Chapter 193: Surgical Management of Ovarian Carcinoma 2057

A B

Fig. 20. A: The entire peritoneal envelope, including the anterior and posterior cul-de-sac with the cervix is retracted anteri-
orly so as to expose and skeletonize the upper rectum. B: The lateral view demonstrates the anterior and posterior
exposure of the upper rectum levels facilitate transection of the upper rectum and removal of the specimen. Note
that the Wertheim clamp is placed above the point of resection.

integrity of the staple line is assessed by
ex-amination of the two rings of large
bowel re-moved in the stapling device and
by insufflat-ing air into the rectum with a
bulb syringe after filling the pelvis with
warm saline, look-ing for bubbles issuing
from a potential de-fect in the anastomosis.
Although the extent of disease in some
patients does not require en bloc resection
of the rectosigmoid with the intraperitoneal
viscera, approximately two-thirds of our
patients do present with the bulk of their in-
trapelvic disease on the rectosigmoid colon.
Given the alternative course of piecemeal
dissection of individual nodules from the
sigmoid and its mesentery as well as from the
surrounding peritoneal surfaces, the ease and
safety of this procedure, coupled with its lack
of significant complications in our hands
encourages us to employ this
technique in the majority of patients with
stage IIIC ovarian cancer. Approximately
one-half of our patients undergoing recto-
sigmoid resection have evidence of deep in-
vasion through the muscularis. With early
postoperative chemotherapy using Taxol and
carboplatinum, targeted for postopera-tive
day 5, we have greatly reduced the likeli-
hood of pelvic recurrence of disease com-
pared to historical controls. Of 26 patients

Nongastrointestinal Transabdominal Surgery

A B

Fig. 21. A: Anterior view of the pelvis at the procedures completion. All pelvic peritoneum, associated tumor,
lymph nodes, and the intrapelvic peritoneal organs have been removed. B: The distal end of the rectosigmoid is
transected and stapled below the tumor; bowel continuity is restored using an EEA stapling device.