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Surgical approach of the left upper quadrant for ovarian cancer in 10 steps
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  1. Martina Aida Angeles1,
  2. Hélène Leray1,
  3. Federico Migliorelli2,
  4. Manon Daix1,
  5. Alejandra Martinez1,3 and
  6. Gwenael Ferron1,4
  1. 1Department of Surgical Oncology, Institut Universitaire du Cancer de Toulouse—Oncopole, Institut Claudius Regaud, Toulouse, Toulouse, Occitanie, France
  2. 2Department of Gynecology and Obstetrics, Paule de Viguier Hospital, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
  3. 3INSERM CRCT Team 1, Tumor Immunology and Immunotherapy, Toulouse, France
  4. 4INSERM CRCT Team 19, ONCOSARC—Oncogenesis of Sarcomas, Toulouse, France
  1. Correspondence to Dr Gwenael Ferron, Surgical Oncology, Institut Claudius Regaud, 31059 Toulouse, Occitanie, France; ferron.gwenael{at}iuct-oncopole.fr

https://doi.org/10.1136/ijgc-2021-002963

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    Summary

    Complete cytoreductive surgery without residual tumor is one of the most important prognostic factors in advanced ovarian cancer patients.1 During cytoreductive procedures, it is not unusual to require multiple digestive and/or visceral resections,2 which undoubtedly increase surgical morbidity and can also decrease patients’ quality of life.3 Therefore, it is essential to be as conservative as possible during cytoreductive procedures and to avoid, whenever possible, multivisceral resections without compromising the main goal of the surgery which is to achieve the absence of residual tumor. In this video article (Video 1) we show the surgical approach of the left upper quadrant in a patient with peritoneal carcinomatosis from ovarian origin who underwent an en-bloc left diaphragmatic peritonectomy, splenectomy, and infragastric omentectomy, among other procedures which are not included in the video. The surgery was carried out in a French Comprehensive Cancer Center by a senior oncological surgeon, following Sugarbaker principles.4 To perform the surgery, we used different energy instruments, a multifunctional device which employs ultrasonic energy and advanced bipolar energy, a bipolar forceps, a monopolar tip, and a monopolar roller ball. We divided the surgical procedure in the 10 following steps:

    Step 1: Surgical exposure

    Video 1

    Step 2: Beginning of left diaphragmatic and paracolic gutter peritonectomy

    Step 3: Mobilization of the splenic flexure of the colon

    Step 4: Spleen mobilization

    Step 5: Complete left diaphragmatic peritonectomy

    Step 6: Hepatic mobilization

    Step 7: Infragastric omental detachment

    Step 8: Splenic vascular pedicle ligature

    Step 9: Coloepiploic detachment

    Step 10: Chest tube insertion

    To summarize, we propose an alternative surgical approach to spare a transverse colectomy in a patient who presented with an omental cake highly adherent to the transverse colon. It is crucial to reduce the surgical radicality of cytoreductive surgery in patients with advanced ovarian cancer, without hindering the oncological outcome.

    Figure 1
    Figure 1

    Infragastric omental detachment with gastroepiploic arcade preservation.

    Data availability statement

    Data are available upon request.

    Ethics statements

    Patient consent for publication

    References

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      1. Chi DS,
      2. Eisenhauer EL,
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      . Improved progression-free and overall survival in advanced ovarian cancer as a result of a change in surgical paradigm. Gynecol Oncol 2009;114:26–31.
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      . Phase III randomised clinical trial comparing primary surgery versus neoadjuvant chemotherapy in advanced epithelial ovarian cancer with high tumour load (SCORPION trial): final analysis of peri-operative outcome. Eur J Cancer 2016;59:22–33.doi:10.1016/j.ejca.2016.01.017pmid:http://www.ncbi.nlm.nih.gov/pubmed/26998845
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      1. Sugarbaker PH
      . Peritonectomy procedures. Ann Surg 1995;221:29–42.doi:10.1097/00000658-199501000-00004pmid:http://www.ncbi.nlm.nih.gov/pubmed/7826158
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    Footnotes

    • Twitter @AngelesFite, @Alejandra

    • Contributors MAA: Conceptualization, video editing, writing-original draft. HL: Conceptualization, video editing, writing-original draft. FM: Conceptualization, video editing, writing-original draft. MD: Conceptualization, video editing, writing-original draft. AM: Conceptualization, project administration, supervision, writing-review. GF: Conceptualization, project administration, surgery and video recording, supervision, writing-review.

    • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

    • Competing interests GF reports personal fees from Olympus outside of the submitted work.

    • Provenance and peer review Not commissioned; externally peer reviewed.