectomy initiated by the paracolic gutter incisions. (A) Pelvic mass (circle with white dots) causes adhesion of the organs of pelvis to obliteration. Sigmoid colon (bigger white dot) does not move due to adhesion of the pelvic mass. (B) Anterior pelvic peritonectomy. The paracolic gutter incisions are extended caudally to the anterior pelvic peritoneum. The bladder is placed in traction and the peritoneum of anterior pelvis is deperitonealized by using the electrosurgical unit.

Figure 2

The pelvic dissection. (A) Identifying retropelvic space structure. The ureter is identified and mobilized from their attachment of the medial side of the pelvic peritoneum. (B) By suture ligatures of the IP ligament early in the course of operation, the pelvic mass is devascularized.

Figure 3

The cardinal ligament is identifying by developing the pararectal and paravesicle spaces. Mobilize the ureter to see the path to the bladder. After developing the Tunnel of Wertheim, place the ureter anterolaterally and cut the Tunnel of Wertheim. Then we can see the ureter entering the trigone of the bladder.

Figure 4

The hysterectomy is completed in a retrograde fashion by first making an anterior colpotomy. (A) Anterior colpotomy expose the vaginal lumen. Allis clamps are used to clamp on the cutting edge of anterior vagina. (B) Using the Allis clamp, traction the cervix and uterus helps dissection. The posterior vaginal wall is also incised and the rectovaginal space developed caudally along the rectum until it reached to the lowest 2–3 cm of margin from tumor deposit.

Figure 5

The recto-sigmoid colon is divided. (A) The rectum is dissected at 2–3 cm from at the lowest of tumor for safety margin; (B) the rectum is divided at 2–3 cm from at the lowest of tumor by using TA stapler and a proximal bowel clamp; (C) the pelvic mass removed en bloc with uterus and rectosigmoid colon; (D) the anvil shaft inserted into the cartidge shaft of the main CEEA instrument, until it sounds click.