ABSTRACT
The rate of optimal cytoreduction varies between institutions, and to some degree depends on specialty training, philosophy, and surgical aggressiveness (25,26). It is essential that the surgeon is able to make a reasonable judgment as to whether any aggressive procedure will lead to optimal cytoreduction. The surgical morbidities must always be considered. Most often for the surgeon, the extent of upper abdominal disease and bowel/mesenteric involvement may limit the ability to perform optimal cytoreduction. Aggressive attempts at tumor resection may require radical hysterectomy, omentectomy, resection of either small or large intestine, splenectomy, diaphragmatic peritonectomy, hepatic resection, or other related procedures. Splenectomy, diaphragmatic peritonectomy, and partial hepatectomy, as well as the elimination of peritoneal implants by peritonectomy, can be safely performed in carefully selected patients with upper abdominal disease (19,25-29). Due to the special tumor biology and pelvic distribution of ovarian cancer, it is recommended
that an “en bloc resection” be performed in a retrograde fashion, that is, including peritoneum of the pelvis, uterus, adnexal masses, and sigmoid. These procedures should be considered if they would result in an optimal cytoreduction, because patients with optimally resected upper abdominal disease have similar outcomes to other patients who are optimally cytoreduced (30). Bowel resection is often necessary to achieve optimal resection or to treat bowel obstruction; it is safe to perform, and will offer a survival benefi t if the end result is optimal cytoreduction (17,31). Ovarian cancer rarely progresses below the pelvic peritoneal refl ection, and therefore it is possible to safely perform low colorectal anastomoses in the majority of cases (31).
