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Resection of metastatic ovarian cancer in the supragastric lesser sac in 10 steps
  1. Libing Xiang,
  2. Yulian Chen,
  3. Lina Shen,
  4. Zhihua Huang and
  5. Rongyu Zang
  1. Ovarian Cancer Program, Department of Gynecologic Oncology, Zhongshan Hospital Fudan University, Shanghai, China
  1. Correspondence to Dr. Rongyu Zang, Department of Gynecologic Oncology, Zhongshan Hospital Fudan University, Shanghai 200032, China; zang.rongyu{at}

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The supragastric lesser sac, lying posterior to the lesser omentum and the hepatoduodenal ligament, is a site of occult metastases and a barrier to complete resection in ovarian cancer.1 2 Veerapong et al introduced the resection of tumors from the supragastric lesser sac.3 We have made a few modifications to Veerapong’s procedure in this video. The key points of the procedure are as follows: (1) Shaving the ventral peritoneum of the hepatoduodenal ligament after the dissection of the adhesions around the hepatic pedicle and the accomplishment of the cholecystectomy. (2) Mobilization of the duodenum by the Kocher maneuver. (3) Detaching the peritoneum from the common bile duct and the inferior vena cava. (4) Dissection of the peritoneum along the superior border of the pancreas. (5) Dissection of the tumor along the portal vein. (6) Dissection of the dorsal area of the hepatoduodenal ligament. (7) Pulling the tumor out from the space posterior to the portal triad and then resecting it en bloc. (8) Stretching the stomach caudally and shaving the peritoneum along the lesser curve. (9) Retracting the caudate lobe cephalad and shaving the peritoneum covering the right crus. (10) Ligation of the lymphatic vessels.

In our procedure, the upper recess could be directly exposed without damage to the major anatomic structures in a time-saving way in the majority of patients, except for those patients with obesity. Our method is effective and safe for complete cytoreduction of the metastases in the supragastric lesser sac.

Figure 1

Supragastric lesser sac in a cadaver. The sac is a compartment lying posterior to the lesser omentum and the hepatoduodenal ligament (outlined by yellow solid and dashed lines, respectively). Diseases in this recess could always compromise complete resection. CHA, common hepatic artery; CL, caudate lobe (liver); CT, celiac trunk; D, duodenum; GB, gallbladder; GDA, gastroduodenal artery; LGV, left gastric vessels; LLL, left lobe (liver); P, pancreas; PHA, proper hepatic artery; PV, portal vein; RCD, right crus of the diaphragm; S, stomach; URLS, upper recess of lesser sac; VN, vagus nerve; .

Video 1 Resection of metastatic ovarian cancer in the supragastric lesser sac in 10 steps

Data availability statement

All data relevant to the study are included in the article.

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We would like to express our sincere gratitude to Professor Deyan Tan and Wensheng Li for their guidance in anatomy, and to Dr Kai Xu, Yixuan Liu, and Xiao Xu for participating in the surgery.



  • LX and YC contributed equally.

  • Contributors LX, YC, and RZ were responsible for the concept and design of this surgical video and the manuscript. LX and ZH performed the surgery and took the surgical video. LX, YC, and LS wrote the manuscript and edited the video. RZ reviewed the manuscript. LX was responsible for the overall content as the guarantor. All authors have approved the final manuscript.

  • 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 None declared.

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