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The Sandwich Technique of Diaphragmatic Stripping or Full-Thickness Resection for Advanced Ovarian Cancer: How to Keep it Short and Simple
  1. Christoph Grimm, MD*,,
  2. Philipp Harter, MD*,
  3. Florian Heitz, MD* and
  4. Andreas du Bois, MD*
  1. *Department of Gynecology and Gynecologic Oncology, Kliniken Essen-Mitte, Essen, Germany; and
  2. Department of General Gynecology and Gynecologic Oncology, Comprehensive Cancer Center, Gynecologic Cancer Unit, Medical University of Vienna, Vienna, Austria.
  1. Address correspondence and reprint requests to Christoph Grimm, MD, Department of Gynecology and Gynecologic Oncology, Kliniken Essen-Mitte, Henricistraße 92, 45136 Essen, Germany. E-mail: c.grimm{at}


Objective Residual tumor is an important prognostic factor in advanced ovarian cancer patients. A recent analysis from a large Gynecologic Oncology Group trial identified the diaphragm as the most common localization for residual tumor after surgery in advanced ovarian cancer. This stresses the need for more knowledge and training in diaphragmatic surgery in patients with advanced ovarian cancer.

Methods/Materials We aimed to describe a safe structured technique to perform transection of the peritoneal diaphragm or full-thickness resection of the diaphragm.

Results The structured technique consists of 5 steps as follows: (1) knowledge of anatomical landmarks, (2) adequate exposure of the surgical field, (3) mobilization of the liver, (4) demarcation of the resection lines of the peritoneum, and (5) mobilization of the diaphragmatic peritoneum by using the sandwich technique or performance of a full-thickness resection with subsequent suture.

Conclusions Diaphragmatic surgery is an important part of upper abdominal surgery in advanced ovarian cancer patients. It is a safe structured procedure, which should be routinely performed to achieve optimal surgical results for these patients.

  • Ovarian cancer
  • Diaphragm
  • Diaphragmatic surgery
  • Upper abdominal surgery

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  • The authors declare no conflicts of interest.