• Surgical Oncology
• Carcinoma, Ovarian Epithelial
• Gynecologic Surgical Procedures
• Peritoneal Cavity
• Laparotomy

Surgical treatment of gynecologic malignancies often involves advanced cytoreductive procedures, especially in advanced ovarian and endometrial cancer. Cytoreductive surgeries include procedures such as pelvic peritonectomy with or without rectosigmoid resection, pelvic and para-aortic lymphadenectomy, excision of lymphadenopathies in the celiac trunk or cardiophrenic area, multiple visceral resections (including small bowel, colon, stomach, spleen, or pancreatic tail), radical omentectomy, and diaphragmatic peritonectomies, among others.1

These surgeries are long and highly demanding, so proper patient positioning, avoiding nerve injuries, thromboembolism, and maintaining normothermia is needed to ensure patient safety. In the same way, maintaining good surgeon positioning is essential when accessing the different areas of the abdomen to uphold ergonomics and prevent excessive fatigue.

Most cytoreductive procedures require access to difficult-to-reach areas of the abdomen, so creating a good surgical field from the beginning of the surgery, and the proper use of a retractor is essential for adequate exposure to facilitate procedures (Figure 1).

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Figure 1

Complete peritonectomy.

Many of the procedures performed require previous systematic exposure maneuvers. To access the right diaphragmatic dome, proper hepatic mobilization is required.2 Similarly, complete colon mobilization is required to access both kidneys and ovarian pedicles. Furthermore, mobilization of the left colon, including the splenic flexure, will facilitate radical omentectomy. The Kocher maneuver enables excellent access to the inferior vena cava, particularly when para-aortic lymphadenectomy is needed.3 To obtain proper pelvic exposure, Trendelenburg positioning is not always necessary if the intestinal package is manipulated correctly.

In this video article, we will demonstrate, in 10 systematic steps, how to achieve proper patient positioning, adequate surgical exposure, and the surgical maneuvers necessary to perform most cytoreductive procedures.