1. Invasive adenocarcinoma of the ovaries, stage 3C.
2. Left periureteral involvement secondary to tumor.

1. Examination under anesthesia.
2. Tumor debulking and cytoreduction.
3. Total abdominal hysterectomy and bilateral salpingo-oophorectomy with removal of left ovarian mass.
4. Infracolic omentectomy.
5. Bilateral pelvic and left common iliac lymph node dissection.
6. Left ureteral resection and ureterolysis secondary to tumor.
7. Operative laparoscopy.
8. Insertion of an interpersonal Port-a-Catheter system.

BACKGROUND: The patient is a 53-year-old female, developed left adnexal/ovarian mass approximately 8 cm in diameter on examination and scan. She also was noted to have a CA-125 elevation consistent with ovarian cancer. The patient was appropriately counseled and brought to surgery.

OPERATIVE FINDINGS: Operative laparoscopy was first carried out which revealed the presence of a left ovarian mass and omental metastases consistent with ovarian cancer, and therefore laparoscopy was terminated and laparotomy carried out.

At laparotomy, there was no ascites. There was no diffuse carcinomatoses. The liver parenchyma, liver casts, both diaphragms, splenic area, lesser omentum, stomach, pancreas and kidneys palpated and looked normal. There was no retroperitoneal pelvic or perilymphadenopathy. The omentum was involved behind the left ovary with a 3 cm mass, but the upper omentum was clear. The pericolic gutters, small bowel and large bowel were clear, including the cul-de-sac and rectosigmoid. The bladder was clear.

There was left paracervical periureteral involvement by tumor which required left ureteral dissection in order to mobilize ureter away from the tumor so it could be debulked. Therefore the site of involvement was the left ovary, the left periureteral, paracervical area and the omentum draped up behind the left ovary.

The above procedures were carried out, and at the end of the procedure, all visible and palpable disease was completely removed, so there was no visible or palpable disease left in the peritoneal cavity, and there was no suspicious periaortic and pelvic lymphadenopathy. The pelvic lymph nodes were removed as part of the staging process, but were enlarged but soft and not suspicious.

Final pathology is therefore pending.

OPERATIVE PROCEDURE: After the appropriate informed consent, the patient was taken to surgery and placed on general anesthetic. Examination under anesthesia carried out with the above findings.

A Jarcho cannula was placed. The patient was placed in modified lithotomy position. A Foley catheter placed. The abdomen prepped and draped in the usual fashion. A small incision made subumbilically. A Veress needle inserted under 3 mm of pressure. 3.5 liters of CO2 insufflated into the abdomen. Operative laparoscope was placed through a 5 mm trocar without difficulty, and we could immediately see the above findings, and therefore I terminated the procedure after examining the upper abdomen with the laparoscope and seeing no evidence of disease.

Once the laparoscope was removed, the Jarcho cannula was removed, and the patient's legs were placed down. A vertical incision was made opening up down to peritoneum. On opening up the peritoneum, we immediately could mobilize the omentum away from the back of the ovary and reflected it off the transverse colon, cross clamping the pedicles with Peans and tying up the pedicles with 0 Vicryl suture with excellent hemostasis. Exploration of the upper abdomen then carried out with the above findings. Small, large bowel run with the above findings. No evidence of disease anywhere other than the omentum which had been removed. The abdominal contents were packed off gently, and a padded retractor gently placed. Pean clamps were placed across each uteroovarian pedicle. The round ligaments on each side clamped, cut and tied with 0 Vicryl suture. The retroperitoneum opened up while they developed and explored, and a large soft sentinel was noted on the right pelvic, left pelvic and common iliac area with no other adenopathy noted. These were removed with excellent hemostasis. The right ureter was easily mobilized out of the way and the right eye peeled, clamped, cut and doubly tied with 0 Vicryl suture. The bladder flap was carefully taken down while past cervix. The cul-de-sac peritoneum was incised. The rectovaginal sac was developed, and the rectum mobilized away from the back of the cervix and vagina. The left retroperitoneum was further developed and the left ureter identified by the area of the left uterosacrum and paracervical area ligament. The left ureter was noted to be covered over on the retroperitoneal aspect by tumor, but without invasion of the ureter. Therefore left ureteral resection was commenced using the right anal clamp. The Thompson clamp completely immobilizing the ureter throughout its pelvic course underneath the uterine vessels and away from the left paracervical tumor. Once this was done, the left side labia was clamped, cut and doubly tied with 0 Vicryl suture and the left ovarian pedicle mobilized towards the uterus and removed.

The uterine vessels were then isolated, clamped, cut and tied with 0 Vicryl suture with the uterine under direct vision on the left side and the ureter well away on the right side. Cardinal and ureterosacral ligaments were clamped, cut and tied with 0 Vicryl suture. The paracervical tumor was mobilized free after isolating the uterine vessels on the left side and ligating them.

All visible tumor was thus completely removed. Cardinal uterosacral ligaments were clamped, cut and tied with 0 Vicryl suture, and the Heaney clamps were placed below the cervical-vaginal junction removing the specimen in close fashion giving it to Pathology. The vaginal cuff was closed with 0 Vicryl hang suture at each angle incorporating ureterosacral and cardinal ligaments and 0 Vicryl figure-of-eight sutures in the midline.

All areas were carefully irrigated out, inspected and found to be dry. There was no visible palpable tumor visible or palpable tumor left. All peritoneal surfaces remaining were clean and smooth. There was no evidence of injury to the rectum, rectosigmoid, bladder or ureters.

One more time, all areas were irrigated out, inspected and found to be dry. Sigmoid was brought down the left side. Cecum brought down the right side. The omental pedicles were inspected and found to be dry after carefully removing the lap sponges.

The abdominal cavity was irrigated out one more time with warm saline. All packs being removed, the padded retractor was gently removed.

Anterior peritoneum and fascia were then closed with looped 0 PDS suture from each angle towards the midline and tied. An 8-0 Vicryl figure-ofeight suture was used to secure and bury the knots.

Subcutaneous tissue was irrigated and inspected and found to be dry. The skin incisions were closed by the means of staples.

Prior to closure, optimal debulking had been carried out for stage 3C disease. Insertion of an intraperitoneal catheter was carried out with a 2.9 mm venous access catheter, the well being sutured to the fascia in the right lower quadrant, away from the anterior superior spine, bringing the catheter too into the peritoneal cavity, placing in the pelvis and up the right gutter and then easily flushing with the dilute heparinized solution.

Once this was done, all areas were carefully irrigated out, inspected and found to be dry, and a closure was completed as above.

Throughout the procedure, the patient tolerated the procedure well. Vital signs remained stable. Sponge and needle count was correct. Estimated blood loss was 150 cc. The patient returned to the recovery room in good condition.

RONALD S. LEUCHTER, M.D.

Signed by LEUCHTER, RONALD at 5/28/2007 17:37